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A REFERENCE HANDBOOK 


OF 


THE MEDICAL SCIENCES 


~ SCIENTIFIC AND PRACTICAL MEDICINE 


AND 


ALLIED SCIENCE 


Beveov Van lOUS. WRITE RS 


A NEW EDITION, COMPLETELY REVISED AND REWRITTEN 


EDITED BY ALBERT H. BUCK, M.D 


New Yor« Crry 


VOLUME II. 


ILLUSTRATED BY NUMEROUS CHROMOLITHOGRAPHS AND SEVEN HUNDRED 
AND SIXTY-FIVE HALF-TONE AND WOOD ENGRAVINGS 


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LIST OF CONTRIBUTORS TO VOLUME II. 


EDWARD A. AYERS, M.D New York, N. Y. 
Physician-in-Chief, Mothers’ and Babies’ Hospital; Ob- 
stetrician, Polyclinic Hospital. 
FRANK BAKER, M.D WASHINGTON, D. C. 
Professor of Anatomy, Georgetown University School 
of Medicine, Washington, D. C.; Superintendent, 
National Zoological Park, Smithsonian Institution. 


LEWELLYS F. BARKER, M.D........ Cuicago, Inu. 
Professor and Head of the Department of Anatomy, 
University of Chicago and Rush Medical College. 


ELIAS HUDSON BARTLEY, M.D 
Pe 3) 


a lq) 618) 0) 6) .6.<) &. 0118! 


me Poe Ce BROOKLYN, 

Professor of Chemistry, Toxicology, and Pediatrics, 
Long Island College Hospital Medical School; Dean, 
and Professor of Organic Chemistry, Brooklyn Col- 
lege of Pharmacy. 


WALTER ARTHUR BASTEDO, Pu.G., M.D...NEw 
PORN. Y¢ 
House Physician, St. Luke’s, Hospital; Formerly In- 
structor in Materia Medica, University and Bellevue 
Hospital Medical College, and Torrey Lecturer on 
Botany at the New York College of Pharmacy. 


MiwWatie a, BIRGE, Pa: D.......... Mapison, WIs. 
Professor of Zoology, University of Wisconsin. 

ALBERT N. BLODGETT, M.D........Boston, Mass. 

Wee DOMUNS. M.D. 22.8. ok. oes Roxpury, Mass. 


Professor of Materia Medica and Botany, Emeritus, at 
the Massachusetts College of Pharmacy; Visiting 
Surgeon, Boston City Hospital. 


DAVID BOVAIRD, Jr., M.D.......New Yor, N. Y. 

Clinical Instructor in Diseases of Children, the Uni- 

versity and Bellevue Hospital Medical College; Path- 
ologist to the Foundling Hospital. 


CORNELIUS COLE BRADLEY, M.D....NEw Yorx, 
UN Y. 


Attending Ophthalmologist to New York Catholic Pro- 
tectory, to St. Joseph’s Orphan Asylum, to House of 
the Good Shepherd, and to St. Joseph’s Institute for 
the Deaf and Dumb. 


ees BROWNING, Pu.B., M.D...... BROOKLYN, 

wile 

Professor of Diseases of the Mind and Nervous Sys- 
tem, Long Island College Hospital; Attending Neu- 
rologist to the King’s County, German, and Norwe- 
gian Hospitals; Consulting Neurologist to the Long 
Island State, Brooklyn, St. John’s, and St. Christo- 
pher’s Hospitals, Brooklyn, N. Y. 


noe NORTON BULLARD, M.D 
ASS. 
Physician to the Department of Nervous Diseases, City 
Hospital; Neurologist to the Children’s Hospital; 
Consulting Neurologist, Carney Hospital. 


CHARLES N. BANCKER CAMAC, M.D........NEw 
York, N. Y. 

Instructor in Clinical Pathology, Cornell University 

Medical College in New York City; Physician to 
City Hospital. 


Boston, 


see eee 


ill 


WILLIAM B. COLEY, M.D New York, N. Y. 

Clinical Lecturer in Surgery, Medical Department, Co- 

lumbia University; Attending Surgeon, General Me- 
morial Hospital. 


WILLIAM JUDKINS CONKLIN, M.D......Dayrton, 
OuTIo. 
Consulting Surgeon, St. Elizabeth’s Hospital and The 
Protestant Deaconess’ Home and Hospital. 


WILLIAM T. COUNCILMAN, M.D...Boston, Mass. 
Shattuck Professor of Pathological Anatomy, Harvard 
University Medical School. 


JAMES. K: CROOK, M.Di®.....5..New YORK, N; Y. 

Adjunct Professor of Clinical Medicine and Physical 

Diagnosis, New York Post-Graduate Medical School; 
Attending Physician, Post-Graduate Hospital. 


ANDREW F. CURRIER, M.D NEw York, N. Y. 
Assistant Surgeon, Skin and Cancer Hospital; Consult- 
ing Gynecologist, McDonough Memorial Hospital. 


EDWARD CURTIS, M.D New York, N. Y. 
Emeritus Professor of Materia Medica and Therapeu- 
tics, Medical Department, Columbia University. 


CHARLES TOWNSHEND DADE, M.D 
YW.ORK. N.GY¥c 
Clinical Assistant, Department of Dermatology, Van- 
derbilt Clinic, Columbia University ; Attending Der- 
matologist, Randall’s Island Hospital. 


HASKET DERBY, M.D Boston, Mass. 
Ophthalmic Surgeon, Massachusetts Charitable Eye 
and Ear Infirmary, Boston, Mass. 


HENRY HERBERT DONALDSON, Pa.D 
CAGO, ILL. 

Professor and Head of the Department of Neurology, 
University of Chicago. 


WILLIAM K. DRAPER, M.D New York, N. Y. 
Instructorin Physical Diagnosis, College of Physicians 
and Surgeons, Medical Department of Columbia Uni- 
versity; Attending Physician, City Hospital; Visit- 
ing Physician, Scarlet Fever and Diphtheria Hospital. 


sere eees 


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HARRYeB: FERRIS; M Dee... New Haven, Conn. 

Hunt Professor of Anatomy, Medical Department, Yale 
University. 

PTD RRA a ELS Hib oe. cae einer: IrmHaca, N. Y. 


Assistant Professor of Physiology, Cornell University. 


EDWARD M. FOOTE, M.D New York, N. Y. 
Instructor in Minor Surgery, Medical Department, Co- 
lumbia University; Visiting Surgeon, City Hospital. 


JOHN ADDISON FORDYCE, M.D 
NEES 


eee wees 


eon New York, 
Professor of Dermatology and Syphilology, The Uni- 
versity and Bellevue Hospital Medical College; Vis- 
iting Derm: tologist, City Hospital. 
ROBERT FORMAD, M.D PHILADELPHIA, PA, 
Demonstrator of Normal Histology, Medical Depart- 
ment, University of Pennsylvania; Pathologist to 
St. Mary’s Hospital. 


Ce er 


C1529 


LIST OF CONTRIBUTORS TO VOLUME II. 








JOSEPH FRAENKEL, M.D........ New York, N. Y. 
Instructor in Diseases of the Nervous System, Cornell 
University Medical College in New York City; Phy- 
sician to the Montefiore Home; Neurologist to the 
City Hospital. 
GEORGE C. FREEBORN, M.D....NEw York, N. Y. 


Instructor in Normal Histology, Medical Department 
of Columbia University. 


CHARLES BE. HACKLEY, M.D....Nrew York, N. Y. 


WILLIAM A. HARDAWAY, M.D....S1r. Lovrs, Mo. 
Professor of Diseases of the Skin and Syphilis, Medi- 
cal Department of Washington University, St. Louis. 


DUD VIGSEHE KRG BIN SIMaD eae aeeereee CurcaGo, ILL. 
Professor of Pathology, Rush Medical College. 


CLARENCE L. HERRICK, Pu.D.....ALBUQUERQUE, 
New Mexico. 
President of the University of New Mexico; Editor of 
the Journal of Comparative Neurology. 


HERBERT M. HILL, Px.D BuFrato, N. Y. 
Professor of Chemistry, University of Buffalo; Chem- 
ist to the City of Buffalo. 


AWM ORI DNNE TER IEMNOIO SS, OID) Boe aoc oe Boston, Mass. 
Associate Professor of Chemistry, Harvard University 
Medical School. 


GUY HINSDALE, M.D PHILADELPHIA, PA. 
Secretary, American Climatological Association. 


ORVILLE HORWITZ, M.D....... PHILADELPHIA, Pa. 
Clinical Professor of Genito-Urinary Diseases, Jefferson 
Medical College; Surgeon to Jefferson Medical Col- 
lege Hospital, to Philadelphia Hospital, and to State 
Hospital for the Insane. 


RELD “HUNT. Pa D eM Drea BALTIMORE, Mp. 
Associate in Pharmacology, Johns Hopkins Medical 
School. 


GEORGE THOMAS JACKSON, M.D....New York, 
Ay 


Instructor in Dermatology and Chief of Clinic, Medi- 
cal Department, Columbia University; Consulting 
Dermatologist, Presbyterian Hospital and the New 
York Infirmary for Women and Children. 


WILLIAM W. KEEN, M.D PHILADELPHIA, PA. 

Professor of the Principles of Surgery and of Clinical 

Surgery, Jefferson Medical College; Surgeon to the 
Jefferson Medical College Hospital. 


GEORGE T. KEMP, Pu.D., M.D....CHAmparen, Iu. 
Professor of Physiology, University of Illinois. 


ABRAM T. KERR, B.S., M.D Irnaca, N. Y. 
Assistant Professor of Anatomy, Medical Department, 
Cornell University, Ithaca, N. Y. 


SIMON P. KRAMER, M.D CINCINNATI, OHIO. 
Professor of Pathology and Bacteriology, and Lecturer 
on Clinical Surgery, Cincinnati College of Medicine 
and Surgery; Attending Surgeon, Emergency Hos- 
pital of Cincinnati. 


GEORGE E. MALSBARY, M.D....Crycrnnatt, Onto, 
Assistant in Medicine, Medical College of Ohio. 


LEWIS L. McARTHUR, M.D Curcaao, Inu. 
Professor of Surgery, Post-Graduate Medical School 
and Hospital; Surgeon to St. Luke’s Hospital, to 
Michael Reese Hospital, and to Chicago Orphan 
Asylum. 


EDWARD §8.-McKEE, M.D CINCINNATI, OHIO. 


JAMES LANCELOT MINOR, M.D...Mempuis, TENN. 
Professor of Physiology, Memphis Hospital Medical 
College; Surgeon (Ophthalmic), St. Joseph’s Hospi- 

tal, Memphis. 


ee ee eee 


ee eet 


iv 


CHARLES SEDGWICK MINOT, 8.D., LL.D... .Bos- 
TON, Mass. 
Professor of Histology and Embryology, Harvard Uni- 
versity Medical School. 


BENJAMIN MOORE, M.A Lonpon, ENGLAND. 
Lately Professor of Physiology, Medical Department, 
Yale University ; now Lecturer on Physiology at the 
Charing Cross Hospital Medical School, London, 
England. 


WILLIAM S. MORROW, M.D...MontTREAL, CANADA. 

Lecturer in Physiology, McGill University Medical 

School; Cinical Assistant in Medicine, Royal Vic- 
toria Hospital. 


CAPT. EDWARD L. MUNSON,..Wasuineton, D. C. 
Assistant Surgeon, United States Army. 


EDWARD O. OTIS, M.D Boston, Mass. 
Ex-President of the American Climatological Associ- 
ation; Visiting Physician to the Free Home for Con- 
sumptives; Physician to the Department of Tuber- 
culosis of the Lungs, Boston Dispensary. 


FREDERICK PLTERSON, M.D...NEw York, N. Y. 
Instructor in Neurology and Chief of Clinic, Medical 
Department, Columbia University; Neurologist to 
the City Hospital; Consulting Physician, Manhattan 
State Hospital. 


JULIUS POHLMAN, M.D BuFFato, N. Y. 
Professor of Physiology, Medical Department, Uni- 
versity of Buffalo. 


tee ew eee 


N. J. PONCE DE LEON..>) feet New York, N. Y. 
T. MITCHELL PRUDDEN, M.D., LL.D........ New 
VORK NGL Ye 


Professor of Pathology, and Director of the Labora- 
tories of Histology, Pathology, Bacteriology, and 
Clinical Microscopy, Medical Department of Colum- 
bia University. 

MARY PUTNAM-JACOBI, M.D....NEw York, N. Y. 
Visiting Physician, St. Mark’s Hospital. 
LHOPOLD (POUTZHL, At Der. sea New York, N. Y. 


JOSEPH RANSOHOFF, M.D CINCINNATI, OHIO. 

Professor of Anatomy and Clinical Surgery, Medical 

College of Ohio; Surgeon to the Cincinnati, Good 
Samaritan, and Jewish Hospitals. 


IRVING OC. ROSSE, M.D., F.R.G.S..... WASHINGTON, 
D.C 


Lately Professor of Diseases of the Nervous System, 
Medical Department, Georgetown University. 


HENRY) HeRUsb YM Dao. canes New York, N. Y. 

Professor of Materia Medica and Pharmacology, in the 

University and Bellevue Hospital Medical College, 
and in the New York College of Pharmacy. 


OTTO" H, SCHULTZE, MD rans: 
Instructor in Gross Pathology, Cornell University Med- 
ical College in New York City; Professor of Pathol- 
ogy, Medical Department, University of Vermont; 
formerly, Coroner’s Physician of New York County. 


R. Jak SCOTT, A.D WuitE Puarns, N. Y. 
Attending Physician, Bellevue Hospital, Out-Patient 
Department. 


NICHOLAS SENN, M.D., LL.D....... CricaGgo, Inu. 

Professor of Surgery, Rush Medical College; Attend- 

ing Surgeon, Presbyterian Hospital; Surgeon-in- 
Chief, St. Joseph’s Hospital. 


JOHN V. SHOEMAKER, M.D., LL.D 
DELPHIA, PA. 

Professor of Materia Medica, Pharmacology, Thera- 
peutics, and Clinical Medicine, and Clinical Profes- 
sor of Diseases of the Skin, The Medico-Chirurgical 
College of Philadelphia; Physician to the Medico- 
Chirurgical Hospital. 


sees ew eee 


LIST OF CONTRIBUTORS TO VOLUME IL. 


BEAUMONT SMALL, M.D........ OrTTawa, CANADA. 
Attending Physician, St. Luke’s General Hospital, 
Ottawa; Consulting Physician, The Children’s Hos- 
pital; Late Examiner in Materia Medica, College of 
Physicians and Surgeons, Ontario. 


Demo LON SMITH, M.D.. i ic..0.s Boston, Mass. 
Assistant Physician, Department for Skin and Venereal 
Diseases, Boston Dispensary. 


PHO Ne on SOLOMON: Mabon oss. > LOUISVILLE, Ky. 

Professor of Materia Medica and Therapeutics and of 

Clinical Medicine, Medical Department, Kentucky 
University ; Pathologist, Louisville City Hospital. 


M. ALLEN STARR, Pu.D., M.D...New York, N. Y. 

Professor of Diseases of the Mindand Nervous System, 

Medical Department, Columbia University ; Consult- 

ing Physician, Presbyterian, St. Vincent’s, and St. 

Mary’s Hospitals, and the New York Eye and Ear 
Infirmary. 


Hew SteENSULAND, M.D..........: Syracuse, N, Y. 
Lecturer on Pathology, College of Medicine, Syracuse 
University ; Pathologist to St. Joseph’s Hospital, the 
Hospital of the Good Shepherd, and the Hospital for 
Women and Children. 


ENOCH VINE STODDARD, M.D....... ROCHESTER, 
N. Y 


. Emeritus Professor of Materia Medica and Therapeu- 
tics, University of Buffalo; Consulting Physician, 
Rochester City Hospital; Late Commissioner of 
Health, Rochester, N. Y. 


EMMANUEL J. STOUT, M.D....Patapepnta, Pa. 

Instructor in Dermatology, Jefferson Medical College; 

Associate Physician, Northern Dispensary, Depart- 
ment of Skin Diseases. 


HENRY LING TAYLOR, M.D....NeEw York, N. Y. 

Assistant Orthopedic Surgeon, Hospital for Ruptured 

and Crippled; Consulting Orthopedic Surgeon, New 
York State Epileptic Colony, Sonyea, N. Y 





WILLIAM H. THOMSON, M.D....NEw Yorks, N. Y. 
Visiting Physician, Roosevelt Hospital. 


LOUIS McLANE TIFFANY, M.D...Bautrworg, Mp. 
Professor of Surgery, Medical Department, University 
of Maryland. 
ae ELIZABETH WALKER, M.D....NEw York, 
ms 


Clinical Assistant, Hospital for the Relief of the Rup- 
tured and Crippled. 


BRN RYSA BauW AR DP rel ieee ss sects: Lincoun, NEB. 
Professor of Zoology, University of Nebraska; Zoolo- 
gist of the State Board of Agriculture. 


MOSES C. WHITE, M.D.*...... New Haven, Conn. 
Formerly Professor of Pathology, Medical Department, 
Yale University. 


BOY ADE WHITMAN MoDers. cae: New York, N. Y. 
Chief of Clinic and Instructor in Orthopedic Surgery, 
Medical Department, Columbia University. 


JAMES T. WHITTAKER, M.D.*..Crnctnnati, Onto. 
Formerly Professor of the Theory and Practice of Med- 
icine, Medical College of Ohio, Cincinnati. 


BURG. WILDER, Mibrasonscceeet se IrHaca, N. Y. 
Professor of Neurology, Vertebrate Zoology, and Phys- 
iology, Cornell University. 


LIGHTNER WITMER, M.D...... PHILADELPHIA, Pa, 

Assistant Professor of Psychology, University of Penn- 

sylvania; Psychologist tothe Pennsylvania Training 
School for Feeble-Minded Children. 


JOHN McGRAW WOODBURY, M.D., M.R.C.S..... 
New York, N. Y. 
Instructor in Orthopedic Surgery, Cornell University 
Medical College in New York City. 


* Died while the volume was in course of preparation. 





A REFERENCE .HANDBOOK 


OF 


THE MEDICAL SCIENCES. 


BLASTODERM.—Blastoderm is a term of somewhat 
varied signification according to the animal to which it 
is applied, and, indeed, according to the stage of de- 
velopment. The blastoderm of vertebrates is different 
from the so-called blastoderm of many invertebrates. 

: The term is applied especially 
to meroblastic ova, but is also 
used in reference to the mam- 
malian ovum; it designates 
the layer or layers of cells 
which partially or completely 
cover the yolk and directly 
participate in the formation of 
the embryo. The blastoderm 
may be defined as the stratum of 
cells resulting from segmenta- 
tion of the ovum, and not belong- 
ing to the yolk. We cannot en- 


% 


SIONS 
SoHE 


Oo 
sy 


eeaes 


of the blastoderm throughout 
the animal kingdom; let it 
suffice to point out that the 
structures so called are by no 
means always homologous. 
‘Thus, in insects, segmentation is partial and produces 
a single layer of cells (Fig. 499), which gradually 
spreads over the yolk and apparently represents only 
the ectoderm. In vertebrates, however, the blasto- 
derm is more complex, and consists, in: most forms, 
of several layers of cells, or rather at first of a thick 
stratum of cells not separated into distinct layers 
until later stages. The typical vertebrate blasto- 





Fic. 499.—Section of Egg of 
Oniscus Murarius. (After 
Bobretzky.) 









[eT ekotsZs2 
SER SL 
SO oo aseaeeony dues 

YES 
=m Beppe 


‘Fic. 500.—Ovum of a Flounder in Transverse Vertical Section, 
Semidiagrammatic. 7z, Vitelline membrane; kw, segment- 
ing zone (Keimwall); Bl, blastoderm; s.c., segmentation 
cavity ; s.g., subgerminal plate; gl, oil globule of yolk. 


-derm can, perhaps, be best seen in the eggs of 
bony fishes. The disposition has been very care- 
fully studied by Dr. C. O. Whitman, to whom I am 


Vou. IT.-—1 


ter into a detailed comparison, 


Blastoderm, 
Blastoderm., 


indebted for the accompanying semi-diagrammatic figure 
(Fig. 500) of the ovum and blastoderm of a flounder. 
The ovum is surrounded by a vitelline membrane, ¢, 





Fig. 501.—Kgg of Axolotl after Segmentation. Transverse section. Bl, 
Primitive or ectodermal blastoderm ; 8.c., segmentation cavity ; kw, 
(Keimwall) germinal wall; Yolk.segmented yolk. (After Bellonci.) 





FiG, 502.—Ovum of Rabbit ; ninety-four hours after coitus. He, External cell 
layer; i.m., inner mass of cells; Z, zona pellucida. 
resents an optical section, the lower half a surface view.) 
Beneden.) 


(The upper half rep- 
(After Van 


1 


Blastoderm, 
Blastoderm. 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





from which it has slightly withdrawn, notably at the 
upper pole, where lies the thick cap of cells constituting 
the blastoderm, 67, in the stage represented the outer 
layer of cells is just becoming marked off as a distinct 





pellucida; He, ectoderm ; i.m., inner mass. 


layer, the ectoderm; underneath the blastoderm is the 
well-marked segmentation cavity, s.c.,; everywhere at 
the edge of the blastoderm lies the segmenting zone, 
kw., a ring of granular protoplasm with rapidly dividing 
nuclei; the cells resulting from these divisions are added 
to the edge of the blastoderm, which thus enlarges by 


peripheral additions as well as by the proliferation of its: 


component cells. The segmenting zone is prolonged in- 
ward, forming the floor of the segmentation cavity, or, 
as it is named, the subgerminal plate, s.g. This plate 
grows in from the periphery toward the centre; it con- 
tains nuclei and thins out from the edge of the blasto- 
derm inward. The segmenting zone, kw., is essentially 
the homologue of the germinal wall of the amniota, 
which has been described under Avea, but it is sharply 
bounded against the yolk, and in that respect differs 
from the wall in the chick, because in the latter the 
germinal wall merges gradually into the yolk. 

In the ovum of elasmobranchs (sharks, etc.), we find, 
at the so-called close of segmentation, that the blastoderm 
is a lenticular mass of cells, a little thickened at one 
point where the primitive streak arises later, and resting 
at its edge upon the very large yolk, which forms an en- 
circling zone of segmentation around the blastoderm; 
between the mass of cells and the yolk there is a cavity 
commonly described as the segmentation cavity. If this 
designation be correct, then the comparison with the 
teleost ovum is direct and evident. It is possible, how- 
ever, that the space under the blastoderm is not the 
true segmentation cavity, but the entodermic cavity, as 





Fic. 504.—Diagram of a Segmented Mammalian Ovum. Bl, Blasto- 
derm; s.¢., secondary cavity of the yolk; Yolk, layer of cells, rep- 
resenting the remnant of segmented yolk. 


maintained by Balfour; in other words, that the disposi- 
tion of parts is the same as in the birds, which we pro- 
ceed to describe. 

The birds and reptiles being very closely related, we 
find very close resemblances between the blastoderms in 
the two classes. The actual homologies of the parts 
have been worked out as yet only in the birds, but there 
eannot be much doubt that essentially the same features 
exist in the blastoderm of reptiles. Duval has recently 
shown that in birds the primitive blastoderm represents 
only the ectoderm, as is the case also with the amphibia; 


2 


(After Van Beneden.) 


it is separated from the underlying yolk by a distinct 
cavity; in birds this cavity is very small, and is overlaid 
by a single row of cells, the ectodermal or primitive 
blastoderm; the cavity is very soon obliterated by the 
development of cells below it, and these cells, 
together with the outer layer first formed, con- 
stitute the secondary blastoderm, which, there- 
fore, contains, first, the young ectoderm, and, 
second, a deeper-lying stratum of cells, shown 
by their subsequent history to be the meso- 
derm united with part of the entoderm; in 
other words, at this stage the mesoderm and 
entoderm are not distinct. Underneath this compound 
blastoderm appears a second cavity, which is not what 
it has been often called—the true segmentation cavity— 
but is entodermic, being bounded by the true entoderm 
above and the yolk below; the yolk, it must be remem- 
bered, is modified entoderm. In birds (and probably 
reptiles) the thick blastoderm of the teleost is represented 





Fig. 505.—Sections through Three Successive Stages, Ovum of the Mole, 
to show the changes in the inner mass,i.m. z and 2 designate the 
zone pellucida; Hc, subzonal cell layer, usually called ectoderm, but 
probably entoderm; hy, portion of the inner mass, which enters 
into the composition of the entoderm of later stages. (After Heape.) 


by only a few cells; the secondary blastoderm is another 
structure, consisting of two layers, and developed later. 

The similarity between the eggs of ganoids and of 
amphibians permits us to consider these two classes to- 
gether. At first sight the segmented ovum of an am- 
phibian seems very unlike that of the mesoblastic verte- 
brates, but if we begin by the study of parts obviously 
identical, I believe that we can determine the homologies 
of all the parts. Fig. 501 represents a transverse section 
of an ovum of an axolotl; the membranes of the ovum 
are not represented. The parts can be readily compared 
with those in the teleost. The blastoderm, Bi, is very 
large in proportion. to the whole ovum, and is composed 
of several layers of cells, all of which belong to the ecto- 
derm, and at this stage are found to be multiplying with 
extreme rapidity; the yolk is segmented, and accord- 
ingly consists of large cells. At the edge of the yolk, kw, 
is the zone in which cells are being added to the blasto- 
derm, and which is therefore the homologue of the 
germinal wall. The segmentation cavity, 8.c., is very 
large; the yolk cells bounding it inferiorly may, perhaps, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





be homologous with the nucleated subgerminal plate of 
teleosts. The segmentation cavity is ultimately obliter- 
ated, and a secondary blastoderm, including the three 
germ layers, is developed, as described in the article 
Fetus, Development of. Underneath the secondary blasto- 
derm arises a second distinct, or true entodermic cavity 
(Fig. 506). The relations are strictly comparable, there- 
fore, to those in the birds. 

The mammalia, according to the description hitherto 
given, offer no homology in the blastoderm stage with 
other vertebrates. The formation of the blastoderm is 
described under Segmentation. The result of segmen- 
tation is the so-called blastodermic vesicle, a hollow 
sac formed by a single layer of cells (Fig. 502, Ec.) 
lying close against the zona pellucida; at one pole, where 
the embryo is subsequently formed, lies a lenticular 
mass of cells, 7.m. Now, the exact relations of this cell 
mass have never been thoroughly studied by any one with 
the view of elucidating the homologies of the parts, all in- 
vestigators having apparently come to a tacit agreement 
to neglect this problem. Van Beneden, to be sure, at- 
tempted an interpretation by calling the outer vesicle the 
ectoderm, and the inner mass the invaginated entoderm, 
thus defining the whole as a modified gastrula. It has 
since been definitely settled that Van Beneden was in 
error in this. Our knowledge of the changes that take 
place in the inner cell mass is based almost wholly upon 
the study of various rodents (rabbits, guinea-pigs, and 
mice), all of whom pass, during their early development, 
through phases which obviously represent great modifica- 
tions of the normal mammalian ontogeny. In the rabbit 
the cells where the inner mass lies soon form three layers 
(Fig. 503). These are not, however, the three germ layers; 
for, as Rauber has shown, the two outer layers form the 
ectoderm, and the third inner layer forms the entoderm ; 
the mesoderm arises later. Here, then, we reach a 
definite point of comparison. The whole of this mass of 
cells performs the role of the secondary blastoderm in 
the chick, teleost, and frog; I therefore conclude that it 
is the mammalian blastoderm. The second point to be 
made is that the so-called cavity of the blastodermic 
vesicle is probably not the segmentation cavity, but 
the secondary yolk cavity, which later fuses with the 
notochordal canal (see Notochord) to form the definitive 
archenteron. Hence comes the third point, that the 
cellular vesicle represents not the ectoderm, as has 
hitherto been universally assumed, but the yolk sac 
hollowed out. 

For convenience of comparison with Figs. 500 and 502, 


the accompanying diagram (Fig. 504) of a mammalian - 


ovum after segmentation is given. According to the 
identification of homologies I have here hypothetically 
advanced, the blastoderm, Al, must include both ecto- 
derm above and entoderm within. If we imagine the 
yolk of the axolotl, Fig. 501, very much reduced, so as 
to form only a single layer of cells, we should have the 
mammalian condition, Fig. 504. 

It appears to me that the invagination of the inner cell 
mass is a general phenomenon in the development of 
placental mammals, and that the remarkable inversion 
of the germ layers in the guinea-pig is only a persistence 
of thisearly invagination. Itis a law which, asI pointed 
out several years ago, holds throughout the animal king- 
dom, that the result of segmentation is to produce two 
sets of cells: one of small-sized cells, belonging to the 
ectoderm, the other of larger cells, belonging to the en- 
toderm. In mammals also segmentation produces the 
two kinds of cells, but the smaller ones (ectoderm) form 
most of the inner cell mass which Van Beneden errone- 
ously called entoderm. It seems to me clear that this 
first invagination has nothing to do with a gastrula in- 
vagination. The inner cell mass gradually flattens out 
again in most cases, but in some mammals it remains 
permanently turned in (guinea-pig, arvicola, etc.). The 
process of the flattening out of the inner cell mass is 
shown in Fig. 505, which represents sections. In the 
mole the inner mass is nearly globular, A, and quite small 
in proportion to the whole vesicle. It soon becomes lens- 


Blastoderm, 
Blastoderm, 


shaped, B, and next separated into three layers, C, the 
outermost of which disappears; the middle layer becomes 
the ectoderm of the embryo; the innermost, part of the 
entoderm. These changes are discussed in the article 
Fetus. For the present it must be said that we have no: 
clear notions as to the passage of the segmented mam- 
malian ovum into the embryo, because we do not know 
yet either the history of the segmentation cavity nor the 
origin of the entodermic cavity. 

Concuiusions.—The blastoderm of (probably all) verte- 
brates passes through two stages: the primary blastoderm 
consists of ectoderm only, which is separated, except at 
its edges, from the yolk by the segmentation cavity; 
the secondary blastoderm is constituted by portions of the 
three primary germ layers, which overlie a second cavity 
Ys 












Fic. 506.—Egg of Axolotl, Longitudinal Section. (After Bellonci.) 
Bl, Primitive blastoderm; Pr, accumulation of cells, showing the 
commencement of the secondary blastoderm; this accumulation 
corresponds to the primitive streak of birds; bl, blastopore and 
commencement of the entodermic cavity. 


belonging to the entoderm and lying behind and separated 
from the segmentation cavity; the secondary blastoderm 
is the commencement of the embryo. 

The history of the changes in the secondary blasto- 
derm is given under Fetus. We will note here only the 
nature of the first step, which is an accumulation of cells, 
appearing at the posterior end of the blastoderm, and 
which is known in the higher vertebrates by the name 
of the primitive streak. It is almost the first step toward 
the addition of inner layers to the ectoderm or primary 
blastoderm, and it remains recognizable for a consider- 
able period at the hind region of the blastoderm or germ- 
inal area. Charles Sedgwick Minot. 


LITERATURE. a 


The general works of K6lliker and Balfour. 

Balfour and Leighton: A Renewed Study on the Germinal Layers of 
the Chick. Quart. Journ. of Microsc. Sci., 1883. 

Bellonci, G.: Blastoporo e Linea primitiva dei Vertebrati. 
Accad. Lineei, Roma, 3d ser., t. xix. (2 Marzo, 1884). 

Beneden, Ed. Van: La formation des feuillets chez le lapin. Arch. 
Biologie, i., 1880. 

Braun : Die Entwickelung des Wellenpapageies. Semper’s Arbeiten, v. 

Dansky u. Kostenitsch: Ueber die Entwickelung der Keimblatter. 
Mém. Acad. St. Petersburg, xxvii., article 13, 1880. 

Disse, J.: Die Entwickelung des mittleren Keimblattes in Hiihnerei. 
Arch. mikrosk. Anat., xv., 68. 

Duval, Matthias: De laformation du blastoderme dans l’ceuf d’oiseau, 
Ann. Sci. Nat. Zool., xviii., 1884, article 1, pp. 208, pl. i-y. 

Goette, Alex. : Entwickelungsgeschichte der Unke. 

Heape, Walter: Development of the Mole. Quart. Journ. of Microsc. 
Sci., 1883. (Reprinted in Sedgwick’s Studies, ii., 29.) 

Hensen, Victor: Beobachtungen ueber die Befruchtung und Entwicke- 
lung des Kaninchens und Meerschweinchens. Zeitschr. Anat. En- 
twickelungsges., 1875-76. 

Hertwig, Oskar: Die Entwickelung des mittleren Keimblattes der 
Wirhelthiere Jenaische Zeitschr. Nat. Wiss., 1881, 1882. 

His, W.: Untersuchungen ueber die erste Anlage des Wirkelthierleibes, 
Leipsic, 1868. 

His, W.: Neue Untersuchungen ueber die Bildung des Huhnerembryo. 
Arch. fiir anat. Physiol., Anat. Abth., 1877, 112-187, Taf. v.-vi. 

Hubrecht, A. A. W.: The Development of the Germinal Layers in 
Sorex ee Quart. Journ. of Microsc. Sci., xxxi 62, pl. 
XXXVi.-xlii. 


Mem.. 


3 


Blastopore, 


Misgharonianne REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Kupffer, O. : Sitzber. Akad. Miinchen, 1882. ; ing of a tube passing through the primitive streak, or 

xe : ay be ae erste pe ttees o 3 Kaninchens. Sitzber. | the thick mass of cells at the posterior end of the blasto- 
aturforsch. Ges., Leipsic, 1875. ts 

Robinson, A.: Observations upon the Development of the Segmenta- | Germ (or later embryo). Now, if from any cause the 


tion Cayity, etc., in Mammals. Quart. Journ. of Microse. Sci. | walls of the tube grew together, the lumen would dis- 
xxxiii., 869-455, pl. xxiii.-xxvii. 

Salensky, W.: Embryology of Accipenser (Russian). 

Sarazin, C. F.: Reifung und Furchung des Reptilieneier. Semper’s 
Arbeiten, 1883, p. 159. 

Schafer, E. A.: Description of a Mammalian Ovum in an Early Con- 
dition of Development. Proc. Roy. Soc. London, 1876. 

Scott and Osborn: On Some Points in the Early Development of the 
Common Newt. Quart. Journ. of Microsc. Sci., xix. 

Scott, W. B.: Embryology of Petromyzon. 

Strahl, Hugo: Beitrige zur Entwickelungsges. von Lacerta Agilis. 
Arch. f, anat. Physiol., Anat. Abth., 1882. (Cf. also 1883, 1884.) 





BLASTOPORE.—In the lower vertebrates, notably in 
the Elasmobranchiata, Ganoidea, Dipnoe, and Amphibia, 
there appears during the formation of the entodermic 
cavity a small opening at the posterior edge of the blas- 
toderm. This opening leads directly into the entodermic 
cavity, and is known as the blastopore. It persists dur- 
ing early embryonic life. This opening is best seen ina 
longitudinal section (Fig. 507). The blastoporic opening 
leads into a descending canal, which directly communi- 
cates with the posterior, or caudal, end of the entodermic 
space, which lies between the yolk, Vz, and the dorsal | F1G. 507.—Longitudinal Section of an Ovum of the Sturgeon After the 





entoderm, Ent. The appearances of the ova of the | Germ; nt, entoderm: Bl, blastopore + At, diverticulum of the 

lamprey, or of any amphibian, at a corresponding stage, digestive tract; Vi, yolk. (After Salensky.) 

are closely similar to those of Fig. 507. 
The blastopore is also found in reptiles, birds, and | appear, and the primitive streak would become a solid 

mammals, but the recognition of its occurrence in these | mass of cells. This is the condition we actually find in 

forms was long hindered by the fact that it doesnot exist | the mammals (Fig. 508, A). Now, since the primitive 

at first asa canal. The blastopore is the external open- | streak really is morphologically the thick wall of the 

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F1G. 508.—Formation of the Blastopore in Lacerta Muralis. (After Weldon.) A, B, C, longitudinal sections of three successive stages in the 
development of the blastoderm, made after its removal from the yolk; D, transverse section of the posterior part of a blastopore a little 


younger than C. Ece,ectoderm; Hn, entoderm; Pr, primitive streak; bl, blastopore ; Ch, notochord ; mes, mesoderm; Som, somatopleure ; 
Spl, splanchnopleure. ; 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blastopore. 
Blepharospasm, 








blastopore, the homologies are not altered by the tem- 
porary disappearance of the canal, especially as the canal 
reappears as such in later stages, at first as a pit upon 
the external surface (Fig. 508, B, 07); this pit soon be- 
comes a complete perforation (Fig. 508, C, 0/7). 

It is a remarkable but very common phenomenon in 
vertebrate development to encounter tubular organs 
existing temporarily as solid cell masses in the embryo. 
This occurs with most glands, the Wolffian duct, the 
vagina of man, the urethra in the penis, the nares, the 
meatus auditorius externus, the posterior part of the 
medullary canal in the axolotl, the intestines of teleosts, 
etc. There is, therefore, nothing specially remarkable in 
the temporary absence of the blastoporic lumen, and the 
want of an opening is not a valid argument against the 
homology of the amniote blastopore with that of the 
amphibia and similar forms. 

(For the relation of blastopore to the nervous system, 
see Newrenteric Canal.) 

The blastopore usually disappears by closure, and a 
new posterior opening, the true or permanent anus, is 
formed. Miss Johnson states that in the Triton the anus 
is the persistent blastopore, an observation of great theo- 
retical importance. Charles Sedgwick Minot. 


LITERATURE. 


The literature of the blastopore is very extensive. 
The following list cites only a few of the most important 
articles; those by Balfourand Bellonci may be signalized 
as of especial value. 

Balfour, F. M.: Comparative Embryology, vol. ii., chap. xi. 

Bellonci, Guiseppe: Blastoporo e Linea primitiva dei Vertebrati. Me- 
moire Accad. Lineei, Roma, ser. 3, vol. xix. 

His, W.: Ueber die Bildung der Haifisch-embryonen. Zeitschr. f. anat. 
Entw-ges., ii. 

Kupffer, C.: Die Gastrulation an den mesoblastischen Eiern der Wir- 
belthiere und die Bedeutung des Primitiy-streifen. Arch. f. anat. 
Physiol., Anat. Abth., 1882. : 

ts A.: Primitiy-streifen und Neurula der Wirbelthiere, Leipsic, 

‘ 


Scott and Osborne: On the Early Development of the Common Newt. 
Quart. Journ. of Microsc. Sci., xix. 

Strahl, H.: Ueber die Entwickelung des Canalis myelentericus und der 
Allantois der Eidechse. Arch. f. anat. Physiol., Anat. Abth., 1882. 
Weldon, W. F. R.: Note on the Early Development of Lacerta Muralis. 
ate J oB8L) of Microsc. Sci. (Reprinted from Sedgwick’s Studies, 

At Decks 5 


BLENNOSTASINE is a compound of unstated formula 
derived from one of the cinchona alkaloids. It is seda- 
tive to the central nervous system and has given much 
relief in hay fever, coryza, laryngitis, etc. It is not ap- 
plied locally, but is given by the mouth in doses of gr. i. 
to iv. frequently repeated. W. A. Bastedo. 


BLEPHAROSPASM. — DerrnitTion. —Spasmodic con- 
traction of the orbicularis palpebrarum muscle, tonic or 
clonic in character, evidenced by occlusion of the palpe- 
bral fissure when the entire muscle is affected, or by 
fibrillary contraction of a limited portion. 

It occurs generally as a symptomatic affection, al- 
though it can exist as a disease by itself. 

Its causes may be divided into three groups: first, 
affections of the eye and ear; second, affections of the 
nervous system; third, general diseases. The first group 
includes foreign bodies in the conjunctiva or cornea, in- 
flammations of the conjunctiva, cornea, iris and ciliary 
body, sympathetic irritation, ectropion, entropion, trich- 
iasis, heterophoria, ametropia, foreign bodies in the ex- 
ternal auditory canal, and otitis media. 

The second group comprises affections of the facial and 
trigeminal nerves, hysteria, and chorea. 

The third group includes as causes, chlorosis, perni- 
cious anzemia, malaria, rheumatism, and influenza. 

Symptoms.—It occurs in the form of a tonic or of a 
clonic spasm. In the tonic form the palpebral fissure is 
tightly closed, great force often being required to open 
it. It is an excessive action of the normal reflex mechan- 
ism, often persisting as a troublesome affliction in excess 
of its cause. It may be intermittent in character, com- 
ing on suddenly, and frequently placing the patient in 


great danger, when it is binocular; or continuous, some- 
times to sucha degree as to cause a temporary amaurosis. 
The latter condition is usually observed in children of 
three or four years of age, after relief from a very pro- 
tracted blepharospasm. They are unable to see large 
objects, and orientation is practically impossible. The 
pupillary reflex will be found active, strong light pain- 
ful, and ophthalmoscopic examination negative. The 
amaurosis is believed to be cortical in nature (Leber, 
Uthoff), owing to the absence of peripheral stimula- 
tion. Samelsohn has considered it to be analogous 
to the suppression of the image in alternating strabis- 
mus. Others believe it to be due to the disturbance 
of the intra-ocular circulation by the prolonged press- 
ure of the eyelids, in support of which belief they cite 
individual cases which have exhibited choroidal and re- 
tinal changes. 

In clonic blepharospasm there are intermittent con- 
tractions of the entire muscle, manifested by constant 
opening and closing of the palpebral fissure, or by con- 
tractions of a limited number of fibres, as evidenced by a 
slight twitching of the lids, more often of the lower lid. 
While the spasm may be intermittent at the outset, its 
continuance engenders its becoming constant and _ per- 
manent, and frequently the spasmodic impulse extends 
to neighboring muscles, 

CausEs.—Tonic spasm is particularly induced by 
foreign bodies in the conjunctiva and cornea, and by 
abrasions or inflammations of the conjunctiva and cornea, 
the phlyctenular variety particularly giving rise to it. 
This form of inflammation, which is seen in strumous 
children, is frequently accompanied by nasal disease, 
which may cause a persistence of the spasm long after 
the conjunctival and corneal disease has disappeared. 
The intense photophobia, and the cedema of the lids, 
particularly of the upper, caused by the compression of 
the veins of the lids by the firmly contracted muscle, 
render the examination of the eye extremely difficult. 
Fissures of the commissures and spastic ectropion or en- 
tropion are induced. It is believed that the blepharo- 
spasm in keratitis is due to direct irritation of the corneal 
nerves; Iwanoff having found that the cellular infiltra- 
tion extended along the course of the corneal nerves. It 
is, however, in part voluntarily induced by the patient for 
the purpose of relieving the photophobia. The forcible 
separation of the lids is often accompanied by pain, suffi- 
cient in some cases to induce epileptiform convulsions, 
and by sneezing, reflex in character, caused by the hyper- 
wsthesia of the retina to light. The violence cf the spasm 
is by no means in direct proportion to the severity of the 
disease of the eye, slight corneal abrasions ora small for- 
eign body frequently inducing the most violent tonic 
spasm. Iritis and cyclitis are occasionally accompanied 
by blepharospasm. Donders speaks of it occurring as a 
sympathetic neurosis in cases of irido-cyclitis. Rampol- 
di reports cases that were caused by the presence of for- 
eign bodies in the external auditory canal, Ziem a case 
following syringing of the cavity of the tympanum, and 
Berger cases accompanying suppuration of the sinuses 
adjacent to the orbit. 

Clonic blepharospasm is frequently observed in young 
children on their commencement of school life, either as 
a decided complete contraction of the muscle, or in the 
form of fibrillary twitchings, often difficult to discover 
on close inspection, though extremely annoying. In the 
first instance it is often a manifestation of commencing 
chorea, the children presenting a marked anemia. The 
fibrillary form is generally due to uncorrected errors of 
refraction. Adults presenting heterophoria and ametro- 
pia, particularly hypermetropic astigmatism, are prone 
to this variety. 

Affections of the facial nerve through traumatism or 
cerebral lesions may give rise to blepharospasm, though 
it is more often a reflex phenomenon due to a local or 
distal irritation of one of the branches of the trigeminus. 
Supra- and infra-orbital neuralgia, caries of the teeth or 
maxille, ulcerations of the tongue, mouth, and palate, 
and chronic affections of the lachrymal canal may be 


: 5 


Blindness. 
Blindness, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





cited as causes of such irritation. Saemisch has men- 
tioned cases which were caused by the imprisonment of 
sensitive nerve filaments in cicatrices. In neuralgia of 
the different branches of the fifth nerve sensitive points 
can be found, pressure upon which will often arrest the 
spasm. ‘These spots may be situated at the point of exit 
of the nerves from their foramina, or may be located 
some distance from the affected muscle, as at the back of 
the neck, over the spines of the vertebre. Romberg 
found that pressure upon the facial nerve at its exit from 
the stylo-mastoid foramen would arrest the spasm in 
some cases. The patient often discovers where these 
pressure points are situated, and will avail himself of 
this knowledge to obtain relief. Pressure upon certain 
parts of the body has been known to bring on blepharo- 
spasm, as in the case reported by Zehender, in which 
pressure in the region of the first cervical vertebra in- 
duced it. Cases like this one are undoubtedly of hys- 
terical origin. Indeed, not a few cases of blepharospasm 
are of hysterical nature. The spasm may be caused 
primarily, in these subjects, by traumatism, by a carious 
tooth, or by a foreign body in the conjunctiva, cornea, 
auditory canal, etc. Its continuation after removal of 
the cause and disappearance of all irritation would indi- 
cate its hysterical character. It is usually binocular, 
tonic in character, and rarely preceded by clonic move- 
ments. Its disappearance is as sudden as its invasion, 
and its duration varies greatly. Dr. Charles Laségue 
cites a case of monocular hysterical blepharospasm, 
caused by traumatism, which lasted four months, while 
the immediate effects of the traumatism lasted but twenty- 
four hours. A constant twitching of the upper lids re- 
peated about twice a second is characteristic of hysteria, 
and is believed by Knies to be due, like nystagmus, to a 
weakening of the motor cortical innervation of the mus- 
cles. Anesthesia of the palpebral skin may be noticed 
as an accompanying symptom, as shown by Gilles de la 
Tourette. In anzemic and nervous children blepharo- 
spasm occurs as the commencement of general chorea. 
The habit-chorea (Weir Mitchell), which commences in 
childhood, ceases after a few months or years, although 
it occasionally goes on to middle life. When it com- 
mences in middle life it is generally permanent. It is 
more common in females, following some impairment of 
the general health, fright, injury or overwork, and in 
boys, as the result of masturbation. Imitation can bring 
it on and observation increases it. Refractive errors, 
follicular conjunctivitis, and blepharitis are also found 
as frequent causes. It is oftenassociated with symptoms 
of hysteria in young women, making it difficult to de- 
termine to which disease the spasm properly belongs. 
Anzemic women occasionally present a clonic monocular 
spasm, due to the general debility induced by uterine 
and ovarian disease. 

Proenosis.—The prognosis in blepharospasm is un- 
certain except where it is due to hysteria, traumatism, 
conjunctival or corneal disease. Prolonged contraction 
may involve serious consequences to the eye, through 
the pressure of the lids causing definite lesions of the 
choroid or retina. 

TREATMENT.—The treatment of blepharospasm re- 
solves itself into treatment of its causative conditions. 
A careful search should be made for foreign bodies in the 
conjunctiva, cornea, nose, andear. If conjunctivitis and 
keratitis, particularly of the phlyctenular variety, are 
present, they should be carefully treated. Cocaine, 
while often of value in relieving blepharospasm and 
rendering the examination of the eye easier, should be 
avoided in cases in which there are corneal ulcerations; 
holocain should be used instead, in one-per-cent. solu- 
tion. The dilatation of the pupil with consequent in- 
crease of the photophobia, owing to the hyperesthesia of 
the retina and the softening of the corneal epithelium 
following the use of the cocaine, are avoided by the sub- 
stitution of the holocain, the latter being primarily an 
anesthetic and secondarily an antiseptic. In cases in 
which the spasm persists after the conjunctival and cor- 
neal disease has been cured, forcible opening of the pal- 


6 


pebral fissure, during chloroformization, with canthotomy 
if necessary, and the dropping of iced water on the ex- 
posed eyeball at half-hour intervals, will usually suffice 
to produce a cure. These children should not be allowed 
to remain in the dark, nor should dark glasses be given. 
Fissures of the canthi may be touched with a crystal of 
sulphate of copper or with nitrate of silver, and the ac- 
companying nasal disease, when present, should be 
treated. In cases in which eserin is seemingly indicated 
it may be found that the spasm is increased by its use, 
eserin having been known to cause violent blepharospasm. 
De Wecker recommends its use as a curative agent, be- 
lieving that it diminishes the tendency to reflex trans- 
missions. Errors of refraction must be corrected under 
atropinization, and muscular errors should be carefully 
remedied. In cases due to irritation of some branch of 
the fifth nerve, careful search must be made for pressure 
points. Hypodermic injections of morphine, in doses of 
from gr. 7 to 4, may be made at these points. Conium, 
in the form of the fluid extract, may be given in doses 
of ten drops, from three to six times daily, until the 
physiological effects of the drug are shown. The extract 
of conium may at the same time be used externally in the 
form of an ointment. Gelsemium may be found of bene- 
fit in the cases of true tic doloureux. Galvanism, used 
after the method of Remak, the negative pole being ap- 
plied over the muscle and the positive over the fifth 
cervical vertebra, is sometimes efficacious. 

The careful examination of the mouth and teeth by 
a competent dentist should always be insisted on, the 
patient often being unaware of the presence of dental 
or buccal trouble. Other remedies having failed, and 
pressure upon sensitive points having been found to 
give relief, division of the offending nerve may be prac- 
tised. This operation was first performed by von Graefe 
in a case following the lodgment of a foreign body 
in the folds of the conjunctiva. The nerve divided was 
the supra-orbital, and success followed the operation. 
The supra- and infra-orbital nerves should be divided at 
their exit from their respective foramina, the temporal 
branch of the malar in the temporal fossa, and the in- 
ferior dental in the mouth. The nerve should be com- 
pletely cut through; in fact, some authorities think that 
a better result is obtainable by the excision of 1 to 2 cm. 
of the nerve. The relief given by section of the nerves 
is not always permanent, the spasm after a short period 
returning and being accompanied by the development of 
new pressure points. This is particularly true in senile 
blepharospasm. Excision of a portion of the nerve is 
productive of more lasting relief, although it gives rise 
to a prolonged anzesthesia of the region supplied by the 
nerve. Stretching of the nerves has been advocated by 
Panas. Dieffenbach practised subcutaneous division of 
the orbicularis muscle, but without much success. 

Treatment of hysterical blepharospasm is decidedly 
unsatisfactory. Tonics, sea bathing, the use of the ap- 
pliance devised by Mathewson and used with success by 
Strawbridge, and the application of the Charcot magnet 
with suggestion, may be tried. The device of Mathew- 
son consists of a rubber band fastened to the upper lid 
below, and to the forehead above. The constant traction 
eventually overcomes the resistance offered by the muscle. 
Arsenic given internally, or hypodermically, as suggested 
by Weir Mitchell, appears to be the most efficacious 
remedy in the cases of habit-chorea. 

C. Cole Bradley. 


BLINDNESS.—(Lat., Cecitas; Ger., Blindheit; Fr., 
Aveuglement.) Amaurosis is sometimes used synony- 
mously with blindness, and in selected cases—the cause of 
which is obscure, or is located in the nervous apparatus 
—this is admissible, with the same limitations that apply 
to blindness. Blindness is a misleading term, being a 
symptom only, and should not be used in scientific 
language (except in a generic sense) without a qualify- 
ing phrase which describes the condition upon which it 
depends—as blindness from optic-nerve atrophy. <A 
strict application of the term would include only such 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blindness, 
Blindness, 





eyes as are not possessed of light perception. It is, how- 
ever, usually understood to embrace all eyes incapable of 
recognizing the outline or shape of objects; and prac- 
tically it should include all eyes with vision less than 
xh 2.é., all eyes which are able to count fingers at only 
one foot, for such individuals have to be Jed around. 

Economic ErFects oF BLINDNEss.—Blindness is a mis- 
fortune not only to the individual, but to a community, 
for a blind person has to be supported, and, too, he is not 
a producer. To illustrate the importance of these two 
factors, let us apply them to the United States, which, 
according to the census of 1890, had 50,411 blind in- 
habitants. The cost of supporting one blind person in an 
economical manner may be placed at $132 annually ($2 
per week for board, $28 for clothing), so that the cost to 
this country for caring for its blind is $6,654,252 annu- 
ally. The producing capacity of a man at $1.20 for each 
working day and of a woman at $0.40 a day would be 
$404 and $256 respectively annually, which would give 
$17,024,480 as the annual earning capacity lost to this 
country by its blind—cost and loss together amounting 
to $23,678,732. 

The GEOGRAPHICAL DISTRIBUTION of blindness as 
shown in Table I., compiled by Mayr, of Munich, in 
1877, has been subject to slight changes by later statistics, 
so far as the proportion of the blind to the population is 
concerned. 














TABLE I. 
Total Number 
Country. Population.| number of | of blind in 

blind. 10,000. 
England and Ireland 31,159 9.85 
Denmark 1,465 7.86 
Norway 2,320 13.63 
Sweden 3,359 8.06 
Finland 3,891 22.46 
PANS ERAS a claintotaisi® ve 9,070 aoe ovsiare as 11,329 51D0 
Hungary 18,523 12.01 
Switzerland 2,032 7.61 
Netherlands 1,593 4.46 
Belgium 3,675 8.11 
PANIC reat einen see's ewis’ote vs 30,214 8.37 
OTSLATE eens Cnishars a tetesis'6 516% c.0 10. 10-016) 15,658,531 17,379 11.26 
WHaLYseneeeiae< © A, aS CORB ROOCE Lai 26,413,132 26,826 10.16 
United States of America ...... 38,558,371 20,320 5.27 
Argentine Republic............ 1,748,199 3,529 20.24 

British colonies in— 
INOLUNTAMNETICA cs sie ccs cca cece 583,535 361 6.19 
IV ORUATTICIOS varnice-cis srelercislouisis e's 905,730 2,030 22.41 
PATCH nea Cac cacle cis'sie oes 330,460 416 12.53 
PAISDI HLH citer, sre c=3'.e.06'0: os'sie «vie 305,730 116 3.79 
MG ORUGAID Yi etstele aia vc sis's's seis sie salsa. 39,862,183 85,048 8.79 
PODS Weistetelsteanterae sveve.vveiernere ot 248,148,446 | 215,585 8.74 





The population of the United States in the above table 
is taken from the census of 1870. The census for 1880 
shows a population of 50,155,788; number of blind, 
48,928; number of blind in ten thousand, 9.73. <A strik- 
ing difference is the great increase of blindness in the 
United States in the subsequent decade, as is shown in 
the figures for 1880. Various causes must be considered 
in determining the reasons for this increase in blindness, 
the most important of which are the following: 1. The 
census returns were more complete for the last census 
than they have been heretofore. 2. Injuries more or less 
remote from the eye, sustained during the late war, con- 
tinue to swell the ranks of the blind, and with pensions 
in view a considerable number make the ciaim unjustly. 
8. The foreign element in our population adds to the 
percentage of blind; for natives of the United States 
furnish 9.13 blind to 10,000 inhabitants, while 13.45 blind 
are found in the same number of our foreign population. 
4, The increase of manufacturing interest and its spread 
to localities remote from competent professional care. 
5. The increase of those competitive trades that bring 
bodily and mental strain, which are liable to produce 
changes in the nervous system, in which the eyes partici- 
pate. 

The last decade—census for 1890—shows a gratifying 
reduction in the proportion of blindness: population, 


62,622,250; blind, 50,411; number of blind in 10,000, 8.1; 
number of natives blind in 10,000, 7.4; number of for- 
eigners blind in 10,000, 10.1. This improvement is due 
to two causes: first, the proportion furnished by the late 
war has been depleted by death, and the proportion of 
foreigners has been lessened by laws restricting emigra- 
tion; second, people are being educated to seek proper 
relief for diseases and injuries of the eyes. 

The latest foreign statistics, as obtained from Eulen- 
burg’s Real-Eneyclopddie, p. 502 (1894), show the num- 
ber of blind to 100,000 inhabitants of the countries re- 
ferred to, as follows: 


TABLE II. 
Hollandisewess cine 44> PrUussifivesgerisn: « SS ENOLWAY, <seese wees = 134 
Canada .....s.000- 2 \ MEI CO vere stereiers sje OF | SPAIN cass. cits a asi 148 
POUR s s uss 01670) 70 | Germany........ 85 | Caucasia ......... 150 
GAT Y cr treate tte clorcie 75 | England .. 88 | Argentina......... 202 
Switzerland....... (C) PANIES, Sk caudse 94 | European Russia.. 210 
Denmark... +++ 79 | United States.... 97 | Finland............ 211 
Sweden....... 80 | Ireland.......... IPD esate Gece anguac 219 
BO] LIN cieeieiers clas Sl || Rungaryies. at. 2S ICEIAN Gs facie vp iether 340 


The statistics in Prussia, according to Guttstadt, show 
that in 1871 there were 22,977 blind—7.e., 9.5 per 10,000 
—whilst in 1880 there were 22,678, or 8.2 to 10,000. 
This shows a diminution of 1.3 per 10,000, although the 
population had increased 10.6 per cent. In Saxony the 
figures declined from 7.9 to 7.1. 

The latest blind census in Austria, on December 31, 
1890, showed 81 blind to 100,000, there being 907 females 
to 1,000 males. 

The CLIMATIC INFLUENCE, as illustrated in Europe, 
is shown in Table III., from Magnus, of Breslau, 1883. 


TABLE III. 
Between latitudes 30° and 40° the number of blind in 10,000 is 11.09 
oe oe 40 oe 50 oe oe oe “ce oe i oe 8.63 
“ be 50 be 60 oe Ld + iat be 10,000 oe 7.55 
oe oe 60 os 70 oe oe ee “ ee 10,000 oe 18,04 


It is true also of the United States that the proportion 
of blindness gradually increases from the north to the 
south. The proportion of blindness is greatest in the 
Eastern portion of the United States, less in the middle, 
and least in the Western. - 

And for the Western continent the same author gives 
Table IV. 


TABLE IV. 5 
Between latitudes 10° and 20° the number of blind in 10,000 is 22.41 
i es 20 ‘ 30 (vacant). 
e a 30 ‘ 40 the number of blind in 10,000 is 8.96 
oe be 40 oe 50 be ee be +e oe 10,000 be 5.36 


The hot southern latitudes are injurious, because of 
their dry, sandy interiors (in which the glare and the 
prevalence of high winds, accompanied by clouds of a 
fine sandy dust, exert an irritating influence upon the 
eyes), and their moist, swampy, miasmatic borders and 
water-courses. The cold northern latitudes are injur- 
ious, because confinement in badly ventilated quarters 
is a necessary concomitant; and, the days being short 
during the long winters, the work of the eyes is crowded 
into a limited time, or is prolonged in insufficiently lighted 
rooms, where work becomes injurious. The most tem- 
perate zone presents the least number of these objec- 
tions, hence we find here the smallest percentage of 
blindness. There are also geological causes which in- 
fluence the percentage of blindness; for instance, it is 
more frequent on one side of the Jura Mountains than 
on the other, 

It has been asserted that blindness was more frequent 
in cities than in rural districts, and this, aside from such 
causes as lead to blindness from injuries, trades, etc. ; but 
investigations in Russia, and by Howe in this country, 
would seem to refute that claim under the present ex- 
isting circumstances. Investigation of the number of 
blind in cities of the United States containing fifty 
thousand and upward inhabitants showed that the 
proportion was thirty-three per cent. less than in 
the country; and still further investigation by Howe 
seemed to show that this improvement was due to the 


7 


Blindness, 
Blindness, 





more general use of preventive measures against oph- 
thalmia neonatorum in cities than by the country prac- 
titioners. 

That there are RACE PECULIARITIES is shown by the 
fact that out of 10,000 Christians there are only 9.4 blind, 
while the same number of Jews furnishes 13.3 blind. 
One reason for this large percentage of blindness in 
Jews is the great frequency with which they suffer 
from glaucoma. It is said that the sclera is more dense 
and less elastic in people of this race than in others, and 
that this condition favors the development of glaucoma. 
It has been further claimed that dark eyesare more prone 
to amaurotic affections than light ones, and that Jews, 
who usually have dark eyes, are therefore more liable to 
suffer from blindness. This, however, is not borne out 
by facts, for dark races are usually possessed of deeply 
pigmented eyes, yet the percentage of blindness is not 
great with them. It should be remembered, however, 
that the so-called amaurotic affections constitute but a 
small proportion of the causes of blindness; and the fact 
should not be overlooked that overcrowding and bad 
ventilation are often found in the class to which the ma- 
jority of Jews belong—and such surroundings are prolific 
sources of external inflammations of the eye. Consan- 
guinity in marriage is another cause which renders the 
Jewish race more prone to blindness than others. They, 
too, almost invariably live in cities, where the percentage 
of blindness has heretofore been higher than in rural dis- 
tricts. The number of blind negroes in the United 
States in 1890 was 7,160 out of a population of 7,470,040; 
or 9.5 to 10,000. Lack of care for diseases and injuries 
is the probable cause of much blindness with them, 
rather than any other racial difference. 

INFLUENCE OF SEx.—The United States has a popu- 
lation of 32,067,880 males and 30,554,370 females, which 
gives a preponderance of 1,513,510 in favor of males. 
The number of blind males is 27,988, and of females 22, - 
428, which gives a preponderance of 5,555 in favor of the 
male blind. The number of blind in 10,000 males is 8.7 
and in the same number of females 7.8. This difference 
is a slight one, and can be easily accounted for by the 
accidents arising from exposure of the eyes to the injuri- 
ous influences of the trades followed by men. An inter- 
esting fact bearing upon this point is the comparative 
diminution in the percentage of blindness in males 
after they reach an age which recalls them from pur- 
suits that endanger the eyes to surroundings more 
nearly like those of females. Table V., prepared by 
Magnus from the Prussian census, illustrates this con- 
dition most aptly. 





























TABLE V. 
NUMBER NUMBER 
i OF BLIND, 1871. OF BLIND, 1880. 
ge. 
Males Females. Males. | Females. 
Under 10 years........... 664 558 572 488 
10 to:20 years\- (ner ee oles 1,113 845 992 823 
20:10. D0) Years’. wacecmee sey 2,572 3,336 3,565 2,989 
QOyer 0 Years =. <ssieene ss 5,752 7,100 6,148 6,975 


See in this connection Table X. for the causes which 
produce blindness at different ages. 





















TABLE VI. 
» 
Percentage of | Percentage | Number 
Age. blind between of of blind in 
the ages given. | population. 10,000. 
Itor LO yearsyaccn sims 3.7 24.9 sre 

TOMO 20) VOAVS aaetieals ace 4.6 19.9 2.36 
20 to) 50) Years: wereciens sees * 9.8 16.4 3.20 
380 to 40 years ..-...... A Bil 13.0 3.81 
40 to 50 years 15.2 ania 6.84 
50 to 60 years 17.3 7.5 11.50 
60 to 70 years TAS 4.7 26.23 
70 to 80 years 13.5 1.8 92.44 
80 to 9) years 4.3 3) 7.00 
90 to 100 years ol -02 373.20 











Ca 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Table VI. gives the percentage of blind of different 
ages in column 2, and the percentage of population at 
different ages in column 3 (Katz), while column 4, which 
has been adapted from Meyr’s table, shows the number 
of blind in 10,000 at different ages. 

This table, which is a very interesting and instructive 
one, deserves attention for its own merits; yet it becomes 
more instructive when considered in connection with 
Table X., which gives the causes that produce blindness 
at different ages. 

The following table from Eulenburg’s Real-Encyelo- 
padie, p. 505 (1894), shows the percentage of blindness at 
different ages in the countries referred to, as follows: 














TABLE VII. 
aa .|Se ci 3 g Sy 
S83 \8Scaq| 48 3 5 238 
Ages. = ES BS aa| a 3 =I ‘bo Ss 
bof ja” Al eg | 25 | goes 
tif ee 145 | 161 | 1.70| 069 | 047 | 058 
Sis ll see 2°63 | 2:30 | 2391 1.00 "79 | 1.66 
lito ine ee. 242 | 323 | 321 | (98 | 160 | 2:75 
16'to Mona Ae 373 | 3.76 | 430] 1:92 | 187 | 3.38 
Pl teak ee 440 | 512 | 17.00 | 1.98 | 319 | 3.30 
Bo 40. Aces 641 | 781 | 1252 | 295 | BBL | 4a 
a1 ts BOs 9.90 | 10.95 | 12631 | 431 | 1411 | 6.55 
Over stn 33.18 | 37.39 | 103.49 | 16.59 | 25.85 | 23:73 
Not stated........ 50.82 | 13.27 | 19.31 | 12:76 | .... | 13.56 











INFLUENCE OF OccuPATION.—The causes of blindness 
incidental to occupation may be divided into two classes, 
viz., traumatic and non-traumatic. 

Traumatic.—Under this head are included such oc- 
cupationsas necessitate exposure of the eyes to the direct 
influence of injurious agents from without, which result 
from the work performed—as machinists, who are con- 
stantly exposed to flying bits of metal, which often pro- 
duce injury of the eye and blindness; and the same is 
true of blacksmiths, locksmiths, stone-cutters, and miners. 
The last named are also exposed to the dangers of pre- 
mature or careless explosions. Cases of monocular blind- 
ness almost invariably arise from the causes just con- 
sidered. 

Cohn found 5385 men with 554 blind eyes, and 241 
women with 446 blind eyes. Preference is shown for 
neither eye. The United States census reports for 1890 
show 98,988 cases of monocular blindness—or 15.1 to 
10,000. The males show 21.7 to 10,000; females, 8.3 to 
10,000. The greater frequency of binocular blindness 
in females is another argument in favor of the accidental 
occurrence of blindness from the injurious trades fol- 
lowed by men. 

Non-traumatic.—Under this head are included such 
occupations as produce blindness indirectly—as myopia, 
from over-use of the eyes. Professional men, whose 
duties necessitate much study; and others, who, from 
necessity or preference, do much reading, or much fine 
work, which requires close and long-continued use of the 
eyes, are liable to suffer from myopia and the train of 
symptoms which in this disease lead to blindness. Work- 
ers in lead are liable to suffer from neuro-retinitis or 
atrophy of the optic nerves; and workers in India rubber 
are exposed to the same dangers, from sulphide of car- 
bon. It is claimed that optic-nerve atrophy sometimes 
occurs in workers who are exposed to the fumes of 
tobacco or of alcohol. Soldiers in crowded barracks 
are apt to suffer from conjunctival diseases, and the 
exposure to wind, dust, glare, and inclemencies of 
weather, when marching, may also cause the same 
trouble. Sailors who are constantly exposed to the 
vicissitudes of weather are liable to suffer from ‘con- 
junctival and other forms of eye disease, and their 
crowded quarters and often meagre fare are also con- 
ducive to eye affections. 

CAUSES OF BLINDNESS.—Table VIII. gives an anatom- 
ical grouping of the causes of blindness, compiled by 
Magnus from 770 cases. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blindness, 
Blindness, 








TABLE VIII. 


Per cent. 
MGOTITULICTAVE scle's sstie's ecb ein e.c ec ci6itelcicine apie vie vine’ sista ststrenie 16.364 
CUMTIEE Wsonice.cd SHO SeIOC DT OOOO DOCOOBUODODOCDEDE Enno ane ae 10.650 
PVERISUOL VG aiviceidiele tie.c.encie's eis ose BS COgn aan CSOPS Rate eterereie 22.208 
MS ESULISIR ETS aa eie oc e.oia'e ais icies Sis eivje'eleleidicrvis s/s x viethie emee rerey 16.259 
WEISEL DV Clals sig/t a reials/o%s 80:08 p a’alelsisinolerave:ols oleveleca Sartenabein 22.597 
Ram USETECRNITE Tote Oe c cuslateree vist vis otslotevsrcsateinn, Ws aisle Afeererolb by siavsierats 12.597 
Congenital deformities of the €ye.....--e..sssseeeees ee 2.468 
UTI BRATTIAOIGc 5's cc's scls vine pine eis SOS ODCRORTOL ADO ANC OrE 2.857 


Table IX., compiled by the same author from a study 
of 2,528 cases reported by various writers, gives the 
causes of blindness, arranged in pathological groups, and 
the percentage of each individual cause. 













TABLE IX. 

A.— Congenital blindness. Per cent. 
Anophthalmus and microphthalmus ..+.++-+e+seeeeeeee 1.068 
MGCAIODNUNAIINUS score sciccccesssessteses Risisiswrdialvisie's tre 435 
MGM COLAT ACK screiceetivicrs cise oie onicle.o cele scles ve vabloien A Ali) 
Choroiditis, congenital ........- ..+. vcltisrasvsisleerete oF RG 158 
Atrophy of optic nerve, congenital...........+. sees eee See OL 
Retinitis pigmentosa congenitalis......-.....ee08 ce eee 751 
Congenital blindness with retinal atrophy.......+...... 07 

= DEV OL Rate ci Rahim sissies aimerigie’e ecciere s APR oicierek 039 

by amaurosis, not specified........ peer eistiates aye 287 

B.— Acquired blindness—(a) From idiopathic diseases of 
the eye. 

Ophthalmia neonatoruM.....--.s..eeeeee eerernate Sanaating 10.87 
Trachoma and blenorrhcea of adults.....--- COAG ae ans 9.492 
Diphtheritic conjunctivitis............-++.06. ACHR GHD AL 356 
Diseases of the cornea........ Binie(elolsieinre\eleleie'y eivisiniaieie.si6ie - 8.068 
Irido-choroiditis, cyclitis, iritis ...06 2622 seeescccases 8.860 
RTeee HOI TU O DICT ic ais aie's vs.cv's'sicscie'clelais s sleieic.cl vsitiewie.s 949 
Choroiditis, Choroido-retinitis........e.seee0s eae erase LelOK 
Retinitis pigmentosa, acquired .....-......e+005 atrceleee L200 
Retinitis apoplectica.........ssee....+. ee taitesien vote 119 
INGUITOTOLINIUIS. <. >. 060s ve ssices.0 Veer OL: 
Detachment of retina ....... Rbehanttia nicicsiustes ocecee 4.140 
CH etre SS at eB ie oe a atantencc Rn ontelcor 8.97 
Idiopathic optic-nerve atrophy.........+.++6+ Facardpape 7.751 
Tumors of the eye and its surroundings.......... Sonus: Popes 
MERC ITCRA LG Mavis alreivsveiscle lic mie’s.¢ cceis | 4.9 0/0 00,0 dns eoteaiieen? (8,506 

0.— Acquired blindness—(b) Injuries. 

Direct injury of the eye...............006 piateretalen eres 4.034 
Unsuccessful operations ......... ol olesaefoteiovels: eoaial b's orale cieveie 1.938 
ALICE OF NCA foo vs es wes seOcin ed ateebeyondeeor. tt 
Traumatic sympathetic ophthalmia...... Ss SENAO IO SOES 4.509 
D.— Acquired blindness—(c) The eye disease being in 
consequence of disease of the body. 
Diseases of the eye from syphilis..............- Heche AT 
Gonorrhoeal CONJUNCTIVITIS... 6... 6. eee eee eee SOO ES OLE .910 
Scrofulous diseases of the eye.........-.. eel stetaate ineces .039 






Trido-choroiditis with meningitis . 
Atrophy of optic nerve, cerebral. 





SOL ir Sa sphagoo podon poppers 
ne Mrs ad “of neuritis following hama- 
TEMMeSIS eect esean iver 22000 
cs ae eo ‘* “after vomiting, not blood..... 07 
Atrophy from hemorrhage from piles. ...--...eeseesee., -039 
. after facial erysipelas .-.<..s.ccecsercces Soon PAE 
MEENTICL INSAMIGV ctivrcinies sisiviiercioitie.c(s\se'a vee 0151s meaetle .039 
Bs Bees ODLIGD SY aiecs trace sete 5) sreveislere Suicisie Ccerasee as 158 
* Sem CLUBONLOLV ns actiiee sire teeeretets caine Seousd. eifty 
Retinitis nephritica.......... ...... Santncoedencanonoton -ale;s" 
Diseases of the eye from typhus ...-.....- aatioue eisv ican oe 
We os Sipe MCASIES. 46 <sc0s MP eaten etre bee 
i ie Eig SCATAUNIAS bectaes aad 514 
o =e eM cad VAT IOI Ey a warkce crite os oa tole oad ee 2-216 
es Lee OX ANTENA tae) certs.e tsa v ners .285 
i My pe gee CATIPCISCASEL aa. ae aaieee se .089 
- = “childbirth and pregnancy ....-. 481 
TMPOMICATION AMAULOSIS 61... oss c cies ec eve ce vies omiaeas sr 039 
Blindness from disease of the orbit ....... .........-- 039 


Congenital anomalies constitute nearly four per cent. 
of the causes of blindness. The majority of instances 
occur as a result of consanguineous marriages, or where 
there isan hereditary tendency toward defects of the eye, 
or as a result of syphilitic manifestations in intra-uterine 
life. They are usually hopeless—cataract being the only 
cause in this category which is amenable to treatment. 
Among 34 children, the offspring of 14 marriages in 
which one or both parties were blind from birth or child- 
hood, Magnus found 8 cases, 7.¢., 23.5 per cent., of blind- 
ness or bad sight. 

The various ages at which other causes of blindness 
arise are well shown in Table X. from Magnus, which 
gives the percentage of causes at the ages when they are 
developed. 


TABLE X. 


PROPORTION OF BLINDNESS IN 10,000, AND THE 
PERCENTAGE OF ITS CAUSES AT DIFFERENT 





AGES 
Cause 
of blindness. [ap g/S PS wR gl IS HIS lS alSaieaulsa 
See eee ee eeeeiceeeice 
S3/Sg Sse SsiSsiSsissiSsississ3 
TS PS lS Bl lS Rl i i lc i 
Ophthalmia neona- 
Lorybeuncotayqone 1.99 
Trachoma ........ re OLOd teentilisaies nese 22 10.0710. 0210. 0510.12 
[hia jrwle-bageneb eta: -O1| .04'0,02/0.05 0.10/0.21/0.18} .19| .05 


Optic -nerve atro- 
phy of all forms.| .35 
Uveal tract with 
choroido - retini- 
tis, retinitis pig- 


.26| .27| .26) .380) .28] .69] .61! .47| .26) .12 





mentosa......., .2¢| .11/9.14| .13] .27| .28) .25| .29) .82) .49) .12 
Detachment of 

TOLN Ge cts ess Ol) .04) J07) 05) .20) .24) .10) 14] £29) .10 
Glaucoma ........ hnrass letoverelireraallimetselbties ema wh |p ced | SOOT DULL. OO 
Operations........ Bate viwsesal| aroreTes|'s ehatan| are ret| brave Nims Ol tae ce'| eI ereteraiineeo 
Corneal diseases ..| .27| .04) .04} .02) .13] .14] .05) .04] .14] .10 
MANDIGO citecnisis vo: wes OE ee al lin Ops eteistatliave aac ays fee, liiee (0 
MéGaSICSscascacoe: 13 
SCATIRENTIA ote) telat sie 07) .04 
TYPHUS sess eee. .O1) .04| .07] .15} .03] .03 
































The various causes of blindness, as given in Table 
IX., will now be considered individually, with such re- 
marks and deductions as are of general interest. 

(1) Ophthalinia neonatorum furnishes 10.876 per cent. 
of the blind, a larger proportion than any other single 
cause—which in itself invests it with grave importance; 
and this importance is greatly enhanced when it is con- 
sidered that blindness from this cause means an entire 
life of blindness; that this disease can be practically pre- 
vented by proper prophylactic measures; and further, 
that even after it is developed, prompt, energetic, and 
appropriate treatment will usually bring it to a success- 
ful termination without impairment of sight. The sim- 
ple measure of washing the eyes of all infants with 
warm water as soon as they are born, and instilling a few 
drops of a two-per-cent. solution of silver nitrate into the 
conjunctival sac, and subsequent attention to cleanliness, 
would almost banish this disease from our lists, as has 
been lately proven in the Maternity Hospital in Vienna 
and other similar institutions. Ophthalmia neonatorum 
is almost always caused by the irritating discharges from 
the vagina, which gain access to the eye either during 
birth, or, later, by the careless handling of the infant 
with unwashed hands which have been about the vulva. 
And it should be borne in mind that these discharges 
may produce inflammation in any conjunctiva with 
which they come in contact. Furthermore, the contagi- 
ousness of conjunctival discharges should never be over- 
looked, and this action should always be explained to 
those who have to deal with any form of conjunctivitis. 
As a rule, the contagious material from a mild form of 
conjunctivitis will produce a slight attack in another 
eye, and vice versé for virulent forms. Yet this is not 
always the case. 

(2) Trachoma and blennorrhea of adults, with a per- 
centage of 9.492, come next in order of importance. 
Trachoma occurs chiefly in the lower walks of life, where, 
from necessity or indifference, there are overcrowding, bad 
ventilation, lack of cleanliness, and a general disregard 
of the laws of hygiene. It is often seen in the poor and 
neglected of our city population, in the crowded bar- 
racks of military camps, and in the confined quarters of 
northern latitudes. Its development is favored by low 
and damp localities on the one hand, and by dry and 
sandy districts on the other. The contagiousness of the 


secretion is also an important element in the spread of 


the disease in crowded quarters. The presence of tra- 
choma, even ina mild form, renders an eye very prone 
to take on an active form of inflammation (blennorrhcea), 
which will assume epidemic character if conditions favor 
its spread, as is seen in Egyptian or military ophthalmia. 
Once developed, trachoma becomes always an obstinate, 
and often a serious, disease; hence prophylactic measures 


9 


Blindness, 
Blindness, 


against it are of the utmost importance, and they are to 
be found in a correction of the sanitary conditions re- 
ferred to. Its local treatment should be prompt, ener- 
getic, and persistent. 

Blennorrhea of adults may arise from the same con- 
ditions that produce trachoma, and it is often an out- 
growth of the latter. It is frequently—in fact usually 
—the result of contagion. The discharge from any form 
of conjunctivitis, as also leucorrheeal or other irritative 
discharges, gaining access to the eye may produce the 
disease. The observance of care and cleanliness, with 
proper regard to hygiene, would cause both of these dis- 
eases to disappear, and appropriate treatment would 
cure most cases, even after the disease has developed. 

(8) Diphtheritie Conjunctivitis.—Diphtheritic and mem- 
branous ophthalmia are sometimes caused by direct in- 
fection of the conjunctiva by diphtheritic material from 
the throat of another person, while in other cases the 
diphtheritic process creeps up the nasal duct from the 
nose, and thus reaches the lining membrane of the eye. 
But in the majority of cases of diphtheritic ophthalmia 
the disease is a local one, in which the inflammation 
takes on this special form. No doubt there is often 
something peculiar in the patient’s health, or in the state 
of his eye tissues, which givesa proclivity to this particu- 
lar pathological process. These cases are, for instance, 
seen with particular frequency after measles, and less 
commonly during or after scarlet fever, and are. more 
likely to occur in children than in adults. The existence 
of old, granular disease of the conjunctiva also gives a 
strong tendency to a diphtheritic type of inflammation, 
and the same tendency is seen sometimes ina well-marked 
degree in ophthalmia neonatorum, and in gonorrheal 
ophthalmia. 

(4) Diseases of the Cornea.—This furnishes rather a 
large contingent of blind, and it is not to be wondered at 
when we consider that transparency and regularity of 
curve of this membrane are essential to good vision. 
Keratitis, in its various forms, may leave opacity suffi- 
cient to cause blindness; and the same is true of super- 
ficial ulceration; while deeper ulceration may lead to 
prolapse of the iris, displacement or obliteration of the 
pupil, etc., and all are at times liable to be followed by 
softening of the cornea, with development of staphyloma, 
etc. Hypopyon keratitis furnishes a larger number of 
blind than all other corneal affections put together. 
Kerato-conus and kerato-globus are sometimes causes of 
blindness. 

(5) Irédo-choroiditis, Cyclitis, Iritis.—The different dis- 
eases enumerated under this heading are placed together, 
first, because they often combine; and, second, because 
the structure involved—the uveal tract—is common to 
each of the several anatomical parts designated. The 
term uveitis is often and advantageously employed to 
describe, collectively, inflammations in these parts. 
Jritis, uncomplicated, rarely causes blindness; yet it 
may do so if the pupil becomes glued down to the lens 
and the pupillary space becomes blocked with exudation 
(occlusion of pupil). Both this condition and that of 
exclusion of pupil (complete posterior synechiz) are very 
apt to be followed by secondary glaucoma. More fre- 
quently synechiz from previous inflammation cause re- 
current attacks of iritis; and the inflammatory process, 
extending to the choroid, or to the ciliary body, or to 
both, gives rise to opacities in the vitreous, and later to 
detachment of the retina, cataract, ete. The trouble 
may begin in the choroid, or, less frequently, in the 
ciliary body, and, extending to other parts or remain- 
ing in either locality, may cause blindness in the same 
way. 

(6) Choroiditis myopica (6) and detachment of the retina 
(11) will be treated of together under the head of the 
latter, both being considered as effects of myopia. 

(7) Choroiditis, Retino-choroiditis.—The choroid and 
retina are so intimately associated that it is difficult to 
have an affection of one of these structures without in- 
volvement of the other. Syphilis, acquired or inherited, 
is the usual cause; and blindness is produced by the 


10 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





formation of opacities in the vitreous and disturbance or 
destruction of the retinal elements. 

(8) Retinitis Pigmentosa, Acquired.—Though this af- 
fection may be developed at almost any period of life, 
it cannot be considered an acquired disease, for it occurs 
in particular groups of individuals who, from hereditary 
tendencies or from consanguineous marriages, show con- 
genital deficiencies in this and in other ways. Such cases 
are hopeless; and even when the disease is recognized in 
an early stage little or nothing can be accomplished in 
the way of treatment. 

(9) Retinitis Apoplectica.—The chief significance of 
this disease is the index which it furnishes of the condi- 
tion of the blood-vessels in the brain; for it is usually 
but a precursor of similar trouble within the cranium. 

(10) Neuro-retinitis, as an idiopathic affection, is al- 
most unknown. It usually occurs as an accompaniment 
of some other disease—as syphilis, Bright’s disease, in- 
tracranial disease, pregnancy, cardiac disease, etc.; but 
as these diseases are specially considered as sources of 
blindness further on, we are reduced to very narrow 
limits. It must be admitted that cases of neuro-retinitis 
are occasionally seen without apparent cause. And it is 
probable that such vague causes as prolonged exposure 
of the eyes to very bright light, with great heat, as the 
glare of a furnace, or to the reflection of the sun from 
the waters of the tropics, or from excessive use of the 
eyes by strong, artificial light, may produce the disease 
and thus lead to blindness. 

(11) Detachment of the Retina and (6) Choroiditis 
Myopica.—Myopia, the cause common to each of these 
conditions, is of great importance, and merits careful 
consideration. It may be said to be an outgrowth of 
civilization and education, and it may be taken as an 
index of the studious habits and of the close eyework 
of a people. In this present busy age of progress and 
competition, which calls for work at high pressure, and 
necessitates the forcing process as soon as school days are 
begun, there are many causes at work which serve to 
swell the ranks of myopes, and to lay the foundation for 
its future increase. The long hours of confinement in 
the schoolroom, and the lack of proper out-of-door ex- 
ercise and fresh air, tend to cultivate sedentary habits 
and to lessen the resisting power of the tissues of the 
body. The close application of the eyes at near work, 
with badly constructed desks and insufficient illumina- 
tion, which necessitate stooping over the pages and strain- 
ing the eyes, brings on congestion of the fundus of the 
eye, with thinning and bulging of the sclera at the point 
of least resistance—the posterior pole; and the develop- 
ment of myopia is the consequence. This condition, once 
produced, is increased by a continuation of the causes 
which induced it; and, in unpromising subjects, even 
the removal of these causes does not put a stop to its 
progress. 

The development and increase of myopia during school 
life are nowhere better shown than in the following table, 
taken from Fuchs and prepared by Cohn. The village 
school corresponds to our lowest grade, and then follow 
in regular sequence the higher grades, until the last or 
university course is reached: 














TABLE XI. 

Percentage Degree 

of myopia. | of myopia. 
VITA GS SCHOO; !s. viate'ssi¢.6'e'eleleia'eie(s'Sisle)siateh aisisiaters 1.4 Viagra 
Elementary SChOol.......-cccsescocee: Baer 6.7 1/og-7 
Intermediate SCHOO] ....ccsescccessecescss- 10.3 If sas 
HAG SCHOOL Rice wks setovae ote elatevernarete © arog terete) tela nt g 1/1996 
Gymnasium) (college) Faces seni scceset cle siee 26.2 / 1897 
AD UV ORS Uy ists cietee cumeie stsrelet nie ereiciet creetae teint «pein 59.0 /12 2 


It was furthermore noted that the percentage of 
myopia increased in each school from class to class. 
Among theological and medical students, whose term of 
study is prolonged beyond the ordinary university course, 
the percentage of myopia is still further increased, reach- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blindness, 
Blindness, 





‘ing in the case of theological students seventy-eight per 
cent. And in reference to confinement and indoor life 
on the one hand, and out-of-door life and exercise on the 
other, Erisman found the percentage of myopia in resi- 
dent scholars to be forty-two per cent., and in day scholars 
to be thirty-five per cent. Dor found even a greater 
-difference—thirty-three per cent. against eighteen per 
cent. 

Myopia abounds among studious people, and is almost 
unknown among the ignorant and illiterate. It is not 
congenital, yet the tendency to its development is cer- 
tainly transmitted from parent to child. The prophy- 
lactic measures against myopia are of the utmost impor- 
tance. First and foremost are: A proper amount of 
-out-of-door exercise during school life; well-ventilated 
schoolrooms, with good illumination, properly con- 
‘structed desks, so that the light will fall to best advan- 

_ tage upon the page, and avoidance of the habits of stoop- 
ing or bending the head over the work, and of holding 
objects close to the eyes. After the development of my- 
opia, much can be done for its relief by the use of atro- 
pine and the wearing of properly selected glasses. It 
‘sshould be remembered that myopia fosters sedentary and 
studious habits; and it at times becomes advisable to 
-discontinue the use of the eyes for near work altogether; 
and it not infrequently falls within the province of the 
physician to decide upon the child’s future mode of life 
and employment. 

A few cases of myopia with choroiditis occur inde- 
pendently of the causes here ascribed to it; yet they are 
so infrequent that they may be left out of consideration. 
And, too, detachment of the retina is sometimes seen in 
eyes that are not myopic; but it rarely occurs in such as 
a primary affection, and when secondary to some other 
pathological lesion, that, and not the detachment, is the 
cause of blindness. 

(12) Glaucoma.—The importance of this disease, as 
indicated by its quota of blind, is forcibly increased, 
when its usual amenability to treatment is considered. 
While a well-marked case of glaucoma presents unmis- 
takable symptoms of the disease, which it would be un- 
pardonable to overlook, there are other cases which are 
obscure and misleading. The very fact of this uncer- 
tainty should, however, put us upon our guard; and 
there are few cases indeed which would run the gaunt- 
let of careful examination and close observation. Once 
recognized, prompt and energetic treatment is indicated ; 


and there is no operation in the whole range of surgery ° 


that affords more brilliant results than does iridectomy 
in cases of acute glaucoma. Sclerotomy and eserine 
have their spheres of usefulness; and stretching the ex- 
ternal nasal nerve has recently been much lauded in the 
treatment of certain obstinate forms of glaucoma. Un- 
fortunately the more obscure cases attract but little at- 
tention until the disease is far advanced, and medical 
“advice is sought only after serious and permanent im- 
pairment of sight comes on. A more thorough knowl- 
edge of the disease and greater familiarity with its symp- 
toms by the general practitioner will not only insure its 
more prompt recognition, but will lead the laity to a 
better understanding of the affection, and cause greater 
care in the observance of eye symptoms. A few cases 
of glaucoma are strongly allied to optic-nerve atrophy, 
and these are very unfavorable. 

(13) Idiopathic optic-nerve atrophy occurs most fre- 
quently in subjects who have inherited a tendency to 
nervous disorders. It is often a precursor of spinal cord 
or of cerebral disease; and as the length of time which 
may intervene between the development of optic atrophy 
and central changes is often considerable, the diagnosis is 
usually difficult and uncertain. The disease is one of the 
most obscure that we have to deal with, and the prog- 
nosis is unfavorable. It is much more frequent in men 
than in women. : 

(14) Tumors of the Hye and its Surroundings.—Malig- 
nant diseases, as glioma of the retina, sarcoma of the 
choroid, of the ciliary body, and of the iris, and epithe- 
lioma or lupus of the conjunctiva, or of the cornea, may 


produce blindness through destruction of the globe by 
their own growth; yet their chief importance is in their 
danger to life. Cysts of the iris, if they are not re- 
moved, may cause blindness by increase in size. 

Gummata of the ciliary body and of the sclera may 
also produce blindness in the same way. Other tumors 
of the eye rarely cause blindness. Tumors arising from 
parts adjacent to the eye may produce blindness, directly 
by extension of the disease to the globe, or indirectly by 
pressure effects upon the globe or optic nerve, as is seen 
in vascular and cystic tumors of the orbit, and in tumor 
or distention of the frontal, ethmoidal, nasal, or maxillary 
sinuses. 

(15) Unelassifiable.—The percentage here given may 
be taken as a fair example of the proportion of the blind 
which present such complicated conditions as to preclude 
classification. 

(16) Direct Injury of the EHyes.—The more important 
proportion of these cases occur in individuals whose labor 
necessitates exposure of the eyes to flying bits of metal 
or stone, as machinists, workers in stone, miners, etc., 
and in those who have to deal with explosives, as in 
blasting, the manufacture of explosive materials, etc. 
The use of protective glasses, preferably of mica, which 
combines perfect transparency with considerable strength, 
is a measure that would afford much protection to the 
eyes, though it has been but little adopted by workmen 
exposed to these dangers. 

A certain number of cases occur from unavoidable and 
unforeseen accidents, and of these it is unnecessary to 
treat. 

Injuries of the eye in the German army during the 
Franco-German war (1870-71) were met with in 786 cases 
—being 0.79 per cent. of the whole number of injuries, 
and 7.8 per cent. of head injuries; and affections of vision 
after head injuries were met with in 74 cases—or 0.7 per 
cent. of head injuries. 

(17) Unsuccessful Operations.—The percentage here 
furnished certainly appears small, when it is considered 
that many eye operations are attended with considerable 
risk to the eye, even in the hands of the most accom- 
plished operators. Cataract extraction—the most im- 
portant operation in ocular surgery, and at the same 
time the most formidable—is accountable for most cases 
of blindness from operative measures. As it is per- 
formed late in life, when the process of repair is impaired 
by age and often by disease, it isto be wondered that the 
proportion of unfavorable results is not larger. 

(18) Injuries of the head produce blindness through 
lesions of the optic nerve, at or about the optic foramen. 
It is known that blows upon the head may cause frac- 
ture of the bones about the apex of the orbit, or at the 
optic foramen; and blindness ensues from injury to the 
optic nerve—immediately if the injury be severe, and 
more slowly if dependent upon secondary degenerative 
changes (atrophy). Meningitis following injuries of the 
head may cause optic neuritis or atrcphy and blindness. 
And injuries of the angular gyrus may produce blindness. 

(19) Traumatic Sympathetic Ophthalmia.—This is one 
of the most important of eye diseases, and, because of its 
insidious character and its intractable and uncertain 
course, merits the utmost care in its consideration at the 
hands of ophthalmologists, and general practitioners as 
well. Resulting, as it does, from previous mechanical 
injury which has greatly impaired or entirely destroyed 
the fellow eye, its treatment involves great responsibility. 
And as it not infrequently happens that the sympathiz- 
ing eye is ultimately left in a worse condition than the 
exciting one, advice should be well and intelligently con- 
sidered. The disease may appear within a few weeks, 
or it may not develop for years; and while its prodromes 
may extend over periods varying from weeks to months, 
it sometimes comes on unannounced, and quickly leads 
to blindness. Arising at times from wounds, apparently 
trivial, in the ciliary region, it occasionally fails to ap- 
pear after extensive injury to this, the vulnerable zone. 
Treatment of the disease after it has developed is of course 
important, and while it is sometimes unsatisfactory, it is 


11 


Blindness, 
Blindness, 


usually productive of great good. The measure above 
all others to be adopted is prophylaxis; and this includes 
the proper care of the primarily injured eye, as well at 
the time of the injury as later on; and this of course in- 
volves the question of enucleation. This is an important 
problem, and there are many points to be carefully con- 
sidered before a conclusion is reached. It may be stated 
as a cardinal point, however, that an eye so seriously 
injured in the ciliary region as to preclude the possibility 
of retention of sight should be promptly removed; for 
such an eye is not only a useless organ, but is a source 
of constant menace to its fellow. - 

(20) Diseases of the Eye from Syphilis.—Syphilis is a 
prolific source of eye disease, and may cause almost any 
form of it. The ¢nheriied form of syphilis, through de- 
fective development or inflammation of the several parts 
of the eye during intra-uterine life, may cause blindness. 
And abnormalities in the osseous development of the 
orbit or of the skull may, through pressure upon the 
visual tract, cause optic neuritis or atrophy and blind- 
ness. Diffuse (parenchymatous) keratitis—a disease of 
early life—is also occasionally productive of blindness. 
Either the inherited or the acquired form of syphilis may 
cause blindness through kerato-iritis, iritis, irido-cyclitis, 
irido-choroiditis, choroiditis, retino-choroiditis, and optic 
neuritis or atrophy. In tertiary syphilis, gummata— 
affecting by preference the sclera or the ciliary body— 
may produce destruction of the eye. And the periosteal 
or bony lesions of this stage may cause, through partici- 
pation or by their pressure effects, disease of the eye or 
of its conducting apparatus, which leads to blindness. 
An early recognition of the specific taint, and prompt 
and energetic measures against it, constitute the sheet- 
anchor of success in all diseases dependent thereon. 

(21) Gonorrhaal Conjunctivitis.—This is a most viru- 
lent form of purulent ophthalmia, due to inoculation of 
the conjunctiva with the discharge from a specific ure- 
thritis or vaginitis. The material is conveyed to the eye 
by accident or by carelessness, through unwashed hands 
in persons with gonorrheea, or in those treating it, and 
the use of towels or of linen which have become contami- 
nated. Perfect cleanliness and care, observed by gonor- 
rheeal subjects and by their attendants and associates, 
would expel this disease from the category of eye affec- 
tions. 

(22) Serofulous Diseases of the Hye.—The strumous con- 
dition is a fruitful source of eye disease, yet the diseases 
to which it most frequently gives rise—ophthalmia tarsi, 
phlyctenular troubles, etc.—seldom cause blindness. 
One of its diseases, however—cyclo-keratitis—is a most 
serious disease, and often produces blindness. It was 
first described by Dalrymple, and is sometimes spoken 
of as Dalrymple’s disease. Itis fortunately rare. Lupus 
is usually considered a strumous disease, and this may 
lead to destruction of the eye—whether attacking the 
eye primarily, or involving it secondarily. Tuberculosis 
may also cause blindness, through choroiditis, iritis, and 
keratitis. 

(23) Lrido-choroiditis with Meningitis.—This disease is 
commonly spoken of as metastatic choroiditis, and is 
caused by an extension of inflammation from the head to 
the eye in simple meningitis, or, as is more frequently 
seen in cerebro-spinal meningitis, by metastasis. The 
disease usually destroys the eye, and treatment is ordi- 
narily unavailing. 

(24 and 25) Atrophy of the Optic Nerve (Cerebral and 
Spinal).—It is often difficult and sometimes impossible 
to locate the lesion upon which optic-nerve atrophy de- 
pends, and it will be convenient to consider these two 
forms together. According to Galezowski, who tabu- 
lated 166 cases of optic-nerve atrophy, about 50 per 
cent. are due to diseases of the brain and spinal cord; 
18 per cent. are traumatic; 9 per cent. are due to 
alcoholism; 8 per cent. to syphilis, and the remain- 
ing causes are of the most varied kind. And accord- 
ing to von Graefe, about 30 per cent. of cases of primary 
atrophy of the optic nerve are due to spinal disease. 

Cerebral optic-nerve atrophy may be consecutive to 


12 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


optic neuritis (of central origin), or it may follow lesion 
of the chiasm, of the cerebral centres, or of the cortex 
about the angular gyrus, or it may be caused through 
pressure upon the nerve by an exostosis, tumor, or aneu- 
rism ; through narrowing of the optic foramen by hyperos- 
tosis or by pressure upon the chiasm from distention of 
the third ventricle. Meningitis, chronic or acute, may 
also cause ptosis, or atrophy without recognized neuritis, 
etc. Spinal atrophy occurs with locomotor ataxia, of 
which it may be the earliest symptom; or it may, as is 
often the case, come asa late manifestation of the disease. 

(26) Atrophy of the Optic Nerve, or Neuritis after 
Hematemesis.—Loss of blood is occasionally followed by 
affection of vision, which may be temporary or perma- 
nent. It is with the latter that we have to deal, and this 
usually depends upon either neuritis or atrophy. Clini- 
cal experience has taught that hemorrhages from the 
gastro-intestinal tract cause disturbance of vision more 
frequently than hemorrhages from other localities (thirty- 
five percent.). The connection between the loss of blood 
and disease of the optic nerve has so far received no sat- 
isfactory solution. The same connection probably exists 
between atrophy of the optic nerve after bleeding from piles 
(27), and after dysentery (28). 

(29) Atrophy of the optic nerve after vomiting is rare, 
and the connection between the two is obscure. The 
straining and consequent congestion may produce retro- 
ocular hemorrhage, or serous effusion; or it may be due 
to the connection which exists between the stomach and 
the corpora quadrigemina. 

(80) Optic-nerve atrophy after facial erysipelas is usually 
caused by an extension of the cellulitis to the tissue of 
the orbit, and the resulting damage to the trunk of the 
nerve. 

(81) Atrophy of the Optic Nerve with Insanity.—Atrophy 
sometimes occurs among the insane, and most frequently 
in subjects of general paresis—though it sometimes oc- 
curs in dementia and in other forms of insanity. Itisa 
degenerative change, associated with similar lesions in 
the central nervous system. 

(82) Atrophy with Epilepsy.—It does not appear that 
idiopathic epilepsy has connection with any form of eye 
disease. It is only in such cases as are dependent upon 
gross intracranial lesions that changes are observed in 
the disc, and the atrophic changes here differ in no way 
from those seen in the usual forms of brain disease. 

(83) Retinitis nephritica occurs in about twenty-five 
per cent. of cases of chronic Bright’s disease. It is more 
important as a means of diagnosis than as a cause of 
blindness, for not infrequently it is the first symptom 
which leads to a detection of disease of the kidney. It 
rarely causes blindness, however, in spite of the marked 
pathological changes that are noticeable in the retina, 
and often in the optic nerve. 

(384) Diseases of the Eye with Typhoid.—Loss of sight 
has been many times observed during convalescence from 
typhoid fever, and, subsequently, optic-nerve atrophy 
has usually been found. In some of these cases cerebral 
symptoms have been observed, and in others there was 
none. Keratitis is sometimes seen, and blindness may 
be one of its consequences. 

(85) Blindness from measles may be due to optic neu- 
ritis, or it may result from neglected diseases of the ex- 
ternal eye, ¢.¢., conjunctivitis, keratitis, etc. 

(86) Disease of the Eye from Scarlatina.—The fre- 
quency with which renal disease accompanies scarlet 
fever renders affections of sight not very rare conse- 
quences of the disease. Yet neuro-retinitis does occur 
without the presence of renal disorder. Atrophy of the 
optic nerve may also be the result of scarlatina. In 
malignant cases sloughing of the cornea has been ob- 
served, and in other cases keratitis may produce blindness. 

(87) Disease of the Eye from Variola.—Variola may 
cause neuro-retinitis or atrophy of the optic nerve; but 
its chief danger is from diseases of the external eye, al- 
most any part of which may be the seat of the eruption. 
The most dangerous seat is the cornea, where ulceration 
often leads to blindness. Iritis has also been observed. 





























Blindness. 
REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. alindncss! 
TABLE XII. 
Preventable causes of blindness. Probably preventable blindness. Unpreventable blindness. 
Per cent. Per cent. Per cent. 
Ophthalmia neonatorum ..-......+.... Diseases of the COrN€d......eeeeeeeeeees 4.034 | Diseases of the COrn€ad.........sseeeveees 4,034 
Trachoma and blennorrhoea........- Direct injuries of the eye ...........+... 2.017 | Direct injuries of the eye........ A eas 2.017 
Diphtheritic conjunctivitis.........-.. Unsuccessful operations ........ Satie. 1.978 | Tumors of eye and surroundings ........ B56 
MHOPCIGIUS MYOPICA<. 602. ce ceetes oe Irido-choroiditis, cyclitis, iritis.... .... 4.480 | Irido-choroiditis, cyclitis, iritis........... 4.430 
Detachment of retina .........secccese Detachment of retinad........sseee wees 1.000 || Injuries to the head. .....05.. ..crce. ie eae 
Glaucoma ........ssseeeeeee seseccenes 000 | Glaucoma ......+..seeeseeee iste oisecseleis .978 | Scrofulous diseases............-..... eoee 039 
Sympathetic ophthalmia......... siexiont 4.009) (DT ClASSINIA DIC. ce neieccrecisis<s.0¥ se si0 et Gols VU MCIASSIN ADO murat + slcswlec atek aaa) eters 1.681 
Gonorrhceal ophthalmia.......... ++» _.910 | Diseases of the eye from syphilis ....... .2388 | Disease of eye from syphilis ......... SO ss! 
Diseases of eye from smallpox.....--+-+ 2.216 | Choroiditis, chorio-retinitis ............. .369 | Choroiditis, chorio-retinitis ............. 738 
Intoxication amaurosis..... seceeseeses .039 | Idiopathic optic-nerve atrophy...... +++» 2,000 | Idiopathic optic-nerve atrophy..--+...+.. 5.751 
Optic-nerve atrophy, cerebral........... 2.000 | Optic-nerve atrophy, cerebral............ 4,961 
Optic-nerve atrophy, spinal............. .3383 | Optic-nerve atrophy, spinal........ rete si 2.000 
Typhoid, measles, scarlatina, etc ....... 1.165 | Typhoid, measles, €tC ......-..seeeseeees 1.165 
Trido-choroiditis with meningitis......... 1.424 
Other causes, including 3.835 per cent. of _ 
congenital blindness. ..... eres nt sfesiamiie 5.412 
41.093 22.22 34.523 








Important as the local treatment of these disorders may 
be, the prophylactic measure of vaccination should 
supersede them all, and thus prevent entirely the disease 
upon which they depend. 

(88) Disease of the Eye from Heart Trouble.—The most 
frequent cause of blindness from heart disease (valvular) 
is the so-called embolism of the central artery of the 
retina. This is usually monocular, but sometimes both 
eyes are affected. Thrombosis of the central vein of the 
retina behind the eye, in association with disease of the 
heart, may also produce blindness. In ulcerative endo- 
carditis retinal hemorrhages often occur, and sometimes 
panophthalmitis is observed. 

(89) Diseases of the Hye from Childbirth or Pregnancy. 
—In pregnancy we are liable to have albuminuric reti- 
nitis, and, following childbirth, we may have metastatic 
choroiditis, or retinal hemorrhage; and cases of atrophy 
of the optic nerve are sometimes dependent upon lactation. 

(40) Intoxication Amaurosis.—Under this head are in- 
cluded cases of blindness resulting from the abuse of cer- 
tain noxious agents, chief among which are alcohol and 
tobacco. It is claimed that the free and long-continued 
use of either of these substances not infrequently leads to 
a form of optic-nerve atrophy possessed of certain dis- 
tinctive peculiarities. There seems to be good reason for 
attributing such to alcohol, but the reasons in favor of 
tobacco are not so strong. 

(41) Blindness from Diseases of the Orbit.—Inflamma- 
tory processes in the orbit, whether in the cellular tissue 
or in the periosteum or bone, may cause either simple 
atrophy of the optic nerve or neuritis and consecutiye 
atrophy. With much swelling of the orbital tissue there 
is danger that the nutritive supply of the globe may be 
cut off by pressure, and that the inflammation or slough- 
ing which results may produce blindness. Tumors of 
the orbit may act as inflammatory products, or, the dis- 
ease extending to the eye, may directly cause destruction 
of this organ. 

An important matter in the consideration of the causes 
of blindness, is the proportion composed of those whose 
origin is unavoidable, and the course of which is beyond 
control. If arranged under the headings of Preventable, 
Probably Preventable, and Unpreventable Blindness, we are 
at once struck with the large number included under 
the first and second headings, and the small proportion 
embraced under the last. Absolute accuracy in this 
arrangement is, of course, not claimed, but it will serve 
the purpose of illustrating the large amount of blindness 
arising from avoidable causes, and such as are amenable 
to treatment. 

It may be of interest to state that the first institution 
for the blind was founded in Memingen, by Weef VL., 
in 1178: the second in Paris, by St. Louis, in 1260; the 
first for the employment of adult blind was opened in 
Edinburgh, by Dr. Johnston, in 1793. There were, in 
1873, one hundred and forty-eight institutions for the 
blind in the world. 


There are certain irregular forms of blindness which 
will be treated of under appropriate headings elsewhere, 
and it will be necessary to refer to them here only in a 
general way. The free exhibition of quinine or of sali- 
cylic acid sometimes causes blindness, and it has been 
observed in rare instances to follow the use of séver, of 
mercury, and of lead. Prolonged exposure to the fumes 
of sulphide of carbon may produce amblyopia; and the 
fumes of osmic acid may bring about the same condition. 
The circulation, in the blood, of asuperabundance of wrea 
is apt to cause transient attacks of blindness. And in 
migraine, or sick headache, attacks of blindness are not 
infrequent. The attacks of blindness in the foregoing 
conditions of the system are usually transient, and per- 
fect recovery quickly follows: yet, if they are often re- 
peated, permanent impairment of sight may result, which 
in some instances declares itself as a low grade of optic 
neuritis or atrophy. Hysterical amblyopia is a recog- 
nized condition. It is temporary and irregular, and is 
usually attended by other hysterical symptoms. Tem- 
porary blindness may occur as the aura of an epileptic 
attack. Cases of word-blindness which were dependent 
upon lesions about the angular gyrus have been observed 
in individuals who could talk and even write. Night- 
blindness or moon-blindness—hemeralopia—is a condition 
of torpor of the retina which usually affects those who 
have been long exposed to bright lights—as sailors or 
marching soldiers, inthe tropics. Insufficient food, either 
as to quantity or quality, seems also to be a factor in the 
disease. Day-blindness, or nyctalopia, is a form of retinal 
hyperesthesia which is also usually caused by long ex- 
posure to glistening surfaces brilliantly illuminated by 
the sun. Snow or ice blindness is a variety of nycta- 
lopia, though there are usually with this form signs of 
conjunctival implication. One-sided blindness, or hemt- 
anopsia, Which may exist in various forms, is occasion- 
ally seen, and it is often of importance in locating intra- 
cranial lesions.  Llindness from disuse—amblyopia ex 
anopsia—is claimed by many to result from the long- 
continued disuse of an eye. Stimulated blindness can 
usually be detected, yet it is often done with difficulty. 
Color-blindness — achromatopsia —may exist in various 
forms. It is of great importance, and receives ample 
consideration elsewhere. 

Prevention of Blindness.—Much can be done toward 
peventing blindness through a better understanding of 
its causes by the laity, while the profession should not 
only be alive to these points, but should be able 
quickly to recognize diseases of the eye, and acquainted 
certainly with the simpler forms of treatment. The most 
prolific source of blindness—ophthalmia neonatorum— 
can be stamped out by the observance of the simplest 
procedure—Credé’s method—already referred to. So 
important is this disease that the legislatures of some 
of the European countries, and of some States in our 
Union, have enacted laws for the guidance of those 
concerned, 


13 


Blisters. 
Block Island, 





The act of New York, which will serve as an illustra- 
tion, is given here :— 


“AN AcT TO PREVENT BLINDNESS. 


“Sect. 1. Should any midwife or nurse having charge 
of an infant in this state notice that one or both eyes of 
such infant are inflamed or reddened at any time within 
two weeks after its birth, it shall be the duty of such 
midwife or nurse, so having charge of such infant, to 
report the fact in writing within six hours to the health 
officer, or some legally qualified practitioner of medicine, 
of the city, town, or district in which the parents of the 
infant reside. 

“Sect. 2. Any failure to comply with the provisions 
of this act shall be punishable by a fine not to exceed 
one hundred dollars, or imprisonment not to exceed six 
months, or both. 

“Sect. 8. This act shall take effect on the first of 
September, 1890.” James Lancelot Minor. 


BLISTERS.—This subdivision of agents, otherwise 
and technically known as vesicants or epispastics, be- 
longs to the larger order of so-called Irritants. They 
also belong, in the arbitrary classification of drugs, to 
the Neurotics—on account of their counter-irritant action, 
which effect is produced largely through the nervous 
system. There are four degrees of irritant action, and 
these are expressed in the following classification: (1) 
Rubefacients; (2) Vesicants or Epispastics (blisters); (8) 
Pustulants or Suppurants; and (4) Escharotics. Each of 
these, which differ only in degree, represents substances, 
which, when applied to the skin, produce more or less 
irritation, ¢.e., vascular reaction or excitement. Rube- 
facients, by rousing the capillaries, are intended to ex- 
cite mere redness; if allowed to remain in contact with 
the skin too long, they sometimes produce vesication. 
Epispastics applied to the skin excite not only redness 
but also more or less local inflammation, accompanied 
by the transudation of serum beneath the cuticle. Such 
fluid transudations, forming between the epidermis and 
the dermis, at first minute, soon coalesce into one or more 
larger accumulations, called a blister. 

The list of principal vesicants includes cantharides, 
iodine, the volatile oil of mustard, the confined vapor of 
ammonia, the confined vapor of chloroform, chloral hy- 
drate crystals (if confined), glacial acetic acid, rhus tox- 
icodendron, euphorbium, mezereon, heat in the form of 
Corrigan’s hammer, the moxa or plain boiling water, 
also turpentine and other agents. All of these may act 
either as mere rubefacients or as vesicants, according to 
the length of time during which they are permitted to re- 
main in contact with the surface of the skin, and also 
according to their degree of concentration. 

Physiological Action.—When a blister is applied to the 
integument, the superficial vessels, and particularly the 
capillaries, become engorged; and at the same time the 
subject of the experiment feels a sense of warmth and 
tingling, which latter soon gives way to heat, burning, 
and actual pain. Reflexly, the deep-seated vessels may 
also undergo dilatation, and in this consists the cownter- 
trritant action of blisters. After a variable length of 
time—dependent upon the character and activity of the 
vesicant employed, as well as, also, to some extent, upon 
the histological character of the tissue to which the 
blistering agent is applied—clear serum, plasma, and 
finally, in some instances, more or less blood corpuscles 
escape from the vessels and collect between the epidermis, 
which is now raised, and the true skin, forming what is 
known as a bleb, blister, bulla, bulle (French), Blase (Ger- 
man). Occasionally, where the blistering material is 
weak, its action may cease with mere capillary dilatation, 
heat and redness (rubefacient effect). On the other hand, 
it is possible, for a very strong and active epispastic, if 
kept for too long a time in contact with the skin, to act 
with such force, as to cause pustulation. The size of 
the vesicle is proportionate to the dimensions of the 
blistering material used, the surrounding skin being more 


14 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








or less inflamed and erysipelatousin appearance. Prima- 
rily, a stimulant action is observed not only in the organs. 
and parts in close proximity to the blister, but also in the 
entire superficial circulation. With this is associated a 
corresponding diminution in the deep-seated vascular 
pressure, and this secondary depression is proportionate 
to the size of the blister or, more properly, to the amount. 
of albumin abstracted from the blood. Under certain 
circumstances, and especially in old or debilitated persons, 
this depression may become alarming. 

The exact modus operandi of vesicants is not clearly 
understood. By some the counter-irritant action is 
thought to play the most important part, and these per- 
sons explain this action as taking place through the 
nervoussystem. They maintain, that, by a determination 
of nervous as well as vascular energy to the blistered 
part, there is produced a derivative or revellent effect in 
the deeper structures,—an effect, which is accompanied 
not simply by anemia, but also by changes in the nutri- 
tion and secretion of the organ or part affected. Other 
authorities attach importance to the stimulant action, 
which is exerted, by extension, upon the capillaries of 
the inflamed structure or structures (in behalf of which 
the blister was applied to the skin). 

Uses of Blisters.—To relieve pain; to reduce swelling 
and to allay deep-seated inflammation; to facilitate ab- 
sorption; to stimulate secretion; to recall suppressed dis- 
charges or to recall suppressed inflammation, as in mumps 
(see below); to stimulate the whole body, as in syncope 
(or in coma), or a part of the body, as in paralysis; to 
prepare a surface for endermic medication. Blisters are 
employed to good advantage in chronic inflammation of 
joints, either of rheumatic or of gonorrhceal origin; in 
chronic thickening about the joints; in chronic synovitis 
and periostitis; in spinal and in cerebral meningitis; in 
insolation (sunstroke); in optic neuritis and in iritis (ap- 
plied behind the ears); in otitis media; in mastoid inflam- 
mation and in inflammation of the sinuses (frontal sinus, 
antrum of Highmore, etc.) ; in neuralgia, gastralgia, enter- 
algia; in pleurodynia; in hysterical paralysis; in facial 
paralysis; in reflex cough; in aphonia; in obstinate vom- 
iting; in enuresis; in spermatorrhea; in alcoholic or 
opium narcosis; in lumbago; in sciatica; in endocarditis, 
pericarditis, and pleuritis; in hydropericardium or in 
dropsy of other sacs, especially in hydrocephalus; in hepa- 
titis, splenitis, ovaritis; in metastatic orchitis (of mumps, 
when it is well to place the blister over the parotid); in 
prostatitis and in chronic gleet. Blisters are also employed 
to stimulate indolent ulcers or fissures; and in chronic 
eczema and other chronic dry and scaly skin disorders, 
especially of a somewhat inflammatory character, to sub- 
stitute a healthy, acute inflammatory action for the ex- 
isting, long-continued, chronic inflammation. What the 
action of blisters is in such cases is not known, but 
they have been used to good advantage in erysipelas, as 
a means of preventing the spread of the process. In 
functional diseases of the nervous system, the counter- 
irritant action and the stimulant as well as the moral 
effect of the blister almost invariably prove salutary. 
Good results have also been reported from the application 
of a blister over the perineum in spermatorrheea, over 
the back of the neck in incontinence of urine, and over 
the epigastrium in persistent nausea. 

Contraindications.—Blisters should be avoided in the 
very young, in the very old, and in those who are de- 
bilitated, or who have depressed vital forces. They 
should never be applied in the following situations: 
directly over an inflamed part, over a bony prominence, 
over a part pressed upon by clothes, over recumbent 
parts which are pressed upon in bed, over parts which 
are deprived of vitality by the presence of cicatricial 
tissue or by paralysis—in a word, over any part in which 
the circulation is poor, and in which consequently the 
blister might cause gangrene and sloughing. In parts 
of the body, where there is considerable loose connective 
tissue— such, for example, as the scrotum, the labia, the 
eyelids, or the axilla—blisters should not be applied. In 
pregnancy, also, it is best not to make a blistering appli- 





cation about the breasts. Diabetes, scurvy, purpura, and 
the acute exanthemata contraindicate the use of blisters. 
Too long contact of the vesicating material with the skin 
should be carefully avoided, as deep ulceration may 
occur, and a special warning must be given in regard to 
cantharides, which should not be allowed to remain too 
long over any portion of the thorax or abdomen, lest in- 
flammation of the pleura or of the peritoneum arise. 
Cantharides should blister in from four to seven hours. 
The confined vapor of aqua ammonie fortior acts in from 
three to ten minutes, but a blister thus produced is very 
painful. For this reason, the following mixture, called 
Granville’s lotion, is preferable: it consists of five parts 
of the aqua ammonize fortior, two parts of the spirit of 
camphor, and one part of the spirit of rosemary. A 
piece of flannel is saturated with this lotion and laid on 


the skin. It will produce a blister in from three to ten 
minutes. Gondret’s vesicating ointment is also very 
satisfactory. It is prepared with two parts of expressed 


oil of almond, melted together with thirty-two parts of 
lard, and to which seventeen parts of aqua ammonie 
fortior are added. It will blister in ten minutes, caus- 
ing less pain than plain ammonia does. Pain is not al- 
ways a safe guide, as regards the time when the blistering 
agent should be removed, and this is especially true in 
cases in which blisters are applied as stimulants—as, for 
example, in syncope or in the shock following hemor- 
rhage or injury,—for, in these conditions, pain may be 
entirely wanting. Cantharides, the prince of blistering 
agents, is contraindicated, as a rule, in renal disease, also 
in inflammatory conditions of the genito-urinary tract, 
in which it is accused of producing priapism, erotic ex- 
citement, strangury, pain, tenesmus, bloody urine, and 
the like. These latter very distressing effects of can- 
tharides may be prevented, at times, by the use of 
powdered camphor or bicarbonate of soda, sprinkled on 
the blistered surface. A thin piece of silver paper, spread 
over the blister, is also said to prevent strangury. 

Synergists.—On the absorbents, the action of blisters 
is aided by alteratives; and it is also probable that the 
various drugs, that belong to the class of stimulants 
synergize vesicants. The blister either may be permitted 
to heal or it may be converted into a running sore, just 
as the physician may prefer. Perpetual blisters, how- 
ever, are very seldom employed to-day. In fact, the 
hitherto very commendable custom of blistering has 
fallen into an undeserved disrepute in recent years. So 
soon as the blister has formed, it is well to puncture it 
at its most dependent point, allowing the serum to 
escape. Then a simple dressing of cerate or any other 
bland, unirritating material will favor prompt healing. 
Basilicon salve or other more irritant ointment may be 
employed in those cases in which it is intended to main- 
tain the discharge. When the vesicant has been re- 
moved, and no blister forms, a bread-crumb poultice, 
made with milk, will help it to develop. Lead water 
and laudanum is recommended as an application for 
painful blisters. A succession of small blisters, applied 
one after the other, whereby continuous counter-irritant 
action is obtained, represents what are termed “ Flying 
Blisters.” Besides the commonly employed Spanish fly 
plaster, which is made by mixing ceratum cantharida- 
tum with wax and spreading it on a thin cloth, there are 
numerous other cantharidal preparations—ethereal, alco- 
holic, watery, and hydrochloric extracts of cantharides, — 
all more or less active; and, among these, none is more 
useful than cantharidal collodion. It possesses one great 
advantage: it can be applied to any surface, no matter 
how irregular it may be. Asan application in alopecia 
circumscripta (functional) and in tinea tonsurans and 
circinata, collodium cantharidatum is much used. The 
cantharis vittata or potato fly, inhabiting the potato plant 
of the United States, contains a percentage of cantharidin, 
and resembles, ‘in its effect, the imported Spanish fly. 

It is to be hoped that the pendulum will one day, in 
the near future, swing back from its present extreme 
position, and give to this branch of our therapeutic 
armamentarium its proper place. Thestatement has been 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











Blisters, 
Block Island. 





made by the former writer upon this subject ina previous 
edition, that venesection, only, can so quickly and radi- 
cally induce changes in the physical and physiological 
condition of limited areas of surface or of extensive parts 
or organs as vesication. If this statement be true, and 
we believe that it is, then it were well for steps to be 
undertaken to instruct the profession in a therapeutic 
procedure which is fast disappearing. 
Leon L. Solomon. 


BLOCK ISLAND.—This island (Lat. 41° 13’ N., Long. 
71° 85’ W.), lying some ten miles out at sea, and situated 
about midway between Point Judith, on the Rhode Island 
coast, and Montauk Point, the eastern extremity of Long 
Island, is, with perhaps the single exception of Nan- 
tucket, farther distant from the mainland, and con- 
sequently more thoroughly exposed to purely maritime 
influences, than is any other resort lying along the At- 
lantic coast of the United States. According to “Lip- 
pincott’s Gazetteer,” the length of the island, from north 
to south, is eight miles; its breadth from east to west 
varies between two and five miles. The greater part of 
the island is considerably elevated above sea level. The 
rocky bluffs lying upon its southern and southeastern 
shores are said to rise some two hundred feet above the 
water, rendering this part of its coast exceedingly pictur- 
esque and bold in appearance; while an elevation of 
some three hundred feet is said to be attained in some 
parts of the interior. The general surface of the island 
by no means consists, however, of a uniformly elevated 
tableland, but is decidedly undulating and of uneven 
configuration. On the eastern shore, where the chief 
hotels are located, there is a fine beach for bathing. The 
facilities for boating and for fishing are also said to be 
unsurpassed. Besides the meagre account of Block Island 
contained in the pages of “ Lippincott’s Gazetteer,” the 
writer has hitherto seen no description of the island, save 
that contained in the two pamphlets circulated as adver- 
tisements of its hotels. In these pamphlets, however, 
there is to be found a long extract from an account of 
Block Island as a health resort, written by Dr. H. Hol- 
brook Curtis, of New York, a physician who was for- 
merly in the habit of passing his summers at this seaside 
resort. The reputation of this gentleman is such as to 
give the greatest weight to his comments, which are 
based, moreover, upon personal experience. In this 
article, published originally in the pages of the New 
York Medical Record, Dr. Curtis bears witness to the ex- 
ceptional purity of atmosphére existing at Block Island, 
to the coolness of the place in summer, to the bracing 
and remarkably tonic, as well as soothing, effect of its 
climate, and to the decided benefits attainable and at- 
tained by a summer sojourn at this spot in cases of ner- 
vous prostration, insomnia, malarial poisoning, and in 
some cases of pulmonary phthisis. The doctor also 
testifies to the good quality of the water supply, the 
comfort of the hotels, and the perfect system of drainage 
in vogue at the latter. His article also contains a table, 
showing the temperature at noon for each day of the 
two months of July and August, 1880, as taken by a 
gentleman who was staying at the island. Similar tables 
for those two months during the years 1881, 1882, and 
1883, based also upon private observations, are given 
elsewhere in the two pamphlets already referred to. 
From the figures of these four tables the present writer 
has deduced by calculation the following chart, which 
shows the average noon temperature for July and August, 
in each of the four years specified (1880, 1881, 1882, and 
1883), as also the absolute maximum and absolute mini- 
mum noon temperatures, the average maximum and 
minimum at noon, the absolute and the average range, 
and also the absolute and the average number of days in 
each month upon which the mercury rose to 80° F. or 
above, and upon which it stood at 70° F. or lower, at the 
hour specified. A glanceat this table will show not only 
the coolness, but also the great evenness of the midday 
temperature at this exceptionally and truly maritime 
resort. 


15 


Blodgett’s Springs. 
Blood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





NOON TEMPERATURES AT BLOCK ISLAND. (Fahrenheit Scale.) 
(July and August, 1880, 1881, 1882, and 1883.) 



































Seite Celis US 
&® |€@_25 |#_28 
P| Oanc Taso 
: S HBS lH SEO: 
g S ~ o0 Fy | O'S S oH 
fe) 3 = & Fe = D ° o i = Do 
- | € | § | & |2a882/205sr 
S| # | ga] 8 18°ss je su 
< = a rat lea E |z 5 
July ..| 75.5° | 81.0° | 70.0°| 11.0] 3.0 4.0 
1880 | ‘Aug ..| 743 | 82.0 | 62.0 | 20.0 3.0 5.0 
1881 July ..| 73.4 | 80.0 | 66.0 | 14.0 2.0 9.0 
Aug ..| 72.2 | 79.0 | 58.0 | 21.0 0.0 9.0 
1882 {July . 74.2 82. 60.0 22.0 6.0 6.0 
~) aug ..| 74.4 | 80.0 | 68.0 | 12.0 1.0 6.0 
1393) July -.| 73.8 | 80.0 | 65.0 | 15.0 2.0 6.0 
S) Aug ..| 72.6 80.0 66.0 14.0 2.0 9.0 
{ July ..| 74.22 | 80.75 1.22 y 2 2 
Average 4 ‘aug ..| 72.37 | 80.22 | 63.50 | 16.7 15 72 








Huntington Richards. 


[Below are added some more recent data in regard to 
the climatological conditions which exist at Block Island: 


METEOROLOGICAL DATA OF BLOCK ISLAND FOR THE FOUR MONTHS, 
JUNE, JULY, AUGUST, SEPTEMBER, FROM 1890 TO 1897 INCLUSIVE, 

















FROM THE UNITED STATES WEATHER BUREAU. (Fahrenheit 
Scale.) 
“aes Mean Mean 
igs maximum | minimum Relative 
Ae es tem- tem- humidity. 
Pte, perature. perature. 
ak! UnaAieeceo cea: 65.2° 73.0° 60.0° 87.3° 
SOL Ratercieresieeents 65.2 81.0 52.7 89.0 
LSO2 eetmetsiieieisieiese 65.7 81.0 53.0 86.4 
SOB Macrlameparentee 64.4 (9.7 51.5 85.0 
BOS reswiefeteiaeteeie 65.9 80.5 52.5 85.5 
W8OS rates. 65.8 81.5 50.0 86.6 
BOB saemiatelerccare 65.5 80.0 52.5 36.5 
Ibe e aon GONE 65.4 79.9 5L.7 85.7 











The temperature of the summer proper is 67° F.; of 
autumn, 53° F.; winter, 32° F.; spring, 48° F.; and the 
annual mean, 56° F. The mean annual rainfall is 53 
inches. Sunshine for summer, 63 per cent. ; autumn, 43 
per cent. ; winter, 51 per cent.; and spring, 48 per cent. 
Annual mean, 53 per cent. (Medical Record, 1897). 

The island is reached from New York, Providence, 
Newport, and New London. From the private letter of 
a gentleman who has passed many summers on the island, 
the following is extracted: 

“There are more or less fogs on the island, but gener- 
ally not enough to be uncomfortable; the bathing is 
good and perfectly safe. There is almost always a 
breeze, and of course no land breeze, so that the weather 
is cool and comfortable, and no one need fear any dis- 
comfort from the heat; there is practically absolute free- 
dom from mosquitoes.” 

In another private letter of a gentleman who spent 
two months on the island it is stated that “the bathing 
is poor, dangerous on the seaward side, and stormy on 
the protected side.” As he was unfortunate in meeting 
with an unfavorable season—“ damp, foggy weather ”— 
and was a sufferer from rheumatism, he may have been 
prejudiced in his opinion of the island and of its bathing 
facilities. 

“There are probably twenty or thirty hotels on the 
island,” says the former correspondent, “ good, bad, and 
indifferent.” There are also said to be cottages especially 
adapted for invalids and convalescents. 

Block Island is a favorite place for excursionists, a con- 
dition which may be of annoyance to the summer resi- 
dent.—Z. O. 0.) 


BLODGETT’S SPRINGS.—Santa Clara County, Cali- 
fornia. Hotels and cottages. These excellent springs 
are picturesquely located in the coast range of moun- 
tains, about eight miles west of Gilroy. They are 


16 


reached by the Southern Pacific Railroad to Gilroy, and 
from thence by a daily stage. The surroundings are 
beautiful. The atmosphere is pure, balmy, and invigor- 
ating, and the mineral water and baths are of consider- 
able therapeutic value. One of the principal fountains 
is the Soda Spring. Anderson’s analysis: 


ONE UNITED STATES GALLON CONTAINS: 


Solids. Grains. 
Sodium chloride............. GoodioncaudongaT owen nea 8.20 
SOGUM CATDONALO wi 6/6101 co:eieis1e-0falels velivis siete ie 14 angen 9.92 
SOOUUMI SUN DMA Meroe cle ci cieicalsissinjalse terete sie aiale(ale sche tint Trace. 
POtASSIUNY CHIOLIGDE) se oiciece ceo we vin =n sels Ota sie esntateleiete tate . Trace 
Potassitvum LOGIE i hsiels isis hs ce veteya's 0:0: 8o les icles cle Trace. 
Potassium carbonate ....- Saeeitsles Sie nye) 6°; sietaVore MTom 0.47 


Magnesium carbonate 
Magnesium sulphate ... 
Calcium carbonate .. 
Calcium sulphate... 












Ferrous carbonate .... F F 
ALUMINA’ ays Wickes ec c Mae sallatelcte eine Wie creleeitie cine tare eaters 4.13 
BOTates sciisescsescce we olete ate e.o% eis Goleta sisigiels/eisieieterieiats vest Trace: 
Silica ..... ps (ois[als Sri Ta Vm. 8,6) 9/46) «. dycholmtoreey Ors Meeeiesr ey Si cea 4.11 
OTPanie MAW. can, esiels we oesete cee sia oe a:aie'u o/siareteeyetets Trace. 

TOLA] SOLAS sn sistas iets oitrete etnies Ptiels fevers classpath 44.13 

Gases. Cubic inches. 

Carbonic acid ....... Gia eiete cise Mraceivis erie siete aleselace/eie teeters 9.25 
Sulphureted hydrogen..... ....... Abe ioral ele lai ajaineeren ena Trace. 


The waters are antacid, diuretic, aperient, and tonic, 
and of value in acid dyspepsia and catarrh of the stomach, 
in constipation, and in kidney and bladder troubles. 

The next spring in importance is the Sulphur Spring. 
It is very similar in chemical composition to the Soda 
Spring, but contains a much larger volume of sulphu- 
reted hydrogen (7.25 cubic inches per United States gal- 
lon). This water is also antacid, laxative, tonic, and diu- 
retic, and is said to be useful in rheumatism and sciatica, 
chronic arthritis, and skin diseases. Excellent bathing 
facilities have been constructed. James K. Crook, 


BLOOD, CIRCULATION OF THE. See Circulation 
of the Biood. 


BLOOD, FORMATION OF THE.—A complete ac- 
count of the formation of the blood ought naturally to 
contain a discussion of the origin and maintenance of 
the liquor sanguinis or plasma, in addition to a descrip- 
tion of the formation, growth, and life history of the 
different corpuscular elements which are found suspended 
in that fluid and which constitute, together with it, the 
blood. But such an inclusive use of the term would 
open up to discussion under this heading all the phe- 
nomena of nutrition, metabolism, and excretion, for all 
these are concerned in the preservation of a normal blood 
plasma, and would lead to a repetition of much that has 
been treated of elsewhere. Accordingly, we shall confine 
ourselves in the present article to a description of the 
formation of the blood corpuscles, only incidentally 
mentioning the first origin of the (éqguor sanguinis in the 
feetus, and omitting all description of its subsequent 
maintenance in normal condition. It will be convenient, 
in treating of the origin of the corpuscles, to divide the 
subject into two headings and describe separately their 
formation during intra-uterine and during extra-uterine 
life, since their mode of origin is somewhat different in 
the two conditions; and it will also add clearness to de- 
scribe in each of these two sections the formation of the 
red corpuscles, or erythrocytes, including here what is 
known concerning the origin of the blood platelets, and 
then separately take up the account of the white cor- 
puscles or leucocytes. 

The literature which has accumulated upon the sub- 
ject of the origin, growth, and regeneration of the blood 
corpuscles is enormous, so that a mere recapitulation of 
the titles of papers written upon the subject would prob- 
ably occupy more space than this entire article, which 
can accordingly not aim at completeness, but instead 
at giving a comprehensive bird’s-eye view of the subject, 
and an outline only of the more important opinions held 
by various authors. At.the end of the article are given 
a few references to summarized accounts of the subject 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blodgett’s Springs, 
Blood, 





from various standpoints in which some hundreds of 
references to other original papers will be found, and the 
writer here acknowledges his indebtedness to the authors 
of these articles for the subject matter of the present 
sketch of the subject. 

Intra-uterine Formation of Blood Corpuscles.—It is ex- 
ceedingly interesting, from the evolutionist’s point of 
view, to note that the first erythrocytes observed in the 
earlier embryonic stages in man and other mammals re- 
semble those which persist throughout life in the lower 
vertebrates in being nucleated cells. In the human em- 
bryo at the fourth week all the red blood corpuscles are 
nucleated; at the third month, the nucleated cells form 
only one-sixth to one-eighth of the total number of blood 
corpuscles; at the fifth month, the nucleated cells are 
still quite numerous, although present in much dimin- 
ished percentage; while at birth at full term nucleated 
red blood corpuscles are entirely absent, having been 
completely replaced in the circulating blood by the bicon- 
cave discs which characterize the blood of the mamma- 
lian adult. 

It is generally agreed that the earliest red blood cor- 
puscles which have been observed, arise outside the grow- 
ing embryo in a portion of the mesoblastic tissue which 
is known as the area vasculosa. Here certain pigmented 
patches appear, caused by the development of hemo- 
globin within the cells, which are known as “blood 
islands,” and it is generally admitted that it is in these 
“blood islands” of the mesoblast outside the growing 
foetus that the first blood-vessels and erythrocytes origi- 
nate. Ata later stage the blood-vessels within the em- 
bryo are formed by outgrowths from these, and from 
similar developments taking place within the body of 
the embryo. 

There are, however, two principal theories extant as 
to the manner in which the initial blood-vessels and red 
corpuscles are formed in the mesoblastic cells. 

The earlier of these two theories, which was originally 
supported by Reichert and K6lliker, states that the first 
blood corpuscles originate from solid cords of cells which 
later develop to form the heart and vessels, with the con- 
tained plasma and corpuscles. These solid cords appear 
in the vascular area and develop so as to form a com- 
municating network. The peripheral cells in the cord 
alter later to form the walls of the future blood-vessel, 
while the central cells become pigmented by hemoglobin, 
acquire a spheroidal shape, and remain attached to the 
peripheral part in tufts; meanwhile a fluid appears be- 
tween the masses of cells within the developing vessel 
which forms the future plasma; this fluid, being set in 
motion by the contractions of the heart which has now 
developed in connection with the system, detaches by 
degrees the adherent cells, which then circulate and form 
the first red blood corpuscles. The number of circulat- 
ing cells is increased afterward both by indirect division 
of those already circulating and by increase in a similar 
fashion of those still adherent to the wall of the embry- 
onic blood-vessel and their subsequent detachment. This 
theory has lately been somewhat revived, as a result of 
direct observation during life on the transparent embryos 
of certain fishes. Here it is said that the first fluid driven 
round by the developing embryonic heart is a colorless 
plasma, in which nucleated red blood corpuscles appear 
later. It is further claimed that these corpuscles can be 
observed becoming detached at certain areas of the vas- 
cular system, and that from the frequency of karyoki- 
netic figures occurring in the circulating corpuscles at 
this stage they undoubtedly undergo increase by indirect 
division while circulating. 

The other view, which was introduced by Klein and 
is supported by Balfour, Schiifer, and most English his- 
tologists, holds that the first red blood corpuscles are 
formed by free endogenous subdivision of the nucleus 
within large mesoblastic cells of the vascular area. 

The cells which are to form the future blood-vessels 
send out processes in various directions which anastomose 
with one another, and later communication is established 
by means of these processes, so that a continuous commu- 


Wior, 1k 


nicating network of vessels is thus formed. Meanwhile, 
within each of these large branching cells alterations 
take place resulting in a liquefaction of a portion of the 
cytoplasm to form the future plasma, while the remainder 
continues adherent around the nucleus. Extensive pro- 
liferation of the nucleus also takes place, and around each 
of the daughter nuclei a portion of protoplasm forms 
which finally becomes pigmented with hemoglobin, so 
giving rise to red blood corpuscles. Still later the inter- 
commuicating channels enlarge so as to allow of the, 
passage of the corpuscles along them, and by the con- 
tractions of the heart which has now developed the cor- 
puscles are driven along the system. The primary 
erythrocytes formed in this way closely resemble leuco- 
cytes in their appearance and properties, possessing like 
these the power of amceboid movement and of increase 
by cell division, and differ only in the almost complete 
absence of granules and in the faint yellow color of their 
cytoplasm, 

According to Howell, two distinct types of nucleated 
red blood corpuscles are present side by side in the 
blood of the early embryo. One of these types is large 
and oval in shape, being two to four times as long in 
the long diameter as the corpuscle of the adult, and being 
in some cases biconcave, in others biconvex. The other 
variety is circular in outline and of about the size of the 
ordinary blood disc of the adult, from which it differs in 
being nucleated. Howell suggests that the large oval 
corpuscles may represent the form of the red corpuscle 
characteristic of the ancestors of the mammalia, and that 
they may hence be spoken of as ancestral corpuscles, 
while the smaller circular corpuscles of the usual size of 
the nucleated red corpuscles of the mammalia exhibit 
a modification of this ancestral form which has become 
characteristic of the blood of most of the mammalia. 
These latter corpuscles afterward lose their nuclei and 
are converted into the biconcave blood discs, the transi- 
tion taking place in the young embryo in the circulating 
blood stream itself, but later being confined to certain 
specific organs. 

The first blood-vessels within the body of the embryo 
are probably formed in a similar fashion from cells of the 
mesoblast, and communicate by a network with those al- 
ready developed as above described in the vascular area 
outside the body. Through this whole system a current 
of blood is driven by the contractions of the fetal heart. 
In the later stages of embryonic life such a general 
formation as has been above described of red corpuscles 
throughout the vascular system probably entirely ceases 
except in regions where new vessels are being formed. 
The formation of new corpuscles, to replace those broken 
down, or to increase the number in the circulation as the 
embryo grows and the vascular system increases in vol- 
ume, is confined in the later stages of embryonic life to 
certain organs exclusively; and it is further known that 
the organ most active in so supplying new corpuscles 
varies as the development advances. At first, the liver 
is the most important organ in the development of em- 
bryonic red blood corpuscles, but at a later stage this 
organ takes up other work, and the development of cor- 
puscles in it gradually comes to a standstill. During 
this period the spleen has been increasing in size, and 
this organ next becomes the chief seat of formation of 
new red blood corpuscles. Still later, as the long bones 
develop and become capable of taking up the function 
of developing erythrocytes within their marrow, the 
hematopoietic function of the spleen also becomes de- 
pressed, and soon after birth it is probable that this func- 
tion of the spleen, at least under normal conditions, be- 
comes abortive, and the red marrow of the bones is finally 
left the sole source of supply of erythrocytes during the 
remainder of the life of the animal. 

That the liver becomes a seat of formation of new red 
blood corpuscles in the embryo almost as soon as it be- 
gins to form, was first clearly shown by K®élliker, who 
believed that the nucleated erythrocytes developed from 
certain nucleated white corpuscles contained in the de- 
veloping blood-vessels, that they became pigmented from 


17 


Blood. 
Blood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





a formation of hemoglobin, and then subsequently lost 
their nuclei, so becoming transformed into non-nucleated 
red blood corpuscles. Neumann states that the red 
blood corpuscles are formed within certain large cells of 
the embryonic liver by an endogenous division of the 
original nucleus and a portion of the cell protoplasm, 
whereby a number of nucleated corpuscles appear within 
the original large cell. 

Howell describes the blood-forming cells in the em- 
bryonic liver as occurring, not indiscriminately, but 
grouped into cords or strings lying between the columns 
of true liver cells which are just commencing to show a 
definite structural arrangement. (See Fig. 509.) These 





Fig. 509.—Section of the Liver of a Fetal Cat, 2.7 cm., Showing the 
Development of the Liver Vessels and the Nucleated Red Corpuscles. 
To the right of the figure the newly formed vessel contains a num- 
ber of non-nucleated red corpuscles. (After Howell.) 


cords of cells develop into the blood-vessels, and it is prob- 
able that the peripheral cells, by flattening and otherwise 
altering, form the endothelial wall of the vessel, while the 
central cells are set free as red blood corpuscles. Also at 
places the solid mass of cells is interrupted by vacant 
spaces filled with plasma which contains only a few fully 
developed red corpuscles either with or without nuclei. 
The masses of cells above described are at first colorless, 
but afterward they develop hemoglobin, thus becoming 
pigmented. 

The formation of red blood corpuscles in the spleen is 
demonstrated by the presence in that organ of nucleated 
erythrocytes in considerable number from the fifth month 
of intra-uterine life until a few months after birth. 

The share taken by the spleen in the formation of red 
blood corpuscles in the embryo is in any case an impor- 
tant one only during the latter half of intra-uterine life, 
after the process of formation in the liver begins to abate 
and before the long bonesare fully formed. The process 
of multiplication of erythrocytes in the spleen is prob- 
ably identical with that above described in the case of the 
liver; it persists, though in much lessened degree, up to 
the end of fetal life, and even for a period thereafter 
which is variously stated by different observers as from 
two or three weeks up to as many months. Eventually 
the formation of red blood corpuscles in the spleen entirely 
ceases, according to most modern observers, and this proc- 
ess is afterward confined to the red marrow. It has been 
clearly shown that the nucleated erythrocytes in all stages 
of intra-uterine development increase in number by mi- 
totic division, and the relative activity of different organs 
as seats of formation has been rated from the relative num- 
ber of erythrocytes showing karyokinetic figures in any 
given part. At first the cells undergoing division are 
seen in the circulating blood; later they may be observed 
only in the liver, and do not occur, or only occasionally, 
in the blood in other parts of the body; still later they are 
found in great numbers in the spleen; but at the close of 


18 


intra-uterine life and thereafter they are found but rarely 
in the spleen save after extensive bleeding, and are almost 
solely confined tothe red marrow. This isan interesting 
confirmation of the order, stated above, in which the 
hematopoietic organs of intra-uterine life take up their 
functions. 

The manner in which these nucleated erythrocytes are 
converted gradually into non-nucleated cells as embryonic 
life advances, is probably the same as that by which a 
similar change occurs in extra-uterine life, and hence the 
reader is referred to that section of the article for a dis- 
cussion of the subject. 

A mode of development of red blood corpuscles which 
is distinctly different from all those above described in 
that non-nucleated corpuscles are formed therein, was 
first observed independently by Schiifer and Ranvier as 
taking place in large cells of the connective tissue just 
before birth, or just after birth in the case of mammals 
born in an immature condition, such as the white rat. 

The large connective-tissue cells in which this peculiar 
intracellular formation of blood discs has been observed 
were named angioblasts by Schiifer and vaso-formative 
cells by Ranvier. Schiifer describes this method of 
formation of blood discs somewhat as follows: 

A portion of the protoplasm of the angioblastic cell 
acquires a reddish hue from the development of hemo- 
globin, and after a time this pigmented substance sepa- 
rates in the form of globules within the cells, which at 
first vary in size from a minute speck up to globules of 
the diameter of a mature red blood disc or even larger; 
but later the globules become more uniform in size. At 
a later stage, the angioblastic cells become elongated and 
pointed at their ends, and processes grow out from them 
to join similar processes of neighboring cells. Vacuoles 
now form within the cells, and by enlarging coalesce 
to form a cavity filled with fluid in which the reddish 
globules, which are by this time becoming disc-shaped, 
float. Finally the cavity extends through the cell proc- 
esses into those of adjoining cells, thus constituting a 
hollow network of communicating vessels which becomes 
united with blood-vessels already formed so as be a part 
of the vascular system. In this manner the blood discs 
formed as above described pass into the circulating blood. 

This type of formation of blood discs in the mammalia 
is confined to the portion of intra-uterine life immediately 
preceding birth, but in a few mammals which are born 
in an immature condition it may be observed for a short 
period after birth. Ata later stage, although new ves- 
sels are similarly formed in growing connective tissue, 
no blood discs are observed in the process of genesis 
within them. Quite recently Hayem claims to have ob- 
served blood platelets as well as blood discs within these 
vaso-formative cells of young connective tissue. 

Little is known as to the formation or mode of growth 
of either blood platelets or leucocytes during embry- 
onic life, but it is certain that both are .present in the 
blood during the later stages of intra-uterine existence, 
and also that both appear at a much later period than 
the red corpuscles. In a human embryo of five months 
Howell found both white blood corpuscles and blood 
platelets, but both were present only in small numbers. 
The white corpuscles were of two kinds, as in the adult, 
one variety being of small size with a single vesicular 
nucleus resembling the lymphocytes, while the other 
kind was of larger size, faintly granular, and apparently 
with several nuclei or a fragmented nucleus. 

According to Schiifer, the earliest white blood cor- 
puscles of embryonic life are in all probability amoeboid 
cells of mesoblastic origin which have wandered into the 
blood-vessels or lymphatics, where they either may be 
increased in number by similar additions or may mul- 
tiply by division. — 

Lowit states that white blood corpuscles are also formed 
in the liver during a portion of embryonic life, but at a 
later stage than the red corpuscles. It will subsequently 
be pointed out that during extra-uterine life white cor- 
puscles are chiefly formed in lymphatic tissue. The 
lymphatic glands commence to develop somewhat late in 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





fetal life, and after this there is no doubt that they, like 
the somewhat more diffuse lymphatic tissue formed else- 
where before them, take up the function of supplying 
leucocytes by mitotic division of the ameboid cells 
which they contain. It has also been stated that leuco- 
cytes are formed in intra-uterine life in the intestinal 
epithelium or the tissue underlying it. 

According to Ziegler, the white corpuscles may be re- 
garded as separated cells of the mesoderm, and the lym- 
phatic glands as portions of the mesoderm which retain 
in this respect their embryonic character, and accordingly 
throughout life give rise to fresh mesodermic cells (the 
white blood corpuscles) which are carried off in the 
lymph. 

The fact that the leucocytes are not found in the circu- 
lating blood in the earlier stages of fetal life shows that 
these are not formed in those organs which generate the 
erythrocytes, and hence that they are not, properly speak- 
ing, intrinsic constituents of the blood, but rather have 
been added from without probably by the agency of the 
lymph-forming organs. At this stage amceboid cells are 
also to be found in the tissues outside the blood-vessels 
as well as in the circulating blood stream, and accordingly 
they may be looked upon as normal constituents of all 
tissues which are carried into the blood by the agency of 
the lymph stream, and then afterward circulate in the 
blood for a variable time. 

Fixtra-uterine Formation of Blood Corpuscles.—The 
earliest view entertained with regard to the origin of the 
red blood corpuscles in extra-uterine life was that they 
developed from the white corpuscles. This view was 
first enunciated by Wharton Jones in 1846, who supposed 
that the red corpuscles were the modified nuclei of the 
white corpuscles. The formation of a red corpuscle from 
a white one, according to this observer, consisted in a dis- 
appearance of the protoplasm surrounding the nucleus 
and a development of hemoglobin in the latter which 
took on the peculiar shape of the blood disc. Kélliker 
also supported the view that the red were formed from 
the white blood corpuscles, but gave an entirely different 
account of the mode of development. He thought, from 
a comparison in size, that the blood discs arose from the 
small uni-nucleated white corpuscles derived from the 
lymphatic glands, and claimed that these have frequently 
a yellowish tinge, probably due to the presence of heemo- 
globin, and hence that they may develop into erythro- 
cytes just as in the embryo, where, he states, the first 
nucleated cells found in the blood-vessels are originally 
colorless. Kd6lliker admitted that no transition stages 
could be satisfactorily demonstrated in the blood, and in 
part attempted to explain this as possibly due to the 
rapidity of the change in certain stages. He supposed 
that the chief acts in the change were the disappearance 
of the nucleus and the modification in shape of the pro- 
toplasm. He further admitted that the large multinuclear 
leucocytes probably did not undergo any such metamor- 
phosis into red blood corpuscles. This theory was sup- 
ported by many observers, and some described the ap- 
pearance in the blood of transitional forms between the 
white and red corpuscles, especially under exceptional 
conditions, in which the rate of formation of red corpus- 
cles might be expected to be increased, as, for example, 
after excessive hemorrhage or in leuksemia; while under 
opposed conditions, such as inanition, these transitional 
forms were said entirely to disappear. Thus Erb claimed 
to have observed certain red corpuscles which contained 
a fragmented nucleus or granules apparently of nuclear 
origin. He supposed that white corpuscles arose in the 
lymphatic glands and spleen and passed into the blood 
stream as small uni-nucleated cells with a scanty cyto- 
plasm. The cell increased in size and then underwent 
two modifications, one of which consisted in the partial 
disappearance of the nucleus by fragmentation, and the 
other in the development of hzemoglobin in the cyto- 
plasm, so giving rise to his observed transitional forms. 
Finally, the cell became somewhat smaller and took on 
the characteristic shape of the blood disc. 

A later theory located the origin of the blood discs in 


Blood, 
Blood, 


the spleen, where they were supposed to be formed endog- 
enously within certain large cells of the splenic pulp. 
This theory rested on the experimental observation that 
within these splenic cells blood discs could be observed 
in various stages of formation; but while this experi- 
mental observation is generally admitted to-day, it is 
taught by many observers that this indicates a destruc- 
tion of effete red blood corpuscles within the organ, and 
not a building up of new ones. The stages of alteration 
within these erythroclastic cells present all the appear- 
ances of degradation in the irregular and broken outline 
of the corpuscles, and not those of new formation. 

The chemistry of the spleen proteids also supports the 
view that there is such a breaking down of hemoglobin 
within this organ accompanied by a conservation of the 
iron-containing portion of the hemoglobin molecule, for 
the spleen is the richest organ of the body in iron-contain- 
ing proteids other than hemoglobin. A similar presence 
of proteids containing iron in the liver, as well as the for- 
mation of the bile pigments which are so closely related 
to hemoglobin, indicates that chemical processes con- 
nected with the metabolism of hemoglobin also occur in 
the liver cells. The fact first demonstrated by Schiifer, 
that the plasma of the splenic vein contains no free 
hemoglobin, shows clearly that the chemical alteration 
undergone by the red corpuscles disintegrated in the 
spleen is a deep-seated one, and not merely a physical 
breaking up of the blood disc as a physiological organiza- 
tion. 

The next important advance in our knowledge of 
the extra-uterine formation of red blood corpuscles was 
made independently and practically simultaneously by 
Neumann and Bizzozero in 1868, by the discovery of 
nucleated red blood corpuscles in great number in the 
red marrow of bone, which closely resemble those found 
in embryonic life, but differ in being present at all stages 
of the animal’s subsequent life. This important discov- 
ery may be said to have completely revolutionized our 
knowledge of the subject, and it is now very generally 
believed that except under very abnormal conditions no 
red blood corpuscles are formed elsewhere than in the red 
marrow of bone, although there are still differences of 
opinion as to the origin of these nucleated erythrocytes 
of the red marrow, as to the way in which they increase, 
and as to the manner and place in which they alter so 
as to giverise to the perfected blood discs. The erythro- 
cytes of red marrow are nucleated cells of very variable 
size which are capable of very active amceboid move- 
ment, but differ from ordinary leucocytes of blood or 
lymph, and also from the other leucocytic elements of 
the marrow itself, in that they are tinged a light yellow 
color in the fresh condition by the presence of hemo- 
globin. These cells undergo division, as was first shown 
by Bizzozero, by karyokinesis, and in this way undoubt- 
edly are largely if not entirely regenerated in the marrow. 
In most sections of red marrow karyokinetic figures are 
easily observed, of which the diaster is the most fre- 
quently occurring form, It is also stated that the num- 
ber of cells undergoing 
such indirect division is 
enormously increased af- /—& 5 
ter severe hemorrhage, so 
illustrating the much-in- 
creased rapidity of forma- 4a 
tion of blood discs. aly 

Howell divides the nu- 
cleated red blood corpus- 
cles into immature cells 
and mature cells, accord- 
ing to the behavior of the 
nucleus toward chroma- 
tin-staining reagents. As 
extreme types he describes those containing in their nuclei 
a network of chromatin showing conspicuous, highly 
staining granules at its nodal points, and those in which 
the nucleus shows no reticular structure whatever, but 
takes a uniform stain as though the chromatin were 
evenly distributed throughout it (see Fig. 510). The 





Fic. 510.—Nucleated Red Corpus- 
cles, Showing the Mature and the 
Immature Forms, the Intermedi- 
ate Stages, and the Colorless 
Erythroblasts. (Adapted from 
Howell.) 


19 


Blood 
Blood. 











latter is the more mature type; in it the nucleus is smaller 
than in the immature type, and, according to Howell, is 
being prepared for extrusion by being situated eccentri- 
cally, or indeed partially extruded. All shades of transi- 
tion are to be found between the typically mature and 
immature types. 

In addition to the nucleated erythrocytes, the red mar- 
row contains other varieties of cells which are interesting 
here because they have been assigned by many observ- 
ers a function as precursors of the nucleated erythrocyte 
stage of development. 

That one of these to which much importance is gener- 
ally attached as a forerunner of the erythrocyte is a leuco- 
cytic cell which cannot be said to differ in appearance in 
any respect from the immature nucleated red cell above 
described, save in that it contains no hemoglobin. This 
type of cell has been described by Osler, Léwit, and 
others, and has been designated, from this supposed func- 
tion, an erythroblast by Lowit. These cells must not 
be confused with ordinary leucocytes of the blood, also 
found in the marrow, and may be distinguished by the 
homogeneous appearance of their cell protoplasm, and, 
according to Léwit, by the fact that they never make 
amoeboid movements nor ingest foreign particles. 

The third type of cell seen in red marrow is what is 
termed the ordinary or proper marrow cell. This is 
somewhat larger than the other cells described above, 
and contains a prominent vesicular nucleus of oval shape 
showing one or two clearly marked nucleoli. In some 
varieties of this cell, according to Howell, the nucleus 
becomes elongated in shape and may be bent horseshoe- 
shape, or may even be coiled upon itself one or more 
times. Other cells, according to the same observer, may 
be detected in which the cell protoplasm is loaded with 
coarse granules. 

In addition to these three types of cell of ordinary 
size the marrow contains a large number of cells pecul- 
iar to this tissue called giant cells; these are huge cells 
with only a single nucleus, which may be either notched 
or elongated and coiled upon itself so as to simulate the 
appearance of a number of nuclei. These cells are said 
by most authors to be different from the myeloplaques 
found near the developing bone, as well as in pathological 
formations under many conditions. The latter are multi- 
nucleated, and when found in bone marrow occur in such 
positions as to make the observer surmise that they are 
connected with bone absorption and accordingly are not 
intrinsic constituents of red marrow. 

Many views are still maintained as to the origin of the 
nucleated erythrocytes of the marrow. One of the most 
important of these is that enunciated by Bizzozero, who, 
as above stated, first drew attention to the frequent oc- 
currence of indirect division in these cells. This ob- 
server holds the view that the cells in question are direct 
descendants of the similar embryonic cells described above 
as occurring in embryonic life, which are carried to the 
red marrow as soon as this begins to develop, and take 
on the hematopoietic functions which were up till then 
taken care of by the embryonic spleen and liver. In the 
red marrow these cells increase by karyokinetic division, 
and in this way replace that fraction of their number 
which is continuously being modified to pass into the cir- 
culation as blood discs. Bizzozero is of the opinion that 
no other mode of origin of nucleated erythrocytes has been 
demonstrated, and that such a mode of origin forms 
an adequate explanation. Accordingly he regards the 
smallest faintly pigmented erythrocyte as the first stage 
toward the formation of the blood disc in the red marrow, 
and considers that the other types of cells present take 
no part in the formation of the red blood corpuscles. 
This view, that the nucleated erythrocytes of the marrow 
form a type which is sw generis, is supported by Schiifer 
and other observers; but probably the majority of writers, 
while not denying that these cells when once formed can 
increase by indirect division, hold with Neumann that 
they originate from non-pigmented cells of the marrow. 
Most of those holding the latter view consider that the 
second type of marrow cell described above is the color- 


20 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





less predecessor of the erythrocyte of the marrow, and 
have described these cells independently under different 
names. L6wit terms them erythroblasts, and deprecates 
the common use of this term to describe their colored 
descendants, which, according to him, should be called 
nucleated erythrocytes. Neumann also objects to the 
term of erythroblasts for the nucleated hemoglobin-con- 
taining cells of the marrow, contending that such a term 
is applicable only to the colorless forms which precede 
them. 

Malassez states that the nucleated red blood corpuscles 
are derived from the proper marrow cells by these giving 
rise first to spherical cells of large size which do not 
readily stain, contain little or no hzemoglobin, and possess 
a very diffuse nucleus. These cells are termed proto- 
hematoblasts by Malassez, and give rise to the nucleated 
erythrocytes by passing through two or three stages of 
alteration in which the cell protoplasm becomes granu- 
lated, and the nucleus at. first enlarges, becomes promi- 
nent and uniformly granular, but later decreases in size 
and shows a reticular structure. At the same time that 
these changes are progressing the cell becomes more and 
more deeply tinted with hemoglobin and takes on the ap- 
pearance of the nucleated erythrocyte. 

Foa and Salvioli express the view that the first stage 
in the formation of the erythrocyte is one type of the 
giant cell, namely, that described by Bizzozero as the 
type with budding nucleus, in which the nucleus is not 
multiple but apparently made up of a convoluted string 
of nuclei still in connection with one another. This giant 
cell, which is termed an heematoblast by these authors, 
breaks up into a number of small hyaline cells by the 
separation of the compound nucleus into its constituent 
buds, each of which has a fragment of the original cell 
protoplasm attached to it. The hyaline cells later change 
to nucleated red corpuscles by the development of hzemo- 
globin. Osler derives the nucleated red blood corpuscles 
from colorless hyaline cells of 9 to 12 u in diameter con- 
taining a finely granular nucleus, which in turn arise from 
small lymphoid elements (2.5 to 5 y“) resembling free 
nuclei but often showing a narrow border of cell proto- 
plasm. A very similar view has been proposed by Obrast- 
zow, who, however, believes that the free nuclei give rise 
both to erythrocytes and proper marrow cells. Accord- 
ing to this author, the erythrocyte contains no nucleus 
in the living state, the apparent nucleus being a post- 
mortem effect. 

Howell combines most of these theories of origin of 
the mature nucleated erythrocyte by describing them 
as different consecutive stages in a rather lengthened 

s course of development. 
We may, following 
this author, probably 
trace the stages in de- 
velopment backward 
as follows: The nu- 
cleated red blood cor- 
puscles differ in struc- 
ture with their age, 
and two extreme types 
may be distinguished 
—one mature and 
ready to be converted 
into a non-nucleated 
corpuscle, and one im- 
mature, as shown by 
the character of the nu- 
cleus and the amount 
of hemoglobin. The 
immature corpuscle 
multiplies by karyokinesis, and the daughter cells sooner 
or later appear as mature nucleated corpuscles. The im- 
mature or young nucleated corpuscles are in turn derived 
from spherical colorless erythroblasts, having a definite 
histological structure and found in the marrow. These 
erythroblasts multiply by karyokinesis. The erythro- 
blasts again are derived from larger embryonic cells, 
usually described in the adult as ordinary marrow cells. 





Fig. 511.—Multiplication of the Nucle- 
ated Red Corpuscles. Marrow of 
young kitten after bleeding. Show- 
ing above karyokinetic division of 
erythroblast, and below the formation 
of mature from immature erythro- 
cytes. (Adapted from Howell.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood. 
Blood, 





In these cells the structure of the nucleus differs from 
that of the erythroblast. The erythroblasts do not arise 
from these larger marrow cells in the same generation 
by a diminution in size, but the marrow cells multiply 
by karyokinesis, and the daughter cells of the first or fol- 
lowing generations acquire the structure of erythroblasts. 

There is also much diversity of opinion as to the man- 
ner in which the nucleated erythrocyte of red marrow 
becomes converted into the characteristic non-nucleated 
biconcave disc of mammalian blood. In fact all possible 
opinions have been presented by the ingenuity of various 
authors between the extremes that the red corpuscles are 
still nucleated, and that they are the nuclei of the nucle- 
ated corpuscles of which the cell protoplasm has disap- 
peared. There is little doubt, however, that the non- 
nucleated corpuscle arises by the disappearance of the 
nucleus in some manner, and we need discuss here only a 
few of the chief ways in which it has been claimed that 
this disappearance of the nucleus is accomplished. 

The earliest view and at the same time that which at 
the present day claims most adherents was originally ex- 
pressed by KG6lliker with regard to the nucleated embry- 
onic erythrocytes, and was later extended by Neumann 
to include those cells discovered by him in the red mar- 
row. According to this view the nucleus is gradually 
absorbed by the cell protoplasm after a previous partial 
fragmentation. “The cells gradually become more and 
more fiattened, and even present slight excavations, 
whilst their nuclei manifestly diminish, and, on the ap- 
plication of acetic acid, exhibit a great tendency to dis- 
integration. Ultimately, the nuclet disappear altogether 
and the blood cells become non-nucleated, like those of 
the adult, of which they all soon assume the form, being 
at first somewhat irregular” (K6lliker). 

Neumann describes the nucleus as becoming smaller, 
more homogeneous, and later notched or indented, in the 
process of disappearing. He also describes certain cells 
containing only one or two granules of nuclear matter 
which he regards as the final stage in the disintegration 
and absorption of the nucleus. Another view which is 
supported by Rindfleisch, Howell, and others is that the 
nucleated cells become non-nucleated by a process of ex- 
trusion of the nucleus. The various authors who hold 
this view differ somewhat as to the manner in which the 
nucleus is expelled. Rindfleisch describes the nucleus 
as escaping from the cell surrounded by a small amount 
of colorless protoplasm, and leaving behind a residue of 
a reddish-yellow color, which is at first somewhat. bell- 
shaped from the escape of the nucleus and afterward 
takes on the biconcave shape of the adult red blood cor- 
puscle. For every red blood disc so formed there is in 
this manner set free in the circulation a colorless element, 
the further fate of which the author leaves unsettled. It 
is possible that it may once more form hemoglobin in its 
cell protoplasm, which may increase in bulk and later 
give birth in similar fashion to a second non-nucleated 
red blood corpuscle. 

Howell, on the other hand, states that the nucleus is 
extruded from the cell in a free condition and he has never 
been able to observe an envelope of protoplasm surround- 
ing it as it escapes. Also free nuclei which have pre- 
sumably been extruded from corpuscles are frequently 
seen in sections and teased specimens of red marrow. 
Howell admits that the homogeneous nucleus of ripe 
erythrocytes of the marrow may often be seen segmented 
or notched as described by Neumann, but as he has also 
seen similarly altered nuclei in the process of extrusion 
he holds that this segmentation does not prove that the 
nucleus disappears by absorption. 

The extrusion of the nucleus can best be seen in teased 
specimens from the red marrow of animals which have 
recently been bled previous to killing and in which, there- 
fore, the rate of formation of blood discs would naturally 
be much increased. All stages can be detected from that 
in which the nucleus has merely an eccentric position up 
to the period when it lies completely outside the cell. 

It is well known that the nuclei are readily pressed out 
from the red blood corpuscles of amphibia after death 











by simple pressure of the cover glass or the action of 
chemical reagents, and Howell points out that the ex- 
trusion of the nucleus in the erythrocytes of the marrow 
cannot be any similar artefact for the following reasons: 
1. The number of extruding nuclei is increased in ani- 
mals which have previously been bled frequently. 2. 
The process of extrusion can be observed with the cor- 
puscles in a perfectly fresh condition as soon as the 





Fig. 512.—Shows the Way in Which the Nucleus Escapes from the 
Nucleated Red Corpuscles. 1, 2, 3, 4, represent different stages of 
the extrusion noticed upon the living corpuscles; @, specimen from 
the circulating blood of an adult cat, bled four times; b, specimens 
from the circulating blood of a kitten forty days old, bled twice; ¢, 
specimens from the blood of a fetal cat, 9 em. long. Others from 
the marrow of an adult cat, two of the figures showing the granules 
present in the corpuscle which have been interpreted erroneously 
as a sign of the disintegration of the nucleus. (After Howell.) 


specimen has been teased out in the animal’s own serum. 
3. Extrusion is seen when the cells have been fixed as 
rapidly as possible either by corrosive sublimate or by 
methyl green solution. 4. All the cells showing extru- 
sion belong to Howell’s mature variety (vide supra), for 
none of the extruding nuclei show any traces of a nuclear 
network. Stillit is stated by Fellner, Osler, and other ob- 
servers that the extrusion of the nucleus is to be regarded 
as a post-mortem change and that such extrusion does not 
occur under normal conditions in the living cell. Malassez 
denies that the nucleated red blood corpuscles lose their 
nuclei at all, maintaining that these retain their individu- 
ality throughout their life, but give rise to the red blood 
discs by a process of gemmation or budding. At some 
portion of the cell the cell protoplasm sends out a bud 
which enlarges, becomes constricted off from the rest of 
the cell, and is finally detached as a globule of heemo- 
globinated protoplasm which afterward takes on the 
biconcave shape of the blood disc. 

With regard to the place of formation of the blood 
discs, it is almost universally admitted that the red mar- 
row of bone is the tissue in which they are produced most 
abundantly. Neumann even maintains that this tissue 
is the only one which yields them, even under most ex- 
ceptional circumstances, for their increased production, 
such as after excessive or oft-repeated blood-letting. 
Other observers, such as Bizzozero, hold that while the 
red marrow is the only seat of production under normal 
physiological conditions, yet other organs may take on the 
function of forming red blood corpuscles under abnormal 
conditions of increased production. Thus, nucleated red 
blood corpuscles have been found in the spleen of the dog 
and guinea-pig if the animals have previously been sub- 
jected to excessive bleeding (Bizzozero and Salvioli). 
Clinical observations also are on record in which it is stated 
that nucleated red corpuscles are found in the blood in 
severe cases of leuksemia or pernicious anzemia (Osler and 
Gardner). Howell has also observed a recurrence of the 
hematopoietic function of the spleen with regard to red 
blood corpuscles after excessive bleeding, although nor- 
mally no nucleated red blood corpuscles are present in that 
organ. 

Loéwit and one or two other observers claim that both 


21 


Blood, 
Blood, 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





spleen and lymphatic glands are to be looked upon as 
blood-forming organs in addition to the red marrow. In 
all of these organs, according to Lowit, two kinds of 
colorless cells may be recognized which he terms “ leuco- 
blasts” and “erythroblasts” respectively, because the 
former give rise to the white and the latter to the red 
blood corpuscles. These two types of cell are distin- 
guished by differences both in the action of their nuclei 
toward staining reagents, and in the mode of their divi- 
sion in reproducing new cells; also no intermediate forms 
between the two can be observed, showing them to be dis- 
tinct types. The leucoblasts possess a prominent nucle- 
us which contains one or more nodules of chromatin, 
usually of irregular outline, connected by delicate threads 
to the nuclear membrane. The after-fate of these is con- 
sidered under development of white blood corpuscles. 
Division takes place by a movement of the chromatin 
granules from the equator toward the poles which Léwit 
proposes to call divisio indirecta per granula, to distin- 
guish it from the true karyokinetic division which takes 
place in the erythrocyte and which he terms divisto per 
jila. The erythroblasts have a network of chromatin in 
their nucleus, and divide by ordinary karyokinesis; they 
never show amceboid movement nor ingest foreign parti- 
cles; finally they develop hemoglobin in their cell sub- 
stance and so become nucleated erythrocytes. 

In the marrow of bone always, and in the spleen under 
certain conditions above alluded to, transition stages may 
be observed, but in the lymphatic glands no intermediate 
forms between erythroblast and nucleated erythrocyte 
are ever to be seen, and hence Lowit supposes either that 
the transition in this latter case takes place in the lymph 
or blood stream or in both, or that the erythroblasts 
formed in the lymphatic glands are carried to the marrow 
and there undergo the final change into nucleated erythro- 
cytes. Lowit further holds that a great number of the 
erythroblasts enter the blood stream from the spleen and 
lymphatic glands in a colorless condition, and are in the 
blood stream itself rapidly converted first into nucleated 
and later into non-nucleated erythrocytes. The two 
types of cells above described have also been observed 
subsequently by Denys and by Gibson, and the latter 
writer claims to have observed nucleated red blood cor- 
puscles in the mesenteric lymphatic glands after ligature 
of the thoracic duct. Denys states that in the marrow 
of birds which has been double stained with fuchsin and 
methyl green, the nuclei of the erythroblasts stain green 
while those of the leucoblasts stain red. As a result of 
this distinctive staining the important fact is brought 
out that the two types of cell are not indiscriminately 
mixed, but that the erythroblasts occur in cords or strings 
forming the capillary portion of the vascular system of 
the marrow. A delicate endothelial wall marks off the 
cord of erythroblasts from the surrounding mass of leuco- 
blasts. 

Some observers state that red blood corpuscles develop 
in bone and cartilage, and particularly in the line of 
ossification between the growing bone and its hyaline car- 
tilage, but this has again been denied by Neumann and 
others. Winogradow states that nucleated red corpuscles 
form in the lymphatic glands of the dog after spleen ex- 
tirpation, but this result also has failed to obtain confirma- 
tion at the hands of other workers. Quite a different 
theory to all these is that supported by Hayem, in that 
it ascribes the origin of red blood corpuscles to the blood 
platelets or “elementary particles” of Zimmermann in- 
stead of the nucleated erythrocytes. This view was orig- 
inally suggested by Zimmermann, but has been worked 
out in detail by Hayem, who has given more attention to 
the blood platelets than any other worker on the subject. 
Hayem describes the blood platelets as young red blood 
corpuscles and terms them hzmatoblasts. Certain of 
them, according to his description, are similar in shape to 
the biconcave discs, and possess a greenish tint from the 
presence of hemoglobin. He claims to have observed 
intermediate forms between the typical blood platelet 
and the typicalred blood corpuscle, and states that these 
transitional forms are greatly increased in number after 


22 





severe hemorrhage when a more rapid regeneration of 
corpuscles is presumably taking place. Under such’ cir- 
cumstances the blood platelets may increase so greatly 
in amount as to outnumber the red corpuscles. 

There is also much difference of opinion as to the man- 
ner in which the blood platelets are formed. Pouchet, who 
supports Hayem’s view that the red blood corpuscles are 
formed from the platelets, supposes that the platelets are 
either extruded from the white blood corpuscles as “ polar 
bodies” or that they arise as concretions in the plasma. 
Gibson describes two varieties of platelet under the 
names of colorless and colored “microcytes.” The for- 
mer he supposes to be derived from the extruded nuclei of 
both nucleated red corpuscles and white corpuscles, and 
the latter (which he regards as identical with Hayem’s 
hematoblasts) he supposes arise from fragmentation of 
mature blood discs in some manner in the circulation. 
Howell denies that the extruded nuclei of the erythro- 
cytes give origin to blood platelets, showing that during 
the period that they persist in the blood as morphological 
elements, they stain quite differently from the blood 
platelets. It is probable, according to this author, that 
the extruded nuclei of the red blood corpuscles dissolve 
in the plasma, and possibly increase the percentage ot 
fibrinogen therein. With regard to the origin of the 
blood platelets, Howell supports the view that they are 
the final products of disintegration of the multinucleated 
leucocytes, by drawing attention to the close resemblance 
between well-preserved blood platelets and the frag- 
mented nuclei of the multinuclear leucocytes as far as 
size, shape, and general appearance are concerned. The 
resemblance is increased by the appearances noticed in 
the blood of an animal after frequent bleeding. Here 
blood platelets may be observed containing one or more 
deeply staining granules which closely resemble the 
chromatin granules of the nuclei, and are probably the 
result of too rapid expulsion of the nucleus on account 
of the increased activity in the blood connected with re- 
generation. The blood platelets further stain similarly 
to the nuclei when subjected to the action of multiple 
staining. Howell suggests that such disintegration of 
corpuscles within the plasma may have an important 
function in the regeneration of the proteids of that fluid. 

It is almost universally agreed that the lymphocyte is 
the youngest form of leucocyte found in the blood. The 
lymphocyte is so termed because it is believed that it 
originates in lymphoid tissue and is added to the blood 
in the lymph stream. 

The fact that the number of lymphocytes in the lymph 
is largely increased after its passage through a lymphatic 
gland, as well as the presence of immense numbers of 
similar cells in the lymphoid tissue, demonstrates that 
lymphocytes are formed in the lymphatic glands and are 
continuously carried away by the lymph and added to 
the circulating blood. Also in the blood white corpuscles 
are to be found which differ in no respect from these 
lymphocytes of the lymphoid tissues, and between these 
and the other varieties of leucocyte transitional cells are 
to be observed, so that there can be little doubt that all 
the other forms are stages in the further development of 
the lymphocyte. 

Most observers also hold that leucocytes are formed in 
the spleen and red marrow in addition to the lymphoid 
tissues. Lo6wit describes the leucocytes as arising from 
certain cells in these tissues which he terms leucoblasts. 
The general characteristics which distinguish these from 
erythroblasts have already been stated; it may be added 
that Léwit describes the leucoblasts as entering the 
lymph stream and eventually reaching the blood as uni- 
nuclear leucocytes which are rather small and are devoid 
of the power of making ameboid movements. In the 
blood stream they increase in size while the nuclei take on 
the form seen in the polymorphonuclear cells; ultimately 
multinuclear leucocytes arise from these as a final stage 
which is followed by the disintegration and solution of 
the corpuscle. L6wit believes, from estimations of the 
relative number of the different forms of leucocyte in 
the blood coming from the blood-forming organs, in the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





right and left heart, and in the peripheral arteries, that 
the transition from the lymphocyte to the other forms 
takes place rapidly in the venous blood before reaching 
the left heart. Flemming and a great many other work- 
ers hold, in contradistinction to Léwit, that multiplication 
of the leucocytes takes place by a true mitotic division. 
It is certain also that the eosinophile cells of Ehrlich 
exhibit karyokinetic figures while undergoing division. 
Bannworth has described cells possessing all the proper- 
ties of Léwit’s leucoblasts, as undergoing karyokinetic 
division in the spleen pulp. 

The life history of the leucocyte may then probably be 
described as follows: It arises from leucoblastic cells in 
lymphoid tissue and probably also in the splenic pulp 
and red bone marrow, and reaches the blood as a small 
cell, with a prominent vesicular nucleus surrounded by 
a trace of cell protoplasm. This variety of leucocyte is 
incapable of amceboid movement, but gives rise in process 
of growth to a large cell which is ameeboid, and is further 
characterized by possessing a large envelope of finely 
granular protoplasm around its nucleus. In some 
varieties of this stage the granules in the cell protoplasm 
are more conspicuous than in others. The next develop- 
ment takes place by an alteration in the nucleus, which 
is no longer spherical or oval but drawn out into a strap 
or horseshoe shape, or indeed coiled or folded upon itself 
so as in some cases closely to resemble a multiple nucleus. 
This gives rise to the polymorphonuclear cell, which is 
still capable of amceboid movement, and which by frag- 
mentation of the complex nucleus gives rise to the multi- 
nuclear leucocyte. 

The earlier view was that the polymorphonuclear and 
multinuclear leucocytes were those in process of cell divis- 
ion, but itis now more commonly believed that the nucleus 
in these cells is undergoing fragmentation previous to the 
disintegration of the cell. Benjamin Moore. 


The following references will be found to furnish a key to the source 
of most of the statements given in this article: 


Bizzozero: Ueber die Bildung der rothen Blutkérperchen. Virchow’s 
Arch., Bd. xcy., 1884, Sn. 26-45. 

Briickner : Neuere Arbeiten aus dem Gebiete der Physiologie und 
opto tog des Blutes. Schmidt’s Jahrbiicher, Bd. eclv., 1897, S. 


Hayem: Du sang et de ses altérations anatomiques, Paris, 1889. 

Howell: The Life History of the Formed Elements of the Blood, es- 
peciaty ve Red Blood Corpuscles. Journ. of Morphology, vol. iv., 
pp. d/- 

Léwit: Die Anordnung und Neubildung von Leukoblasten und 
Erythroblasten in den Blutzellen bildenden Organen. Arch. f. 
mikr. Anat., 1891, Bd. xxxviii., Sn. 524-612. 

Léwit, Minkowski, u. Andere: Verhandlungen des Congresses f. inn. 
Med., xviiter Congress, Wiesbaden, 1899, Sn. 184-213. 

‘Neumann: Ueber Blutregeneration und Blutbildung. Zeitsch. f. klin. 
Med., Bd. iii., 1881, S. 411-449 

Oppel: Unsere Kenntniss von der Entstehung der rothen und weissen 
Blutkérperchen (zusammenfassendes Referat). Centralblatt f. allg. 
Path. u. path. Anat., Bd. iii., 1892, Sn. 193-217 u. 241-259. 


Schafer: In Quain’s Anatomy, tenth edition, 1893, vol. i., pt. ii., pp. . 


216-221 and 265-267. 


BLOOD, NORMAL.—The blood would seem to con- 
form to the general definition of a tissue, in that it is 
composed of a cellular and an intercellular substance. 
It differs, however, from any other tissue of the animal 
body in the fact that the intercellular substance is a 
fluid, and that it is a moving substance propelled by the 
beat of the heart throughout a system of closed tubes; it 
also, perhaps, contains a greater variety of morphologi- 
cally and physiologically dissimilar elements than any 
other tissue; the blood, or its congener the lymph, is 
found in all structures, affording nourishment to them 
and taking in their waste products in return. There is 
no passage of morphological constituents from the gen- 
eral tissues into the blood as may sometimes occur from 
the blood to the tissues, as during diapedesis. 

According to the same standard, the lymph would seem 
to come within the limits of the definition, although it is 
poorer in cellular elements. Whether certain of the 
semi-fluid secretions, such as the orchitic and mammary 
during the colostrum period, might come within the 
range of this definition, we may perhaps regard as un- 
settled, although it is a question if the fundamental pro- 


Blood, 
Blood, 


cedure is not analogous when we consider the relation- 
ship of the leucocytes to the lymph glands and that of 
the red corpuscles to the bone marrow and certain other 
organs. 

The total number of cells in the body has been esti- 
mated by C. Francke* to be 26,500,000,000,000, of which 
4,000,000,000,000 are fixed cells, while the cells in the 
blood are not fixed, and according to the best calculations 
these amount to 22,500,000, 000, 000, So that the cells in 
the blood, which are small, outnumber those of the other 
tissues (some of which, for example the muscle cells, are 
relatively immense) about five and one-half times. 

Blood in general has for its functions (a) the convey- 
ance of nutritious material to all parts of the body, (0) 
to remove waste products from the tissues, (¢) to carry 
oxygen for tissue (or internal) respiration, and (d) to 
equalize the temperature of the body. 

COLOR AND CONSTITUENTS.—Blood has the appearance 
of a red, slightly viscous fluid, this effect being due to the 
suspension of innumerable microscopic bodies, the red 
corpuscles or erythrocytes, in a clear yellowish fluid, the 
plasma or liquor sanguinis. In addition to the red cor- 
puscles, but much less numerous, are the white corpus- 
cles or leucocytes. <A third element is the blood platelet, 
a small discoid colorless particle, demonstrable micro- 
scopically in freshly drawn blood. There may also be 
blood granules of different kinds, considered as trans- 
formation products of the formed elements. 

The color of arterial blood is a bright red, that of the 
veins is darker or of a bluish-purple tint. This differ- 
ence is due to the relative amount of oxygen or carbon 
dioxide present. Arterial blood furthermore differs from 
venous in that it possesses more O, less CO., more ex- 
tractives, more salts, more sugar, less urea, and is usually 
warmer. 

Arterial blood becomes dark when respiration is im- 
perfect, for example, in the foetus, during anesthesia by 
chloroform, when the trachea is compressed, and in in- 
dividuals when submitted to a high temperature (which 
reduces the excretion of COz). Venous blood is rendered 
brighter in animals which have been made to breathe 
pure oxygen, or when poisoned by carbon monoxide gas, 
in blood leaving glands in a state of secretory activity 
or muscles in a state of rest (Bernard), and in hibernating 
animals. 

In the pulmonic circulation the arteries normally con- 
tain dark, and the veins bright red blood. 

Ovor.—Blood has an odor which differs in man and 
animals. This is thought to be due to the presence of 
certain volatile acids. If concentrated sulphuric acid be 


_added to blood it liberates these acids from their com- 


binations with alkalies, and the characteristic odor is 
more perceptible. 

TastE.—Blood has a saline taste, due to the various 
salts dissolved in the plasma. 

TEMPERATURE.—Blood varies normally in its tempera- 
ture from 36.5° to 37.8° C. (97.7° to 100° F.). It varies 
also in different parts of the body. The warmest blood 
in the body is in the hepatic vein. The blood of the 
left is cooler than that of the right ventricle, because as 
it passes through the lungs it is cooled by the inspired 
air. The blood of the skin is also slightly cooler than 
that of the viscera. In the arteries, however, it is, as a 
rule, slightly warmer than in the corresponding veins. 

Amount.—The amount of blood in the body has usu- 
ally been determined by drawing a measured amount, 
defibrinating it, and diluting portions of it in differing 
degrees for later comparison. The rest of the blood is 
then collected and defibrinated, and the vessels washed 
out with salt solution until the solution comes out color- 
less. The washings are added to the collected blood, and 
this is further diluted until it corresponds in tint to one 
of the previous samples of known dilution. The total 
quantity of blood in the vessels can then be calculated. 
In addition to this the whole body can be minced inte 
fine pieces, extracted with water to get any blood that 





* ** Die menschliche Zelle,’’ 1891. 


23 


Blood. 
Blood. 


may sti‘! remain in the tissues, and this also be added to 
the mass of blood. Some hemoglobin, however, is yielded 
by the muscles. 

Another method, used by Gréhant and Quinquand, is 
to determine the amount in the living animal. A meas- 
ured amount of carbonic oxide (mixed with oxygen) is 
inspired. A measured amount of blood is then drawn 
off and the amount of carbonic oxide in this quantity is 
determined. The amount of the gas in the total blood 
of the body would be in the same proportion as in the 
sample, from whence the whole amount of the blood can 
be calculated. 

From these methods it is estimated that the blood is 
equal to from one-eleventh to one-fourteenth of the body 
weight (about 12 pounds in a man weighing 154 pounds). 

In the newly born child the amount of blood is esti- 
mated at one-nineteenth of the body weight. This pro- 
‘portion will vary, however, according to the time of 
ligaturing the umbilical cord. 

The amount of blood in different organs may be esti- 
mated by quickly tying their blood-vessels tntra vitam. 
An aqueous extract of the minced organ is prepared 
and the quantity of blood estimated as previously de- 
scribed. A rough approximation of the division of the 
blood in the body by this method gives one-fourth to 
the lungs, heart, and large blood-vessels, one-fourth to 
the skeletal muscles, one-fourth to the liver, and the 
remaining one-fourth to the other organs. 

Less blood will be obtained from a fasting animal than 
from one which ‘has digested a hearty meal. This fact 
is probably one of the causes of the discrepancies in the 
figures given by different investigators. 

Reaction.—The alkalinity of the blood may be recog- 
nized in spite of its red color by applying a drop of it 
to the surface of glazed litmus paper. Or still another 
method is to soak a strip of ordinary litmus paper in salt 
solution and allow it to dry. Apply a drop of blood to 
this and it will be found that the substance upon which 
the alkalinity depends will diffuse itself around the drop 
and give the characteristic color to the litmus. 

To the presence of the carbonate and phosphate of 
soda is attributed the alkaline reaction. This is un- 
doubtedly true for the plasma, but it is questionable if 
these salts account for it in the corpuscles as well, where 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





alteration. It is also diminished after withdrawal, and 
during the process of coagulation. The alkalinity is also 
decreased in fever and in many diseases. In diabetic 
coma and in the cold stage of cholera an acid reaction 
has even been detected. The decrease in alkalinity is 
accompanied by a diminished amount of carbonic acid 
in the blood. The acid reaction frequently occurring in 
menstrual blood may be due to the uterine mucus and 
vaginal acids. 

SPEcIFIC GRAvITy.—The specific gravity of normal 
blood varies within small limits. For men it ranges ~ 
from 1.057 to 1.066; for women from 1.054 to 1.061. Itis 
slightly less in children than in adults, but is higher in 
the foetus than in the mother; it is highest in the child at 
term, in which it is 1.066, while that of the maternal 
blood is then only about 1.050. In the ox and dog it is 
about 1.066. In a given case in a man in whom the 
specific gravity of the blood was found to be 1.060, the 
corpuscles gave a specific gravity of 1.088* and the 
plasma, 1.081. 

The specific gravity of the blood is lowered slightly 
when much fluid is ingested, and increases somewhat 
after profuse perspiration. It varies also according to the 
part of the body from which it is taken, subject perhaps 
to accidental admixture with lymph. Blood from the 
finger has been found to be slightly lower than that ob- 
tained from the skin over the shin. 

The variations in age and sex are closely related to the 
variations in the amount of hemoglobin. The specific 
gravity of blood from an artery is nearly the same as 
that from the corresponding vein. 

The blood of birds has a higher specific gravity than 
that of mammals, and there has also been noted in the 
latter slight variations in different species. 

The method commonly used for determining the 
specific gravity of blood is known as: Roy’s method; it 
consists in transferring minute drops of blood to a mix- 
ture of glycerin and water, or some similar mixture 
which is mixed in varying proportions to form a series 
in which the specific gravities are known. The mixture 
in which the drop of blood neither rises nor falls gives 
the specific gravity of the biood. 

The analysis of blood as given by Hammarsten follows, 
1,000 parts being taken: 





















































PIG BLOOD. Ox BLOoD. HORSE BLOOD. || DoG ‘BLOOD. re chap ce HOY ee 
24°52 do 32 ns fhe 33. Sep Ila 3 acco in 32 jo [lo Be Fe) 
gade| £5 ||Eege| Bs |/Sede| Ba Begs] ce | 2282) 22 |[Eess| 88 
BSoS| $8 ||ms?S| ZS |aese] SF |lms°s| 5 | mses | SR |lss?s| SS 
Water oot. . covers cuinemcn et 272.20 | 518.36 192.65 | 616.25 243.87 | 551.14 || 277.71 | 514.80 349.69 439.02 || 272.56 | 551.99 
Solids. carats wccseu ceieee evans 162.89 46.54 132.85 58.2 153.84 | 51.15 || 165.10 | 42.89 163.33 47.96 || 128.68 | 51.77 
Hzemoglobin.......+ssseeee 142.20 leas eee 1GSA10 Fi eee 125 OMe neetoets 1456 orem 
Proteld ix acstevceseienenesas 8.35 38.26 20.89 48.901 20.05 | 42.65 2.36 | 34.05 
SUP AIH 2 wie tiaccwevesice lois ere wisjereral An jeceieiarere Hee lll A oaar E708 wile sisterctece SOOT awecsiets 74 Organic 
OhOlesterinigndaveseiatemesetele 213 OL 1.100 835 26 31 -56 7 bodies 
Tecithin sive. see teh bette be 1.504 805 1.220 1.12 1.93 1.05 1.02 98 159.59 120.13 | 46.70: 
Patvec.)G ok coe eee cous nelle TOG Geant. HBO aaiitieete ees ABO NMR erpcleters 91 
Hatty Qld’ cs aonma cc sacriastes 027 4 OT eel | encsrieraite |e Oh Sse 2 a; sal | Leste 7 Inorg: 
Phosphoric acid as nuclein . 0455 0123 0178 -0089 5 OL -05 01 3.74 4.14 3.55 5.07 
SOUR idan ches ehleoammerine : 2.401 1266} 2.9084 || ...... 2.62 1.27 2.39 24 1.66 65 1.92 
Potash macarcteiiva aebrast alts 2.157 152 2351 1719 1.32 15 Ais 14 1.59 15 1.41 20 
TLOMPOMIGS Wire arenes ite easels t= 606 Fl Since vec TD44 mal metarelerss OO Wartevernuece tat 
Tae! tics: 5 niece caine wae wiastat | Meare cree 0680 lenis SOBOD || eset. LOT Ae oe 06 
Magnestars cccsicsclenies onsisies 0656 0233 -0056 -0300 04 -08 -03 03 
OhOvING: 5 tew se paetiaee 642 2.048 -5901 | 2.4889 18 2.20 .60 2.31 90 1.72 36 14 
Phosphoric acid ............ 8956 -1114 2092 1646 15 67 14 
Inorganic PaO gens neem 7194 0296 1140 .0571 76 05 54 .05 











it is probably due to the presence of organic substances 
of a weak basic nature. 

Saturation of the blood with carbonic acid causes the 
corpuscles to become less, and the plasma more alkaline. 

The alkalinity of the blood seems to vary during the 
day, being lowest in the morning and gradually rising in 
the afternoon, and becoming lower again in the evening. 
It also rises during digestion. Muscular work diminishes 
it, especially if there is little or no proteid in the diet; 
while with a diet rich in proteids there is very little 


24 








RED Bioop CorpuscLes.—Swammerdam in 1658 was 
the first to discover red blood corpuscles in the frog. 
Malpighi in 1661 was the first to describe them in a mam- 
mal (hedgehog), and in 1673 Leeuwenhoek demonstrated 
their presence in man. 

Red blood corpuscles differ in shape and size in differ- 
ent groups of animals. In all mammals they are non- 
nucleated in the adult. With the exception of the camel 


* The specific gravity of the red corpuscles is usually given at 1.105, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood. 
Blood, 


a a a a a a a a eee 


family, in which they are of eliliptical form, they present 
a circular outline and are biconcave. In birds, reptiles, 
amphibia, and fish they are nucleated, elliptical, and bi- 
convex. Anexception to the elliptical form is noted in the 





Fic. 513.—Red Blood Corpuscles of Different Vertebrate Animals. 
from Boehm and yon Davidoff.) X 1,000 diameters. 


deer. 


Marsipobranchii, as represented by the lamprey eel, in 
which they are circular but nucleated. In man the aver- 
age diameter is between 7 and 8 microns and 1.9 microns 
thick at the edge; in the frog the long diameter is about 
22 microns; in the Proteus about 60 microns, while in 
the Amphiuma, where the corpuscles can be distin- 
guished with the unaided eye, the long diameter is 
about 80 microns. 

The relatively larger size of the corpuscles in the so- 
called cold-blooded animals than in mammals is an in- 
teresting fact, and has served as a basis for some investi- 
gations to determine the effect of climate upon the size 
of the corpuscles of the inhabitants. Evidence on this 
point is conflicting. According to Hamilton the meas- 
urements of the corpuscles of representatives of the fol- 
lowing nationalities gave the subjoined list. 





Mars eccinsctanie ee csie dsiesitier ceeeistee) <<< (4.0-1.0 microns, 
MORSTICIE 4 ccclereiece ovina. sie ADDO DUCR ECO GORO LMR teat ali #5 
Germans ...-. m ctepsvalereloe ein ne tare nate Bereetecayaye 7.8 ty 
Norwegians..........++- don sto bb Bsoanenndogn 8) aes 


Differences in size, as reported by different observers, 
are probably due to different standards of measurement. 
Parker, taking the average measurement of 500 cor- 
puscles, obtained the following results: 


Italian, seventeen years Old ......-+---+.... +e.» 4.79 microns. 
American girl, seventeen years Old ......-..+-+ A a 
Girl from Finland, twenty-five years old........ 7.89 = 
MISQMIMAUX CITT oe aie ees cee ven s ows pitese er eeitoas 8.07 -s 


It is interesting to note that the measurement of the 
corpuscles of the girl from Finland is less than that usu- 
ally given for Norwegians, although she came from a 
higher latitude. 

The specific gravity of the red corpuscles, usually given 
at 1.105, is susceptible to variation according to osmotic 
currents between the corpuscle and the plasma, the cur- 
rents being determined by the composition of the plasma. 
One cubic millimetre of blood contains .000397 gm. of 
moist red corpuscles; 1 litre, 397 gm.; and an adult man 
having 5 litres of blood in his body has nearly 2 kilo- 
grams (4.4 pounds) of red corpuscles. The total mass of 
red cells in 5 litres of blood, in round numbers, is put at 


(Welker’s models ; 
a, From Proteus (salamander) ; 
b, from the frog; c, froma lizard; d, from asparrow; e, from acamel; f and g, from 
the human being; h, from myoxus glis (dormouse) ; 7, from a goat; k, from the musk- 


25,000,000,000,000. The total length of these cells would 
be in the neighborhood of 175,000 kilometres (109,370 
miles), more than four times the circumference of the 
earth (Viault et Jolyet). The total surface of the cor- 
puscles (including the two faces and 
edges) would be equal to 2,816 square 
metres (more than half an acre). This 
immense amount of surface is exposed 
to and absorbs oxygen as the blood cir- 
culates through the lungs. This oxy- 
gen-absorbing surface decreases in dif- 
ferent animals, other things being equal, 
with the size of the corpuscle. It di- 
minishes from the mammals to the ba- 
trachians. 

The elasticity of the corpuscle is feeble 
but perfect. It permits these cells to 
pass through capillaries narrower than 
their own diameter, and later to regain 
their original form. They have, how- 
ever, no inherent power of contractility, 
except, perhaps, in the embryonic con- 
dition. Carbon dioxide causes them to 
lose their elasticity and distorts them. 

The property of adhesion of the cor- 
puscles, already recognized by Hewson 
in 1770, refers to the arrangement of the 
corpuscles in rouleaux. It occurs either 
in blood drawn from the body, or in blood 
stagnant in the vessels. This phenome- 
non appears to be due to a beginning 
alteration in the structure causing a 
greater viscosity of the surface of the 
corpuscle. 

In blood drawn from the vessels the 
corpuscles change their form quite rap- 
idly on-account of the exosmosis of their salts, becom- 
ing quite markedly crenated. Cold, heat, electricity, 
water, and various chemical reagents cause this change. 
Bile and the biliary salts render 
the corpuscles pale and_ later dis- 
solves them (Kiihne). Urea acts 
similarly. Urine acts like saline 





Fig. 514.—Red Blood 
Corpuscles of Man. 
a, Surface view of 
normal corpuscles ; 





Fig. 515.—Crenated Blood Corpus- 


b, edge view. (After cles (Human). X 1,500 diam- 
Boehm and yon Da- eters. (After Boehm and von 
vidoff.) Davidoff.) 





Fig. 517.—Red Blood Corpus- 
cles (Human) as They Appear 
After They have been Subject- 
ed to the Influence of Water. 
xX 1,500 diameters. (After 
Boehm and von Davidoff.) a, 
swollen, but with color still 
retained ; b, swollen and de- 
colorized __(** blood-corpuscle 
shadows ’’). : 


Fic. 516.—Blood 
Corpuscles (Hu- 
man) in Rou- 
leaux, like 
pieces of coined 
money. X 1,500 
diameters. (Af- 
ter Boehm and 
yon Davidoff.) 


solutions, causing the corpuscles to swell and dissolving 
their coloring matter, making it difficult to see them. 

In some cases the serum from an animal from a differ- 
ent species causes swelling, distortion, and destruction of 
the red corpuscles. In the transfusion of blood from one 
animal to another of a different species there is quite 
likely to occur a reciprocal destruction of the transfusing 
and transfused corpuscles. 


25 


Blood, 
Blood, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








Two views exist as to the structure of the red cor- 
puscle: that of Rollet, in which it is believed that a 
spongy and elastic framework or stroma exists holding 
the hemoglobin; the other is that revived and main- 
tained by Schiifer, namely, that the corpuscle consists of 
a delicate but resistant external envelope enclosing colored 
fluid contents, or, in other words, a solution of hemo- 
globin. 

The corpuscles are at times subjected to considerable 
pressure and often become markedly distorted. They 
are, however, remarkably elastic bodies, and it is due to 
this physical property of the stroma or envelope that the 
normal shape is regained. 

The organic matter in one hundred parts of dried 
blood is as follows: 











Human. Dog. Goose. 
Proteids and nuclein.......... .... 5.10-12.24 12.55 36.11 
HeMoglopinwicaseeah pom tees ele eis ..| 94.30-86.79 |. 86.50 62.25 
Lecithin 4 Rcigdnceeh wolgcere se ates ac) OD meal 59 46 
Gholesterin asco sar eee ease ee ureme A 25 386 48 


The higher percentage of proteids in the goose’s blood 
is due to the included nuclein, which is usually the case 
in nucleated red corpuscles. 

The mineral constituents vary greatly in different 
species of animals. In man potassium constitutes 40.89 
per cent. of the total ash of the red corpuscles and sodium 
only 9.71 per cent. In the dog the percentage of potas- 
sium is 6.07 and of sodium 36.17. In the plasma there 
is a large excess of the sodium over the potassium salts. 

Origin and Fate of the Red Corpuscles.—A corpuscle, 
like the body itself, has an allotted time of activity and 
then disintegrates. All red corpuscles, even of mam- 
mals, are nucleated at a certain period of development. 
In the human feetus at about the fourth week, all of the 
red corpuscles possess nuclei. These corpuscles gradu- 
ally diminish in number, however, until at birth they 
have nearly or quite disappeared. The nuclei are ex- 
truded or absorbed and the non-nucleated condition 
characteristic of adult mammals appears. In the rat, 
which is born in a somewhat immature state, many of 
the red corpuscles may be found to be nucleated for 
a short time after birth. The first corpuscles formed 
in the embryo (chick, guinea-pig) are entirely outside 
the body. Even 
before the heart 
has begun to beat 
there are certain 
mesoblastic cells 
in a zone, the 
“vascular area,” 
around the em- 
bryo, which send 
out long, anasto- 
mosing processes, 
soon assuming a 
hollow form—the 
capillary blood 
vessels. At the 
same time groups 
of nuclei, formed 
by the division of 
the original nu- 
clei of the cells, 
assemble at the 
nodes of the net- 
work. There isa 
bit of protoplasm 
around each nu- 
cleus, which soon 
develops hsemo- 
globin in its sub- 
stance, and the newly formed corpuscles float away in 
the newly developed vessels. 

Later on, during embryonic life, the nucleated cor- 
puscles seem to be developed, in part at least, in the 





Fig. 518.— Developing Capillary Blood-Vessels 
from the Tail of a Tadpole. (After Klein.) 
v, Capillary vein with clumps of pigment in 
the wall; a, nucleated protoplasmic sprout ; 
1, solid anastomosis between two neighbor- 
ing capillaries. 


26 








liver, spleen, red bone marrow, and the blood, by divi- 
sion of the nucleated corpuscles themselves. 

After birth the chief seat of development of the red 
corpuscles in mammals seems to be the red marrow of 
the bones of the skull and trunk and of the ends of the 
long bones of the limbs. The formation of red cor- 


Fic. 519.—From the Bone Marrew of the Dog. X 1,200times. 
Boehm and yon Davidoff, after H. F. Miiller.) 
lymphocyte; c, leucocyte with acidophile granules; d, non-nucle- 
ated blood corpuscle; e, nucleated red corpuscle in the act of divid- 
ing; f, nucleated red corpuscle. 


(From 
a, Mastzelle; b, 


puscles is also known under the name of hematopoiesis. 
In this marrow there are special nucleated, feebly amae- 
boid cells, originally colorless, which multiply by karyo- 
kinesis, and are transformed by various stages into the 
ordinary non-nucleated red corpuscles, which are washed 
away in the blood stream. Such blood-forming cells 
have received the name of erythroblasts or hzematoblasts. 

The loss of the nucleus and the fact that hemoglobin 
is the parent substance of the bile and urinary pigments, 
and that these pigments are constantly being excreted, 
render it certain that the life of the red corpuscle cannot 
be a long one. Just how long this life is, and where and 
how the corpuscles go to pieces, has not yet been fully 
determined. 

It has been suggested that the spleen is especially con- 
cerned in this destruction from the fact that a certain 
amount of iron is found there, and that in histological 
preparations of teased spleen tissue certain large cells 
have been found which contain red corpuscles in various 
stages of disintegration. It has been supposed that the 
large cells have ingested the red corpuscles, presumably 
selecting those which are ina weakened condition. Some 
hold, however, that this may be a post-mortem phe- 
nomenon, because, since the blood flow has stopped, the 
corpuscles lie at rest, while the amceboid movement of 
the leucocytes continues—a state of affairs which would 
be favorable for ingestion. Still more important is the 
fact that complete removal of the spleen does not seem 
materially to lessen the normal destruction of the cor- 
puscles. 

Turning to the liver, in which the bile is formed, it is 
noteworthy that although no iron is found in the bile, 
there is an abundance of it in the cells of the liver. It 
would seem, therefore, that the iron must be removed 
from the hemoglobin, or one of its derivatives, by the 
liver cells, and the pigment material carried away by the 
bile. It would appear that although the corpuscles are 
destroyed in the liver to a considerable extent, they may 
meet a like fate in the spleen, in the red bone marrow 
under some pathological conditions, and even in the blood 
itself. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





It is interesting to note that some of the organs in the 
adult, which are concerned in the destruction of the cor- 
puscles, have a totally opposite action in the embryo— 
being then the seat of their origin. 

Number of Red Corpuscies.—The average normal num- 
ber of red corpuscles in the adult male is commonly 
given at 5,000,000 per cubic millimetre; in the female, 
at 4,500,000. There are, however, numerous normal con- 
ditions which increase or decrease this number. It varies 
in individuals with the constitution, nutrition, and 
manner of life; age is also a factor, the number being 
greater in the foetus and newly born child; there isa 
decrease after meals. In the female, the number varies 
in menstruation and in pregnancy, being somewhat in- 
creased in the former and diminished in the latter. The 
influence of high altitudes in increasing the number of 
corpuscles is an interesting fact. Ithas been shown that 
a residence of two or three weeks in high mountains will 
cause an increase in the blood of from 2,000,000 to 
3,000,000 corpuscles per cubic millimetre. It would 
seem to follow from this that a diminished pressure of 
oxygen in the atmosphere stimulates the corpuscle-form- 
ing tissue to a greater activity. The diminution in 
oxygen pressure probably results in a diminished oxy- 
gen supply to the tissues, including the red marrow, 





Jn mann  €. 


Fig. 520.—Diagram Showing Relation of the Solid Portions of the Cir- 
culating Blood to the Walls of the Blood-Vessel. (After Eberth and 
Schimmelbusch.) «a, Blood plaques or third corpuscles; b, red cor- 
puscles ; c, white corpuscles. 


and as a consequence the hematoblasts are stimulated to 
greater activity. This change in the number of cor- 
puscles is naturally related to a difference in the amount 
of hemoglobin, and is probably an adaptation for insur- 
ing a normal oxygen capacity for the blood. 

The above explanation is, perhaps, equally applicable 
when a considerable amount of blood has been lost dur- 
ing hemorrhage. Experience has shown that the blood 
rapidly regains its normal condition and that the cor- 
puscles are manufactured quickly to replace the drain 
that has been made upon their numbers. The anszmic 
condition undoubtedly causes a diminution in the oxygen 
supply to the corpuscle-forming tissue and the hemato- 
blastic cells are stimulated to more rapid multiplication. 

With reference to the influence of altitude upon the 
corpuscles, there are some who ascribe the apparent in- 
crease of the corpuscles to other reasons than those men- 
tioned, namely, that there is an increased evaporation 
from the general surface, and thus a loss of water from 
‘the blood; that there is an increased arterial tension, in- 
-creasing the amount of lymph, which also assists in giv- 
ing a higher concentration of the blood, and thereby an 
apparently larger number of corpuscles. Weiss experi- 
mented upon this point by keeping some rabbits at a 
high altitude for about four weeks, and compared them 
with animals at lower levels. He found an increase of 
corpuscles to the extent of twelve to twenty-four per 
-cent., but no absolute increase of hemoglobin in the 
whole body. 

HaMoGLOBIN.—Hemoglobin is a very complex, iron- 
containing crystalline coloring matter, which forms the 
most important constituent of the red corpuscles, and in 
virtue of which they perform their functions as the 
oxygen carriers of the organism. This substance pos- 
-sesses the property of linking to itself a molecule of oxy- 
gen, so as to form an easily dissociated compound, which 
is termed oxyhemoglobin, to distinguish it specifically 


Blood. 
Blood, 





from the coloring matter which has parted with its oxy- 
gen. This is termed by many hemoglobin, although 
numerous others prefer to call it reduced hemoglobin. 

Both oxyhemoglobin and reduced hemoglobin invari- 
ably (Hiifner) exist side by side in varying proportion in 
the living blood; the former being most abundant in 
arterial, and the latter in venous blood. 

It has hitherto been held that the hemoglobin of the 
blood normally combined with the oxygen, and that the 
carbon dioxide was held by the plasma in combination 
with soda as sodium carbonate and sodium bicarbonate. 
The combination is very feeble in both cases—easily 
made and unmade. It is true that carbon dioxide is 
present to a large extent in the plasma, but that some of 
it is also taken up by the hemoglobin is now quite well 
demonstrated. In a mixture of O and CO, each gas is 
absorbed by hemoglobin solutions independently of the 
other, so that such a solution nearly saturated with oxy- 
gen can unite with as much CO, as though it held no 
oxygen in combination. It has been suggested by Bohr 
that the O and CO, may unite with different portions of 
the hemoglobin, the O with the pigment portion, and 
the CO, with the proteid portion. The exact value of 
hemoglobin as a carrier of CO2, as compared with the 
plasma, has not yet been accurately determined. 

Hemoglobin constitutes about 40.4 per cent. of the 
weight of the moist corpuscles, and about 95.5 per cent. 
of all the organic substances contained in them. 

The question as to the form and manner in which the 
hemoglobin is retained in the corpuscle is an extremely 
difficult one to solve. It has been held by some that it 
is in solution either by the liquid contents of the cor- 
puscle or by combining with other constituents. Others 
hold that it is in a solid or semi-solid condition either in 
a crystalline or in an amorphous form. The following 
facts bear more or less directly upon this matter. 

The blood corpuscles as compared with the other soft 
parts of the body contain a relatively smaller proportion 
of water. According to Bunge the corpuscles contain 
36.7 parts of solids and 63.3 parts of water; muscular 
tissue contains about 25 per cent. of solids and 75 per 
cent. of water; nerves contain about 22 per cent. of solids 
and 78 per cent. of water. The amount of water in the 
corpuscle seems insufficient to hold the hemoglobin in 
solution. Moreover, in some animals the hemoglobin is 
so sparingly soluble that it is said that the whole of the 
water in the blood would not suffice to dissolve the 
hemoglobin stored up in the corpuscles. 

On the other hand it is shown that the hemoglobin 
does not exist in the blood corpuscles in the form of 
minute crystals, by the use of crossed Nicol prisms, as 
doubly refractive particles, while experimentally hemo- 
globin crystals, reduced to the finest state of division, 
do show this appearance. The highest powers of the 
microscope also fail to show any crystalline or granular 
structures in the corpuscles. 

Against the view that hemoglobin goes into solution 
in combination with other constituents, e.g., alkalies, 
potassium, etc., is offered the argument that if such 
were the case the plasma of the blood, which also con- 
tains these substances, would dissolve the hemoglobin; 
and this, as is well known, does not occur. Taking the 
view, however, that the hemoglobin is in solution within 
the envelope of the corpuscle (Schiifer’s idea), this solu- 
tion in the plasma could not normally occur on account 
of the indiffusibility of haemoglobin through an unaltered 
membrane. Another assumption, advanced by Hoppe- 
Seyler and very generally accepted, is that the hemo- 
globin exists in some combination with the stroma of the 
corpuscle, possibly lecithin. Gamgee assumes that the 
combination is with an as yet unknown constituent of 
the corpuscle. This compound, whatever it may be, is 
characterized by remarkable instability, for it is easily 
decomposed, setting free the hemoglobin. This goes 
into solution when the plasma or serum in which the 
corpuscles are suspended is diluted, or when such sub- 
stances as ether, chloroform, or biliary salts act upon 
the corpuscles. Heat, alternate freezing and thawing, 


27 


Blood, 
Blood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











and induced electrical shocks bring about the same result. 

Although the coloring matter of the blood in different 
species of animals behaves in the same manner with 
reference to its combining with gases to form more or 
less easily decomposable compounds, and although it pos- 
sesses identical powers in absorbing the rays of the spec- 
trum, the hemoglobin in different animals shows differ- 
ences in crystalline form, in solubility, in the quantity 
of water of crystallization, and in percentage composition. 
The hemoglobin in the blood of the rat, guinea-pig, and 
squirrel crystallizes most readily; next in order is that 
of the cat, dog, and horse; while that of the rabbit, 
sheep, ox, and the frog crystallizes with considerable 
difficulty. On the other hand the hemoglobin of the rat, 
guinea-pig, and squirrel goes into solution with difficulty ; 
while that of man and the domestic herbivorous animals 
is easily soluble. 

Hemoglobin is a compound of carbon, hydrogen, 
nitrogen, sulphur, iron, and oxygen. The crystals of 
hemoglobin contain water of crystallization, which varies 
in different animals. When ignited, pure hemoglobin 
obtained from mammalian blood yields an ash composed 
entirely of ferric oxide; that of birds and fishes, and 
probably from all animals possessing nucleated cor- 
puscles, yields an ash which, in addition to Fe,O;, con- 
tains phosphoric anhydride (P20;), derived, probably, 
from the nuclein contained in the corpuscles. 

According to Preyer the average percentage composi- 
tion of 100 parts of hemoglobin is as follows: 





Co escogd:s auearwis Afra ep eliove wicee Wiaye wit alee Uialete © BOE pie palate ateterrte aa 54.00 
TD scerersie exare’s slaietoicne i 7eiartie overavale ean) op vaterotemoreleiee levotele epiniota eterer tists 1.25 
1 Rast teriat Gomorra nns san dour saan Sado sip dou onesd 16.25 
BO) ese ate esa Fiche a: clotiiote Sarr orniete aeeraleree orn alatete BM etn pelatale isk aatase 42 
SS is ini oie atnuctecatie te teetera Bun onc eiaictereua tires ere arora erent at erettnovetetotsrniaces 63 
(0 Bee CARI ArO GARIN OnE OOe nan Ndcadao badd ode tcbobodcnsone 21.45 

100.00 


On the theory that the molecule of hemoglobin con- 
tains one atom of iron, Preyer assigned to it the empirical 
formula Ceo00H»e60NisisFeS3Oi70, the molecular weight be- 
ing 13.382. 

In the analysis of the hemoglobin of the dog, Jaquet 
has calculated the following’ percentage composition : 





with a molecular formula of Cy5sHi203NiosSaleOnre, 

which would make the molecular weight 16.669. 
The question naturally arises, Why should there be 
such an extremely 


high molecular 
weight? <A very 


suggestive expla- 
nation has been 
offered by Bunge 
as follows: 

“The enormous 
size of the hemo- 
globin molecule 
finds a_teleologi- 
cal explanation ; 
if we consider that 
iron is eight times 
as heavy as water, 
a compound of 
iron, which would 
float easily along 
with the blood 
current through 
the vessels, could 
only be secured 
by the iron being 
taken up by so 
large an organic 
molecule.” 



































Fic. 521.—Oxyhzemoglobin Crystals Magnified. 
1, From human blood; 2, from the guinea- 
pig ; 3, squirrel; 4, hamster. (Halliburton.) 


28 


Form of Oxyhemoglobin Crystals.—The blood of man 
and of the majority of animals yields crystals in the form 
of rhombic prisms or needles belonging to the rhombic 
system. Those from the blood of the guinea-pig, as shown 
by von Lang, are in the form of tetrahedra belonging to 
the rhombic system. The blood of certain birds and oc- 
casionally of the rat gives crystals of the same form. The 
oxyhemoglobin of the squirrel crystallizes normally in 
the form of six-sided plates belonging to the hexagonal 
system. 

Amount of Water of Crystallization.—The difficulties 
attending an investigation of this kind are very numer- 
ous and discouraging. The usual procedure is to dry 
pure oxyhemoglobin 77 vacuo at 0° C., and after it ceases 
to lose weight to heat it to a temperature of 115° C. 
The following table shows some of the most reliable re- 
sults obtained. 











Water of 
Oxyhemoglobin. crystallization, Authority. 
per cent. 
DOG prakitsssinas sho ature mernetsgs Sta seites 3.4 Hoppe-Seyler. 
TOT SO a ersrvonteciseaituis Maraleheretine otetnce eeacy 3.94 Hiifner. 
PIG: cr fose le nieve iayais -e-alenrets onde siete clare peter 5.9 Otto. 
GuINGA=PIS se eee etete cre i huabovarmcc 6 Hoppe-Seyler. 
SOMITE Saget cicartiesis cei sveltattene casein 9 Hoppe-Seyler. 











Solubility.—The oxyhemoglobin of all birds, of the 
ox, pig, and man, is readily soluble, the solubility in- 
creasing in the above order. Next in order of solubility 
is that of the horse, dog, squirrel, guinea-pig, and rat, 
the latter being the least soluble. 

The difference in solubility is supposed to be due to 
differences in the amount of the albuminous residue. 

Oxyhemoglobin is soluble in dilute solutions of am- 
monia and other caustic alkalies, and their carbonates. 
It is also soluble in very dilute alcohol. On the other 
hand it is insoluble in absolute alcohol, chloroform, ben- 
zol, and carbon disulphide. 

Diffusibility.—Oxyhemoglobin is an exceptional ex- 
ample of a soluble crystalline body, which from its in- 
ability to pass through a septum of parchment paper is 
considered to be absolutely non-diffusible. This charac- 
teristic is dependent upon the immense size of its molecule. 

Absorption Spectra.—Solutions of hemoglobin and 
compounds derived from it give distinctive absorption 
bands when examined with the spectroscope. In order 
to obtain satisfactory results very dilute solutions of 
oxyhemoglobin must be used. When they are examined 
with the spectroscope two absorption bands appear, 
both occurring in the portion of the spectrum included 
between the Fraunhofer lines Dand E. The band nearer 
the red end of the spectrum is known as the “ a-band,” 
and is narrower, darker, and more clearly defined than 
the other, the “$-band.” With a solution containing 
0.09 per cent. of oxyhzemoglobin, and examined in layers 
1 cm. thick, the a-band extends over the part of the 
spectrum included between the wave lengths 4 588 (583 
millionths of a millimetre) and 2 571, and the -band be- 
tween A 550 and 4 5382 (Gamgee). The width and dis- 
tinctness of the bands vary with the concentration of the 
solution used. With a minimal percentage of oxyhzemo- 
globin (less than 0.01 per cent.) the 6-band is lost and 
the a-band becomes very faint. With stronger solutions 
the bands become darker and wider and finally fuse, 
while some of the extreme red end and a great deal of 
the violet end of the spectrum are also absorbed. The 
absorption which takes place as the concentration of the 
solution increases affects the red orange end of the spec- 
trum last of all. 

Solutions of reduced hemoglobin show only one ab- 
sorption band, known as the “y-band.” This band lies 
also in the portion of the spectrum included between the 
lines D and E. The y-band is much more diffuse than 
the oxyhemoglobin bands, and its limits, especially in 
weak solutions, are not well defined; in solutions of 
blood diluted 100 times with water, which would give a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood, 
Blood, 





hemoglobin solution of about 0.14 per cent., the absorp- 
tion band lies in the part of the spectrum included be- 
tween the wave lengths 4 572 and 4 542. The width and 
distinctness of this band vary also with the concentration 





Bers... D Ed F G 
le i 7. Od: ww wx 1810 tt 18 19°90 24°29 93 2% |95 
RATES PTR Te ee ate MU TROT puantoobonoDodusTantal ul 











7 


“© 





as 
a 


fos 
a 





Fig. 522.Spectrum. 1, Absorption spectrum of a solution of oxyhs- 
moglobin; 2, absorption spectrum of a solution of hemoglobin, ob- 
tained by the action of an ammoniacal ferro-tartrate solution on an 
oxyhzmoglobin solution ; 3, absorption spectrum of a faintly alka- 
line solution of methzmoglobin ; 4, absorption spectrum of a solu- 
tion of hzmatin in ether containing oxalic acid; 5, absorption 
spectrum of an alkaline solution of hzmatin ; 6, absorption spec- 
trum of an alkaline solution of hzemochromogen, obtained by the 
action of an ammoniacal ferro-tartrate solution on an alkaline he- 
matin solution; 7, absorption spectrum of an acid solution of uro- 
bilin; 8, absorption spectrum of an alkaline solution of urobilin 
after the addition of a zinc chloride solution; 9, absorption spec- 
trum of a solution of lutein (ethereal extract of the egg yolk). 
(Hammarsten.) 


of thesolution. In this case, the last light to be absorbed 
is partly in the red end and partly in the blue, thus ex- 
plaining the purplish color of hemoglobin solutions and 
of venous blood. Oxyhzmoglobin solutions can be con- 
verted to reduced hemoglobin solutions, with a corre- 
sponding change in the spectrum bands, by placing the 
former in a vacuum, or, more conveniently, by adding 
reducing solutions. Those most commonly used for this 
purpose are ammonium sulphide and Stoke’s reagent. 
The latter is made by dissolving 2 gm. of ferrous sul- 
phate in 100 c.c. of distilled water, adding 3 gm. of tar- 
taric acid and making faintly alkaline by the addition of 
ammonia. This solution should be used fresh. If a 
solution of reduced hemoglobin is shaken with air, it 
quickly changes to oxyhemoglobin, and gives two 
bands instead of one when examined through the spec- 
troscope. This is an easy way of showing the facil- 














ity with which hemoglobin takes up and surrenders 
oxygen. 

Solutions of carbon monoxide hemoglobin also give a 
spectrum with two absorption bands closely resembling 
in position and appearance those of oxyhemoglobin. 
They are distinguished, however, by being slightly nearer 
the blue end of the spectrum. Furthermore, a solution 
of carbon monoxide is not reduced as is oxyhemoglobin, 
by the addition of Stoke’s fluid; the two bands still per- 
sist. A solution of carbon monoxide may be easily pre- 
pared by passing ordinary coal gas or illuminating gas 
through a dilute oxyhemoglobin solution for a few 
minutes and then filtering. 

Compounds Derived from Hemoglobin.—Methemoglobin 
is obtained by the action of oxidizing agents on hzemo- 
globin. It is frequently found in blood stains or patho- 
logical liquids containing blood, which have been ex- 
posed to the air forsome time. It is practically the same 
as oxyhemoglobin, except that the oxygen is in a firmer 
combination. It crystallizes in the same form as oxy- 
hemoglobin, but has a different and characteristic spec- 
trum. 

Hematin (C32H32N,FeO,) is obtained when oxyhzxemo- 
globin is decomposed by acids or alkalies in the presence 
of oxygen. It isamorphousand hasaspectrum peculiar 
to it. 

Hemin (C32Hs2NisFeO,HCl) is a compound of hematin 
and HCl, and is easily obtained in crystalline form. The 
crystals are very characteristic and are readily obtained 
from blood clots 
or blood stains, Sian ate 
even if not recent. 
In medico- legal 
cases involving 
the detection of 


blood this form of se \ 

crystal is the one i i >< Y rs 

usually sought ss 

for. \d Z pe ant 4 
Hematoporphy- lm Sr oe 

rin (Cs2Hs6NiO¢) of) ny z= 7 De 

is obtained by the < rare pats of +f 

action of strong Cee) 7] 

sulphuric acid on ie “ 

hematin. It is Pee Ok I oe 


characterized by 
the absence of 
iron. 

Hemochromogen is obtained by decomposing hemo- 
globin with acids or alkalies in the absence of oxygen. 
It crystallizes and has a characteristic spectrum. 

Hematoidin (C:6HisN2Os). This name was applied by 
Virchow to a crystalline substance found in old blood 
clots, formed, without doubt, from the hemoglobin of 
the clotted blood. It has been shown to be identical 
with one of the bile pigments—bilirubin. It shows no 
definite absorption band in 
its spectrum, but causes a 
general absorption of the 
ultra - violet, violet, and 
blue rays. 

Bile and Urinary Pig- 
ments. —Heemoglobin is con- 
sidered to be the parent sub- 
stance of the urinary as well 
as of the bile pigments. 

“Laky Buioop” is the 
term applied to the blood 
when the hemoglobin has escaped from the corpuscles 
and becomes dissolved in the plasma. ‘Normal blood 
with the hemoglobin enclosed in the corpuscles is 
opaque even in a very thin layer, whereas laky blood 
in thin layers is transparent. 

A sufficient disturbance of equilibrium or osmotic re- 
lations between the corpuscles and surrounding medium 
will cause this escape of the hemoglobin. Blood may 
be made laky by the addition of distilled water, acids, 
alkalies, heat, ether, chloroform, bile or bile salts, by 


29 


Fig. 528.—Hzemin Crystals Magnified. 
(Preyer.) 





Fig. 524.—Heematoidin Crystals. 


Blood. 
Blood, 





alternate freezing and thawing, by the serum from the 
blood of another animal, electricity, and numerous other 
methods. 

Isorontc SOLUTIONS, as applied to the blood, refer to 
liquids containing soluble substances with an attraction 
for water, in quantities sufficient to prevent the imbibi- 
tion of water by the red corpuscles. The liquid must be 
concentrated enough to prevent the absorption 
of water by the corpuscle. <A certain amount 
of water exists normally in the corpuscle. If 
the concentration of the surrounding liquid is 
diminished this equilibrium is disturbed and 
water passes into the corpuscle; enough water 
may pass into it to cause swelling and ultimately 
the discharge of the hemoglobin, thus producing 
laky blood. 

A solution containing a lesser percentage of 
salt or other soluble substance than suffices to 
keep the hemoglobin is known as “ hypisotonic ” ; 
while a solution containing a greater percentage pig. 
of salt than will preserve the equilibrium is 
known as “hyperisotonic.” The essential fact is an 
alteration of the permeability of the corpuscle either 
by the solution or mechanically, so that the hemoglobin, 
or one or more of its constituents, diffuses itself into the 
surrounding fluid. 

In isotonic solutions the concentration varies accord- 
ing to the substance used. Thus a solution of sodium 
chloride from 0.64 to 0.9 per cent., or of sugar 5.5 per 
cent., or of potassium nitrate 1.09 per cent., is isotonic 
to the corpuscles, or, at least, the latter do not imbibe 
water sufficient to cause them to discharge their hemo- 
globin. The isotonic relations of certain substances 
have been quite well worked out for the red blood cor- 
puscles; but it seems reasonable that the other cells of 
the body have likewise an isotonic relationship with 
fluids coming in contact with them; and speaking gener- 
ally, it may be said that normal blood and lymph are 
isotonic to the various tissue elements, and must be kept 
so in order to avoid pathological conditions. 

Wuitr BLoop CorpuscLes OR LEUCOCYTES.—These 
elements were discovered by Hewson in 1770. They are 
uncolored bodies possessing the power of amceboid move- 


ig c 


Fig. 525. —Leucocytes trom Normal Human Blood. X 1,200 diameters. 
(From Boehm and yon Davidoff, after H. F. Miiller.) «a, Red blood 
disc ; b, small mononuclear leucocyte ; ¢c, large mononuclear leuco- 
cyte ; g, leucocyte with a nucleus of very irregular shape; d, e, f, 
leucocytes representing transitional forms between ¢ and g. 


ment, are often of a spherical form, and are slightly 
larger but much less numerous than the red corpuscles. 
The investigations of Ehrlich, Schultze, and others have 
shown that there are at least three different forms of 
leucocytes present in the blood, corresponding, perhaps, 
to three stages in their development: (1) A small spheri- 
cal cell, with scanty protoplasm and a relatively large 


30 





Fic. 526.—Ehrlich’s Granules in Leucocytes. 
ules, relatively large and regularly arranged; ¢, neutrophile granules; 8B, am- 
phophile granules, not numerous and irregularly arranged ; y, mastzellen with 
granulations of unequal size; 6, basophile granulations. 
mal blood; y, from leukemic blood of man; 8, from the blood of the guinea- 

(From Boehm and von Davidoff, after H. F. Miiller.) 





REFERENCE HANDBOOK OF ‘THE MEDICAL SCIENCES. 


nucleus, amceboid movement very doubtful. They are 
called lymphocytes because they resemble the leucocytes 
found in lymph glands and are supposed to be brought 
into the blood through the lymph. (2) Mononucleated 
leucocytes. They possess a greater amount of cyto- 


plasm, are of a finely granular character, and have some 
power of amceboid movement. 


(8) Polynucleated or 





< 1,200 times. a, acidophile gran- 


a, 6, and e, from nor- 


polymorphous leucocytes. They are large, irregular in 
form, finely granular, and possess a lobulated nucleus or 
as many as four separate nuclei. They have very pro- 
nounced amceboid movements, and form about 70 to 75 
per cent. of the white corpuscles. 

Other classifications have been made, based upon 
microscopic structure and reaction to stains. Ehrlich 
divides the leucocytes into three groups, according to 
the size and the staining of the granules found in the 
cytoplasm. The oryphiles or eosinophiles or acidophiles 
are those leucocytes in which the granules stain only 
with acid aniline dyes—.e., where the acid portion of 
the dye acts as the stain (eosin, picric acid, aurantia). 
The dasophiles are those in which the granules stain 
only with basic dyes (dahlia, acetate of rosanilin). The 
neutrophiles are those in which the granules stain only 
with neutral dyes (picrate of rosanilin). A later paper 
by Kanthack and Hardy states that the neutrophile 
granules of Ehrlich are in reality oxyphile granules. In 
human blood they find the finely granular oxyphile cells 
(neutrophile and amphophile cells of Ehrlich) make up 
60 to 80 per cent. of the whole number of leucocytes, 
the lymphocytes (and hyaline cells) (basophile granules) 
20 to 80 per cent., and the coarsely granular oxyphile 
cells (eosinophile cells of Ehrlich) less than 5 per cent., 
but these proportions are far from constant. 

Ehrlich’s classification is perhaps more suitable for 
pathological than for normal conditions of the blood. 

It is said that the eosinophiles and neutrophiles are 
relatively few in normal blood. Eosinophile granules 
occur in the polynucleated cells. These cells are greatly 
increased in leukeemia. The basophile granules occur 
also in connective-tissue corpuscles, especially in the 
neighborhood of epithelium; they are always greatly 
increased where chronic inflammation occurs. The large 
polynucleated amceboid cells found outside the vessels in 
inflammations exhibit a neutrophile reaction. Neutro- 
phile granules are not found in the lymphocytes nor in 
the mononuclear cells. It is questionable if such a 
classification even for pathological conditions is wholly 
satisfactory, since no definite function for the granules 
has yet been established, and it is still undetermined 
whether the specific granules are permanent or tem- 
porary structures. 

It is indeed a question if the different forms of leuco- 
cytes are distinct histological elements having independ- 
ent origins and different functions, or whether they do 
not, after all, represent different stages in the development. 
of a single kind of cell, the lymphocytes representing an 
early and the polynucleated leucocytes the last stage. 

Specific Gravity.—Leucocytes have a lighter specific 
gravity than the red corpuscles, as is shown when the 
blood clots slowly, as it does normally in some animals, 
e.g., the horse. ‘The red corpuscles, on account of their 
greater density, sink to the bottom, while the leucocytes, 
being much lighter, form the upper portion of the clot. 

Number.—The leucocytes average about 1 for every 500 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of the red corpuscles, or 10,000 per cubic millimetre in man 
and 9,000 per cubic millimetre in woman. The number 
will vary under different conditions. They are increased 
after digestion, hemorrhages, pregnancy, in diseases in 
which suppuration occurs, and in leucocythzemia, in 
which disease they may equal even the red corpuscles. 

Conditions which diminish the number of leucocytes 
are fasting, old age, and the action of certain medicines. 

Leucocytes are more numerous in the capillaries and 
veins of the spleen, liver, glands, and intestinal mucosa 
than in the corresponding vessels of the skin, muscles, 
and general cellular tissue. Leucocytes are also more 
numerous in the blood of the newly born—about 19,000 
per cubic millimetre (Hayem). 

The chemical constituents of leucocytes are variable 
and difficult to analyze with accuracy. Lilienfeld, who 
has carried on investigations along this line, gives the 
following quantitative composition: 


NAT REM TE he telalsriretalec oierecere tee vielole. cs ovcia'eiele/s's sje o.sieve vets ese 88.51 
Pre NMRE iia cre iclaifielcjse'sigjele vac@ajepemeedobecrsseseveas 11.49 
POL civsie cielo ce ces vives s ce aieeletiacile velseiwe-s tiv.e 1.76 
ASTID | a AI OCS e DIEING DEI CIDIOOIT DIFIOIO ORI OOO ra 68.78 
Histon (proteid part of nucleo-proteid)..............0608 8.67 
RMSE eRiemrenetel etch are, sve. Ache) oie v:erarslessiote.«,scerere evs eueiciste ste oe sveleielels 7.51 
TOLUENE fascist e cle viulocs ele Saldes cewisise na ecbie.v os sreiee sae 4.02 
Rete CST AEM geie rettraiatalaverveletsl cca Vieloie vislove ei) sie's We sieivio silermalnis.e.s 4.40 
em SA EET CTA s levele cial slave icletelo cle eleldles'sipiers 8.eleisivla aie'e pla s.e wale .80 


Pus cells are leucocytes which show a considerable 
amount of fatty degeneration and are generally dead. 

Functions.—The functions of leucocytes are various; 
some theories formerly accepted are now advanced with 
doubt, among which may be mentioned the assistance 
supposed to be rendered in the absorption of peptones 
and fats. Recent and careful experiments point toward 
the intestinal epithelial cells as the important factor in 
this process. Peptones appear to be converted into co- 
agulable albumin during their passage through the epi- 
thelium, as practically no peptone is found in the blood 
orchyle. Ithas likewise been quite satisfactorily demon- 
strated that by far the greater amount of fat is likewise 
taken up by 
the epithelium 
and but little, 
if any, by the 
leucocytes. 

Leucocytes, 
or their prod- 
ucts, are an 
undoubted 
factor in the 
coagulation of 
blood. Fur- 
ther details 
will be discuss- 
ed under Coag- 
ulation. 

One of the 
most peculiar 
properties of 
leucocytes is 
their power of 
independent 
movement, in 
virtueof which 
they are often 
called “wan- 
dering” cells. 
A leucocyte 
may be con- 
sidered in 
some ways as 
a typical cell 
formed of unmodified protoplasm, wholly unspecialized 
and potentially equivalent to a unicellular animal, ¢.y., 

an amceba. Movement is accomplished by the pushing 
’ out of a portion of the cell substance to form a pseudo- 
podium; this may be retracted, and other pseudopodia 
formed, and in this way the corpuscle may move or 





Fig. 527.—A Vein (Frog), As It Appears When the 
Current Begins to Slow. The red corpuscles re- 
main in the central portion of the blood stream, 
while the leucocytes creep slowly along the wall 
of the vessel, sticking here and there. (After 
Craig.) 





Blood, 
Blood, 


“flow” from place to place, and envelop or ingest such 
particles as come in its way. This form of motion was 
first noticed in the ameeba, and is therefore called ame- 
boid in the leucocyte. In a certain sense body corpuscles 
would be a more appropriate term than leucocytes; for 
they or similar cells are found in many locations and 
wander everywhere in the spaces of the connective tissue. 
They pass into the 
blood - vessels with 
the lymph, and pass 
out of them again in 
virtue of their power 
of amaboid move- 
ment. This process 
of migration occurs 
normally, but is 
greatly increased 
under certain patho- 
logical conditions, 
This phenomenon of 
migration is known 
as diapedesis (discov- 
ered in 1846 by Wal- 
ler), and is especially 
prominent when a 
vascular part is irri- 
tated, causing dilata- 
tion and congestion 
of the vessel. The 
leucocytes then be- 
gin to adhere to the wall; they accumulate and finally 
pass through, probably between the endothelial cells of 
the capillaries. After this emigration they may wander 
away, or become organized and form new tissue (Waller), 
or they may accumulate, degenerate, and form pus. 
Red corpuscles are also sometimes seen to pass through 
the walls. Leucocytes may, however, play another 
part, namely, the repair of injured tissues. A clean 
healthy wound is soon covered with a layer of lymph, 
which is largely composed of white corpuscles. If 
repair progresses in a healthy manner the leucocytes 
may become organized and assist in the development of 
connective tissue, forming the cicatrix by which the 
wound is closed. 

Certain amceboid cells of the blood, lymph, and splenic: 
pulp are able to ingest or “eat up” foreign particles with 
which they may come in contact. This process is known 
as phagocytosis, and the cells are therefore known as. 
phagocytes. This term, however, does not include all 
leucocytes nor does it exclude all other cells, as some 
fixed cells—e.g., the endothelial cells of blood-vessels— 
show phagocytic properties by being able to send out 
protoplasmic processes, while, on the other hand, the 
small immobile lymphocyte is not a phagocyte.  Al- 
though the phenomenon of phagocytosis has not as 
yet as exact a physiological value as some other proc- 
esses, there is little doubt but that it plays an impor- 
tant role in the defence of the organism from outside in- 
vaders, as, for example, pathogenic bacteria, etc. This 
action of the phagocytes is of very great interest and 
importance. Metschnikoff, from his investigation upon 
the lower as well as the higher organisms, has added 
much useful information to science. He found that in 
some instances the leucocytes were victorious over the 
invaders, the latter being ingested and destroyed. In 
other cases the invaders were successful, by poisoning, 
weakening, overpowering by larger numbers and _ ulti- 
mately destroying the leucocytes. Metschnikoff sup- 
posed that the immunity to certain diseases, possessed 
normally by some animals and conferred’on others by 
vaccination with certain protective substances, is due 
largely to the success of the phagocytes in the fight 
with the bacteria. More recent investigations show that 
Metschnikoff’s phagocytic theory of immunity requires 
some modification, at least for man and the higher ani- 
mals, although some of the observations upon which his: 
theory was built still retain their value. He concluded 
that in order to confer immunity, the leucocytes under- 





Fia. 528.—Showing a Vessel in Which the 
Current has Nearly Come to a Standstill. 
The leucocytes are arranged in rows 
along its wall. (After Craig.) 


31 


Blood. 
Blood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





- 


went certain changes and acquired a kind of “ education ” 
which enabled them to fight bacteria against which they 
were previously helpless. 


It seems in the light of the 





Fie. 531. Fig. 532. 


Figs. 529 To 532.—F1G. 529.—Leucocytes sending forth processes which 
penetrate the wall of the vessel. (After Craig.) Fic. 530.—Leuco- 
cytes partly through vessel wall, showing constriction in centre. 
(After Craig.) Fig. 531.—Leucocytes after penetrating wall regain 
former shape. (After Craig.) Fic. 532.—Appearance of vessel and 
surrounding tissue after diapedesis has gone on for some time. 
(After Craig.) 


more recent investigations that the substances which can 
confer immunity may be present not only in the leuco- 
cytes, but in other cells as well, and even in the serum. 
Such substances have the power to destroy, or at least 
inhibit, the growth of bacteria. 

Correlated with the question of phagocytosis is the 
question of the ultimate fate of the particles ingested by 
the leucocytes. This matter has been investigated by 
Miss E. J. Claypole in amphibia (Necturus and Crypto- 
branchus) and by Berry in some of the mammals (rat, 
rabbit, and dog), the latter corroborating in all important 
respects the _ state- 
ments of the former. 
A further important 
function of the leu- 
cocytes, as scaven- 
gers of the body, is 
suggested. Miss 
Claypole says: “ Con- 
sidering the leuco- 
cytes as scavengers 
of the animal body 
in addition to their 
other functions, if 
their individual fate 
is inseparable from 
that of the waste 
material which they 
contain, they them- 
selves must become 
waste material when 
their active functions 
cease, and must ultimately disappear from the organism. 
In the first place, they wander from the circulation 
through the tissues to the epidermal and mucous sur- 








Fic. 533.—Small Vein of Mesentery. 
Showing the arrangement of the gran- 
ules during and after penetration of 
wall by the leucocyte. (After Craig.) 


32 


faces (amphibia), and are carried away with the other 
waste products of the body; in the second place, they 
are destroyed in the spleen by the splenic cells. The 
large numbers found in various stages in the first condi- 
tion and the relatively large number of ingested spleen 
cells prove that the destruction of leucocytes is by no 
means insignificant.” 

Maurel takes the view that the different forms of the 
leucocytes are merely the intervening stages in their de- 
velopment. He does 
not accept the view 
that leucocytes mul- 
tiply in the blood. 
He has seen what he 
terms apparent divi- 
sion of the corpuscle, 
one portion budding 
off from the parent 
substance but still 
connected by an al- s 
most invisible strand, > ds, 
and later a complete | 
reunion of the two a ll ul 


Dorp gus en ae Fig. 534.—Small Vein in Mesendane Lew 
to his classification cocytes sending off a process clear of 
there are three main granules (a and b). (After Craig.) 
types: 1. A small, 

colorless and immobile leucocyte, evidently correspond- 
ing to the lymphocyte of other writers. 2. The second 
type consists of five forms of leucocytes, all of which 
are characterized by the power of displacing a larger or 
smaller amount of their substance and possess a greater 
or less degree of mobility. They differ in respect to their 
granularity. 8. Two forms, one very granular, immo- 
bile, and deformed; the other showing beginning signs 
of disintegration. 

The above types represent the periods of development 
and decay; the second type representing the active life 
of the corpuscle. 

In determining the effect of temperature upon the 
leucocytes of the human blood, Maurel found that at 
about 25° C. (77° F.) movements as evidenced by dis- 
placement of their cellular substance were generally 
manifested. Between 25° and 16° C. these displace- 
ments were very feeble, and at 16° they ceased. If this 
temperature, however, was of short duration and gradu- 
ally raised the movements would return. At 14° C. 
(57° F.) life disappeared from the corpuscles completely. 

‘He concludes that 

a temperature of 

at least 25° is re- 

quired to cause 
, Satisfactory move- 
ments in the cells 
and that the above 
temperature is es- 
sential for the oc- 
currence of diape- 
desis. Between 
25° and 82° C. the 
displacement of 
substance is very 
slight. From 32° 
to 389° C. the 
movements are 
very marked. 
From 39° C. (102° 
F.) to 48° C. (109° 
F.) the maximum 
degree of activity occurs. Above 44° ©. (111° F.) the 
life of the corpuscle is very quickly menaced, and at 45° 
C. (118° F.) the leucocyte takes on a spherical form and 
dies in a short time. The temperature as usually taken 
(axilla, etc.) is supposed to be one to two degrees lower 
than the internal temperature (liver, etc.), so that from | 
the above figures, the greatest activity of the leucocytes 
in the human body takes place at the normal and during 
a febrile state of medium intensity. In animals of dif- 





Blood Capillary. 


i] 
i] 
a bee a e 


Fig. 535.—Diagrammatic Representation of 
the Manner in Which a Leucocyte Traverses 
the Wall of a Capillary Blood-Vessel. (After 
Craig.) a, Leucocyte before penetrating ; 
b, leucocyte sending off process and gran- 
ules beginning to withdraw to farther end 
of cell; ¢, leucocyte partly through wall, 
granules at upper end of cell; d granules 
passing through the wall; e, granules ar- 
ranged in the portion of the leucocyte far- 
thest from vessel; f, leucocyte, after pene- 
tration, resuming its original condition; g, 
leucocyte swept from wall, showing reten- 
tion of the clear penetrating process. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ferent species in which the temperature is normally 
different from that of man, the variations in the ac- 
tivity of the leucocytes are correlated with the tempera- 
‘ture of that species of animal. 

In addition to studying the power of resistance ex- 
hibited by the leucocytes with respect to extremes of 
temperature, Maurel has also investigated their power 
of resistance against certain physical and chemical agents 
and drugs. As with temperature, the leucocytes of dif- 
ferent species will react differently toward the agents 
just mentioned. He found that while human leucocytes 
are sensitive to cocaine and very much so to atropine, 
those of the rabbit were only one-third as sensitive to 
cocaine and not at all to atropine. The leucocytes of the 
frog. will absorb certain pathogenic bacteria with im- 
punity, while those of the rabbit and man will not absorb 
them, but are rapidly killed. 

Horbaczewski has called attention to the fact that 
uric acid originates chiefly from the nuclein of disin- 
tegrated leucocytes, and the greater the number of leu- 
cocytes in the blood the greater is the destruction of the 
same, and hence the elimination of uric acid is corre- 
spondingly increased. Observations on the elimination 
of uric acid harmonize with this theory. In leukemia, 
where there is an abnormally large number of leucocytes, 
the elimination of uric acid is greatly increased. Those 
drugs which increase the number of leucocytes also ia- 
crease, in general, the elimination of uric acid. 

Origin of Leucocytes.—It is evident that leucocytes 
are formed largely in lymph glands, from the fact that 
the lymph leaving such glands is much richer in cor- 
puscles than the lymph coming to the glands. The 
fact that lymph coming to the glands contains leucocytes 
indicates that, although some of them may get into the 
lymph by diapedesis, other parts are also concerned in 
their production, ¢.g., diffuse adenoid tissue, or special 
collections of it such as the tonsils, Peyer’s patches, and 
the solitary follicles in the intestine, and the splenic cor- 
puscles. To a small extent the white corpuscles may 
multiply in the blood by karyokinesis. The latter 
method may perhaps occur more generally in the so- 
called cold-blooded animals than in mammals. 

The fate of the leucocytes is much less easy to ascer- 
tain than that of the red corpuscles from the fact that 
the former contain no such pigment as hemoglobin or 
other substance that would assist in following the path 
of their destruction. It is not improbable that some of 
the leucocytes undergo disintegration in the blood itself 
and that their constituents aid in maintaining a proper 
proteid equilibrium. It has been shown by the work of 
Miss Claypole and of Berry that many of the leucocytes 
are undoubtedly destroyed in the spleen, and it is not at 
all unlikely that other localities are also involved in this 
process. That they are constantly breaking down is 
certain, for they are constantly being produced. 

Bioop PLATELETS OR PLAQuUES.—The Blutpldttchen 
(Bizzozero) or heematoblasts (Hayem) are small, circular, 
sometimes irregular bodies appearing nearly homogene- 
ous in structure and varying in size (0.5 to 5.5 microns). 
They average about 3 microns in diameter and are al- 
ways smaller than the red corpuscles. Hayem’s view 
that they. are heematoblasts or precursors of the red cor- 
puscles is now considered erroneous. Their number in 
the blood has been variously estimated from 180,000 to 
over 600,000 per cubic millimetre. Taking 400,000 as 
the average number, they would be forty times as 
numerous as the leucocytes and about one-twelfth as 
numerous as the red corpuscles. Although there has 
been a great amount of histological research upon the 
platelets, very little is known of their function or 
chemical composition. It is generally believed that they 
are not independent cells. In drawn blood they disin- 
tegrate almost immediately; this fact prevented their 
discovery foralong time after the blood had been studied 
microscopically. To study them, the blood must be 
drawn at once into some fixing solution (osmic acid, 
etc.). They can be seen, however, in capillary blood- 
vessels which have just been removed from animals, in 


Vou. II.—3 


Blood, 
Blood, 





which the blood is still fluid and the constituents there- 
fore still alive. They have not been found in lymph. 
According to Léwit they consist chiefly of a globulin 
and play an important part in fibrin formation (coagu- 
lation). Lilienfeld from a chemical standpoint considers 
that they consist of nucleo-proteid, a substance like that 
obtained from the nuclei of leucocytes. From this 
ground, some take the view that the platelets are de- 









au? 


ere Sa waa er 


a 


1minute ~* bie 
‘& Anns. 






10 mins. AN 





Fig. 536.—Figures of a Leucocyte Undergoing Division (Amphibia). 
(After Claypole.) 


rived from the nuclei of the leucocytes, and that when 
the multinucleated forms go to pieces the fragments of 
the nuclei persist for a longer or shorter time in the 
blood as platelets and are eventually dissolved in the 
plasma. The special function of the platelets, beyond 
that of assisting in coagulation, still remains to be dis- 
covered. 

Frsprin.— When blood coagulates there separates from 
it an albuminous substance, which is nearly insoluble. 
This substance is fibrin, and remains in the clot. If co- 
agulation is prevented by whipping the blood, the fibrin 
adheres to the rods of the whip in the form of elastic 
threads or fibrin masses. These may be .washed free 
from the adhering corpuscles by using a stream of water. 
While wet the fibrin has a white, stringy appearance, 
later drying into an irregular mass. The threads which 
compose fibrin, as seen in a microscopic preparation of 
blood, interlace with one another and form a fine net- 
work, which entangles the blood corpuscles in its meshes. 
These have a strong tendency to retract, and explain 
why a clot shrinks and squeezes out the serum from its 
interior. 

Fibrin exists in the lymph as well as in the blood. 


33 


Blood, 
Blood, 





The blood of mammals and of amphibia, as shown by 
Gage, exhibit an interesting difference in regard to the 
fineness of the constituent threads. In the frog (Necturus 
and Cryptobranchus) the threads are relatively very much 
finer than those in mammals, requiring careful observa- 


A AVES TAK, \ CA, 


ar a 
























x] 


ae 


FIG. 537.—Fibrin Network from the Blood of the Frog. a, 
Granular mass of fibrin; gf, isolated granules of fibrin; 
(After Renaut.) 


= 

SS; 
= = 

EoD 

fe let 

, de- 

formed leucocyte. 


tion with a one-twelfth-inch oil-immersion objective. <A 
very interesting and important fact has been brought 
out in connection with the formation of fibrin in am- 
phibians and birds. Semmer has shown that after the 
usual amount of fibrin has formed in the blood from 


a: : itl | 
: AS 


XO 
ee 
TY 





TA 
eS FT EE 


™~ 


Fig. 538.—Fibrin Network from the Blood of Man. gf, gf, Nodal 
points formed by grains of fibrin. (After Renaut.) 


frogs or domestic fowls (also true of Necturus and Crypto- 
branchus), additional fibrin is formed by the addition of a 
solution of sodium or magnesium sulphate. After all of 
the fibrin had been removed in the customary way and 
the source of it eliminated as far as possible by whip- 
ping the blood and pouring off the serum and white 
corpuscles, when the salt solution was added additional 
fibrin appeared, which seemed to differ in no way from 
the original fibrin. Experiments carried on in exactly 
the same way upon the blood of mammals failed in 
every instance to develop any extra fibrin, from 
which it is concluded that the additional fibrin, in 
the cases cited, was due to certain substances con- 
tained in the nucleated red corpuscles, these sub- 
stances having been liberated by the solvent action 
of the salt. A probable explanation of this phenom- 
enon would seem to be that in all nucleated red 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


in the mammals on the one side and the birds and am- 
phibia on the other. 

Fibrin is insoluble in water, alcohol, and ether. It ex- 
pands in 0.1 per cent. hydrochloric acid, also in 0.1 per 
cent. caustic potash or soda, to a gelatinous mass, which 
after several days will dissolve at the ordinary tempera- 
ture; it will dissolve more readily but still slowly at 
body temperature. Fibrin is also slowly soluble in five 
to ten per-cent. solutions of certain salts, such as sodium 
chloride, sodium sulphate, potassium nitrate, magne- 
sium sulphate, ammonium sulphate, also in iodides and 
in solutions of urea. It is said that the fibrin obtained 
from venous blood is slightly more soluble in salt solu- 
tions than that obtained from arterial blood. 

Blood yields from 0.2 to 0.4 per cent. of its weight of 
dry fibrin (Schiifer). 

For the elementary composition of fibrin, Hammarsten 
gives the following: 


Gerri tetaleda rete ose taney eValeteseinielntaieye/apeters nist erefete eveleleieteietct el ste tiet at aaa 52.68 
FA aiaid Sipleisie) «519i 0veiona,'» ev okeressvol ore: sije, sislatele halolans elelstsies eheteteeaaeeEane 6.83 
ANY corey aie nsstafa/< antersterorshn}alecacolets/s = Yafelatafels ovelse}1ee alatstat eet te naan 16.91 
Sos mieterarerete’ eunte (oxsletwrais store) alone, sueteie) Adc rs axe toists cere iets betty eae 1.10 
Ose sleie: o Siorese aie stal eralevem e[v ala ath gahteets iaiose' o.e.ar Sie ote wee cate eran Rena 22.48 


The way in which fibrin is formed and certain other 
phenomena will be discussed under Coagulation. 

PLASMA AND SERUM.—It is convenient to describe these 
two components of the blood together, for, with the ex- 
ception of certain proteids or fibrin factors present in the 
plasma, the remaining constituents are identical with 
those in serum. The relationship of the different parts 
of the blood to each other may be conveniently shown 
as follows: 

Living blood = plasma + corpuscles. 

Dead blood = clot + serum. 

clot = corpuscles -++ fibrin. 

serum = plasma — fibrin(ogen). 

plasma = serum -+ fibrin(ogen). 
Plasma contains about ten per cent. of solids, the red 
corpuscles about forty per cent. 

Plasma may be separated from the corpuscles in vari- 
ous ways. A common method is to collect the blood in 
a receptacle surrounded by ice. Cold retards coagula- 
tion so that the corpuscles may have time to settle at the 
bottom of the jar, leaving the clear plasma entirely sepa- 
rated. Another method is by the use of the hematocrit, 
centrifugalizing, etc.; the corpuscles accumulate in an 
almost solid mass and the volume can be read directly. 
The average percentage of corpuscles in human blood, as 
obtained by various methods, is 48 per cent. for males, 
very nearly one-half of the entire amount of blood; in 
females it is 43.3 per cent., and in children from six to. 
thirteen years it is about 45 per cent. 

Salted Plasma.—Coagulation may be delayed by the 
addition of certain substances to the blood, among which 















































corpuscles nucleo-proteid material is present; in non- 
nucleated corpuscles this material is absent or very 
slight inamount. As the nucleo-proteids are believed 
to be essential in causing the blood to clot (see under 
Coagulation), we can readily understand that the addi- 
tional supply of nucleo-proteid set free from the dis- 
integrated nucleated red corpuscles could assist in the 
formation of more fibrin. Since the non-nucleated cor- 
puscles contain none or an insufficient amount of the 
nucleo-proteid material, no additional clotting or fibrin 
was formed. It would seem that this question of the 
presence or absence of nucleo-proteids in the red cor- 
puscles is an important one in explaining some of the 
differences that exist in coagulation and fibrin formation 


34 
























































Proximal cup, 


Fig. 539.—Daland’s Hematocrit. a, Tubes have lens fronts magni- 


fying the column of blood. (About half actual size.) 
age tube. (Nearly twice actual size.) 
(One third actual size.) 


b, Percent- 
c, Top view of hematocrit. 


are neutral salts, If the blood flowing from a cut artery 
is allowed to mix with an equal volume of a saturated 
solution of sodium sulphate, or with a ten-per-cent. solu- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood, 
Blood, 








tion of sodium chloride, or with one-third of its bulk of 
a saturated solution of magnesium sulphate, coagulation 
will be prevented and the corpuscles will subside, leaving 
the plasma diluted with the salt solution (salted plasma) 
clear. If, however, the above solutions are diluted with 
a sufficient amount of water, coagulation will usually 
occur. 

Oxalate plasma is obtained by the addition of potassium 
or sodium oxalate to the blood; these salts combine with 
the calcium of the blood forming the insoluble calcium 
oxalate. The corpuscles and plasma separate as previ- 
ously described and coagulation is prevented. If, how- 
ever, more calcium be added to the mixture, coagulation 
occurs. The importance of the presence of calcium salts 
in the process of coagulation will be referred to later on. 

Gases.—The gases present in the plasma have not been 
altogether satisfactorily investigated. They are prob- 
ably not very different from those in the serum, <Ac- 
cording to Bunge, in the dog they consist of from 43 
to 57 volumes of carbonic anhydride, 2.25 of nitrogen, 
and 0.25 0f oxygen. The oxygen and nitrogen are prob- 
ably simply in solution in the plasma, the carbonic an- 
hydride for the most part being in chemical combination 
with sodium as the carbonate and bicarbonate. The 
alkaline phosphates also exist in combination. In the 
corpuscles, where they are present in considerable quan- 
tity, they may play an important part in fixing the COs». 

Chemical Analysis of Plasma.—The average of three 
analyses of the plasma from the horse, made by Ham- 
marsten, is given below, 1,000 parts having been used. 
An analysis by Hoppe-Seyler, also of the horse, is given 
for comparison. 











Hoppe-Seyler. | Hammarsten. 

NEA OE MR Bratocate ca vjess sie e wialaleisterave.wloe.¢ 908.4 917.6 
ReGvhe lo peeter a ealcvetchel sieeve. cié.ois\sie 1S.s'e's, 8:4" 91.6 82.4 
SOPIRDEOLELOS) etic vccite eet sive close sas 77.6 69.5 
SITE Cac haps eso dbs p gan OCR EERO BO 10.1 6.5 
TAGIISUL SAR We i yicicrclelcrsiov< + sisivole «:sse'seiue.d AAD 38.4 
STINT cc cvevicie's ve vic elev sais seins AA 24.6 
Pied Peerieeteletaiataie nie tefareloe/s's sietsieelt'erersie <'s 1.2 ) 
Extractive substances............++. 4.0 12.9 
BOLIC SBS calelein cic «ticles a\sieisielo oe cis. 6.4 | a 
PTIBOMMDIGESAIUS slots cryiate s/s ¢ else sisis0.s 0 sale dl yf J 








Inorganic Substances in Plasma.—Plasma consists of 
about ninety per cent. of water, the inorganic salts occur- 
ring to the extent of about 0.8 per cent. The principal 
salt is the chloride of sodium. Carbonate of sodium is 
probably the next most abundant salt, and it is to this salt 
chiefly that the plasma owes its alkalinity and its power 
of absorbing carbonic acid. In addition to these, small 
amounts of the following salts appear to be present: 
chloride of potassium, sulphate of potassium, phosphate 
of calcium, phosphate of sodium, and phosphate of mag- 
nesium, and probably chloride of calcium. 

Organic Constituents.—For convenience these may be 
divided into proteids (serum albumin, etc.) and non-pro- 
teids, and the latter again divided into nitrogenous 
(kreatin, etc.) and non-nitrogenous (dextrose, etc.). 

Proteids.—The proteids of plasma are: one or more 
closely allied albumins (serum albumins); two globulins, 
namely, serum globulin and fibrinogen; a nucleo-proteid 
or nucleo-proteids. Blood normally contains neither 
albumose nor peptones. The albwmins of plasma are 
also found in the serum after the blood has coagulated, 
and from this fact they have doubtless received the name 
of serum albumins. According to its susceptibility to 
heat coagulation, Halliburton has shown that there are 
in reality three kinds of albumin: a-albumin coagulating 
at 72to 75° C.; 8-albumin at 77 to 78° C.; and y-albumin 
at 88 to 86° C. In the plasma of horse, ox, and sheep 
blood, the a-albumin is absent, the other two are present; 
in man and all other mammals and birds investigated 
by Halliburton, all three were found present. In the rep- 
tiles, amphibia, and fishes examined only the a-albumin 
was found. 

The globulins of plasma consist of serum globulin and 





fibrinogen. Serum globulin (paraglobulin, Kihne; 
fibrino-plastic substance, A Schmidt) coagulates at a 
temperature of 75° C. This degree of coagulation is 
almost constant for the animals examined. According 
to Hammarsten the percentage of the globulins in the 
plasma of man is 3.10 per cent.; in the horse 4.56 per 
cent. ; in the ox 4.17 per cent. 

The fibrinogen is the substance which is responsible 
for the so-called spontaneous coagulability of the plasma. 
It is precipitated from plasma along with serum globulin 
by saturation with magnesium sulphate or sodium chlo- 
ride. This precipitate forms the plasmine of Denis, and 
on being dissolved in a more dilute solution of salt causes 
coagulation. As a result of numerous researches, it 
seems likely that fibrinogen is not a simple substance, 
but is probably either a mixture or a loose combination 
of three substances: (1) fibrinogen proper, coagulating 
at 56° C; (2) fibrino-globulin (Hammarsten), coagulating 
at 65° C.; (8) a nucleo-proteid. 

Mathews,* ina recent article on the origin of fibrinogen, 
concurs with Hoffmeister in the view that leucocytes are 
concerned in proteid digestion, basing the evidence chiefly 
on the fact that the blood proteids remain practically 
constant, even during fasting. Under the latter condi- 
tion the proteid material is derived from the wasting 
tissues and the leucocytes are considered as carriers of 
the proteid to the blood, in a way analogous to that seen 
in the phagocytes during the removal and assimilation 
of the wasting tissues of the tadpole’s tail, ete. 

His experiments also confirm those of Bizzozero and 
Dastre, that by successive bleedings, defibrinations, and 
reinjections the fibrinogen may be completely removed 
from the blood of dogs and cats. The lack of fibrinogen 
appeared to cause no serious or characteristic symptoms. 
After the withdrawal of the fibrinogen, in the manner 
above described, it redeveloped in the body with con- 
siderable rapidity, reaching its normal amount in two or 
three days; it sometimes developed to more than the 
normal amount. The redevelopment of the fibrinogen 
took place normally in the absence of the spleen, pan- 
creas, kidneys, and reproductive organs. Experiments 
also showed that the muscles apparently had no influence 
upon the production of fibrinogen. On the other hand, 
the fibrinogen is not redeveloped (or at a greatly reduced 
rate) if the small and large intestines be removed. The 
conclusion is that the intestinal area more than any other 
part of the body is concerned in the formation of fibrino- 
gen. The blood of the mesenteric vein is constantly 
richer in fibrinogen than arterial blood, while other 
venous blood is poorer in fibrinogen than arterial. Be- 
yond the fact that nucleo-proteid is present in the plasma 
and that it seems to be an important factor in the de- 
velopment of fibrin, very little is known of it. It is 
supposed to be confined to the leucocytes and platelets, 
and possibly there isa trace of it in the red corpuscles 
(mammals), which escapes when the blood is shed. The 
principal reasons for this belief are that there is known 
to be a considerable amount of nucleo-proteid in leuco- 
cytes and similar cells (lymph, thymus, etc.). In plasma 
where the corpuscles have been precipitated, more 
nucleo-proteid is obtained from the lower layers of the 
plasma where the leucocytes are most abundant, and 
least from the upper layers where the leucocytes are 
scarce. Again, the pericardial, hydrocele, and ascitic 
fluids frequently contain no leucocytes. When this is 
the case no nucleo-proteid is present, and there is no co- 
agulation although the fluids contain fibrinogen. 

Nitrogenous Substances Not Proteids.—The most im- 
portant of these are urea (0.02 to 0.05 per cent.), krea- 
tin, kreatinin, and uric acid. According to Gréhant and 
Quinquand, the quantity of urea in the blood taken 
from the splenic, portal, and hepatic veins is slightly 
greater than that taken from the carotid artery. Lecithin 
is also said to occur in plasma. Jecorin is said to be a 
constant constituent of the plasma. It is a substance 
which reduces Fehling’s solution and is soluble in ether, 


* American Journal of Physiology, vol. iii., 1899. 


35 


Blood, 
Blood, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





but is not fermentable. It occurs in greater quantity in 
venous blood than in arterial blood. 

The Non-Nitrogenous Substances.—These consist of the 
carbohydrates and fats. In addition there are present 
small quantities of cholesterin and a lipochrome, and 
perhaps of sarcolactic acid. 

Carbohydrates.—These consist of dextrose or grape 
sugar, glycogen, and an animal gum. 

The dextrose is always present in the plasma, even in 
starving animals. In man it is present normally to the 
extent of 1.2 parts per 1,000 and in the dog from 1.1 to 
1.5 parts per 1,000. It seems to be present in nearly 
equal amounts in all parts of the blood except that of 
the portal vein, where it is markedly increased during 
the digestion of carbohydrate food. Between the periods 
of digestion, Bernard found more sugar in the hepatic 
veins than in the portal vein or in the general circulation. 
Pavy and some others have not found this difference, 
while others have confirmed Bernard’s observations. 
Bernard and others have also found a larger amount of 
sugar in arterial than in venous blood. Pavy as a result 
of eleven experiments finds that this difference is very 
slight, the sugar in the arterial blood exceeding that of 
the venous by only 0.003 part per 1,000. He concludes 
that these differences have not been constant and are so 
slight that they may come within the range of experi- 
mental error, and that no appreciable difference exists 
between the two 

The amount of sugar in the blood is increased as the 
result of a hemorrhage, due perhaps to an increase of 
lymph, which contains a larger amount of sugar than 
blood does; or as an effect of an injury acting through 
the nervous system to stimulate the production of sugar 
from the liver glycogen. If the amount of sugar in the 
blood be increased artificially or otherwise to more than 
2.5 or 3 parts per 1,000, the excess passes off in the 
urine. The quantity is increased in diabetes, whether 
this be a result of disease or of puncture of the floor of 
the fourth ventricle. 

A very slight amount of glycogen may be obtained from 
fresh blood. It is said that traces of it occur in the 
plasma. These are undoubtedly derived from disin- 
tegrated leucocytes, which, as is well known, contain it. 
Kaufmann has pointed out that the quantity of glycogen 
is increased in the blood upon the removal of the pan- 
creas (from 0.025 to 0.59 per litre). 

Freund has obtained from the blood a carbohydrate 
resembling that described by Landwehr under the name 
of animal gum. Ithas a formula of (Cs;H,00;), and is 
converted by boiling with dilute mineral acids into a sub- 
stance which reduces Fehling’s solution, but is not fer- 
mentable nor rotatory for polarized light. 

Fats.—These are present in the plasma in but small 
and variable quantity (from 0.2 to 1 per cent.), and are 
most abundant after a meal in which much fat has been 
eaten. The plasma or serum may then have a milky 
appearance on account of the admixture with fat-con- 
taining chyle. A small amount may exist in the form of 
soap. The fatty acids also appear to be partly in com- 
bination with cholesterin. Hoppe-Seyler states that the 
cholesterin in the plasma or serum amounts to about 0,05 
gm. per 100 c.c. of blood. 

The serwm is a viscid liquid which is more alkaline 
than the plasma (Hammarsten). Its specific gravity in 
man ranges from 1.027 to 1.0382, averaging about 1.028. 
Blood serum is in mana pale yellow color, in the horse 
an amber yellow. It is ordinarily clear, but after a meal 
may be opalescent on account of the contained fat. The 
yellow coloring matter of serum is a lipochrome or 
fat-coloring matter which is soluble in amyl and 
ethyl alcohol. In the serum from the horse it is said 
that biliary coloring matters (bilirubin) and others often 
occur. Lipochrome belongs to the so-called group of 
lutens. 

Lactic acid or sarcolactic acid is said to be a constant 
constituent of the normal plasma. Salomon found it 
“only in blood from the dead body, but others have 
affirmed its existence in fresh blood (dog), and thats it also 


36 





exists to some extent in the corpuscles. It is increased 
in amount by the intravenous injection of dextrose, and 
appears to combine with sodium hydrate, driving out 
COz. 

Ferments.—Besides the fibrin ferment (thrombin) or its 
precursor (prothrombin), which will be discussed under 
Coagulation, the blood is said to contain a diastatie fer- 
ment converting starch and glycogen into maltose, and 
a cleavage enzyme, glucase or maltase, which converts 
maltose into dextrose; a glycolytic ferment producing 
the disappearance of sugar, and a fat-splitting ferment 
(lipase). 

Diastatie Action.—The conversion of starch into dex- 
trin and maltose and ultimately into dextrose has been 
effected from the blood and lymph. This result has been 
obtained by mixing blood or serum with a glycogen or 
starch mixture and keeping it at body temperature. 
Cavazzani has obtained the most marked action with 
blood taken from the portal vein. 

Glycolytic Action.—Bernard has shown that the quan- 
tity of sugar in the blood diminishes on standing. This 
isalso true of the lymph. Arthus thinks it probable that 
the ferment is formed from the leucocytes during coagu- 
lation. A temperature above 54° C. destroys all action. 
Lépine and Barral, as well as Arthus, have shown that 
the glycolytic action takes place in the complete ab- 
sence of micro-organisms. Kraus finds that the glycol- 
ysis occurring in ‘blood on standing is accompanied by 
a splitting off of COs, which is probably due to oxida- 
tion. 

Fat-Splitting (Lipolytic) Action.—Hanriot has observed 
that the serum possesses the property of splitting neutral 
fats. Cohnstein and Michaelis have observed another 
action, not to be confounded with the above, which con- 
sists in transforming chyle fat, in the presence of oxygen, 
into an unknown substance soluble i in water. 

The Globulicidal Action of Serum.—Although this 
phenomenon is treated of largely in pathological litera- 
ture, it seems proper to give it a brief notice here. Lan- 
dois was the first to show that when the serum from one 
animal, in some cases at least, was injected into another 
animal of different species, it destroyed the red cor- 
puscles, setting free their hemoglobin and thus produe- 
ing laky blood. After a fuller investigation of this fact, 
the phenomenon has become known under the term of 
“ vlobulicidal” action of serum. It has been found that 
different kinds of serum show different degrees of globu- 
licidal activity, and that white corpuscles may De de- 
stroyed as well as the red ones. The serum from man 
or the dog is strongly globulicidal to the blood of the 
rabbit. The matter is complicated by the fact that the 
serum of some animals does not produce any harmful 
result, as, for example, that of the horse, which does not 
appear to have any globulicidal reaction on the blood of 
the rabbit. That this phenomenon is not due primarily 
to differences in density, osmosis, variations in salts, etc., 
is shown by the fact that when the serum to be injected 
is subjected toa temperature of 55° to 60° C. for a few 
minutes the globulicidal action is destroyed | and laky 
blood does not result. The above temperature is not high 
enough to cause coagulation of any of the proteids in 
the serum, and there is no visible change in the appear- 
ance of the liquid. 

Maragliano and Castellino have noted that the globu- 
licidal power is greater in unhealthy than in healthy 
persons. Charrin and Roger, also Daremberg, have shown 
that the serum of the dog will destroy the corpuscles of 
the guinea-pig in two or three minutes and of the pigeon 
in twenty-five or thirty minutes. 

Bactericidal Action of Serum.—The serum of certain 
animals has been shown to exercise a destructive action 
upon some kinds of bacteria as well as upon the blood 
corpuscles. Much, however, remains to be investigated. 
That this property of the serum assists in the explana- 
tion of the immunity of some animals to certain diseases 
seems likely. The dog, goat, and some others seem to 
be normally immune to tuberculosis. Other analogous 
examples are numerous, and the serum of such sup- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood. 





posedly immune animals is used, on account of its bac- 
tericidal action, to alleviate or cure other persons or ani- 
mals suffering from a disease, to which the animal from 
which the serum was obtained is immune. This prop- 
erty is, therefore, of much importance in serum-therapy. 
Faggioli has observed that serum is quite generally de- 
structive to protozoans, while Chenot and Picq have 
noted the bactericidal action of bovine serum upon the 
virus of glanders. 

Transfusion of Blood.—The process of transferring 
living blood from one person to another or from a lower 
animal to man was at one time regarded as very valu- 
able, as being of use in replacing blood that had been 
lost by hemorrhage and for the cure of various diseases. 
Fatal as well as successful results followed the operation, 
but from what has been learned later regarding the 
globulicidal action of serum, and the fact that the trans- 
fused blood, whether introduced directly or after de- 
fibrination, is liable to contain a quantity of fibrin fer- 
ment sufficient to cause intravascular clotting, the method 
has been regarded as too dangerous to practise. The in- 
jection of physiological salt solution (0.65 per cent. sodium 
chloride) has been found to be an eflicient substitute. It 
is isotonic to the corpuscles and increases the bulk of the 
circulating blood. 

The subject of the coagulation or clotting of blood is 
treated in a separate article entitled Coagulation. 

GENERAL VARIATIONS IN THE BLoop.—As a résumé of 
the general differences existing between arterial and ven- 
ous blood, the following table is appended: 


VENOUS BLOOD. 
Purple, dichroic: reduced hzmo- 
globin. 
More. 


ARTERIAL BLOOD. 
Color.—Bright red, monochroic ; 
oxyhzemoglobin. 
Specific Gravity.—Less. 





Number of Corpuscles. — Rela- 
tively less; blood more diluted. 
Temperature.—Slightly warmer 


Relatively more ; blood more con- 
centrated. 
Slightly cooler, but exceptions ; 


warmest blood in the body found 
in the hepatic vein. 
Less coagulable. 
Less, except in mesenteric vein. 
Numerous local variations. 


in general. 


Coagulation.—More coagulable. 

Fibrinogen.—More. 

General Composition. —More 
uniform. 

Gas.—More O, less COz. More CO,: less O, except pulmo- 
nary veins. 

Less; transudation of water 
through the capillaries causes 
venous blood to be more con- 





Water.—More. 


centrated. 
Urea and Extractives.—Less. More ; except renal vein. 
Glwcose.—More. Less. 
Fat.—Less. More. 
Fibrin.— More. Less. 
Serum Albumin.——Less. More. 
Salts. — More. Less. 


Local Variations of Blood.—Certain organs cause the 
blood which passes through them to undergo more or 
less of a modification in respect to its general properties 
and composition. 

The Blood of the Capitlaries.—Virchow has noted that 
the blood from the capillaries does not coagulate after 
death even when exposed to the air, which apparently 
indicates some modification of the fibrin or fibrin fer- 
ment. 

The Blood of the Mesenteric Vein.—More fibrinogen is 
found in this vein than in arterial blood. 

The Blood of the Portal and Hepatic Veins.—Drosdoft 
has observed in dogs fed with meat, bread, and milk 
that the portal vein contains fewer corpuscles and more 
plasma than that of the hepatic. There is also more fatty 
material present in the portal, which may apparently 
be stored up in the liver. During digestion the portal 
vein contains more sugar than the hepatic, but later the 
reverse is the case, although it is not likely that the 
portal vein is at any time entirely destitute of it. 

The Blood of the Splenic Vein.—The evidence is con- 
flicting here. Some have claimed that a larger number of 
corpuscles are present in this blood, while others hold 
that they are fewer and are destroyed in the spleen as 
well as in the liver. 

The Blood of the Renal Vessels.—The differences are 
best shown in the following table. 














Blood, 
Renal artery. Renal vein. 
WY BLOR ara siacare.t, stthecs wieherensse torent shade ee Geraet vests 790 778 
SOUS 0 tack a Soars de sci PSEA sue bia) acctu’ 210 222 
1,000 1,000 
A VDUTRINGHIS: 5: eerciok crepes erro Nee ERIE Fi less. more. 
Mineraligadltstinnsecs v scttenteetias scanetcan more. less. 
TI VOR A ee slo ie cicye’s acelsPoto vate at SesoNet n ete case tot oe He 
Uric acidjand kreatinve..cnaceitess secest 3 * 
ORV PONS 5 sates cdeeis Sele aera eee aie oh me 


Very briefly, there is loss of water, salts, urea, COz, 
and extractive materials. 

The Blood of the Glands.—The blood which leaves a 
resting gland is dark and possesses the ordinary charac- 
ters of venous blood; that leaving an active gland is 
brighter (Bernard) and contains less CO, than common 
venous blood, because a certain amount of the COs, is 
given off in the fluid secreted by the glands, especially 
the salivary. 

The Blood of the Placenta.—This appears to contain 
more corpuscles and less water than the venous blood of 
the arms, for example. More urea is also present, but 
further investigation is necessary. 

Menstrual Blood.—Menstrual blood seems to be deficient 
in the fibrin-forming elements. The blood does not co- 
agulate or only slightly under normal conditions. As 
this is a capillary hemorrhage and such blood does not 
coagulate readily, we have a reasonable explanation for 
this insufficient coagulation phenomenon. Furthermore, 
the blood becomes mixed with the vaginal mucus and 
has a tendency toward acidity. 

The Blood in Hibernating Animais.—Vierordt has 
shown that the blood in such animals may show a diminu- 
tion in the red corpuscles from a total of seven million to 
two million per cubic millimetre; the changes in the 
blood with respect to the hemoglobin being very feeble, 
and but a slight difference existing in general between 
the arterial and venous blood. 

LITERATURE.—The literature upon the blood and its 
constituents is so extensive that no attempt will be made 
to give a detailed list of such articles. Among those 
which the writer has frequently consulted should be men- 
tioned books, monographs, and papers by Schiifer, Wood- 
ridge, Norris, Mathews, Stewart, Howell, Hammarsten, 
Gamgee, Viault et Jolyet, Maurel, Waller, and numerous 
others. Pierre A. Fish. 





BLOOD. (PATHOLOGICAL.)—APrraraTUS AND TECH- 
NIQUE EMPLOYED IN THE CLINICAL EXAMINATION OF 
THE BLOOD, AND THE INFORMATION OBTAINED THERE- 
FROM. 


PRECIs. 


I. Fresh-Blood Specimen. 
1. Apparatus and technique employed in taking 
fresh specimen of blood. 
2. Information obtained by the examination of fresh 
specimen of blood. 
Il. Blood-Corpuscle Counting. 
t. History of development of instruments for enu- 
meration of blood corpuscles. 
2. Apparatus and technique employed in blood-cor- 
puscle counting. 
3. Information obtained from blood-corpuscle count- 
ing. 
Ill. Hemoglobin Estimation. 
1. Apparatus and technique employed in estimating 
haemoglobin. 
2. Information obtained from estimation of heemo- 
globin. 
3. Color index. 
IV. Blood- Clotting. 
1. Apparatus and technique employed in measuring 
“coagulation time” of blood. 
2. Information obtained by measuring “coagulation 
time ” of blood. 
V. Detection of Blood Stains. 
[ Vote.—As this article deals with such simple apparatus 


37 


Blood, 
Blood, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





only as may be employed at the bedside, the reader is re- 

ferred for full information upon the more complicated 

tests and apparatus for detecting blood stains to the 

article Blood Stains. | 

VI. Dried Specimen of Blood. 

Apparatus and technique ‘employed in taking 

dried specimen of blood. 

Apparatus and technique employed in fixing 

dried specimen of blood. 

. The dyes employed for staining the blood. 

. The technique employed in staining the blood. 

. Formule of blood stains. 

Table of all blood cells and their staining pecu- 

liarities. 

VII. Zable Showing All the Information Obtained by the 
Use of the Instruments Described in this Article. 

VII. A Chart for Making Full Report upon the Blood. 
{| Norr.—The tables which conclude this article are not 

intended to be complete explanations of the diseases 


= 


re 


> OUH> CO 


1 


ag 





3 


Fig. 540.—-1, Bausch and Lomb, 7 inch, No. 1 cover slip; 2, Bausch and Lomb, extra thin slide; 3, 
blood sticker, two views—a, point in sheath for carrying instrument in pocket; ), point in place 
ready for use; 4, clamp forceps, two views—side view, showing close apposition of tip of limbs; 
front view, showing proper extent of grasp of cover slip (1); 5, open forceps, two views—side view, 

Instruments made by F. Arnold & Son, instrument makers, Baltimore, Md.) 


front view. (Note: 
therein mentioned. They are, however, accurate for 
reference for all blood changes in those diseases. For 
fuil instruction upon the following not included in this 
article the reader is referred to other articles in this 
HANDBOOK, such as those on Anwmia, Leucocytosis, Blood 
Stains (Medico-Legal Consideration), Histological Tech- 
nique, Malaria, Typhoid Fever, etc. ] 


I. FresH-BLooD SPECIMEN. 


In preparing the blood for microscopic examination, 
however so careful the technique employed, the oper- 
ator is subjecting one of the most delicate tissues of 
the body to very rough and unnatural surroundings. 
When one realizes the exquisite smoothness of the in- 
tima of the blood-vessels, the wonderfully regulated 
temperature of the body, the delicate structure of the 
red cell, the even more delicate structure of the plate 
which without most careful preservation is entirely de- 
stroyed a few seconds after exposure to the air—when 
one realizes all these factors against observation of the 


38 











. blood as it appears in the circulation, it is a surprise that 


any technique is delicate enough. This realization at 
the same time emphasizes the importance of observing 
every precaution which experience has shown to be 
necessary in the preparation of the blood specimen which 
shall be, outside of the body, as nearly as possible repre- 
sentative of the blood as it appears in the circulation. 

The object then of apparatus and technique is to pro- 
duce surroundings as nearly like those normal to the 
blood in circulation as possible. To accomplish this we 
must observe the following: (1) Absolute cleanliness and 
freedom from moisture; (2) avoid chilling the blood; 
(8) avoid exposure to air; (4) avoid rough treatment of 
the drops and consequently of the constituents thereof— 
the corpuscles. 

The Cover Slip.—Absolute Cleanliness. The cover slip 
should be the thinnest made and square in shape (Bausch 
and Lomb, No. 1, gin. (see Fig. 540, 1). The thicker cover 
slips are often too thick for the focus of the one-twelfth 
immersion lens, and not infre- 
quently specimens from inter- 
esting cases at a distance from 
the laboratory and received by 
mail cannot be examined accu- 
rately owing to this annoying 
condition. It is a good rule 
for those engaged in blood 
work not to have the thicker 
cover slips under any circum- 
stance. 

The Slide.—For the same rea- 
son the thin slide should be em- 
ployed (see Fig. 540, 2). Two 
jars, one containing thick slides 
for urine work, and thin for 
blood work, will be found a 
convenient arrangement. 
These cover slips and _ slides 
should be kept in fifty per cent. 
alcohol. When to be used they 
should be rubbed with a bit of 
clean silk, or some fabric free 
from lint specks. They should 
be rubbed quite free of any 
cloudiness or dust and then 
dried. This last can be done 
either by pouring a little ether 
over the glass and rubbing 
again or by heating gently 
over aflame. The cleaned slip 
and slide should now be laid 
upon a sheet of clean paper. 
The following instruments, as 
first recommended by W. 8. 
Thayer of the Johns Hopkins 
University, will be found es- 
sential : 

The clamp forceps are so 
made that the extreme tips of the limbs meet before any 
other portion, and this enables one to take a small but 
firm grasp of the cover slip (see Fig. 540, 4, 0). The 
clamp, moreover, enables the operator to give his 
whole attention to following the technique, as given 
below, without being diverted by keeping a grasp 
on the cover slips. By placing the cover slip in the 
clamp forceps it can be kept free from dust and moisture 
from the fingers and will be ready for use. 

The lobe of the ear is by far the best locality for 
puncture. For the following reasons: (1) Less sensi- 
tive; (2) the act of puncture and the blood are not seen 
by the patient, important with nervous people and chil- 
dren; (8) pressure, if necessary, is more readily exerted 
and produces better results; (4) the skin in this locality 
is softer and cleaner; (5) there is less likelihood of sub- 
sequent infection. 

The lobe of the ear is then gently wiped (not rubbed, as 
this produces hyperemia) with a silk rag moistened in 
alcohol and the skin is then dried with ether. If ether is 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood, 
Blood, 








not to be had, it is better either to dilute the alcohol three 
or four times or to use distilled water. Alcohol if left 
on the skin hardens the blood and so injures the speci- 
men. 

The Sticker.—The sticker is now employed (see Fig. 
540, 3). This is extremely sharp and is diamond shaped 
on cross section; the object being to produce a similarly 
shaped wound, and therefore one which will the more 
readily bleed. A surgical needle may be used, but an 
ordinary needle or pin is very unsatisfactory. If, how- 
ever, one or the other of the latter is all that can be ob- 
tained, it should be boiled. When cleanliness is observed, 
it is only necessary to dip the end of the sticker into alco- 
hol before and after making the puncture. 

The most dependent portion of the lobe of the ear is 
now punctured by a stabbing motion, the sticker being 
held as in illustration (Fig. 541). The first drop is wiped 
away, the second allowed to flow, if possible, without 
pressure being made upon the skin. If pressure be neces- 
sary it should be exerted far away from point of punc- 
ture, so that this artificial means shall not alter the char- 
acter of the drop taken for examination. 

Avoid Chilling the Blood. It must be remembered that 
the blood is being submitted to a lower temperature than 
normal in this proceeding, and in order to avoid chilling 
the blood it is a good plan to warm the slide and cover 
slip over a spirit lamp, or to have another person briskly 
rub the slide with a bit of silk. 

The clamp forceps holding the cover slip (see Fig. 540, 





Fig. 541.—Method of Making Puncture for Fresh and Dried Speci- 
mens of Blood. Shows position of hands and wrist just as puncture 
is about to be made 


4) are now brought toward the ear, and the under sur- 
face of the cover slip—and therefore that free from dust 
—is made to touch the apex of the drop of blood, not 
the skin of the ear (Fig. 542). The cover slip is at once 
carried to the warmed slide and gently lowered. 

Avoid Rough Treatment. The cover slip should not 
be dropped on the slide. One side of the cover slip should 
be rested on the slide and gently lowered until the limb 
of the forceps touches the slide. The forceps are then 
opened and by a quick jerk drawn away (see Fig. 548). 

Avoid Exposure to Air. It must be remembered also 
that the air isa destructive medium to the blood, and the 
time occupied for these steps must be as brief as possible. 

The cover settles and the good blood specimen spreads 
equally in all directions, being for the most part circular 
with fine spicules at the periphery of the circle. The 
drop should not be so large as to reach the margin of the 
cover slip when on the slide. 





This technique may be summarized as follows: 

1. Apparatus. Thin slide, square thin cover slip, 
sticker and clamp forceps. Alcohol, ether, spirit lamp, 
silk cloth. 

2. Absolutely clean point of puncture and apparatus. 


Fig. 542.—Method of Taking Drop of Blood for Fresh and Dried 
Specimens of Blood. Shows how to hold forceps and ear, how to 
steady hands, and the extent of grasp of cover slip by clamp 
forceps. 


83. Seize cover slip in clamp forceps and place near at 
hand. 

4. Light puncture of the most dependent portion of 
lobe of ear. 

5. Warm slide and cover slip gently over spirit lamp; 
or have another person rub slide briskly with silk cloth. 

6. Wipe away drop from point of puncture. (If press- 
ure is required, exert it faraway from point of puncture.) 

7. Touch apex of drop with under sur- 
face and centre of cover slip. 

8. Place cover slip promptly but gently 
on slide. 








Fig. 543.—Correct Position of Hand in Holding Clamp Forceps. 
Cover slip resting on slide. The illustration represents the position 
just before the forceps are opened and jerked away. 


Characteristics of a Good Fresh- Blood Specimen.—Gross : 
1. Blood does not reach margin of cover slip. 2. Is of 


39 


Blood, 
Blood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








a circular shape with fine spiculated appearance at 
periphery. 3. Is thinner in the centre than at margin of 
specimen. (See Plate XIII., Fig. 1.) 

Microscopic: 1. Corpuscles each lying separate with 
some little space between—not in rouleaux. 2. Majority 
of corpuscles stationary. 8. Each corpuscle circular— 
not erenated. (See Plate XIII., Fig. 6.) 

Poikilocytosis is of course pathologic and cannot be 
avoided; crenation is not, however, and is usually due 
to faulty technique. (See Plate XIII., Figs. 3 and 5.) 

Characteristics of a Poor Fresh-Biood Specimen, and 
Such as Condemn It for Examination.—Gross: 1. Blood 
thick and oozing out from under cover slip indicates 
that too much blood has been taken. 2. Irregular shape 
indicates either that too much blood has been taken, or 
that dust has been on the slip or slide, or that the blood 
has been chilled. 3. Thick at one point and partially 
spread at another indicates dust or moisture. 4. Lump 
of blood—no spreading—indicates general uncleanliness. 


Microscopic: 1. Structureless masses. 2. Abundance 
of rouleaux. 38. Much crenation. 4. Corpuscles closely 
placed, giving tiled-floor appearance. 5. Corpuscles 


rapidly floating about specimen. 6. Corpuscles ragged 
and mutilated. 7. White corpuscles broken into granular 
collections. (See Plate XIII., Figs. 3 and 5 

W nat can be Learned from Fresh Specimens of Blood.— 
When the precautions laid down in the foregoing have been 
observed, the following objects may be distinguished: 

1. The Red Blood “Corpuscles—non- nucleated in the 
normal. 

Size—7u. (Note: « = micron = s34,, 0ofaninch. Itis 
well to become familiar with the size of the red cell, and 
to use it as a unit of measurement when speaking of oth- 
er bodies, as twice, thrice, etc., the size of the red cell.) 

Shape—biconcave discs. 

Color—pale yellow. 

Character—elastic. 

Tend to form rouleaux. 

Become crenated. 

May contain bright round 
spots termed “artifacts.” 

The adjective artifactitious, or simply factitious, might 
be applied to the last three conditions, as they are the re- 
sult of manipulation. 

2. Microcytes or Macrocytes. \ 


3. Poikilocytes. 
eee ‘ajjq_ § Normoblasts. 
4. Nucleated Red Cells. } Gigantoblasts. 


5. Lake-like Areas with irregular shape and mar- [ 
gin in the red cells, due to deficiency of hemoglobin, | 


| Conditions due to faulty 
technique. 


“BIULBUB UT 


termed by Maragliano “degeneration areas, * called 
also vacuoles. 

6. Shadow Corpuscles, described first by Norris, are seen 
in the blood of anzemia from toxicagents and burns. These 
are red cells deprived of hemoglobin. They can be arti- 
ficially produced by adding water to the blood specimen. 
ells. 

7. Small Mononuclear or Small Lymphocytes. 

8. Large Mononuclear or Large Lymphocytes. 

9. Transitional Mononuclear or Transitional Lympho- 
cytes. 

10. Polynuclear Leucocytes. 

11. Eosinophiles. 

12. Myelocytes in leukeemia. 
detected in the fresh specimen. ) 

An approximate idea of an increase in the white cells 
as a whole, and one or other variety of these individually, 
can be had from the fresh specimen. More than four or 
five white cells in a well-spread field with a one-twelfth im- 
mersion lens may be taken to indicate a leucocytosis. In 
lymphatic leukeemia the increase in the small mononuclear 
leucocytes is readily appreciated; so also the presence of 
the cells normally found in the bone marrow, as the myelo- 
cytes, can be detected in the fresh specimen in cases of 
spleno-medullary leukemia. In inflammatory ieucocyto- 
sis the increase in the polynuclear leucocytes can be noted, 
The increase in the eosinophiles, so important a diagnostic 
sign in trichinosis, etc., can-also be detected. 





(The Mastcells cannot be 


40 


13. The Plate * and the Plaque—non-nucleated. 
Size—One-seventh the size of the red cell (1). 
Shape—irregular. 

. Color—colorless. 

Not visible normally. 

By placing a drop of Hayem’s or Pacini’s solution + 
over the point of puncture (the finger must be used 
for this purpose) and allowing the blood to mingle 
with this preservative fluid the plates may be seen. The 
cover slip is applied to the drop in the same way as when ° 
taking a fresh specimen. 

We have no systematic work upon the significance of 
the presence of these bodies. 

The writer has noted them in great numbers (without 
the use of a preservative fluid) in the blood of pneumonia 
cases, in a case of grave anemia secondary to malaria, 
and in a case of Hodgkin’s disease. 

The work of Osler, Bizzozero, Schimmelbusch, Welch, 
and Eberth has been more to prove that these bodies are 
separate corpuscular elements than to explain their as- 
sociation with disease. An exception to this statement 
should be made in favor of- Welch’s work, which goes 
to show that these bodies are the active agents in the 
formation of the white thrombus; but even this has not, 
as yet, been of any clinical value. 

14. Fibrin does not, normally, appear for some time in 
a well-taken fresh specimen. Its presence shortly after 
taking the specimen is therefore of pathological signifi- 
cance. We have not been able as yet, however, to at- 

tach any diagnostic value to this condition. 

15. Blood Dust (hemokoniosis, literally, blood full of 
dust, of Miiller) can be seen as floating particles about 
one-twentieth or one-thirtieth the size of the red cell. 
No satisfactory explanation of the significance of these 
particles has as yet been given. 

16. The Tertian and Quartan Malarial Parasite in all 
its stages of development, and many of the stages of the 
Astivo-autumnal Malarial Parasite, may be seen with 
the one-twelfth oil-immersion lens. 

17. The Filaria Sanguinis Hominis may be seen with 
the 7 or 9 Leitz lens. 

18. Spirochaéte of Relapsing Fever may be seen with 
the 7 or 9 Leitz lens. 

All this information is to be had by the simple pro-. 
cedure of taking, in the way described, a specimen of 
blood. All these points will be found grouped in the 
table at the end of this article. 

Having ascertained, then, from the fresh specimen that 
there is a decrease in the number of red cells, or an in- 
crease in the number of white cells, it becomes necessary 
to determine this decrease and increase definitely, for 
which purpose additional instruments are required. 


II. BLoop-CoRPuscLE CoUNTING. 


History.—It is only of late years that the methods of 
enumerating the blood corpuscles have been simplified so 
as to be clinically applicable, the complicated apparatus 
heretofore used having had place in works on physiology 
only. It is therefore of value to trace the development of 
our present simple apparatus from its complicated be- 
ginnings. When we look over all the methods employed 
to accomplish this last, we find that investigators have 
endeavored to construct apparatus along three separate 
lines, as follows: 1. Actual enumeration. 2. Centrifug- 
alizing and estimating cells according to amount of sedi- 
ment. 95. Color changes and opacity due to decrease in 
number of cells. 

This will therefore be, not a history of blood counting 
in chronological order, but rather the record of the devel- 
opment of apparatus along these three lines. 





* The term plate is here used to refer to the corpuscles; plaque 
to the aggregation of these plates. Platelet, a term synonymous with 
plate, is best discarded. 


+ Hayem’s Solution. Pacini’s Solution. 


Bichloride of mereury.... 0.5 | Bichloride of mercury...... 2. 
Sodium sulphate ......... 5. | Sodium chloride........... 4, 
Sodium chloride.......... 15") GY Cerin dis ons ohse oe 26. 
Distilled water........... OL! Distilled waterwnescie ese 226. 


' ha 
$e 


: ae-* rs 


~ 


Cs 


CY 


EXPLANATION OF 


. w . 
4 TF 0 
> 4, ee. G ~~ 
a a 
7 tf 
. « 7 
. * . o 
. oF 2 
a tS 
4 = ~ = ~ “ 
= 4 
Ae fatd ie ais 
. * = 


PLATE 






EXPLANATION OF PLATE XIII. 


(DRAWN By Dr. E. DUNNING.) 

Fic. 1.—Gross appearance of well-taken fresh-blood specimen. - | gee p, 89: Characteristics of 

a Good Fresh-Blood Speci- 
men. 


Fie. 6.—Microscopic appearance of well-taken fresh-blood speci- 
men. 


Fie. 3.—Microscopic appearance of poorly taken fresh-blood 


specimen. See p. 40: Characteristics of 


a Poor Fresh-Blood Spect- 


Fie. 5.—Microscopic appearance of poorly taken fresh-blood men. 


specimen. 


Fig. 2.—Microscopic appearance of the Thoma-Zeiss count- 
ing stage with normal biood diluted with Toison solution. 
Red cells unstained ; white cells stained blue. This is with 
the low-power objective (8 Leitz) which takes in all sixteen \ See p. 45. 
squares (see Fig. 555, p. 44), but does not magnify the cell 
as much as the higher power (see Plate XIII., Fig. 4), and 
which therefore greatly increases the task of counting. J 


Fic. 4.—Same as Fig. 2, Plate XIII, except that the blood is } 
that of leukeemia (120,000 leucocytes to the cubic millimetre), | 
and the objective is of high power (7 or 9 Leitz). This } See p. 45. 
takes in only one-sixteenth of the entire field, but it renders | 
the corpuscles much more readily distinguishable. 


REFERENCE HANDBOOK 


OF THE PLATE XIll 


MEDICAL SCIENCES 











Fla. 3. 





Kies. FIG. 6, 


HUMAN BLOOD 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








.1. ActuaL ENUMERATION OF BLoop CoRPUSCLES.— 
Vierordt was among the first actually to enumerate the 
red blood cells; and though his apparatus was most 


Blood, 
Blood, 





divided into fractions of a cubic millimetre, as seen in the 
illustration. The microscope is adjusted so as to mag- 
nify the corpuscles as they lie in the artificial capillary 
(see Fig. 546), and their number ascertained 
for a fractional part of this capillary as 
marked on the glass plate. According 
to the fraction of a cubic millimetre which 
that portion selected to count represents, 
the number counted is multiplied. 














Suppose one counts the corpuscles in 








Fig. 544.—Potain’s Mixer. 


crude and his method most complicated, yet his results 
have been abundantly confirmed by subsequent observers 
working with varied styles of apparatus. Vierordt’s fig- 
ures were, 5,174,000 red blood cells per cubic millimetre. 

Vierordt diluted with a fixed quantity of sugar solution 
a cubic millimetre of blood and then spread this upon a 
slide. By means, of a micrometer he counted every cor- 
puscle. For one enumeration it took an entire week. 
The result of this work was to establish the following: 

(1) A known quantity of blood must be taken, that 
quantity being the amount contained in a cubic milli- 
metre. 

(2) A known dilution. 

(3) A cubic millimetre of normal blood contains 
5,174,000 red cells. 

At this time, Kélliker, after declaring that “owing to 
the difficulty of the subject” the most careful estimates 
can “only be described as approximate,” adds: “One 
method only can be successful, consisting in the direct 
enumeration of the globules in accurately determined 
quantities of blood.” Welker adds the next improve- 
ments (1) in using a stage micrometer, and (2) in counting 
the corpuscles in a fraction of a large dilution and multi- 
plying the result of this count by the figures required to 
make the whole cubic millimetre. 

Potain’s mélangeur or mixer afforded the first means of 
accurately diluting the blood. This was nothing else in 
principle, but of cruder make, than the mixer now em- 
ployed in the Thoma and Zeiss blood-counting apparatus. 
Fig. 544 shows this mixer. 

Potain’s mixer was divided precisely as is the Thoma- 
Zeiss mixer, into a dilated and a capillary portion, the 
capillary portion being exactly z+, part of the whole. 
The dilated portion of the Potain mixer contained the lit- 

















































































































(} 


= 500/e5i 


















































Fig. 545.—Malassez’ Artificial Capillary. 


tle glass ball, as in the Thoma-Zeiss apparatus. Malassez 
combined this suction capillary pipette with an artificial 
capillary in the following manner: Blood is drawn up 
by suction into the Potain mixer to the 1 mark, and a 
diluting fluid, called the “artificial serum,” consisting of 
—gum arabic specific gravity 1.020, one volume; sodium 
sulphate and sodium chloride, equal parts and each of 
specific gravity 1.020, two volumes—to the 100 mark, 
making dilution of 1 in 100. The pointed end of the 
mixer is then fastened to a rubber tubing connected with 
the artificial capillary, as seen in Fig. 545. 

The artificial capillary is set in a plate of glass which is 








too Of acubic millimetre; then 400 times 
that number multiplied by the amount of 
dilution represents the number of corpus- 
cles in a cubic millimetre. 

This method offered many difficulties: 1. Complicated 
artificial serum for dilution. 2. Introduction of blood 
without air into artificial tube difficult. 8. Difficult to 
clean apparatus. 

Hayem and Nachet devised an instrument (Héma- 
timétre) by which the blood and serum are obtained in 








































































































Fig. 546.—Artificial Capillary as It Appears Under the Microscope. 
x 180 diameters. (From Ranvier.) 


two separate pipettes and then mixed in a glass receiver. 
A drop of this mixture is then placed upan a glass slide 
arranged as follows: A. circular well, similar to that 
employed in the Thoma and Zeiss apparatus, is con- 
structed with the accurate measurement of 1 em. in 
diameter and 0.2 
mm. in depth. 
An eyepiece mi- 
crometer ruled 
in a large square 
and divided into 
sixteen little 
squares is then 
attached. One 
side of the large 
square measures 
exactly + mm.* 
(see Fig. 547). 
By counting 
the cells in the 
square and mul- 
tiplying this 
count by the 
fraction of a 
cubic millimetre 
which this 
Square repre- 
sents, and the number of volumes of the diluting fluid, the 
number of cells inacubic millimetre is ascertained. This 


oa ~ 

S409) 
° 
q°c oO 


®) Oo 
oo 


OP 
[exe 
O 

° 





Fig. 547.—Appearance of Corpuscles with Hayem 
and Nachet’s Instrument. 


* One-fifth millimetre in depth by one-fifth millimetre on two sides 
pe square Ste the block of blood one-fifth (0.2) cubic millimetre— 
X5X5= 125. 


41 


Blood, 
Blood, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








is complicated, but, as will be seen later, it has contributed 
certain points toward the simple apparatus used to-day. 
In The Lancet for December 1, 1877, Gowers de- 
scribes an instrument which he calls the hemacytometer, 
and which more nearly approaches perfection than any 
already described; it therefore marks what may be con- 
sidered the border line between the ancient and modern 






































Hane 
: ( i i 




















Fic. 548.—Gowers’ Hzemacytometer. (From Kirkes’ ** Handbook of 
Physiology,” twelfth edition.) 


history of blood-counting by the actual enumeration 
method. Gowers’ instrument (see Fig. 548) consists of: 
A, Small pipette (with rubber mouthpiece for suction) 
which, when filled (with diluting fluid) to the mark on 
its stem, contains exactly 995 c.mm._ 5B, Another pipette 
marked to hold 5c.mm. (of blood). D, Glass jar for mix- 
ing (blood and diluting fluid). E, Stirrer (to stir blood 
and diluting fluid in glass jar). C, Brass plate with a 
cell + (0.2) mm. in depth and with the floor divided into 
5 (0.1) mm. squares and a cover glass held in place by 
springs. 

A standard saline solution of sodium sulphate of specific 
gravity 1.025is employed; 995 c.mm. of solution is mixed 
with 5c.mm. of blood with the pipettes. These are mixed 
in the glass jar. A drop is placed in the cell in the brass 
plate and the cover slip held down by the springs. The 
cells are then counted in ten squares, and the calculation 
for 1 c.mm. of 
which this is a 
fraction made. 

As we review 
these descrip- 
tions of appara- 
tus we see that 
the effort of the 
inventors has 
been to over- 
come certain 
obstacles, 7.é.: 

(1) Reduction 
of the corpuscles 
to a countable 
number. Vie- 
rordt accom- 
plished this by 
dilution and by 
fixing the area 
to be counted to 
the cubic milli- 
metre. 

(2) Obtaining the blood so as to prevent clot, and to 
dilute accurately. Welker showed the value of accurate 
dilution. Potain’s mélangeur best accomplished this. 


90000 


lore) eo) fore) O08 





Fig. 549.—Appearance of Corpuscles Under Mi- 
croscope with Gowers’ Instrument. 


42 














(3) Spreading the blood over an area thin enough to 
see each corpuscle. Malassez accomplished this with a 
long narrow tube; Hayem and Nachet with a cell whose 
depth was a fraction of a cubic millimetre. 

(4) Mapping out the area so that the eye could navi- 
gate upon it. Hayem and Nachet accomplished this 
with an eye-piece micrometer. Gowers, without an eye- 
piece micrometer, but with a marked-out slide. 

All these methods depend (as K6lliker has pointed out) 
upon the following priniciples: (1) A known quantity of 
blood for estimation (1 c.mm.); (2) a known dilution of a 
known quantity of blood; (8) a known fraction of a 


, cubic millimetre to be counted. 


Upon these principles and with the information obtained 
from the foregoing inventors, Thoma and Zeiss have con- 
structed their apparatus. This combines the mélangeur 


_ of Potain and the mapped-out cell of Gowers. 


Principle of the Thoma-Zeiss Mixer.—The mixer con- 
sists of a capillary portion and a dilated or bulb-like por- 
tion. The capillary portion enables one to procure a 
fixed quantity of blood that is free from clotting, if 
promptly taken; and the bulb portion enables one to pro- 
















wbowl L00 
N | 
R N Bowl, 
NN 
4 nelle IN iN J fe 
| WN 


Fig. 550.—The Mixer of Thoma and Zeiss Corpuscle-Counting Appara- 
tus. Shows principle of dilution by comparison of pipette (a neces- 
sary instrument in dealing with a coagulable fiuid like blood) with 
an Cea receiver (in which a non-coagulable fluid could be di- 
luted). 


cure a fixed dilution. The principle of this mixer is best 
understood by reference to the diagram shown herewith 
(Fig. 550). 

Suppose the fluid to be diluted were wine or some non- 
coagulable fluid. Then we should pour the wine into 
the receiver, as shown in the diagram, up to the mark 1, 
and the diluting fluid up to the mark 100. This would 
be 1 to 100. Were we to pour the wine up to the .5 
mark only (or +of 1), and the diluting fluid up to 100, ° 
we should have half as much wine as before to the same 
amount of diluting fluid, or in the proportion of 1 to 
200. Half the fluid to be diluted with the same amount of 
diluting fluid has the same result as doubling the amount 
of the latter. 

Now blood cannot be poured in this way. An instru- 
ment must therefore be devised by which the blood can 
be taken free from clotting. Our receiver, therefore, is 
converted into a capillary tube and our pouring is re- 
placed by suction. That portion of the receiver marked 
off as 1 is converted into the pipette, and that portion 
of the receiver marked off as 100 is converted into the 
bowl. We now have an instrument by which a definite 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





quantity of blood can be drawn up together with a definite 
quantity of diluting fluid. This instrument, when full, 
represents 101 of blood and diluting fluid, or 1 of blood 
to 100 of diluting fluid. If the blood be drawn to the .5 
or 4 mark and the diluting fluid to the 100 mark we have 
1 to 200. 

The Thoma and Zeiss apparatus is usually provided 

with two mixers similar in all respects except that one is 
larger than the other: one for counting the white cells, 
the larger one; and one for counting the red cells, the 
smaller one. That for counting the red cells is all that 
is necessary, and, as will be seen later, is preferable to two 
separate proceedings. 

The diluting fluids, at first so complicated, have been 
much simplified. The object has been to obtain a medium 
as nearly as possible like that in which the corpuscles nor- 
mally float. 

Diluting Fiuids: (1) Normal, better named _ physio- 
logical, sait solution.* (2) Acetic acid 1 in 300 destroys 
the red cells and accentuates the nuclei of the white, and 
is therefore valuable in counting the white cells alone. 
(3) By using a basic stain together with the preserva- 
tive salts the results obtained separately by the other 
fluids are combined. The most satisfactory of these is 
the Toison solution. 


Formula. + 


( Oo -CHIOTIGe2..s-.., 2.1162). 1.000 gm. 
| } DOUMIMMEStULD NATE. ace cnse tiers 8.000 gm. 
Pe CREE ae aie kent ors oie sie 30.000 c.c. 

[ UAV CEUWENRS  nc is Sea one Pena Ss 160.000 e.e. 

+ ESS 9 NG Fed (2 AR ge 0.025 gm. 


In the preparation of this solution it is advisable first to 
mix the sodium chloride and sodium sulphate thoroughly, 
and then to add these to the glycerin and water—the 
methyl] violet being added last. The brackets in the above 
formula show these steps in the preparation. 

Principle of the Counting Well.—Having thus an ap- 
paratus for taking a fixed quantity of blood with a fixed 


ae 


uy rey ei i 


1 ¢.mm. 





FiG. 551.— A Cube Representative of the Amount of Blood from Which 
Corpusecle Enumeration is Made. The block represents 1 ¢.mm. 


quantity of diluting fluid, we must next have a means of 
counting the corpuscles. For this a glass slide is con- 


* Normal in chemistry indicates a solution containing the sum of 
the atomic weight of the salt employed in grams to 1,000 c.c. of dis- 
tilled water. As this is not the case with so-called normal salt solution, 
the term is misapplied. Physiological salt solution is, roughly, NaCl 
3 j. to the O j. distilled water. 

+ This solution must be kept in the dark and must be filtered from 
time to time as it losesits color and develops a fungus growth which 
seriously plugs the pipette. This solution preserves the red cells and 
by means of the methyl violet stains the white cells a iight purple, 
making the latter readily distinguishable and enabling 9ne to make 
the count of both red and white cells in one process. 











Blood, 
Blood, 





structed, with a well in the centre of the following known 
dimensions. It must be remembered that each of the 
various parts of this apparatus described has been con- 
structed to overcome an obstacle. The mixer overcame 


0.1 


1¢.mm. 





FIG. 552. 


the clotting and diluted the drop, thus reducing the num- 
ber of corpuscles to a countable figure. The well which 
we are about to describe, (1) reduces the cubic millimetre to 
a depth through which it is possible to see each corpuscle 
separately (a cubic millimetre of blood and fluid to the 
dilution of two hundred times would be so thick and con- 
tain so many corpuscles that the task would be beyond 


0.100 mm. 





Fig. 553.—Full-Face View of Counting Stage. 
Dunning.) 
(German quadrat-square) = smallest square which measures z4, of 
a square millimetre (25 16 = 400).] 


(Drawn by Dr. E. 
(0.100 mm. = depth- 75 of a millimetre; 445 q.mm. 


human skill); (2) maps out that area so that the eye can 
find, as it were, the longitude and latitude of any point 
in the sea of corpuscles. 

What fraction of a cubic millimetre offers the depth 
and contains that number of corpuscles appreciable by 
the human eye? This fraction is found to be one-tenth of 
a cubic millimetre in 1 to 100 or 1 to 200 dilution of blood. 

The illustration (Fig. 551) represents a millimetre cube. 
Tf this consisted of blood, the depth would be too great 
for the human eye to penetrate and would contain so 
many corpuscles as to be beyond human skill to enumer- 
ate. We therefore retain two dimensions of the cube, but 
take only one-tenth of the depth. This layer of blood is 
therefore one-tenth of a cubic millimetre in a 1 to 100 or 
1 to 200 dilution (see Fig. 552). 

The counting stage, to fulfil these requirements, must 
be constructed asfollows: The bottom of the well upon 
which the corpuscles rest must be laid off with a square 
whose dimensions are 1 mm. each way, and the well 
must be one-tenth ofa millimetre in depth. The illustra- 
tion (Fig. 553) shows the full face view of the counting 
stage. In the centre is seen the bottom of the well with 
a square laid off measuring 1 mm. each way. 

The second illustration (Fig. 554) shows the profile of 
this stage with the cover slip in place. The measure- 
ment from the under surface of the cover slip to the bot- 
tom of the well is exactly 0.1 mm. 

When, therefore, a drop of the diluted blood is placed 


42 


Blood, 
Blood, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








in this well and the cover slip isin place, those corpuscles 
which we see contained within the square, the dimen- 
sions of which are 1 mm. each way and 0.1 mm. in depth, 
are the contents of a cube of diluted blood measuring 
zo of a cubic millimetre. 

(Norr.—These microscopic dimensions, but for the 
present simple method of construction, would render this 
instrument in the making a very costly and delicate 
affair. In the manufacture of this counting well a glass 
slide similar in length and breadth, but a little thicker 


Fic. 554.—Profile View of Counting Stage. 
ing.) 


(Drawn by Dr. E. Dunn- 


than that employed for general microscopic work, is used. 
Upon a round block of glass the millimetre square is cut 
or pressed. This block of glass is cemented to the centre 
of the glass slide and forms the bottom of the counting 
well. Another piece of glass, like a thick cover glass 
but with @ rownd hole cut in the centre, is cemented upon 
the slide, so that the block of glass already in place oc- 
cupies, but does not exactly fit, the hole. The difference 
in measurement, from above down, between the upper 
surface of the round block of glass and the upper surface 
of the glass with the hole through it is just 0.1 mm. 


1 mm. 





















































1mm. 































































































Fig. 555.—Subdivisions of Counting Field of Thoma and Zeiss Ap- 
paratus. [1 sq.min.—y5 sq.mm.—q4y (25 X 16) sq.mm.] 


Thus the well with a millimetre square marked at the 
bottom and 0.1 mm. in depth is formed. The fact that 
the block of glass does not completely fill the hole in the 
outer piece of glass explains why there is left about it 
a groove into which the blood flows, if more than is re- 
quired exactly to cover the block of glass is blown into 
the well. This seems an objection, as currents are thus 
produced allowing many corpuscles to flow out of the 
mapped area. There seems no good reason for the pres- 
-ence of this groove except possibly that it obviates the 
additional expense of making the block of glass exactly 
fit the hole.) 

Principle of the Ruling of the Counting Well.—We now 
turn to the marking out of a millimetre square which is 
to render it navigable. Here, as before, an obstacle is to 
be overcome, viz., the inability of the human eye to keep 
its bearings when viewing several thousands of corpuscles. 

The first subdivision of this area (as first done by Nachet 
and Hayem on the eye-piece and by Gowers on the stage) 


+4 











~ 


is into 16 squares. But even this does not overcome 
the difficulty, and it is necessary still further to subdivide 
each one of these into 25 squares (Fig. 555). It now be- 
comes necessary to establish some boundary mark for 





Fie. 556.—Shows Method of Drawing Blood into Mixer. Diluting fluid 
near at hand. 


these 16 large squares, each consisting of 25 small squares. 
This is done by bounding each of the 16 squares on two 
sides with double lines. Now we can readily count the 
corpuscles in one of the large squares which is bounded on 
two sides by the double lines, and realize that this repre- 
sents 7; of the field; or in one of the small squares, and 
realize that this 
represents 3: of 
de, or (16X25 = 
400), zt> of the 
whole millimetre 
square. On the 
glass slide (Fig. 
553) will be no- 
ticed the figures 
0.100 mm., refer- 
ring to the depth, 
which is 74 of a 


. 1 
mm.; also go 
q-mm., referring 


to the smallest 
squares, each one 
of which measures 
£50 sq.mm., (x); of 
5=o0) (Fig. 


ore 
os 


5. 

Once these ma- 
thematical facts 
are Clearly under- 
stood, one may 
countin many dif- 
ferent ways. One 
small square may 
be counted, and 
the result multi- 
plied by 400; or 
25 small squares, 





and the result 1G. 557.—Thoma and Zeiss Corpuscle-Count- 
multiplied by 16 ing Apparatus. Drawing diluting fluid into 

plea by 16, mixer. The blood has already been drawn 
The best method, in. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood, 
Blood, 





however, will be given in the following description of 
the use of the apparatus. 

Now that we understand the principle of the apparatus, 
let us proceed to its use: 

In order to obtain the blood the ear is punctured as for 
a fresh specimen, and the tip of the capillary tube inserted 
énto the drop and retained there while gentle suction is 
exerted, and the blood drawn either to the 1 mark, or the 
.) or 4 mark, as shown in Fig. 556. The latter is pref- 
erable, for the following reasons: (1) Less blood. (2) 
Difficult to stop sharp at the 1 mark without the blood 
passing on into the bowl and necessitating cleaning the 
instrument and beginning again. In using the .5 mark, 
if the blood pass the mark it may be soaked off the tip 
of the pipette with linen or blotting paper until the 
column stands opposite the .6 mark—cleaning, etc., not 
being necessary. : 

As promptly as possible, to avoid clotting, the pipette 
is submerged into the diluting fluid; and then, but not till 
then, suction is again made until the fluid stands opposite 
the 101 mark (Fig. 557). Suction must be gentle through- 
out, and especially so as the fluid is approaching the 101 
mark, as it readily pops into the rubber tubing. The tip 
of the pipette must always be tmmersed in the fluid being 
sucked up, whether it be biood or diluting fluid, other- 
wise air enters the pipette and destroys the specimen. 

Directly the diluting fluid has reached the 100 mark 
the finger is placed on the tip of the pipette and the 
whole shaken in order that the corpuscles may, by the 
aid of the small glass ball in the bulb portion of the mixer, 
be thoroughly mixed with the diluting fluid (Fig. 558). 
As the pipette contains the diluting fluid and no corpus- 
cles, this must be emptied; and to be certain that this 
is done the bulb of the mixer is emptied one-third by 
blowing the fluid out. The diluting fluid should be 
allowed to act upon the blood in the mixer for five or 
ten minutes before the drop for counting is taken from 
the mixer. 

The counting stage is now employed. This stage and 
the cover sip must be free from dust particles. The 
latter (the cover slip), grasped with the clamp forceps, is 
placed conveniently at hand. A thick cover slip with 
accurately level surfaces, to prevent bending, is provided 
with the apparatus; but as this interferes with the use of 
the high-power lens, it is an objection. An ordinary 
cover slip may be used, if care is taken not to press down 
upon it with the objective. From the mixer a drop is 
blown on to the central raised table of the counting well 





FIG. 558.—Position of Hands in Shaking Mixer. 


(Fig. 559). The drop should not (1) flow into the well, 
(2) or contain air bubbles, (3) or particles of dirt. The 
cover slip is lowered until the fluid touches it, then the 
forceps are opened and withdrawn with a jerk as in lay- 
ing the cover slips for fresh specimen (see Fig. 5438). 





There should be no air bubbles, which may be avoided 
by observing the foregoing precautions. 

By holding the slide up to the light on a@ level with the 
eye and making pressure with the point of the forceps 
upon the cover slip, a series of varicolored concentric 
rings will be seen about the point of the forceps where it 
touches the glass. These are the Newton’s rings, which 
are seen only when two pieces of glass are in perfect ap- 





F1G. 559.—Blowing Drop from Mixer on to Stage. 


position, 7.e., when there are no dust particles, etc., be- 
tween them. The presence of these rings is therefore an 
evidence that the glasses are perfectly clean. Two to 
three minutes are now allowed for the corpuscles to sink 
through the depth of one-tenth of a millimetre and rest on 
the mapped-out bottom of the well. By at once observing 
the slide under the microscope this sinking process may be 
seen. Weare now ready to count; the lowest-power lens 
of the Leitz or Zeiss microscope may be used. This takes 
in its field of vision the whole counting area, but magnifies 
the corpuscles so slightly that the strain upon the eye is 
great (see Plate XIII., Fig. 2). The 7 or 9 objective 
of the Leitz takes in only 54; of the counting area, but does 
not strain the eye, and is therefore preferable, as with lit- 
tle practice the stage may be gradually moved until the 
whole area has been examined (see Plate XIII., Fig. 
4), As the proportion of white corpuscles to red is about 
1 to 700, there will be in a given area much fewer white 
corpuscles than red; and in the one-tenth of a cubic milli- 
metre there will be about 38 white cells to about 2,100 red 
cells. The task, therefore, of picking out three white cells 
in an entire field will be a simple one; while it is more 
practicable to count only a fraction of the field containing 
2,100 red cells, and then compute the total by multiply- 
ing the number counted by the fraction adopted (see 
Plate XIII., Figs. 2-4). The following are the steps to 
be taken in counting the red and the white cells: 

Counting White Cells.—(1) Count cells contained in 
entire field, 7.e., 16 squares = ;4) of a cubie millimetre; 
(2) multiply by 10 to make the 1 c.mm.; (8) multiply by 
100 or 200, according as the dilution has been made. 

Counting Red Cells.—(1) Count 4 squares, each consist- 
ing of 25 of the smaller squares: 4 squares out of 16 = 
yj or tof the whole 7; of a cubic millimetre; (2) this 
number multiplied by 4 gives the number contained in 
the #5 of a cubic millimetre; (8) multiply by 10 and by 
100 or 200 as before. 

Now it must be remembered that every time we count 
a fresh drop from the mixer we decrease the range of 
error; so (remembering to shake the mixer well each time, as 
the corpuscles settle rapidly in the bulb) suppose in counting 
the white cells we take from the mixer 5 separate drops 
and count each upon the counting stage. Anaverage of 
the result, obtained by dividing by 5, gives us the num- 
ber of white cells contained in ;45 of a cubic millimetre. 
This average multiplied by 10 and 100 or 200, as before, 
will be a more accurate figure than that arrived at by 
counting one drop only. 

Suppose in estimating the red cells we take from the 








45 


Blood, 
Blood, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








mixer and count 2 separate drops, counting in the first 
drop the four corner squares (Squares Nos. 1, 4, 18, and 16 
in Fig. 555), ¢.e., 34 of the whole field; then in the sec- 
ond drop the same four corner squares, 7.é., 74 also—our 
two counts combined will represent 8; or 4 of the field; 
this multiplied by 2 represents the whole field, 7@.e., 5 of 
a cubic millimetre. This multiplied by 10 and by 100 or 





o- 











ee ee 

















It 


rh orn Pat pee asta hm pam 




















| 

















: 











op 










































































FIG. o6U.— Routes to be Taken in Counting Entire Field and One- 
Sixteenth of Entire Field. 


200, according to dilution, gives the number of red cells 
in a cubic millimetre of undiluted blood. These calcula- 
tions may be expressed as follows: 


White Cells : ame Fs: x 10 x (100 or 200) =2; 


a, b, c, d, and e being the counts of separate drops taken 
from mixer; 5 the average number; 10 for the 7 of 
a cubic millimetre; 100 or 200, amount of dilution; z the 


number of corpuscles in cubic millimetres of undiluted 


blood. 
(Separate drop.) (Separate drop.) 


Red Cells: ( Cee ame foo SEED) 


Y ao wa 
(4 of field) = (14 of field) = 44 of field 
< 10 x (100 or 200) =z, a, b, c, d, each the number of 
corpuscles in ; of field—therefore together equal to 5%; 
or +of field; plus second count obtained from another 
drop from mixer equals 4 of field; and multiplied by 2 
equals whole field. 

One-sixteenth of the field can be readily counted by 
counting znside the double lines up and down, as in 
ploughing a field, and then counting along two sides 77 
the double lines. The route for counting in this way is 
shown by the dotted lines in the upper right-hand corner 
of Fig. 560. For counting the entire field the dotted 
line in the whole field of Fig. 560 marks the route. 
This method will be found to save much time. 

In order to avoid recounting corpuscles on the line, and 
to decide to which square these corpuscles belong, the 
following rule will be found valuable. Count only those 
corpuscles on the left line of the column down which you 
are counting, and in the 7, square count only those corpus- 
cles which lie on the double-line boundary of the square. 

With practice a blood count can be made in from 15 
to 20 minutes, unless the blood be from a case of marked 
leucocytosis or grave angemia in which one wishes an ex- 
tremely accurate count. 

Cleaning the Apparatus.—The Thoma and Zeiss appara- 
tus has received much condemnation from the difficulty ex- 
perienced in cleaning it. By strictly observing the follow- 
ing rules, this difficulty will be almost wholly overcome. 

(1) If by accident the blood is drawn into the bowl 
before being mixed with the diluting fluid, immediately 





46 











draw up distilled water and proceed to clean as given 
below. Do not use alcohol until all trace of blood has been 
removed. 

(2) Do not draw the blood into the pipette until the 
bottle holding the diluting fluid 7s at hand and the cork 
out of the bottle (see Fig. 556). 

(3) See that the diluting fluid contains no flakes or 
fungus growth; if these be present, filter the fluid be- 
fore using. 

(4) Dry the mixer by drawing ether up and blowing it 
out. 

(5) See that the rubber tube is free from saliva and 
food particles. It is well to do this from time to time, 
while using the apparatus, by detaching the tube from 
the mixer and blowing it out and then passing distilled 
water through it. Suppose these precautions to have 
been taken and the diluted specimen to be in the bowl 
and our count completed; we then proceed to clean the 
mixer, 

(6) Remove the rubber tube, blow out the saliva, etc., 
which may have collected (see (5), above). Attach the 
tube to the pipette end of the mixer and blow out the con- 
tents of the bowl (Fig. 561). 

(7) Replace the rubber tube on the large end of the 
mixer and draw distilled water into the bowl. Shake 
the mixer well and blow this water out by reversing the 
tube as recommended in (6), each time blowing the rub- 
ber tube free of saliva. 

(8) With the tube on the big end of the mixer draw up 
95 per cent. alcohol. With tube on pipette end blow this 
out. This removes the stain. If the glass is not entirely 
freed from stain, repeat until desired result is obtained. 

(9) With the tube on the big end of mixer draw in 
ether, and then (without reversing tube) blow the ether 
out through the pipette. This shows that the whole 
apparatus is clear and ready for use next time. 

If epithelium or mucus from the mouth, etc., gets into 
the bowl, it is best removed by drawing undiluted hydro- 
chloric acid up and then introducing an especial make 
of wire which the writer has suggested to Messrs. Eimer 
& Amend to procure. It is known in commerce as 
“stiff brass wire, B. & S. (Brown & Sharp), No. 31 
gauge,” and has the advantage of being very fine but 
very stiff, and can 
be run the whole 
length of the Tho- 
ma and Zeiss mixer. 
With this wire, and 
most decidedly with 
all other wires, one 
must be careful to 
have no kinks, as 
these may break, 
leaving the wire in 
the mixer—an awk- 
ward accident. 

In the Deutsche 
medicinische Woch- 
enschrift, July 29, 
18/007 ee eno ee 
R. Friedlinder, of 
Wiesbaden, de- 
scribed an_ instru- 
ment, devised by 
himself, for count- 
ing leucocytes. He 
was led to the con- 
struction of this in- 
strument by a sense 
of inaccuracy while 
using the Thoma 
and Zeiss counter. 
His objections to the latter instrument were, first, too 
considerable a dilution and therefore too few white cells 
from which to estimate; second, the calculations nec- 
essary With the Thoma and Zeiss instrument are so exten- 
sive that a small variation in the number upon which these 
calculations are based means an error of many thousands. 





Fig. 561.—Cleaning Mixer. Rubber tube on 
pipette end of mixer. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood. 
Blood, 





Friedliinder confirmed these objections by obtaining dif- 
ferent results in a number of counts of blood taken from 
the same individual on a single occasion. In order to 
overcome these objections Friedliinder had Zeiss construct 
the following apparatus: 

A pipette similar to that employed in the Thoma and 
Zeiss apparatus—dilution 1 in 10 or 1 in 20; a counting 
chamber 0.222 mm. deep x 0.3 mm. square, with the 
floor divided into squares—16 & 16 = 256 squares in all. 
The double ruling is omitted; a mechanical stage is em- 
ployed. 

In order, by this method, to arrive at a figure expressive 
of the number of leucocytes in a cubic millimetre, the fol- 
lowing formula is employed: 

Ne 2 
MxQ 

A = amount of dilution. 

Z = number of leucocytes found in these sections. 

M = number of sections observed. 

Q = the cubic area between the floor of the counting 
stage and the cover slip—?.e., 0.09 « 0.22 = 0.0198. 

Example: Suppose 192 squares to have been counted 
and 1,522 leucocytes found; dilution 1 to 20. 

20 X 1,522 
192 x 0.0198 

(Note: There is a mistake in Friedliinder’s formula; 
1,0198 should read as above, 0.0198.) 

As diluting fluid he employs one-per-cent. salt solution 
tinged with gentian violet to whic is added one-third- 
per-cent. aceticacid. Thus the red cells are destroyed by 


= 8,007 leucocytes in 1 c.mm. 








































































































Fia. 562.—Hedin’s Hematocrit. ( From yon Jacksh’s ‘* Clinical Diag- 
uosis.”’) 


the acetic acid and the nuclei of the white cells intensified, 
and at the same time the cell is stained by the gentian 
violet. 

The writer has had no experience with this instrument. 
If the steps as laid down in describing the Thoma and 
Zeiss instrument are followed the resuits should be as 
accurate. 

Asa clinical instrument Friedliinder’s would seem to 
be objectionable if for accuracy it is necessary to count a 
thousand or more cells. Unless we can arrive at accurate 








Fic. 563.—The Daland Hzematocrit. 











results by simple methods an apparatus loses its clinical 
value. 

A number of counting chambers have been devised. 
These differ chiefly in respect of the size of their rulings; 
the larger ones being given the preference in order to 
minimize the possibility of error. The following are some 
of these: counting chamber of Zappert, counting chamber 
of Gabritschewsky, counting chamber of Miessen, 

2. CORPUSCLE ENUMERATION BY MEANS OF THE CEN- 
TRIFUGE.—We now approach the task of corpuscle enu- 

































ne 


sos) 


(From Simon’s ** Clinical Diagnosis.’’) 


meration from a different point of view. As the cor- 
puscles are particles floating in a fluid, we should be able 
to precipitate these and measure the precipitate. If, as 
is the case in anzemia, the corpuscles are few, our sedi- 
ment should be less than in the normal. The task, then, 
is to throw these corpuscles down. This is done by the 
use of the centrifuge. This machine was employed at 
first to obtain serum, and its use for the latter purpose 
suggested its application as a corpuscle enumerator. 

Principle.—W hen blood is placed in the tube of a cen- 
trifuge and the apparatus rotated, the corpuscles collect 
as a red mass at the distal end of the tube and the serum 
as a colorless, semitransparent liquid at the proximal end. 

By taking a fixed quantity of blood and subjecting it 
to a fixed number of revolutions for a fixed time, and by 
noting and marking the height of the column of cor- 
puscles in the tube filled with blood from healthy indi- 
viduals, 2 normal standard is determined. Deviations. 
from this standard may be taken to indicate an increase 
or a decrease in the number of red cells. 

By counting the blood corpuscles with the Thoma and 
Zeiss instrument at the same time that the blood is sub- 
jected to the centrifuge, markings to express this count 
may be made upon the glass tube containing the column 
of corpuscles. 

The instrument for this method of counting is known 


47 


Blood. 
Blood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. , 





as the hematocrit (aia, blood; xpity¢, a separator or dis- 
cerner), blood separator. Hedin’s instrument was among 
the first devised for this purpose (Fig. 562). 

In using this instrument the blood is sucked into a 
capillary tube together with a 2.5 per cent. bichromate 
of potash solution or Miiller’s* fluid, to prevent clotting, 























ber. of revolutions which they make, and each instrument 
should be tested to ascertain how many times it is neces- 
sary to turn the large handle in order to throw down the 
corpuscles so completely that no further revolving influ- 
ences them. It is therefore impossible to give any general 
rule for the number of revolutions necessary beyond say- 
ing that about four thousand revolutions of the cross 
bar to the minute should be the basis upon which to cal- 
culate. By noting the number of revolutions made by 
the cross bar to every single revolution of the handle this 
calculation can be readily made for each machine. The 
test, however, as stated above, is the complete precipita- 
tion of the corpuscles. The capillary tube is then re- 
moved and the column of corpuscles noted, the count 
being according to the figures 2, 3, 4, 5, 6, etc., in mil- 
lions opposite which the top of the column is found to 
be. (See Fig. 564.) 

Dr. J. Metcalfe Polk, working in the clinical laboratory 
at the Cornell University Medical School, has at my sug- 
gestion carried out systematic observations upon the 
hematocrit, comparing it with the Thoma and Zeiss 






































ae ad Ae 














—— 


















































Fic. 564.—Daland’s Hzematocrit. 


(magnified) containing blood. 


and the tube placed in the limb of the centrifuge. The 
wheel is then revolved for a fixed time at a fixed number 
of revolutions (fifty to seventy seconds with the instru- 
ment here represented), when the red corpuscles will be 
found arranged as a sediment at the distal extremity of the 
tube, with a layer of white cells next, and above the 
white cells, again, the diluting fluid and serum. This 
instrument has been simplified very much by Judson 
Daland working in von Jaksch’s clinic (Fig. 564). By 
comparing the cuts (Figs. 562, 563) it will be observed 
how much simpler the latter is, the principle in both, 
however, being the same. 

An instrument (as shown in Fig. 565) is now upon 
the market for the attachment of tubes for testing blood, 
urine, or milk. In using the Daland instrument no pres- 
ervation fluid (bichromate of potash or Miiller’s fluid) is 
employed, a questionable omission. 

The instrument is operated as follows: A large punc- 
ture is made in the lobe of the ear in the usual way. <A 
rubber tube is attached to the capillary tube and blood 
sucked up, more than is required to fill the tube. 'The in- 
dex finger (with a little vaseline to prevent blood from 
adhering to it) is placed on the far end of the capillary 
tube to prevent the blood from escaping, and the rubber 
tube removed. The excess of blood is wiped away from 
the end to which the rubber tubing was attached. The 
capillary tube is now placed in one arm of the machine 
and an empty tube to balance placed in the opposite arm; 
then the handle of the instrument is revolved for two 
or three minutes. These instruments differ in the num- 





* Miller’s fluid: Potassium bichromate, 2.5; sodium sulphate, 1.0; 
distilled water, 100. 


48 


1, The centrifuge with cross piece con- 
taining capillary graduated tubes in place; 2, capillary graduated tube 
(From Simon’s *‘ Clinical Diagnosis.’’) 





Fig. 565.—Daland’s Heematocrit. 


With attachment for urine tubes 
as well as blood tubes. 


blood-counting apparatus. The instrument upon which 
these observations were made is that shown in Fig. 565. 
The following are his findings: 












































1 2 3 4 5 
; Revolu- sending Thoma- Remarks. 
ase. | Time. | tion o Zeiss 
Beam. Eas Count. 
L...|Ist min.| 2,581 Le 
20h . 7,000,000 | 5,056,000 
1 min.| 5,075 
30 see. | 1,450 | 5,200,000 
1 min.} 4,500 | 5,100,000 
1“ | 4200 ! 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood, 





























































































































































































































Blood, 
1 2 3 4 5 1 2 3 4 Bors] 
pie ‘ible 8 foals z Se Neti ee Fitt al (s A 
i 2 Revolu- eae, Thoma- Remarks. : é Revolu- oe Thoma- Remarks. 
ase. ‘ime. | tion 0 eiss ase. ime. | tion o Zeiss 
Beam. a Corhy e Count. Beam. | #@mato-| Count. 
. crit. 
II...|1st min.| 3,480 XVI.../lst min.|} 4,060 
alien > 2,900 | 3,700,000 | 4,215,000 Pauls 4,060 | 4,100,000 | 4,472,000 
Ist min.|} 4,350 Spot of corpuscles in 1st min.| 4,060 
mt 2,900 | 38,900,000 serum at 75. is 4,060 | 8,700,000 
Ill...{Ist min.| 4,490 XVII...|Ist min.| 4,060 : 
35 sec 1,500 | 4,900,000 | 4,748,000 0 ee 4,090 | 2,800,000 | 2,570,000 | Per self. 
Ist min.|} 3,580 Two specks of cor- 1st min.| 4,060 
ed, ** 2, 4,950,000 puscles in serum; Pe 3,770 | 2,600,000 | 2,650,000 | Per Dr. Brown. 
edge at reading ——— 
point ragged. XVIII...}lst min.| 4,070 , 
Be ee — Pape oa 8,900 | 1,800,000 | 2,200,000 | Per self. 
IV...|Ist min.} 4,300 : a 
rea aa 4,200 | 4,500,000 | 4,960,000 lst min.} 4,060 
tee eS reat us 3,770 | 2,000,000 | 2,350,000 | Per Dr. Brown. 
Ist min.| 3,770 Corpuseles not all —— 
20 3,625 | 4,700,000 thrown down. Two XIX.../Ist min.) 4,060 
spots in serum. Pst 4,060 | 4,400,000 | 4,900,000 
V...{Ist min.} 3,200 Ist min.| 4,060 ; 
rd ia 3,480 V6 es 4,060 | 4,100,000 
3 aa 8,200 | 5,300,000 | 4,852,000 = 
os XX.../Ist min.|} 4,060 
Ist min.| 3,770 25 4,060 | 5,000,000 | 4,864,000 | Per Dr. Scott. 
24“ | 3.770 
Ue oe 3,770 lst min.| 4,060 
4th * 3,770 | 5,200,000 20 aes 4,060 | 5,200,000 | 4,656,000 | Per self. 
; 5 7h Le oF Pen aan TE, EO a 
ous cart 5,500,000 From the above tests Dr. Polk draws the following 
conclusions: In revolving handle of hematocrit the num- 
VI...}Ist min.) 4,350 : ber of revolutions per minute was counted by the watch. 
2d 3,770 | 4,100,000 | 4,068,000 _ | There was no stop between the first and second minutes 
1st min.| 4,060 Spot of corpuscles | aS indicated under the time column. The number of 
2a “ | 8,770 | 4,200,000 from 48 to 45. revolutions above a certain number, say 3,900, means very 
VII...lIst min.| 4,060 Spot of corpuscles 44 little, as it is impossible to maintain a uniform number per 
2a ‘* | 4,060 | 3,650,000 | 3,976,000, to 45. five seconds throughout the minute and a half or two 
ao Mau at minutes, as the case may be. If at any time the handle 
Bee ety neni boo is turned with extra violence for ten or twenty seconds 
2 te ; in one specimen and not so in the second, although the 
VIL.../Ist min.| 4,060 number of revolutions will be the same per two minutes, 
a ee ps nO | 2.08% 000 the reading of the first specimen will be from 4° to 8° 
Ist min.) 3,770 From 31 to-34, cor- | lower than that of the second. By looking over and com- 
2d “* | 3,900 | 3,400,000 puscles thin, Sn paring columns 38 and 4, the above point will be evident. 
column read at 34. | ‘Time in taking a blood count with the hematocrit, from 
IX.../Ist min.| 4,060 puncture of the finger to the reading, was on an average 
2d “ | 3,900 | 8,000,000 | 2,900,000 two minutes and forty-five seconds, or in round numbers, 
; Rains” under three minutes; two minutes being allowed for turn- 
Ist min.} 3,900 ; : A = A 
2a “ | 3,770 | 8,200,000 ing the instrument. Time of a Thoma-Zeiss enumer- 
See aaa) con esr licrs ania: ation was over twenty-five minutes. 
.../lst min.| 4, s . ° ‘ ‘ 4p 
24 | 3°800 | 6,000,000 | 4,928,000 | - from 62 to 63. Time from taking the drop of blood to getting it into 
hematocrit and starting the same was never over fif- 
Ist min.| 4,100 teen seconds. The patient was close to the instrument. 
2d 3,625 5,200,000 ____| The hematocrit made so much noise that it could not be 
XI... /1st min.| 4,060 Corpuscles thin from used in the wards. ; 
2d“ | 4,060 | 4,450,000 | 4,504,000) 42 to 4414. Our conclusion as to the value of the hematocrit con- 
Ist min.| 4.350 Gorpiseles'thin'trom |; COL with that of von J aksch and Bleitreu, namely, that 
2d ‘* | 4,090 | 4,200,000 41 to 42. the instrument is extremely useful for routine blood 
Semi nial 20u — | work, but that in accuracy it does not equal the Thoma- 
...{18St mm A ida ¢ . 
"| 4046 | 4,600,000 | 5,088,000 Zeiss apparatus. bh eats 
ee ES ———$—$—$____ Our rule is to employ the hematocrit in routine ex- 
Ist min.| 3,800 Corpuscles thin from | amination, and, should a case present grave anzemia, to 
ad RU el eet ____ | verify the count with the Thoma-Zeiss apparatus. 
XII...|Ist min.) 3.625 Case of marked jaun- 3. ENUMERATION OF BLoop CORPUSCLES BY THE 
2d “ | 3,480 | 3,600,000 | 4,624,000) di Bee s eer a OpricaAL Metuop.—The third method by which the enu- 
SS counts made yi rat] 7 ; r > 
ist min.| 4,060 different people, | meration of the corpuscles is made may be termed the 
*"! 41150 | 3,700,000 | 4,350,000| aboutsame results. | Optical method. : ° 
—_—__|—_._—_ a The instruments used for this purpose depend for their 
XIV.../Ist min.) 4,080 principle upon a change in color or opacity of the blood 
2d. 8,960 | 4,900,000 | 4,968,000 according to its numerical value in corpuscles. 
a egy The globulimeter of Mantegazza* is the earliest of these 
ist min yes 4.600.000 instruments. The instrument consists of.a receiver of 
: ah CS}: glass with parallel walls. Into this receiver the blood is 
; placed, after being diluted with ninety-six times its vol- 
XYV...{Ist min.| 4,060 %e ‘A E ij jeanne 
2a ‘* | 8,950 | 4,200,000 | 4,920,000 ume of a solution of sodium carbonate. A lighted candle 
| eee is placed on the other side of the receiver, and the flame 
1st min.} 4,060 : : 72. = Fe o 
%q 3.900 | 4,700,000 be gs prtne klin. Woch., April 8, 1878 ; New York Med. Record, Octo 
Vou. II.—4 


49 


Blood, 
Blood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





observed through the diluted blood. Blue glasses, one 
after another, are placed between the observer and the 
blood until the flame can no longer be detected. Each 


i! 
uk 


“= in EE ILE TRB: 


{ 
: ‘ 
ae 


— 
t 





FIG. 566.—Oliver’s Haemocytometer. 


subsequent examination. 


Ylue glass represents 125,000*red cells. From one. to 
thirty glasses may be added, when by referring to the 
table the number of corpuscles will be ascertained. 

Knowing, as we now do, that the amount of hemoglobin 
may be far below the number of red cells, this instrument 
seems to be based upon a false principle. The opacity 
and color of the blood are separate conditions, and bear 
no constant relation to the number of the corpuscles. 

Dr. George Oliver, of London, devised an instrument 
which he used in the preparation of his Croonian Lec- 
tures “On the Study of the Blood and Circulation,” pub- 
lished in The Lancet, June 20, 1896. This instrument de- 
pends for its principle upon the opacity of the blood, and 
has nothing to do with the color or tints, so that the term 
tintometer, which has been applied to it, is a wrong one, 
The hemocytometer of Oliver (Fig. 566) consists of the 
following parts: (1) A capillary tube, capacity 10 c.mm. 
(2) A glass receiver whose sides are flattened so that it 
measures less from before backward than from side to side. 
The tube isabout four inches in length, one inch in breadth, 
and about one-fourth of an inch from before backward. 
(3) Adropper. (4) A small candle, the size of a Christmas- 
treecandle. (5) Hayem’s solution (for formula, see p. 40). 

The principle of the instrument is that in an opaque 
fluid (like blood), contained in a flattened glass receiver 
with vertical striations, to which is gradually added a 
less opaque fluid (like Hayem’s solution), there develops, 
when such a receiver is placed between a candle flame 
and the eye, a point in the process of adding the less 
opaque fluid to the more opaque fluid at which the candle 
flame may be seen as a continuous bright line of light, 
which, before this point in dilution is reached, is not 
visible, and which after this point is passed no longer 
appears continuous, but as separate images of the candle 
flame. Moreover, the bright line of light consists of 
myriads of reflections of the candle flame produced by 
the vertical striations upon the glass receiver, which re- 
flections cannot be appreciated by the eye of the ob- 
server until the opacity of the blood has been overcome 
by the addition of the less opaque solution. The point 
at which this line appears is constant for normal blood, 
from which constancy a unit may be established to meas- 
ure blood rich or poor in corpuscles. 

The instrument is used as follows: The skin is punc- 
tured in the usual way and the capillary tube applied to 
the drop as in using the von Fleisch] hamoglobinometer 


50 





1, capillary tube; 2, graduated flattened receiver; 3, dropper; 4, 
candle and stand; 5, Bottle for Hayem’s solution; 6, bottles in which to place blood and solution for 


(see Fig. 578), the blood entering until the tube is entirely 
filled. There should, of course, be no air spaces in the 
column of blood. Excess of blood is wiped from off 
the sides of the tube, care 
being taken not to soak out 
the blood from the tube. 
This may be avoided either 
by not allowing the linen 
used to wipe away the ex- 
cess of blood to touch the ori- 
fice of the tube, or by hold- 
ing the finger over the upper 
end of the tube while wiping 
away the excess. The drop- 
per is now filled with Hay- 
em’s solution and the capil- 
lary emptied by allowing the 
solution to squirt through the 
tube, as shown in Fig. 567. 
This can be done by insert- 
ing the pointed end of the 
capillary tube into the mouth 
of the receiver and holding 
the dropper close to the 
blunt end of the capillary, 
then giving a quick pinch to 
the rubber end of the drop- 
per. This sends a strong 
stream through the capillary 
and empties it almost en- 
tirely. Repeating the process 
will certainly clean the cap- 
illary of blood. It is not necessary to attach the drop- 
per by a rubber connection, as shown in Oliver's illus- 
tration. This is difficult and takes time, and allows the 
blood to clot in the capillary. We may now either 
proceed at once to the estimation, or the mixture thus 
made may be put into a small bottle and estimated at any 
time within twelve hours. Thus several such mixtures 
may be made in the course of the morning’s round and 
placed in bottles properly labelled, the estimation being 





Fic. 567.—Oliver’s Heemocytometer. Washing blood with Hayem’s 
solution from capillary tube, by means of dropper, into flattened 
graduated receiver. 


made when the physician returns to his office. Or the 
specimens may be sent by mail, if the distance be not 
such as to require more than twelve hours in transpor- 
tation. These are distinct advantages over the Thoma- 
Zeiss instrument. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





If a candle flame ten feetaway be viewed in a perfectly 
dark room through the receiver held as shown in Fig. 568, 
the receiver containing blood and Hayem’s solution up to 
the 10 mark, for example, owing to the opacity of the mix- 
ture the flame will appear as a faint diffuse light. Ifnow 
we add little by little the Hayem’s solution, as the opacity 
becomes less the flame will become clearer, and will be 
caught by the vertical striations on the receiver, which 
act as minute mirrors to reflect the flame as a continuous 
line of light. When the mixture has reached that degree 
of opacity which allows of this phenomenon we read off 
the upper limit of the fluid in the receiver: 100 on the scale 

represents 5,000,000; 80, 4,000,000; 
y.e., 20 on the scale indicates 1,000,000 
corpuscles. 

By moving the receiver slightly 
from side to side and from before 
backward, the line may be detected 

1 at the sides a little before it extends 
across the receiver, a signal to the 
observer to add the solution cau- 
tiously drop by drop. Before the 
fluid has reached the height at which 
the line appears continuous the line 
is noticed to be blurred. As we add 






Fig. 568.—Oliver’s Heemovytometer. 
transverse bright line across flattened receiver. 


more fluid than is necessary to produce the continuous 
line, the line ceases to be a continuous one and becomes 
a series of minute but separate images of the candle 
flame. The point, therefore, at which the reading 
should be made is after the line ceases to be blurred and 
before separate images of the flame can be observed. The 
candle should be at least ten feet away and should be not 
larger than the ordinary Christmas-tree candle. The 
receiver should be held in the right hand and the thumb 
pressed well into the side of the nose so as to shut off 
all diffused light, as shown in Fig. 568. 


III. H#MoGLOBIN ESTIMATION. 


Apparatus and Technique.—The task of estimating the 
amount of hemoglobin has long been an unsatisfactory 
one, because all methods, excepting only the specific- 
gravity method, depend upon the comparison of colors, a 
subject upon which nearly all individuals differ, and upon 
the degree of opacity, which is supposed to vary with the 
amount of hemoglobin, a supposition by no means proven. 

The instruments group themselves into three classes, 
as follows: 

Based upon the 
| spit that 
Bizzozero’s chromocytometer) _} the 


Al amount of 
2. Henoque’s heematoscope...... { °° | hemoglobin va- 
ries with the de- 
[ gree of opacity. 
1. Gowers’ hemoglobinometer ) Based upon the 
2. Von Fleischl’s “ supposition that 
3. Von Fleischl’s the amount of 
and Meischer’s “ [ ‘*\ hemoglobin va- 
4. Taylor’s z ses with the in- 
5. Oliver’s tintometer “ | tensity of color. 





Watching for that degree of opacity at which candle flame will be seen as 
a ¢ Holding flattened receiver close to eye, between thumb and 
forefinger of left hand, while adding Hayem’s solution from dropper with right hand; 2, bottle holding Hay- 
em’s solution ; 3, candle ten feet away from observer and on a level with observer’s eye. 











Blood, 
Blood, 


Based upon the 
Gare ni that 
|} the amount of 

hemoglobin va- 

ries with the spe- 
cific gravity. 


i Hammerschlag’ s method } 
2. Roy’s 


1. Opactry Mernops.—TVhe Chromocytometer of Biz- 
zozero®* depends for its principle upon the supposition 
that the opacity of the blood varies with the amount of 
hemoglobin. 

The instrument may also be used to estimate the num- 
ber of red cells, but its value for this purpose is doubtful, 
for it is based in this application, as is Mantegazza’s in- 
strument, upon the false supposition that the opacity of 
the blood varies with the number of cells contained. 

When using it as a cytometer, instead of adding colored 

glasses as in Mantegazza’s instrument (see p. 49), Bizzo- 
zero introduces more and more blood until the opacity of 
the blood gives rise to partial obscuring of a candle flame. 
The thickness of the layer of blood producing this con- 
dition is then measured by comparison with standard 
observations, and the amount of hemoglobin estimated 
accordingly. 
The chromocytometer of Bizzozero is an instrument in- 
tended primarily for 
the estimation of he- 
moglobin. The name 
is misleading. The 
instrument is so 
called because the 
amount of hemo- 
globin is ascertained 
by two methods: (1) 
By observing the de- 
gree of opacity pro- 
duced by the hemo- 
globin unremorved 
from the corpuscle, 
and therefore the ac- 
tual corpuscular 
value of hemoglobin 
—in which applica- 
tion it is called a cytometer (Kitoc, a cell; wétpov, a measure). 
It does not number the corpuscles, as at first the name 
seems to imply. (2) By observing the color produced by 
the hemoglobin removed (dissolved) from the corpuscle 
and comparing this color with a standard colored glass— 
in which application it is called a chromometer (ypaxa, 
a color; “étpov, ameasure). Its application as a hemo- 
cytometer is a wrong one, as already stated. 

As a Cytometer (term understood as above described).— 
Principle: If a fixed quantity of blood be mixed with 






\ 


AK 






177-77 





ried 


Fig. 569.—Diagram Showing Construction of Bizzozero’s Chromocy- 
tometer. r, Well connecting with v, chamber formed by v’, which 
screws into v; 2 and 2’, glass windows. 


a fixed quantity of preserving fluid (saline solution), and 
the mixture placed in a receiver, and a candle flame 
viewed through the mixture in a dark room, then, accord- 
ing to the amount of hemoglobin and the amount of the 
mixture used, the flame of the candle will either be seen 
or will not be seen. By observing the amount of this 


* Atti della regia Accad. d. Se. di Torino, xiv., 1879. 


51 


Blood. 
Blood. 





mixture necessary, in normal cases, partially to obscure 
the candle, and calling this 100, we can, as more or less of 
such a mixture is required in diseased cases, ascertain 
the decrease or increase in the amount of hemoglobin. 
The instrument consists of a well which connects with 
a chamber closed at both ends with colorless glass. The 
chamber con- 
sists of two 
pieces of met- 
al, one screw- 
ing into the 
other. These 
are hollowed 
out so as to 
Lor men t.he 
chamber with- 
in (Fig. 569). 
By screwing 
or unscrewing 
one of these 
pieces the di- 
mensions of 
the chamber 
may be de- 
creased or in- 
creased. It 






Fig. 570.—Bizzozero’s Chromo- 
cytometer. Less diagrammat- 
ic than Fig. 569, showing side 
view. The outer screw unat- 
tached. Lettering same as in 


Fig. 569. m, Handle. (From ee 

von Jaksch’s ‘Clinical Diag- wili be seen 

nosis.’’) that if diluted 
blood “be 


placed in the well which connects with this chamber, the 
blood will flow into the chamber through this connection. 
But only just so much blood will flow into the chamber 
as is allowed by unscrewing the outer screw. When the 
outer portion of the instrument is screwed home (Fig. 571) 
no fluid at all enters the space between the screws—in 
other words, the chamber is then obliterated. Now by 
unscrewing or screwing the piece of metal which fits 
into the other piece and which, together with its fel- 
low, forms the chamber, we can increase or decrease the 
amount of fluid in the space between the screws. 

(1) Suppose now the two pieces of metal to be com- 
pletely screwed together, so that no space exists between 
them, the scale then stands at 
0. (2) We fill the well (Figs. 
569-571, 7) with 50 parts of 
normal saline solution to 1 
part of blood; or, to be more 
accurate, by means of a pi- 
pette we mix 10 c.mm. of 
blood with 0.5 ¢.c. saline so- 
lution (0.75 gm. of NaCl in 
100 ¢.c. water), which pre- 
serves the corpuscles. (3) A 
candle is placed in a dark room 
about four feet away from the 
observer. (4) The instrument 
is held by the left hand and 
close to the right eye, opposite 
the candle. (5) The two ends 
of the chamber, it will be re- 





Fic. 571.—Bizzozero’s Chro- 
mocytometer. Screws com- 


membered, have glass win- pletely screwed together, ob- 
-t ‘andle fis literating chamber. Well 
dows, so that the candle flame ary de clave a SE PN 


will be clearly seen. (6) With 
the right hand the pieces of 
the metal are slowly unscrew- 
ed, which allows the blood to 
flow from the well into the 
chamber. (7) As we introduce 
more and more fluid into the chamber, however, a de- 
gree of opacity must be reached at which the candle flame 
will be almost or wholly obscured. This is just what oc- 
curs. By observing the degree of unscrewing, so to 
speak, necessary to produce this opacity for normal 
blood, we obtain a unit with which diseased blood may 
be compared. By means of the table given below the 
amount of hemoglobin may then be ascertained. 

When the space between the glass windows is obliter- 
ated by screwing the outer portion home, the index on 


position one looks into the 
well. The round ring rep- 
resents the connection be- 
tween well and chamber. 
(From von Jaksch’s ** Clini- 
cal Diagnosis.”’) 


52 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the scale stands at 0. One complete rotation of the 
screw produces a space in the instrument measuring 0.5 
mm. This is therefore the thickness of the contained 
solution of blood. One complete turn, however, renders 
the candle flame decidedly less visible. This complete 
rotation is therefore subdivided on the scale into 0.02 
mm., 25 such subdivisions (0.02 * 25 = 0.5) constituting 
one complete revolution, and 50 such subdivisions (0.02 < 
50 = 1.0) constituting 1.0 on the scale. From a number 
of observations (as stated by von Jaksch) upon the blood 
of healthy individuals, the outlines of the candle flame 
are distinctly seen through a layer of blood 44} mm. 
thick = 1.0, 

This, then, is the unit; z7crease of this number means 
decrease in amount of hemoglobin. For if we must in- 
crease the thickness of the stratum of blood in order to 
obscure the candle flame, it indicates that the fluid is poor 
in coloring matter, and that an excess is required to 
produce dimness of the candle flame. 


Scale Heemoglobin. Seale. Hemoglobin. 
110 represents 100.0 170 represents 64.7 
120 he 91.6 180 * 61.1 
130 i 84.6 190 < 319 
140 *~ 78.5 200 re 55.0 
150 ve 73.3 210 sts 52.4 
160 oc 68.7 220 " 50.0 


If one has not this table at hand the reading can 
be readily interpreted by remembering that 110 = 100. 
Suppose, for example, the reading to be 160 on the scale; 


then: 
100 :110 :: 160: ? 
100 x 110 + 160 = 68.7 


As a COhromometer (term understood as above de- 
scribed).—In addition to the parts of’ the instrument as 
already enumerated, there is a colored glass (see Fig. 
572). This is introduced on one side of the instrument 
so that the colored glass 
and the glass windows 
of the instrument are side Gq D 
by side, as would be the C > 
case with a pair of opera 
glasses if one side were to 
consist of only the eyepiece, 


Ve 4 ) 


and that with a colored : 2 





glass in it. In this use of 
the instrument, moreover, 
the hemoglobin is dissolved 
out with water in prepar- 
ing the blood for observa- 
tion. 

Principle: If a glass col- 
ored to correspond with a 
definite solution of hemoglobin be placed before a bright 
light (the sky) and beside a solution of hemoglobin to be 
tested, the color of the tinted glass and that of the solu- 
tion of hemoglobin will be found to differ. If, however, 
more or less of the solution be added, a point will be 
reached at which these colors correspond. By noting the 
amount of solution required to make these colors exactly 
correspond a scale may be made by which the amount 
of hemoglobin may be estimated. 

Given a tinted glass which corresponds in color with a 
known solution of hemoglobin. Given a known quan- 
tity of blood (10 c.mm.) with a known quantity of water 
(0.5 ¢.c.). If the blood to be tested contains much color- 
ing matter (hemoglobin), it will be necessary to add but 
little of the solution in order to make the colors cor- 
respond; if it contains little coloring matter, much will 
be required to make these colors correspond. These 
quantities are noted and compared with a scale, each 
quantity of fluid corresponding with a percentage of 
hemoglobin. 

By referring to Figs. 570 and 571, the working of the 
apparatus will be readily understood. 

The colored glass is not of the same intensity of color 
in every instrument, so that the glass must be tested for 
each instrument. 


Fi@. 572.—Bizzozero’s Chromocy- 
tometer. Frame holding tinted 
glass. Thisis placed by the side 
of the screw of the main appa- 
ratus. f, Tinted glass; 1, frame; 
ast, rod which passes through 
hole y in handle m of Fig. 570. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 


Blood, 
Blood, 











The test is performed in the following way: Normal 
blood is tested, and is found to be, by the cytometer 
method, 110, and by the chromometer, say 180. One hun- 
dred and ten of the cytometer equals 100 hemo- 
globin. For this glass, then, 130 also equals 100. 

As in the case of the cytometer method, we 
construct a table from these relations. Suppose 
the reading with the chromometer to be 190. 

LOOM VSO R190 26? 
100 x 1380 + 190 = 68.4. 

After a brief experience in using this instru- 
ment the author is inclined to commend it. 

Henocque’s Hematoscope.—This instrument also 
depends for its principle upon the supposition 


Tn addition to the apparatus already described, there is 
an enamelled plate, as seen in Fig. 575. 
This plate is placed behind the prismatic layer of 









































































































































































































































































































































































































































that the amount of hemoglobin varies with the 
degree of opacity of the blood. In this instru- 
ment, in addition to the degree of opacity, the 
quantity of oxyhzmoglobin is ascertained by 
means of the spectroscope. This latter method 
places the instrument among the apparatus of 
an elaborately equipped laboratory and dimin- 
ishes its value for bedside work. Moreover, as 
von Jaksch states, there is a “difference of opin- 
ion as to when precisely the spectrum is formed,” 
making the conclusion drawn from the use of the in- 
strument “always somewhat arbitrary.” 

The instrument consists of two plates of glass, one 
placed above the other so as to enclose between them a 
prismatic space. The dimensions of this space are accu- 
rately stated and are the same for every instrument. 


* 
Thickuest > 
ef acehEs O31. 


Lerzoth BEATE: SOR IE oe y COV. 





Lev. Length, Seale -orem__ 


Lheichrest. oiel2 | 


C0 77n. 


G3 7i77. 


we wade ewe ----- -- ee 


Fic. 573.—Henocque’s Hzematoscope. Diagram showing dimensions 
of prismatic space formed by plates of glass. 


These plates of glass are in contact at one end, forming 
the apex of the prismatic space. The scale of measure- 
ment at this end is therefore 0. 

At the other end the glass plates are separated by a 
distance of 0.38 mm., forming the base of the prismatic 
space. By referring to the diagram (Fig. 573) and illus- 
trations (Figs. 574 and 575), this arrangement will be 
readily understood. 

The scale upon the glass is marked from 0 
to 60, as observed in Fig. 574. 

There are two methods of using the instru- 
ment. 

(1) The first method is based upon the supposi- 
tion that varying opacity of the blood differs ac- 
cording to varying quantity of hemoglobin, so 
that by observing the former the latter may be 
estimated. 

To use the instrument upon this basis, punc- 
ture is made in the skin in the usual way and 
the drop brought to the orifice of the prismatic 
space, which, from its dimensions, will be ob- 
erved to be capillary. The blood on this ac- 
count passes readily into the space without being diluted, 
an advantage over the dilution methods. 

About six drops of blood are necessary to fill the 
space. Excess is wiped away. 






































































































































































































































Fic. 574.—Henocque’s Hzematoscope Filled with Blood. 


Fig. 575,—Enamelled Plate Used with Henocque’s Hzematoscope. 


















































(From yon Jaksch’s 


** Clinical Diagnosis.’’) 


blood, so that the figures 0, 10, 20, etc., correspond with 
the like figures on the glass plate of the hematoscope. 
At the apex end of the prism, and therefore at the thinnest 
portion of the layer of blood, the marking on this en- 
amelled plate will be visible ; but as the eye passes toward 
the thicker portion of the prism of blood a point will be 
reached at which the marking can no longer be seen. If 
the blood tested be rich in hemoglobin the opacity will 
be greater, and therefore the point in the series 15, 14, 13, 
12, etc., at which this obscuring occurs will be higher, 
say 11 or 12, as seen in the illustration. If, on the other 
hand, the blood be poor in hemoglobin, the opacity will 
be correspondingly less, and we shall be able to see the 
figures 10, 9, 8, etc., in the series. 

“One hundred grams of normal blood contain 14 gm. of 
oxyhemoglobin. These figures, therefore, indicate the 
number of grams of oxyhemoglobin in 100 gm. of 
blood. For this use the author commends the instru- 
ment, 

(2) The second method is based upon the supposition 
that the richer the blood is in hemoglobin the thicker 
will be the layer necessary to detect through the spectro- 
scope the characteristic bands of oxyhemoglobin. By 
noting the thickness in normal blood at which the oxy- 
hemoglobin spectrum occurs, a scale may be made with 
which deviations from the normal may be measured. 
The apparatus, with the exception of the enamel plate, 
is used as before. 

The prism is fitted in front of a spectroscope and is 
turned until the oxyhzemoglobin bands appear, when this 
point is-noted on the scale. With normal blood the 
oxyhemoglobin spectrum is seen opposite 14 of the 
millimetre scale. Now for every millimetre on the scale 
the thickness of the prismatic space increases 0.005 mm. 
This can be demonstrated by multiplying 0.005 by 60, the 


20 EGO 40 
anata Ae attin 


Hemalescope d Menoegue 
Iie hk Nis es shle 3 WES Aa 746 





(From yon 


Jaksch’s ‘* Clinical Diagnosis.’’) 


length of the scale; the result is 0.8 mm., the thickness 
of the prism at its base, ¢.e., at the 60 mm. end. As, 
therefore, for normal blood the spectrum appears at 14 
on the millimetre scale, we determine the thickness of 


538 


Blood, 
Blood, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





blood required to produce this spectrum by multiplying 
14mm. 0.005 mm. = 0.07 mm. 
This, then, is a unit; it is the thickness of normal blood 
required to produce the oxyhemoglobin spectrum. 
Suppose a specimen of blood produces the oxyhaemo- 
globin bands at 40 on the millimetre scale. The thick- 
ness of this specimen would be 40 mm. x 0.005 mm, = 
0.2mm. Then: 
7.€. ea a9 gm. of hemoglobin in 100 gm. 
of blood. 
An equation for any reading is the following: 
7 f (y X 0.005) : 0.07 ::14 :@ 
in which 


y = reading on the scale. 

0.005 = thickness of prism for each millimetre division 
on the scale. 

0.07 = thickness of layer of normal blood by which 
oxyhemoglobin spectrum is produced—.e., at 14 on the 
scale (14 « 0.005 = 0.07). 

14 = quantity of oxyhemoglobin in 100 gm. of normal 
blood. 

From these calculations one can make for himself a 
table which will at once give him the amount of the 
hemoglobin for any reading on the scale. Thus be- 
ginning with 5 on the millimetre scale, and substituting 
it for y in the equation, we get the following: 

(5 X 0.005) x 0.07 + 14 = 12.5. 
Therefore 5 mm. of the scale = 12.5 gm. hemoglobin 
in 100 gm. of blood. ; 

If we substitute in the same way 10, 15, 20, etc., the 
table becomes complete. 

The instrument has not been much used in this country, 
and, as already stated, except for the opacity method, 
it requires more apparatus than would be practicable at 
the bedside. 

The author has not had sufficient experience with this 
method to express an opinion upon its value. 

2. Coton Mrtruops.—Before entering upon the de- 
scription of those hemoglobinometer instruments which 
depend for their principle upon the comparison of colors, 
it would be well to quote from Lovibond’s very interest- 
ing and valuable work on “ Measurements of Light and 
Color.” 

“Tt is almost impossible,” says Lovibond, “ without spe- 
cial arrangements to arrive at a reliable judgment between 
two colors which are very nearly, but not quite, alike, 
when these are placed openly side by side. The difficulty 
arises from the unequal incidence of light—sometimes of 
the direct light, frequently of the side lights, or from 
both combined. ‘The disturbing effect is so great that a 
slight change of position in either of the samples, or of 
the observer, generally reverses the first judgment. 

“The same causes account for the frequent differences 
of opinion between two persons judging the same color; 
in fact, the color sensations of our surroundings are. . . 
governed by the ever-varying conditions of light, sur- 
face, substance, texture, and chemical composition. . . .” 

The following are the experiments carried out by Prof. 
Lovibond: 

“Test Tubes containing colored liquids.—The first at- 
tempts were made with colored liquids in test tubes of 
equal diameters, and by these means some useful infor- 
mation was obtained. The liquids, however, svon changed 
color, requiring frequent renewals; and there was always 
a little uncertainty concerning their exact reproduction. 
Also a curious inequality of color relation was found to 
exist between the regular increase of strata thickness and 
their resulting color. This prevented liquids from being 
suitable as standards, because some liquids increase in 
color depth in direct proportion to increase of strata thick- 
ness. Some increase in color in a less but regular pro- 
portion to increase of strata thickness, whilst others 
increase in a less and irregular proportion. 

Another difficulty arose from the convex surfaces of 
the test tubes acting as a lens, and increasing the disturb- 
ance arising from unequal light incidence. The convex- 
ity was reduced by using larger tubes, and enclosing 





54 


them in a blackened case with narrow longitudinal aper- 
tures for looking through the middle of the tubes. The 
results, although useful, were too unsatisfactory for sys- 
tematic work. 

“ Colored glass was next tried, and long rectangular 
wedgesin glass of different colors, with gradually graded 
tapers, were ground and polished for standards, whilst 
correspondingly tapered vessels were made for the 
liquids to be measured. These were arranged to work, 
at the end of the instrument, up and down at right 
angles before two apertures, side by side, with a fixed 
centre line to read off the thickness of each before the 
aperture when a color match was made; but here also 
the difference of ratio between the thickness and color 
depth of the different colored glass and liquids proved 
fatal to the method. 

“ An incidental observation was made during these ex- 
periments concerning the difficulty of arriving at a final 
judgment with tapering colors, owing to one shade 
gradually blending into the next without a break of any 
kind to arrest the vision. The mental effort to arrive at 
a decision, under these conditions of gradual color-blend- 
ing, was troublesome and vexatiousin the extreme. Any 
person may realize this difficulty by attempting to fix a 
definite point by the vision in a graduated color line. I 
was enabled entirely to remove the difficulty by using 
separate glass slips for standards; the line of color de- 
cision made by each additional standard-glass slip used 
being a precise definition between the most minute shades. 

“The effect of these partial failures enabled me more 
clearly to define the conditions from which successful 
work might be expected, which are as follows: 

“Gauged Cells.—The cells for the liquids must have 
parallel transparent ends and be gauged to definite strata 
thickness. 

“ Optical Instrument.—The standard and sample must 
be viewed under equal conditions of illumination. 

“Suitable Light for Color Work.—Considerable differ- 
ences of view exist concerning the most suitable light for 
color work. Some authorities consider that daylight is 
too unreliable in composition, and that an artificial light, 
such as the electric arc, is best, as being always uniform. 

“Captain Abney’s work and apparatus at first sight 
go a long way toward establishing this view. Some 
valid reasons, however, in my opinion, exist in favor of 
daylight; as it isthe light to which normal vision is most 
accustomed, and it isavailable, without cost ata moment’s 
notice, during daylight hours, whereas artificial lights 
require to be worked in camera with somewhat expensive 
apparatus. Again, by far the largest proportion of 
artistic and commercial color work is carried on by day- 
light, so that measurements made by means of any other 
light must be transposed into terms of daylight vatues 
before reliable comparisons can bemade. Without doubt 
the vision can work longer and with less fatigue by day- 
light than by intense artificial light.” 

From the foregoing it will be seen that liquids and 
colored glasses have a distinctive color value, and that 
any method which employs blending colors, as the colored 
prism of the von Fleischl apparatus or the gradually 
diluted blood in the Gowers instrument, presents a wider 
field for error than that method which employs fixed and 
uniform colors for comparison. Also daylight is the 
most reliable. 

Gowers’ Hemoglobinometer.—This instrument is one of 
color comparison. 

Principle: Tf a colored fluid representing a very low 
percentage of hemoglobin be placed by the side of a so- 
lution of a fixed quantity of blood, to which water is 
added little by little, a point in the process of dilution 
will be reached at which the two colors correspond. 

By observing the amount of diluting fluid required to 
bring normal blood to a corresponding color with the 
fixed color, ascale may be made by which deviations from 
the normal may be detected. 

The parts of the instrument (Fig. 576) are (numbers 
correspond with those in cut): 1. A solution of picrocar- 
mine glycerin of the color of a one-per-cent. solution 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


‘ 


Blood, 
Blood. 





of normal blood, contained in a sealed tube. 2. An 
open tube graded from 10 to 120. 3. A pipette measur- 
ing 10and 20cm. 4. A dropper. 

To use the instrument: <A little water is put into the 
graduated tube. Puncture of the skin is made in the 
usual way, and blood drawn up to the 20 c.mm. mark. 
The blood is at once blown into the graduated tube con- 
taining the water. The blood and water are then thorough- 
ly mixed, and more water, little by little, added by means 
of the dropper until the color of the diluted blood and that 
of the standard solution correspond. It will be seen that 


A 2s orcs 





~ 
= 
: 





Fig. 576.—Gowers’ Hemoglobinometer. 3, Capillary tube for taking a 
definite quantity of blood; 4, dropper for adding water; 2, gradu- 
ated receiver for blood and water; 1, tube containing picrocarmine, 
color equal to that of blood with one per cent. haemoglobin. 


if the blood is rich in hemoglobin it will be necessary to 
add a large quantity of water in order to make it of the 
color of the standard solution, which represents only one 
per cent. 

As we add more and more water, however, the 
column of fluid rises on the scale, and therefore in- 
dicates a high percentage of hemoglobin. In cases 
of anzemia the correspondence will be sooner reached, 
and the column of fluid will stand at a lower level 
in the tube, and will therefore indicate a low per- 
centage of hemoglobin. 

This instrument has the advantage of being cheap 
as well as accurate. 


10 





Fic. 577.—Von Fleischl’s Heemoglobinometer. 



















The standard solution, picrocarmine, changes color in 
time, a point noted by Lovibond and by Oliver working 
in Lovibond’s laboratory. 

Von Fleischl’s Hamometer—or, more correctly, hemo- 
globinometer—depends for its principle upon the sup- 





Fig. 578.—Von Fleischl’s Heemoglobinometer. 
in capillary tube. 


Taking drop of blood 
position that a solution of hemoglobin varies in color 
according to the amount of hemoglobin which it contains, 
and that the latter may be measured by comparison with 
the varying colors in a prism of glass, each degree of color 
corresponding to a percentage of hemoglobin. 

We must keep in mind that when water is added to 
blood the hemoglobin is dissolved out of the corpuscles, 
and it is the colored solution which we are comparing, 
not the hemoglobin as contained in the corpuscles. 

The parts of the instrument are (numbers correspond 
with those in illustration, Fig. 577): A stand (1) with a 
horseshoe base. <A stage (2) with around hole in the 
centre for the reception of (3) a well 1.5 cm. in depth and 
divided into two equal parts; the bottom of this well is 

closed by a piece of clear glass. Below the stage 
is a round reflector of plaster of Paris (4). Ina 
12 metal frame is a prism of colored glass (5). On 
the frame opposite the apex of the prism there 
begins a series of figures, the first being 0 and the 
last, which is opposite the base of the prism, 
being 120. At 0 the tint of the color is the 
faintest, this tint increasing in intensity until 
it reaches the maximum, 120. The frame is in- 
troduced into two tracks (6) which run below 
the stage. It is placed so that the colored glass 
prism shall pass beneath one division of the 
well, and the series of figures shall appear 
through an oval opening (7) in the stage just 
behind the well. By means of a rack (8) and 
pinion different parts of the varicolored glass 
prism may be made to pass along the 
bottom of one division of the well, 
and at the same time the figures in- 
dicating the color intensity of the 
glass at that point will appear in 
the oval opening behind the well. 
There are also a capillary tube (9) by 
which a fixed quantity of blood may 
be obtained ; a medicine dropper (10), 
a candle (11), a black tube (12) to 
shut off the surrounding light from 
the eye. 
We have, therefore: 1. A colored 


55 


Blood. 
Blood, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





glass varying in tint with known quantities of hemo- 
globin. 2. A well divided into two equal parts of 
known depth. 3. A capillary tube of known capacity. 
The instrument is used as follows: 
Puncture is made in the usual way and the tip of the 
capillary tube touched to the drop, as seen in illustration 








Fia. 579.—Von Fleischl’s Heemoglobinometer. Washing drop of blood 
from capillary tube with water into one side of double well. 


(Fig. 578). No air space must occur in the tube. If the 
drop at first taken is not enough to fill the tube, in add- 
ing more, care should be exercised that the blood is flush 
with the end of the tube before again touching it to the 
blood drop. By gently tapping the tube this can be ac- 
complished. 

When the tube is quite full we at once insert the end 
into one of the subdivisions of the well, and with the 
medicine dropper send a stream of clear water forcibly 
through the tube (Fig. 579). This must be done promptly 
or the blood will clot in the capillary. The dropper need 
not be fitted on to the capillary tube, a procedure which 
often causes the latter to break. If the stream of water 
has been sent through with sufficient force the capillary 
will be entirely freed from blood. We then fill the well by 
dropping water with the dropper through the capillary. 
This fills the well and at the same time makes sure 
that all the blood has been washed through. 

When the water has reached the top of the well a 
meniscus, which cannot be avoided, will be observed. 
When, however, we fill the opposite well with clear 
water, which we shall proceed to do directly, we must 
see that the meniscus in each well is of the same depth. 

If the well should be full before all the blood has been 
washed from the capillary tube, then the dropper emptied 
of the water may be filled with the diluted blood already 
in the well and this passed through the capillary tube 
again until the latter is free of all trace of blood. Then 
the capillary tube is immersed into the well and the con- 
tents of the well stirred. 

The other subdivision of the well is now filled with 
clear water, care being taken not to allow the contents 
of the two wells to mix over the division wall; also that 
the meniscus in each is of the same depth, as already 
mentioned. 

Attention is called to the fact that the upper portion 
of the well unscrews for the purpose of cleaning the 
glass window at the bottom. These two portions should 
be tightly screwed together before using, so that the 
fluids will not mingle at the bottom of the well. More- 


56 





over, though the wells are the same in all instruments, 
the prisms of glass vary one from the other in inten- 
sity of color. It is necessary, therefore, for the maker 
to test each prism and ascertain what ¢s the amount of 
normal blood which will correspond to the color oppo- 
site the 100 mark. This amount is fixed by the ca- 
pacity of the capillary tubes. Hence it follows that the 
capillary tubes tested for a certain instrument should be 
used only with that instrument. To insure this, the 
number upon the handle of the capillary tube should be 
observed, to see that it corresponds with the number on 
the screw of the stand, just behind the round opening 
for the well. Then, again, the prism of glass must cor- 
respond with the stand, and this is insured by seeing that 
the number on the stand and that on the metal frame of 
the glass prism are the same. 

The above is a most clumsy method of numbering, 
arising probably from the fact that different workmen 
make different parts of the same instrument. The point 
to be borne in mind is that the glass prism and the cap- 
illary tube must correspond, and this can be made certain 
only by observing the above unnecessarily complicated 
system of numbering. The wells are of the same depth 
in all instruments. The figures on the handle of the 
capillary tube refer to the capacity of the tube. 

We have now filled the two divisions of the well, the 
one with clear water, the other with a fixed quantity of 
blood and water. 

The frame with the glass prism is now put in place, 
and the well over the prism, so that the prism shall be 
opposite that division which contains the clear water. 

We now transfer our operations to a dark room lighted 
only by asmall candle. The instrument is placed about 
eighteen inches away from the candle, and a dark tube is 
placed over the well in order to shut off the surrounding 
light from the eye. The plaster-of-Paris reflector is ad- 
justed so as to throw the light into the well, and then the 
screw of the glass prism frame is turned until the color of 
the diluted blood and that of the the colored glass corre- 
spond (see Fig. 580). The figure which appears in the 


oval opening is now read, and this is taken as the per- 
centage of hemoglobin in the blood under observation. 
Some observers claim that there is a difference of several 
degrees between observations made with the operator in 
the position as shown in Fig. 580, and when he is to one 





Fig. 580.—Making Observation of Percentage of Heemoglobin with 
von Fleischl’s Instrument. (Dark room.) 


side of the instrument. This claim, based upon ‘differ- 
ence in color appreciation of the eye in the two posi- 
tions, seems a trivial one, and has not been borne out. 
by the experiments of the writer. 

As observers differ so greatly with one another in the 
comparison of colors, itis better to report a percentage of 


REFERENCE HANDBOOK OF 


Blood, 


THE MEDICAL SCIENCES. Blood. 








hemoglobin over a range of 5; forexample, 65 to 70 per 
cent., 80 to 85 per cent., ete. 

The quantity of hemoglobin i in grams may be estimated 
from this by the Bowne simple equation: 

100 : 14: 

100 gm. of blood contains 14 gm. of hemoglobin. 

y = the reading on the von Fleisch] scale. 

# = amount in grams of hemoglobin in 100 of the 
blood under observation. 

Suppose the reading to be 50, then 100 x 14+50=7 
gm. of hemoglobin. 

This instrument is ver y convenient for bedside work. 
Its chief objection is its expensiveness. 

Professor Miescher, of Basel, has devised a means by 
which the blood to be used in Fleischl’s instrument may 
be more accurately diluted. The parts of the von Fleischl- 
Miescher instrument are shown in the illustration (Fig. 
581). The principal changes are, that instead of the cap- 
illary tube a graduated pipette is used, by means of 
which very accurate quantities of blood with accurate di- 
lution may be obtained, and that wells of different depths 
are employed. There are a few minor changes also. We 
have been unable to discover any superiority in this in- 
strument over the ordinary von Fleischl apparatus. 

If the precautions already laid down by us in speaking 
of the von Fleisch] apparatus are observed (¢.e., to see 
that all the parts correspond), the instrument will be 
found quite reliable. Certainly we deprecate anything 
which increases the cost of the already too expensive von 
Fleisch] instrument. 

Taylor's Hemoglobinometer.—The following description 
and cut (Fig. 582) are from the advertisement of this in- 



























gradually increasing depth of color (the same as is used 
with the von Fleischl heemometer), and a rectangular glass 
plate with a square raised platform in the centre. This 





tl 


th Bi ee 





coe nin i 
VG 




































































































































































































































































































































































































































































Heemoglobinometer. 


FIG. 582.—Taylor’s 


raised platform, which is cemented to the plate nearer 
to one side, has in its centre a circular cavity or cell of 
exactly 1mm. in depth. The rectangular plate is ac- 
curately fitted in a metal frame sliding in grooves, so 
that the cavity with its contents can be brought suc- 
cessively to any part of the wedge for color comparison. 

“To use the apparatus a drop of blood is carefully 
drawn into the mixing tube up to the engraved mark, 
and distilled water is then drawn up till the bulb is en- 
tirely: filled to the second engraved mark on the upper 
constricted end; the diluted blood is then mixed (by 
means of the contained bead) by shaking the bulb. The 
portion remaining in the capillary tube is then blown out 
and discarded. A part of the diluted blood is then blown 
out into the cavity in the platform of rectangular plate 
until it is filled. A ground and polished square cover 
glass (supplied) is placed on top and the contents of cell 
are compared with successive parts of the wedge by re- 
flected light from the white background until the color, 
as seen through both narrow rectangular diaphragms, 
agrees in depth, when the percentage of hemoglobin is 
indicated on the scale. . 

“The blood examined is of a@ known accurate dilution 
made with a pipette, which is very much greater in 
length than that employed in the von Fleisch! instrument, 
so there is less risk of inaccuracy. The quantity of the 
diluted blood to be compared with the Reichert wedge 
is constantly and accurately fixed by the use of a cell of 
1 mm. depth, somewhat similar to the cell employed in 
the Thoma hemacytometer. ... The 
instrument can be closed and easily 
carried in the pocket, being about 
the same size as the case of the small- 
er Thoma heemacytometer. 

“The capillary pipette supplied al- 
lows of a dilution of 1 to 10 or 1 to 20.” 

Oliver’s Hoamoglobinometer. — Dr. 
George Oliver, of London, at the same 
time that he devised his hemocy- 
tometer constructed a hemoglobi- 
nometer upon the principle of the 
tintometer of commerce. 

As stated in describing the hemo- 
cytometer, the term tintometer is 
wrongly applied to the corpuscle- 
counting instrument. The hemoglo- 
binometer of Oliver, however, does 
depend for its principle upon the 








Fig. 581.—Von Fleischl-Miescher Heemoglobinometer. 


strument. Ihave had no experience with Taylor’s hemo- 
globinometer, though evidently it offers no improvement 
over the von Fleischl instrument. The price is $30. 
“This apparatus was suggested... by Dr. A. E. Taylor, 
of the William Pepper Clinical Laboratory of the Univer- 
sity of Pennsylvania Hospital. It consists of a fine capil- 
lary tube and mixing bulb with bead, similar to that 
supplied with the Zeiss hemacytometer, a glass wedge of 


comparison of tints, and it may there- 
fore be called a tintometer. 

The principle on which the instrument is based, 
namely, that every colored liquid, upon dilution or con- 
centration, has a distinctive color curve (the same being 
true of colored glass) as characteristic as the specific heat 
of a substance (see quotation from Lovibond, p. 54), places 
this instrument in point of accuracy above that of Gowers, 
in which picrocarmine is used, and above that of von 

Fleisch], in which a gradation of colors is employed. 


57 


eat REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








Fig. 583.—Oliver’s Haemoglobinometer. 1, Series of tinted glasses; 2, glasses with more delicate variation in tint to be used as riders ; 3, well for 
reception and dilution of blood; 4, capillary tube for taking blood; 5, dropper; 6, candle and stand; 7, collapsible dark tube. 


In Gowers’ instrument, while the standard is fixed, yet | into the capillary tube, care being taken that no air spaces 
the blood is continually changing in degree of dilution, | are formed; excess of blood is wiped away. The blood 


and consequently the true color curve is destroyed. in the tube is then washed into the well by 
Moreover, as already stated, the standard picrocarmine fy means of a stream of water applied with the 
changes color with age. In von Fleischl’s instrument . | dropper. As stated in describing the hemo- 
the dilution is fixed, but there is no uni- of 















formity of color in the area under obser- 
vation. In Oliver’s instrument there isa 
fixed dilution ofa fixed quantity of blood 
compared with a fixed tint. The diluted 
blood and the glass that is compared 
with it must therefore have the same 
color curve. 

The instrument consists of: twelve 
tinted glasses, in two sets of six each, 
mounted on white backgrounds 
™z, of calcium sulphate* and rang- 
ing from 10 to 120; a capillary 
tube (5 cm. capacity) similar to but 
. | larger than that employed in the 
ee] von Fleisch] instrument; a drop- 
per; a well with a white 
background of calcium 
sulphate; a thick cover 
slip (Fig. 583). 













Be Ete BOGE Neca 







ene MERE eer eee Dar ee eae 


RS ete att 8. 





cl NE at E las ttn sete 


Fic. 584.—Dark Box for Estimating Percentage of Haemoglobin by the Tintometric Method. 1, Series of tinted glasses; 2, capillary tube for 
blood; 3, dropper; 4, well for diluted blood ; 5, tinted glasses in position to one side of 4, in position, both of which can be seen and compared 
by looking through 6 when the door 7 is closed and the candle is lighted. 


To use the instrument: Puncture is made in the usual | cytometer of von Fleischl, it is unnecessary and awkward 
way and the blood (quite a large drop) allowed to pass | to attach the rubber tube to the capillary. The well is 
Spe ERE es ; : The ol 5 filled to the top, the blood and water thoroughly stirred, 

S, y Substances tested, was found by Oliver to produce |! and the blue-cover glass adjusted. . A good light. pret 


the least confusing influence upon the appreciation by the eye of dif- i é : 
ferent tints. J erably daylight (see Lovibond quotation, p. 54)—is ob- 





58 ° 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood, 
Blood, 





tained, and the eye screened as with the von Fleisch] in- 
strument; but the dark tube is to be held about eight inches 
away from the well, instead of upon it, as is done in 





of blood varies with the amount of hemoglobin contained, 
these methods of estimating hemoglobin have been 
placed among the important clinical tests. 











1035- 1038 104s 10Y26S- 40050 


Fic. 585.—Roy’s Specific-Gravity Method. 


using the last-named instrument. An expensive and, 
it would seem, unnecessary tube, called a camera tube, is 
supplied with the instrument. 

In order to detect differences between 10 and 20, 20 and 
30, etc., it is necessary to use riders each of which is 
equal to 1 degree. 

By superimposing these riders until the exact shade of 
color is reached, and by then adding the number of rid- 
ers employed to the next lowest figure on the scale, the 
percentage of hemoglobin is ascertained. For example, 
40 + 3 riders = 43 per cent. of hemoglobin. 

A candle flame may also be used for these observations ; 
the illustration (Fig. 584) shows a box for making ob- 
servations by candle flame. If sucha box is not made 
use of, the candle should be placed about three inches 
from the point of observation. 

The instrument has the disadvantage of being very 
expensive. It may be had of I. H. Smith and Co., 
Ziirich, and of Tintometer Co., 6 Farrington Avenue, 
London, E. C.; price, about $30. 

Dr. T. W. Tallqvist, of the Medical Clinic of the Uni- 
versity of Helsingfors, Finland, reports in Nothnagel’s 
“Specielle Pathologie und Therapie,” Bd. viii., Th. i, 
Heft i., p. 10, under “Die Anemie,” by Ehrlich and 
Lazarus, a method for quick estimation of the amount of 
hemoglobin by color comparison. By means of a care 
fully prepared table of colors representing known per- 
centages of haemoglobin, he compares the blood under 
examination received upon a piece of filter paper. 











Zar Bl a See ep 
Set + FEE 


Fic. 586.—Reagents and Pipette Used in Hammerschlag’s Method. 
(Drawn by Dr. E. Dunning.) 


By aid of the von Fleisch1-Miescher hemoglobinometer 
Tallqvist has tested this method and finds ten per cent. 
the degree of error. 

Dr. Arthur Dare has lately devised an instrument for 
estimating hemoglobin without dilution of the blood. 
The instrument is somewhat on the plan of the He- 
nocque hzematoscope, but is much simpler and cheaper. 

3. Speciric-GrRAvity MeEtuHops.—It having been 
shown (by Siegel and Schmaltz) that the specific gravity 


1008 











sug 4057 1052 1053.5 1056 


(Drawn by Dr. E. Dunning.) 


A number of methods have been devised, the most im- 
portant of which are those of Roy and Hammerschlag. 
These two methods have for their principle the com- 
parison of blood with heavier and lighter fluids of known 
specific gravity and such as are non-miscible with blood. 

Roy, in his method, employs glycerin and water, 
fluids of widely different specific gravity. <A series of 
test tubes, as shown in 
Fig. 585, 4 cm. in diame- 
ter and having a capacity 
of from 80 to 100 c.c., are 
filled with the two fluids, 
and the specific gravity 
of each is determined and 
marked, Blood is obtained 
in a pipette or capillary 
by the usual way. A drop 
is blown into each test 
tube, after the pipette has 
been submerged in the 
liquid, and when that 
tube is reached in which 
the blood neither floats on 
the surface nor sinks to the 
bottom, the specific grav- 
ity of the liquid contained 
in that tube is read off. 

Hammerschlag’s meth- 
od, which is clinically the 
more applicable, makes 
use of only one tube. In 
this method benzol and 
chloroform (Fig. 586) are 
the liquids employed, 
which, as before, differ 
widely in specific gravity 
and are freely miscible. 
The blood is introduced as 
in Roy’s method, and the 
chloroform or the benzol 
is added until the blood 
floats in the mixture. The specific gravity of the mixture 
is then ascertained, which will also be that of the drop 
of blood. 

Dr. Scott, the writer’s assistant, working in our labora- 
tory, offers the following comparative observations on 
the different methods of hemoglobin estimation: 

Comparison between the Gowers and von Fleischt In- 
struments and the Specific-Gravity Methods for Haemoglobin 
Estimation.—In the accompanying tables von Fleischl’s 
and Gowers’ instruments and Hammerschlag’s specific- 
gravity method were used. In these experiments the 
utmost care was taken to fulfil every requirement in the 
technique of each method. As a description of von 
Fleischl’s and Gowers’ instruments, and of their methods 
of use, have been given in another part of this article, we 





Fia. 587.—Specific-Gravity Method 
for Estimating Percentage of 


Hemoglobin. Blowing drop of 
blood from capillary tube into 
receiver containing benzol and 
chloroform. 


59 





Fig. 588.—Specific- 
Gravity Method for 
Estimating Hzemo- 
globin. Drop. of 
blood suspended in 
the fluid (chloro- 
form and benzol). 


from a medicine 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





will here describe only the specific- 
gravity method as employed in mak- 
ing these comparative observations. 
We have adopted Hammerschlag’s 
method, which is a modification of 
Roy’s, as being best suited for the 
general practitioner. 

In this method two fluids are ‘se- 
lected which are easily and readily 
miscible, and with neither of which 
will a drop of blood mix; further, the 
specific gravity of the one fluid is low, 
while that of the other is high. 

The fluids selected are benzol (sp. 
gt. 0.889) and chloroform (sp. gr., 

526), which exactly fulfil these con- 
ditions They have the further ad- 
vantage of being cheap, and the 
whole apparatus required is likely to 
be found in every physician’s office. 
We place some of the mixture (sp. gr. 
1.050-60) in a dry clean cylinder, and 
carefully take a drop or two of blood 
in a Thoma-Zeiss mixer (any capillary 
pipette, however, will do); we then 
insert the end of the tube just below 
the surface of the mixture, and blow 
out a drop of the blood (Fig. 587). 
The blood is seen as a bright red 
globule which does not mix with the 
fluid, but either sinks to the bottom, 
floats on the top, or remains sus- 
pended -in the fluid (Fig. 588). If it 
sinks to the bottom this is because it 
is heavier than the fluid, and more 
chloroform must be added. If it 
floats on the top, more benzol is re- 
quired (Fig. 589), If it remains sus- 
pended, it is of the same specific 
gravity as the fluid (Fig. 590). It is 
well to add the necessary benzol or 
chloroform only one drop at a time 
dropper (see Fig. 589), and to stir 


the fluid with a glass rod to cause complete mix- 


ture. 


It has been found that matters are very con- 


siderably simplitied, and much time and patience are 





Fic. 589.—Specific-Gravity Method for Estimation of Percentage of 
Adding fluids (benzol or chloroform) until drop of 


Hemoglobin. 
blood is suspended. 


saved, by having the mixture of such density that the 
drop of blood will sink to the bottom. It is much easier 
to make the globule rise by the addition of chloroform 


60 





drop by drop than it is to cause it to 
sink by the gradual addition of ben- 
zol. Let the drop of blood remain 
suspended for a few minutes to see 
that it will neither float nor sink, and, 
then, when satisfied that it is station- 
ary, ascertain the specific gravity by 
means of an ordinary hydrometer (see 
Fig. 590). By filtering the mixture of 
benzol and chloroform they can be 
used again and again. 

The drop of blood will remain in 
the mixture for a considerable time 
without its specific gravity chang- 
ing. In the illustration (Fig. 590) 
the drop remained suspended for 
forty-eight hours before the photo- 
graph was taken. 

In Table I., below, a variation is to 
be noted between von Fleischl’s and 
Gowers’ estimates, but the variation is 
not constant in either direction. There 
is more steady agreement between 
those of von Fleisch] and of Hammer- 
schlag respectively; and this is more 
particularly seen in Table II., which 
gives comparative estimates of hemo- 
globin of the blood from each ear of 
the patient. Here, too, it will be seen 
that the specific-gravity readings are 
quite constant; while the von Fleischl 
readings vary somewhat, and those of 
Gowers vary considerably. 

Dr. Scott’s tables show very satis- 
factorily how little is the variation 
between the specific-gravity method, 
which is so simple in cost, and the 
expensive instruments. Even with 
the von Fleischl instrument one pre- 
fers to report his observations over 
a range of five points—75 to 80 per 
cent., for example; while with the 





590. — Specifiec- 
Gravity Method for 
Estimating Percent- 
age of Heemoglobin. 


Fie. 


Taking _ specific 
gravity of fluid. 
Drop of blood seen 
suspended in fluid. 


specific-gravity method the observations can be more pre- 
cise—as in Dr. Scott’s tables, where in most instances the 
observations are within a range of two or three points. 


Such reading would also include the 


reading with Gow- 


ers’ or von Fleischl’s instrument. It was for the purpose 
of determining the accuracy of the specific-gravity meth- 


od that Dr. 


Scott made these observations, and our con-. 


clusion is that this method is, clinically, perfectly reliable 


and satisfactory. 




















TABLE I. 
Pereentage Pereentage ipa 
0 0 : 
A _. Specific-gravity.| haemoglo- 
No. | according to | according to | Method of "| bin corre- 
von Fleischl’s! Gowers’ | Hammerschlag. et es 
heemoglo- heemoglo- ee re 
~binometer. binometer. gravity. 
68 69 1050 65 
71 69 1052 68-9 
68 67 1050 65 
63 59 1049 60 
7 69 1055 7 
7 69 1054 7 
78 71 1056 80 
76 7 1054 72 
78 77 1056 80 
93 89 1059 91-2 
81 81 1056 80 
68 67 1052 68-9 
7 69 1054 72 
65 68 1051 67-8 
92 87 1059 91-2 
64 62 1050 65 
91 92 1059 91-2 
53 57 1048 55 
82 88 1057 85 
61 55 1049 60 
52 49 1047 51-2 
65 66 1050 65 
78 76 1056 80 
81 73 1056 80 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


TABLE I.—Continued. 






































Percentage | Percentage rece: 
of of Hero lo 
i Hemoglobin | Hemoglobin | Specific-gravity read 
No. According to | According to | + Method of mere 5 
von Fleischl’s| Gowers’ | Hammerschlag.| ST? THe 
Hemoglo- | Heemoglo- Specific 
binometer. binometer. Gravity. 
ON ROAR CBE 78 fi 1057 85 
oa: Tt 73 1056 80 
Mel (RS OO eSE 96 91 1060 95 
Pilani ares 62 69 1049 60 
pe Ns ee eames 85 1057 85 
BOS sthtentes « 58 57 1050 65 
BES eaiansis.o 71 69 1053 7 
Be ietrstalelaets,s 68 68 1052 68-9 
Seis cciercrecrs 86 7 1058 88-9 
G2 Aa eer 82 83 1057 85 
6S entre 81 83 1057 85 
Bi ds.5 aetna ate 78 73 1056 80 
Bll densa 80 74 1057 85 
eee ae 80 78 1056 80 
BO crictiowes.s 87 83 1058 88-9 
AUD ie oxis6 2,53 90 90 1059 91-2 
Aer ceess: 75 72 1055 75 
BD cS atuicts wi 68 vi 1052 68-9 
ADS ate ite wey 81 83 1056 80 
yO er Oeaar 81 84 1056 80 
AD css eves 78 76 1055 75 
AGE cece. cs 88 88 1058 88-9 
Miamiateeie sie 86 83 1057 85 
Been iceticiers.« 7 72 1056 80 
1 Nee eee 85 7 1057 85 
A ee 82 80 1056 80 
TABLE II. 
LEFT EAR. RIGHT Ear. 
No. 
Von , Specific Von Specific 
Fleischi. |@°We!S:| Gravity. || Fleischl. [€°¥°"S-| Gravity. 
afore 87 83 1058 88 84 1058 
Moats bieveis 90 90 1059 90 90 1059 
Ot ONG 7d 2 1055 63) 73 1055 
Arata ats 68 67 1052 68 7 1052 
Dees « 81 83 1056 81 83 1056 
OR a eaares 81 84 1056 81 83 1056 
ten toerete 78 76 1055 78 76 1055 
Bricthecss 88 88 1058 88 86 1058 
Ces aoe 86 83 1057 86 82 1057 
DOr 78 72 1056 78 7. 1055 
Lae a rece 85 £9 1057 85 86 1057 
5 1 ee 82 80 1056 82 80 1056 





Color Index.—This refers to the relation between the 
number of red cells and the percentage of hemoglobin. 

Suppose the red blood corpuscle count to be 5,000,006 ; 
this being the normal, we may designate it as 100; then: 


5,000,000 red blood corpuscles = 100 


4,500,000 “ — oy 
4,000,000 “ o if = OU) 
8,500,000 “ : is ani 
3,000,000 “ = . == O0) ELC: 


Suppose the hemoglobin to be 100 per cent. This is 
the normal. Then 48? = 1, represents the normal state 
of the blood; 1 is the normal color index. 

A general formula by which the color index may be 
arrived at would be the following: 


a= color index, in which A = percentage of hemoglo- 


‘bin and B the number of red blood corpuscles reduced to 
terms of 100. 

Examples: Chlorosis, =% = 0.5 color index. Perni- 
cious anemia, #¢ = 0.8 color index. Secondary anemia, 
$3 = 0.75 color index. 

Chlorosis, it will be seen, has the lowest index, perni- 
cious anemia the highest; that is, in pernicious anzemia 
each corpuscle is carrying more hemoglobin than is the 
case in chlorosis. This is the value globulaire of French 
writers. 


Blood, 
Blood, 





The Anemias—detected by the use of the blood-counting 
and hemoglobin-estimating apparatus. (For complete 
table, see page 69.) 

cone Chlorosis, 
Primary .. j Pernicious. 
Purpura, 
Hemorrhage, Menses, 
Hemorrhoids, ete. 


Arsenic, 
Lead, 
Mercury, 
Silver, ete. 


POISONS 
Anemia... 


Secondary 
Wasting diseases, 
Malaria, 
Inanition, 
Tuberculosis, 
Chronic suppura- 
tion, 
Chronic Bright’s, 
| Pyrexia, etc. 





Diseases.... 


Terms: Oligeemia—édcyor, too little, aiua, blood—too 
little blood. Oligocytheemia—éAvyoc, too few, Kuroe, circle, 
aiua, blood—too few blood cells. Oligochromemia— 
bAcyoc, too little, ypauy, coloring matter, aiua, blood—too 
little coloring matter. Leuksemia,—/evkoc, white, aiua, 
blood—white blood. Leucocytosis—eveo¢ white, xvtoc, 
circle, cove, full of—full of white corpuscles. 


IV. BLoop-CLortTine. 


The fact that normal blood requires a fixed time for clot- 
ting, and that in certain diseases this time varies, makes 
the phenomenon of blood-clotting of clinical value. 
However, in the description of apparatus and technique 
employed in the clinical examination of blood, the dis- 
cussion of the various causes, etc., producing this phe- 
nomenon can have no place. Text-books on physiology 
and the article on Coagulation should be consulted for in- 
formation on this subject. Therefore, beyond describ- 
ing the apparatus employed and mentioning the diseases 
in which variations in the time required for clotting oc- 
cur, the subject will receive no further consideration. 

Two methods for determining the rate of coagulation 
may be employed: 

1. The rough test, in which two drops of blood, as 
nearly equal in size as possible—one from the case under 
observation and one from a normal individual—are com- 
pared as to clotting time. 

2. The more accurate test, in which Wright’s coag- 
ulometer tubes are employed. 

1. The Rough Test.—A drop of blood from the case 
under observation is received on a glass slide, and simul- 
taneously a drop as nearly as possible of the same size as 
that from the suspected case is taken from a normal case 
and placed upon another glass slide. The time at which 
the operation is begunis noted. The two slidesare placed 
side by side, and by means of a pin touching the edge of 
the drop, the stage of the process of clotting is ascer- 
tained from time to time. The moment of complete clot- 
ting is determined when the pin, being drawn from within 
outward, no longer leaves a small projection at the periph- 
ery of the drop. The time is noted and compared with 
that of the normal blood. This is a test by comparison. 
The actual time should not be taken. 

2. The More Accurate Test.—In this test, equal quanti- 
ties of blood are taken by means of accurately graduated 
tubes. These tubes are blown through, one after anoth- 
er, until that tube is reached which cannot be blown out, 
and in which, therefore, the contained blood has clotted. 
The time from the taking of the blood to the moment 
when the blood has clotted is noted, and this is termed 
the “coagulation time.” . 

Wright’s coagulometer tubes are of two kinds (Fig. 
591): 1. Those for testing the coagulation time of the 


61 


Bleod. 
Blood. 





blood. 2. Those for testing the coagulation power of 


certain substances. ! ; 
1. Those for Testing the Coagulation Time of Blood.— 
These tubes have a centimetre scale, 6 cm. in all, and are 


1 


ert ee 











Fig. 591.—Wright’s Coagulometer Tubes. 1, Ordinary tube; 2, tube with mixing chamber. 


shaped as seen in Fig. 591. There are eight such tubes 
inaset. There is also a round tin receiver, surrounded 
by a jacket, in which there are nine pockets—eight for the 
reception of the tubes, the ninth being for the reception 
of a thermometer (Fig. 592). This part of the apparatus 
is for the purpose of heating the tubes to blood heat before 
use by placing heated water in the centre tin. This is not 
essential, as the normal blood is found to be coagulated 
in the same time without previous heating of the tubes as 
when such heating is 
carried out. If heat- 
ing is resorted to, the 
thermometer should 
register 18.5 cm. (half 
blood heat), or, if 
clotting is very slow, 
37.0 em. (blood heat). 

The test is made as 
follows: The tubes, 
as seen in illustration 
(Fig. 591), are laid 
out (if the heating 
tin is not used) on a 
sheet of white paper 
on a table at the bed- 
side. An open watch 
is also laid upon the 
table. <A fairly large 
puncture is made in 
the skin in the usual 
way. <A rubber tube 
with mouthpiece 
(similar to that used 
with the Thoma-Zeiss 
mixer) is attached to 
the first tube and 
blood is drawn up to 
the fifth division, the 
time by the watch 
being noted. Taking 
the point of the tube 
away from the blood 
drop, the column of 
blood is drawn up to 
the sixth marking, 
thus removing the 
end of the column 
from the immediate 
influence of the air. 
This tube is laid upon the white paper, and the moment 
at which the observation is begun noted down. In about 
half a minute the second tube is treated in the same way, 
in another half-minute the third, and so on for the whole 
set. After the lapse of about one minute the first tube 
is gently blown through; if the blood is still liquid the 
second tube is blown through; and so on until a tube is 
reached from which the blood cannot be blown. The 
time at which this condition is observed is at once noted 





























Fig. 592.—Case and Warm Chamber for 
Wright’s Coagulometer Tubes. Cham- 
ber for warm water in centre sur- 
rounded by leather jacket containing 
tubes and thermometer. 


62 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





and compared with the time, as marked on the paper, at 
which the observation of the blood in that tube was 
begun. The difference between the two numbers consti- 
tutes the time required for this specimen of blood to clot, 
and is therefore the 
“coagulation time.” 
The time is taken from 
the moment the blood is 
drawn into the tube to 
that at which it cannot 
be blown from the tube. 

2. In using the in- 
strument to determine 
the coagulation power 
of certain substances, 
the tubes with the mix- 
ing space are employed 
(see illustration, Fig. 
591, 2). The substance 
to be tested is drawn 
up to one of the divisions on the tube, say the second. 
Blood is then also drawn up, and the blood and substance 
to be tested are thoroughly mixed in the mixing space. 
Unmixed blood is now drawn into another tube, and the 
different coagulation times for the two tubes are noted. 
Prof. Wright exhibited at the Paris Congress, August, 
1900, an improvement upon this instrument. The au- 
thor has obtained the first of these improved instruments 
placed upon the market, but has not as yet tested it 
sufficiently to warrant him in expressing an opinion. 

Cleansing the Tubes.—This is one of the annoyances of 
the Wright tubes, for unless cleaned at once the tubes be- 
come hopelessly clogged. Itis well, therefore, to have an 
attendant draw clear water into each tube the moment the 
observation has been made upon that tube. It is evident 
that as the observer is occupied with his observations, 
those tubes already tested, and containing traces of blood, 
will become dried out and clogged. A wire should be 
passed down the tubes to break up the clotted blood. 

When all trace of blood has been removed, and not till 
then, 95 per cent. alcohol should first be drawn through 
the tubes, and afterward ether. The tubes will then be 
ready for use again. The importance of prompt action 
in the matter of cleaning the tubes cannot be too em- 
phatically stated; disregard of this promptness will ren- 
der the tubes useless.* 





COMPARATIVE TIME OF COAGULATION IN CERTAIN 
DISEASES. 


(Normal, two to three minutes.) 
Coagulation Rapid. 
Malignant disease: 
inflammation or slough- 
ing in progress. 
Pneumonia. 
Hemoglobinemia: 
in severe grade of ma- 
laria ; 
in severe grade of sept- 
iceemia ; 
in yellow fever; 
in typhus fever; 
in burns. 
Poisons: 
snake poisoning ; 
chlorate of potassium ; 
antipyrin and antife- 
brin ; 
hydrocyanic acid ; 
phenacetin ; 
phosphorus; 
carbonic acid; 
illuminating gas. 


Coagulation Delayed. 
Malignant disease: 
uncomplicated. 


Jaundice (important in op- 
eration for gall stones, 
as one of the most com- 
mon complications caus- 
ing fatel results is post- 
operative hemorrhage due 
to reduced coagulability 
of the blood. 

Obscure conditions associ- 
ated with frequent at- 
tacks of epistaxis: 

heemophilia ; 

scurvy ; 

erythema multiforme; 

pernicious anemia ; 

anemia, delayed in ac- 
cordance with sever- 
ity ; 

purpura hemorrhagica. 





*The Wright apparatus may be had of Alfred E. Dean, 73 Hattom 
Garden, London, E. C., for £2 5s; the improved instrument of T. 
Hawksley, 357 Oxford Street, London, for £1 15s. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood, 
Blood. 





The coagulation time may be increased by - 

1. Inhalation of carbonic acid gas. 

2. Ingestion of calcium chloride. 

3. The gelatin treatment for aneurism. (qa) Lan- 
cereaux’s method: 4-5 gm. white gelatin dissolved in 200 
c.c. of 0.7 per cent. sodium chloride solution and sterilized 
at 120° C. (b) Futcher’s method: 250 c.c. of one-per- 
cent. gelatin solution in normal salt solution (Journal 
of American Medical Association, January 27, 1900). 

DETECTION OF BLOOD WHEN IN SMALL QUANTITIES. — 
For full information upon the more complicated appa- 
ratus and technique (spectroscopic and chemical) em- 
ployed in the detection of blood for medico-legal pur- 
poses, the reader is referred to the article on Blood Stains. 

A simple clinical test is the following: Allow a few 
drops of the fluid supposed to contain blood (urine, gas- 
tric contents, etc.) to dry upon a glass slide. Add to 
the margin of the dried fluid a few grains of common 
salt. Now from a pipetteallow a drop or two of glacial 
acetic acid to attack the salt and dried fluid. Gently 
heat the slide until the acid has dried entirely ; examine 
with low power. If blood is present crystals of heemin 
will have formed. Hezemin is a derivative of hematin 
(or hydrochlorate of hematin) which is thus produced. 
If no blood be present no crystals will be formed. 


VI. Srarntinc or DRIED SPECIMENS OF BLOOD. 


Through the labors of Ehrlich we have learned that 
the blood corpuscles react variously to the aniline dyes: 
that some of the white corpuscles contain specific granules 
which in health react to these dyes in one way, while in 
disease these same granules react in a different way. So 
constant is this peculiarity that an entire system of diag- 
nosis has become possible simply through the process of 
staining the blood. 

As this branch of the study of the blood depends en- 
tirely upon the peculiar reaction, not of the corpuscles 
as a whole, but of certain parts ot the corpuscles, our 
technique must be even more delicate than in any sys- 
tem of diagnosis already described. 

There are two methods of preparing the blood for 
staining: (1) The slide method. (2) The cover-slip 
method. 

(1) The Slide Method.—Puncture is made in the skin 





FIG. 593.—Method of Taking Dried Specimen of Blood. First step. 


in the usual way. A drop of blood is received at one 
end of an absolutely clean glass slide. The edge of an 
other glass slide is dipped into the drop of blood and 
drawn gently along the surface of the first slide. This 
produces a large and fairly thin smear of blood. The 
objections to this method are. (a) Too large a smear; (d) 
smear not thin enough; (¢c) unequal spread, thicker in 











one place than in another; 
puscles. 

(2) The Cover-Slip Method.—Several No. 1, % inch, 
square Bausch and Lomb cover slips are thoroughly 
cleaned with alcohol and ether. Every trace of dust and 
cloudiness must be removed. These cover slips are placed 
ona sheet of white paper on a table near the patient. 
It is hardly necessary to state that they should be held 


(d) apt to mutilate the cor- 





Fig. 594.—Method of Taking Dried Specimen of Blood. Second and 
third steps. 


by the edges and not by the flat surface—that portion 
which comes in contact with the blood, and which, 
therefore, we should take every precaution to keep clean, 
A lighted spirit lamp should also be at hand. The point 
of puncture is cleaned with alcohol and ether; this is 
more important in taking the dried specimen than in 
taking the fresh specimen. One of the cleaned cover 
slips is placed in the clamp forceps, as shown in Fig, 
540, No. 4d, p. 88, and the forceps thus armed laid upon 
a table near at hand. Puncture is made in the usual 
way. After removing the first drop, the clamp for- 
ceps holding the cover slip is held in the left hand, 
and the second drop is received upon a cover slip held 
by the open forceps (see Fig. 540, No. 5, p. 38) in the 
right hand. This is the first step, and is shown in Fig. 
593. 

The cover slip with the drop of blood is émmediately 
transferred to the cover slip held in the clamp forceps, as 
follows: The edge of the cover slip upon which is the 
drop of blood and which is held in the open forceps is 
placed against the end of the limb of the clamp forceps 
holding the other cover slip. Thus held, the cover 
slip is slowly lowered until the drop of blood almost 
touches the undermost cover slip. The right hand for- 
ceps is then opened and withdrawn, which allows the 
cover slips to come together with the blood between 
and spreading equally in all directions. This is the sec- 
ond step, and is shown in Fig. 594. If these steps have 
been carefully carried out, the blood specimen should 
appear as in the illustration (see Plate XIII, Fig. 1). 

Directly the blood is no longer seen to spread the two 
slips are drawn apart, in such a manner, however, that 
they shall at all times be parallel with each other. This 
drawing apart must be quickly done, for if performed too 
slowly it will be found very difficult to keep the slips 
parallel with each other—an essential point,—the upper 
slip rising at the last and making a great clump of blood 
on the lower slip 

In order to act thus quickly, and to be sure of the slips 
coming away at one pull, it is well to take an additional 
hold upon the clamp forceps far down the limbs, near to 


63 


Blood. 
Blood. 





the cover slip. This is the third step, and is shown in 
Fig. 594. The cover slips thus separated are now held 
from eighteen inches to two feet above the spirit lamp 
until the blood is quite dry. This is the fourth and last 
step, and is shown in Fig. 595. 

It is recommended by some heematologists to use the 
thumb and forefinger in drawing the upper slip away, 
rather than to use the open forceps. When this plan is 





FiG. 595.—Method of Taking Dried Specimen of Blood. Fourth step. 


followed the corners of the cover slips should not exactly 
correspond, but one cover slip should be allowed to pro- 
ject beyond the other, so as to offer something to hold 
onto. Asit is better not to touch the cover slip except 
with the forceps, and as the moisture of the skin readily 
adheres to the glass and ruins the blood specimen, the 
forceps method should certainly be preferred. 

Thayer mentions that flies attack the dried specimens, 
eating holes in them. While this is undoubtedly true 
in some cases, yet the holes which one sees in dried speci- 
mens are more commonly caused by allowing the blood 
to dry in the air instead of using aspiritlamp. The writer 
has seen these holes in specimens taken in winter. 

The prepared specimens may now be placed in a la- 
belled pill box and kept indefinitely. The method of 
preparation here given permits of the preserving of 
specimens for a number of years, to be used for class 
purposes; or of sending them, packed in a little cotton, 
by mail to an expert. By learning this simple technique, 
therefore, a physician engaged in practice in a section of 
the country removed from laboratory opportunities, or 
one occupied in military duties, may take specimens and 
send them to a laboratory for examination. 

The painful mistakes made in establishing the differen- 
tial diagnosis between typhoid and malaria among the 
American soldiers in the late Spanish war might have been 
avoided, and many lives saved, had the microscope been 
given more place and some of the simple methods above 
described been carried out. The indiscriminate adminis- 
tration of quinine, while perhaps benefiting many ma- 
larial cases, must have produced injurious effects upon 
the ulcerated intestine. 

Before proceeding to the work of staining it is neces- 
sary to “fix” the contents of the corpuscles so that they 
shall not become dissolved; and this is called fixation. 
A number of methods have been employed, which may 


64 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





be divided into fixation (1) by heat; (2) by fluids; (3) 
by vapors. 

(1) Fixation by Heat.—(a) Ehrlich’s copper-bar method. 
(1878). A spear point made of copper and about eighteen 
inches in length is placed upon a support, as shown in cut 
(Fig. 596). A Bunsen burner is so located that the flame 
will strike the extreme point of the bar. The flame of an 
ordinary Bunsen burner, if applied to the extreme tip of a 
bar of this size, will be able to heat 
only a certain amount of the bar 
to a certain degree of heat; beyond 
which the temperature will not 
rise, no matter how long the bar 
is subjected to the flame. In 
other words, the flame has a lim- 
ited heating power. This would 
at once be appreciated if we should 
attempt to heat with the ordi- 
nary Bunsen burner a copper bar 
five or ten feet long. We should 
not be surprised to find the far 
end of the bar cold, no matter how 
long the copper may have been 
submitted to the flame. Weshould 
realize that the little flame, with 
its limited heating power, could 
not heat so largea bar. The heat- 
ing power of an ordinary Bunsen 
burner does not extend, on a. 
metal bar, beyond the distance of 
eighteen inches. What we wish ~ 
to obtain by this heating proce- 
dure is the fixed boiling line on 
the bar. This we accomplish by 
placing drops of water upon the 
surface of the bar, about twenty 
minutes after it has been subjected 
to the flame; and directly the point 
farthest from the apex of the bar 
at which a drop of water boils 
away is found, we draw a chalk 
line across the bar at that point. 
This marks the temporary boiling line. After the lapse 
of a few minutes we put another drop of water just be- 
yond the line; if the boiling point has extended the drop 
will boilaway, and we then draw a second line at the new 
point and still farther from the apex. This procedure is 
repeated until a point is reached at which the water does 





Fic. 596.—Ehrlich’s Copper-Bar Method of Fixation of Blood Speci- 
mens by Heat. 1, Bar placed in upright position to show shape; 2, 
bar in place with Bunsen burner at tip. 


not boil away, when we know that the limit ofthe heat- 
ing power of the flame has been located. Once the per- 
manent boiling line is thus located, no matter how long 
the flame is allowed to attack the apex of the bar, the 
line will never extend any farther from the apex. The 
confirmation of the fact that this line has been reached is 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


afforded when a drop of water boils away almost at once 
on the apex side of the line, but remains until slowly dried 
off on that side of the line away from the apex. This, then, 
is the line we seek, and it is called the fixed boiling point 
or line. The blood specimens, as above prepared, are 
now laid blood side up either upon this line or directly to 
the boiling side of it. If the boiling line has been accu- 
rately located, it is, in the writer’s experience, rather 
severe treatment to place the specimens blood side down 
on this line, as recommended by Cabot (“Clinical Ex- 
amination of the Blood,” third edition, p. 44). Specimens 
so placed are allowed to remain from forty minutes to 
an hour, except in cases of pernicious anemia or of 
grave secondary anemia, when a much shorter time— 
perhaps only twenty minutes—is sufficient. This is not 
satisfactory for malaria specimens. One should be care- 
ful not toallow draughts to influence the direction of the 
flame, as in this way the bar is chilled and the boiling 
point thereby altered for a period of several minutes. 
Ehrlich’s copper-bar method is a good one, in the 
thoroughly equipped laboratory, for specimens prepared 
for class purposes; but it is tedious and calls for much 
watching, and has been replaced by quicker and simpler 
methods which seem, so far as one can at present judge, 
equally good. 

(0) A quick heat method, and one applicable to office 
work, is that by means of the spirit lamp. The speci- 
mens, taken.as above described, are simply held about 
two feet above the flame until the blood is thoroughly 
dried; or the cover slips may be heated to 60° or 70° 
C. (a temperature which can be borne by the skin) before 
taking specimens. This serves for immediate staining 
and examination’; but for specimens which are to be kept 
for a long time, or in which accurate differential exami- 
nation is desired, it will be found unsatisfactory. 

(c) Another fairly quick heat method is that by means 
of the thermostat, brought gradually to a temperature of 
150° C. and kept at this degree of heat for from forty 
minutes to an hour. This is as satisfactory as the cop- 
per-bar method, but not as readily carried out. 

(d) Another simple means is to make use of the top of 
a steam register, upon which the specimens are allowed 
to remain for from forty minutes to an hour. This is a 
very good and convenient method. Care must be taken 
that no moisture shall be on the metal. 

(2) Fixation by Fluids.—(a) Of these, Nikiforov’s 
method is the best. It calls for equal parts of absolute 
alcohol and ether. The specimens are immersed in this 
liquid for from two to four hours. This, next to the for- 
malin method given below, is the best for malarial speci- 
mens. For quick work fairly good results may be ob- 
tained from an immersion lasting twenty minutes. 

(6) Dr. G. A. Tuttle has lately devised a method which 
is described by Dr. Fred P. Solley, in the reports of the 
Pathological Department of the Presbyterian ‘Hospital, 
New York City. It was kindly brought to my atten- 
tion by Dr. W. G. Thompson. The following is taken 
from those reports: 

“Experiments were made by Dr. G. A. Tuttle with 
chromic acid, and after trials of different strengths for 
varying periods of time he found that a two-per cent. 
- solution poured on the film and allowed to remain for 
exactly thirty seconds gave uniformly good results, both 
red and white cells taking up their special stains clearly 
and surely. The nuclei and granules of the leucocytes 
stain quite as sharply as in the best specimens fixed by 
heat—while the protoplasm of the mononuclear lympho- 
cytes is usually better stained than by the latter method. 

“By this method, then, the whole process of preparing 
the specimens for examination is reduced to five or six 
minutes, and when the films are evenly and thinly spread 
the preparations are certain to be available for accurate 
differential computation. The red cells occasionally 
show defects as a result of the action of the acid; but 
this usually means that the solution has been left on too 
long, or that the films were unevenly spread. Indeed, 
the spreading of the films is of the utmost importance 
in securing satisfactory results by any method. . . . The 


Vou. II.—5 


Blood, 
Blood, 





two-per-cent. chromic acid solution is spread from a 
dropper over the film, the cover glass being held in a 
staining forceps. After thirty seconds the acid is thor- 
oughly washed off and the excess of water removed by 
tapping a corner of the square on filter paper. The stain 
is then poured over the film in the same manner, and 
washed off quickly after three minutes. The specimen 
may then be dried between layers of filter paper and is 
ready to be mounted in balsam. 

“By employing this method a complete blood examina- 
tion may be carried out in a little over an hour at the 
bedside of the patient, often affording valuable informa- 
tion in cases in which the desirability of surgical interven- 
tion is in question.” 

This method has proved most satisfactory in my hands. 

(ce) Bichloride of mercury and Miiller’s fluid (formula, 
see p. 48, footnote) may be used, but the results are un- 
certain. 

(d@) Formalin method. Five drops of ten-per-cent. for- 
malin solution are mixed with 10 ¢.c. of 95 per cent. alco- 
hol. The cover slips are immersed in this for thirty 
seconds. 

Futcher and Lazear report this as a most satisfactory 
method for malarial blood. The writer has found that 
when using the Ehrlich eosin hematoxylon stain this is 
a thoroughly reliable fixing method. Futcher and La- 
zear’s statement as to its value for malarial specimens 
is, in the writer’s opinion, to be indorsed. 

(8) Fixation by Vapors.—In this method cotton soaked 
in two-per-cent. formalinis kept at the bottom of a wide- 
mouthed bottle. The specimens are subjected to the 
vapor from this, with the cork in'the bottle, for from 
fifteen to thirty seconds. This is a good office-table and 
classroom method. During one winter my classes at the 
Cornell University Medical College prepared all their 
blood specimens by this method. While quickly ob- 
tained, the stains were not permanent, so that in a few 
months they had almost wholly faded out. 


BiLoop STAs. 


The following is not an exhaustive article upon blood 
staining; it treats of this subject only in so far as it is 
part of the apparatus used in the clinical examination 
of the blood. So much has lately been accomplished in 
the differential staining of the malarial parasite that this 
part of the subject of blood staining will be treated of 
under other heads (Histological Technique, Malaria, etc.). 

In the process of distillation of coal gas from bitu- 
minous coal, for ordinary lighting purposes, there con- 
denses upon the pipes a “thick, black, opaque, viscid 
liquid” which is known as coal tar: From this coal tar 
have been separated great numbers of useful products, 
such as paraffin, naphtha, benzol, creosote, carbolic acid, 
pitch, etc. When benzol is acted on by nitric acid, nitro- 
benzol is formed, and this, when treated with nascent 
hydrogen, produces aniline, which is an oily liquid, ani- 
line oil occurring as a by-product of the process. This 
aniline is a chemical base and unites with acids to form 
salts. These salts are of a great variety of most beauti- 
ful colors—violet, green, purple, etc.—and are the origin 
of our valuable stains in microscopic work. Benzol be- 
ing the source commonly employed in the preparation of 
the aniline dyes for commerce, this would make these 
dyes apparently by-products of coal tar. Aniline, how- 
ever, is a direct product, but in too small quantities to 
make it profitable to separate it. The word anil comes 
from the name of a plant from which indigo is made; 
the word signifies purple, and is applied to this product 
of coal tar as purple is one of the most striking colors 
produced by the combination of aniline with an acid. 

The stains used in microscopic work are manufactured 
by Griibler in Germany and sold in powder form. 
From these, various strengths of stain may be made. The 
system by which these powders are classified is at times 
confusing. It is to be regretted that the names are 
selected so as purposely to convey no information beyond 
that of enabling the compounder to refer to his records and 


65 


Blood. 
Blood, 


there learn the secret process which produced the stain. 
So no further explanation can be given of this classifica- 
tion. Many of these names, as tropaeolin 66 and orange 
“G,” were given by the commercial compounders and 
have been adopted by Griibler, who confines himself to 
the preparation of stains for scientific purposes. Eosin is 
from the Greek word meaning the dawn. Methyl blue 
and methylene blue differ the one from the other in that 
the former, mixed with sodium hydrate, changes color to 
a reddish brown, the latter to violet. Methyl blue is the 
stain usually employed in blood work. 

The stains are grouped into two general classes—acid 
and basic. These terms do not indicate a litmus reaction, 
and are therefore not to be taken in the strict chemical 
sense. The stains are for the most part neu- 
tral salts, that is, made up of a base and 
an acid, but neither acid nor basic in reac- 
tion. Nowif the acid part of a salt is the 3 
staining element in the salt, the stain is called 
anacid stain. Example: ammonium picrate, 
which is a salt made up of ammonia, the base, 
and picric acid, the acid. Picric acid is the 
element in the salt which stains; hence the name acid 
stain. Another stain is rosanilin acetate—rosanilin is the 
base and acetic acid is the acid. 'The base in this salt is 
the staining element, and hence the name basic stain. 
The term neutral stain refers rather to a peculiarity of 
the tissue than to the stain. 

According to this grouping of the stains the tissues are 
also classified. Those tissues which stain with an acid 
stain only are called eosinophilic; those which stain with 
a basic stain only are called basophilic, and those requir- 
ing both an acid and a basic stain are cailed neutrophilic. 
Tissues which consistently stain with an acid stain were 
termed by Ehrlich eosinophilic, because eosin was the 
most striking stain of the acid group. Now that we have 
all our stains clearly classified, however, it is better to 
adopt a term referring to the entire group rather than to 
a single stainin the group. Oxyphilic (0ftc, acid; ¢:Aéo, 
I take to) is therefore a better word. 


THE STAINS. 
(This list contains only a few of the more common stains.) 


Acid. Basic. 
Rosanilin acetate, 
Fuchsin (basic), 
Saffranin, 

Methyl! blue, 


Eosin, 
Fuchsin (acid), 
Orange “G,” 
Picric acid, 


Aurantia, Methy! violet, 
Indulin, Methyl] green, etc. 
Nigyvosin, 


Tropaeolin 66, ete. 


The Tissues, according to the explanation just given, 
are grouped by Ehrlich as follows: 

1. Oxyphilic (6gv¢, acid; @Aéw, I take to), synonymous 
with eosinophilic (acidophilic is a hybrid, and should 
therefore be discarded), refers to tissues taking only acid 
stains. The Greek letter “a” is used to designate oxy- 
philic granules. Example: eosinophiles of human blood. 

2. Amphiphilic (au¢i, both)—refers to those tissues 
staining equally well with either an acid or a basic stain. 
Example: the bone marrow of rabbits. There are no 
amphiphilic granules in human blood. The Greek 
letter “8” is used to designate amphiphilic granules. 

3. Basophilic refers to tissues taking only basic stains. 
Example: Mastzellen. The Greek letter “y” is used to 
designate basophilic granules. 

4, Neutrophilic refers to tissues requiring both an acid 
and a basic stain. Example: polynuclear leucocytes. 
The Greek letter “e” is used to designate neutrophilic 
granules. (The word neutrophilic is a hybrid—neutron, 
neither, and @Aéw, to take to. Oudeterophilic (oddérepoc, 
neither), would be more correct but not as simple, per- 
haps, as the present word.) 

In order to demonstrate these staining reactions of the 
various blood corpuscles and their granules, the stains 
should be each in turn applied to specimens of blood; 


66 


: é - eae — ; 
meemencesoescontoumemen: | POE ae ea UT aes 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


then the specimens should be examined, and those parts. 
which take the stain should be noted. 

For example, subject a specimen of blood to an acid 
stain—eosin. Result: Red cells stained; eosinophile 
granules stained; granules of polynuclear leucocytes. 
very faintly tinged; all else unstained. 

Subject a specimen of blood to a basic stain—methyl 











E.Leitz Wetziar Pa 





Fig. 597.—Mechanical Stage. 1, Slide in place; 2, space and screw for 
reception of and fastening to upright of microscope; 3, screw for’ 
lateral motion of slide; 4, screw for forward and back motion of slide.. 


blue. Result: Nuclei of all leucocytes stained; gran- 
ules of polynuclear leucocytes very faintly tinged; add. 
else unstained. 

Subject a specimen of blood to a neutral stain—eosin. 
and methyl blue. Result: Red cells stained red; eosin- 
ophile granules stained red; nuclei of leucocytes stained. 
blue; granules of leucocytes stained reddish blue. 

The blood thus prepared is now examined and the per- 
centage of normal cells, peculiarities of staining, and cells. 
not normally in peripheral circulation are noted. In order 
to examine these fieldsaccurately and not to recount the 
cells we employ the mechanical stage (Fig. 597). This is. 
so constructed as to enable one to move the specimen a. 
microscopic distance at a time from side to side, up and 
down, and across diagonally. It is moreover supplied. 
with a register by means of which the observer may 
take note of his whereabouts in the field, so that having 
moved away from the field, he may return to it again by 
causing the figures upon the register to stand according” 
to the position previously noted. In this way corpuscles. 
may be restudied and at the same time the whole speci- 
men thoroughly examined. 

When the blood has been fixed as already described it- 
is then subjected to the stains for varying lengths of time. 
The following are a few of the stains and formule em- 
ployed in blood work: 

1. Eosin: 0.5-per-cent. alcohol solution ; one-half to one. 
minute. Methyl blue—saturated aqueous solution; one- 
half to one minute. 


2. Ehrlich’s triple stain: 


1 1 A Cid fuChSInE meee site 3.5 1 
A GUD. Fates Orire poles ee 2.0 
9 i Orange: ie cee ee 6.0) 5 (78 4 
St Methy1 BTeei a5. caer ee 6.5 t 
At te eae at te eesti | 
Absolute alcohol acct. 5.0 


The brackets show the order in which ingredients: 
should be mixed in preparing the stain. 


NorTE.—The sero-diagnosis test for typhoid fever is not included in: 
this article, being considered under the head of Typhoid Fever. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood, 
Blood, 


TABLE SHOWING THE SOURCE, APPEARANCH, STAINING REACTION, GREEK LETTER EXPRESSING STAIN, AND THE 
NUMERICAL VALUE OF EVERY CELL FOUND IN THE PERIPHERAL CIRCULATION UNDER NORMAL OR PATH- 


OLOGICAL CIRCUMSTANCES. 

















nde aie te Z qe ee according 
a accordin: ame according to appear- : to Greek letter : 
Source. RG Name according to stain. expressing Numerical value of each cell, 
: stain. 
Protoplasm. Nucleus. 
x Ser fence RCAC Ory Red: cell eswirs isc sses cs OXVDRVIGH Me wdccese stnascce os CO) r rot wate nts 5,000,000 to cubic millimetre, 
13 E Z _ a Found normally in bone marrow 
Be Eo CABEAAOSACEO a4 Normoblast «+» ) Nucle- * BasOphiliors «iC )inc cc clsietciersts only. In peripherial circulation 
222) DE iGdoSnonpeebene £ oS | Gigantoblast ated a (a) Prnnecdasiee in pernicious and grave sec- 
5b on or megaloblast ) red cells a lL ondary anemia. 
Moi galsteie-si¥isieiatete a6 PATALOR elects wtereesToiaial sis's' sis’ ss RSRSOMMI Ce cnlecc cferes ci aipece CY) crea scat otis 300,000 to cubic millimetre. 
Granules. Nucleus. 
5. Lymphocyte . (Small mononuclear ...... Neutrophilic.......... BaSOpHLUG || Ce) Nearer se elev atarsitiete oe ae { 20-80 per cent. 
a (Sometimes basophilic (6) 6,000 
£ granules at periphery.) to 
6. ay ©} Large Sait Ae eariccte Neutrophilic .......... CE }raerelee sn + 10,000 2-8 pe 
a - 8 Transitional’*  —....... s ; Basophilic t My (Ce) i emienececlacr in’ Gime 
Ce Sener See @ | Polynuclear.....-...+++.: peed dleukeomin f° —-|.(e):coueens osetel (ener cnept | 60-70“ 
ee iela.cicierivee « ex | Coarse granular’... 660... Oxyphilic avcmiccs es (CaS cer rosal W Lancanorene l 2-3 ne 
(Eosinophile) ( Eosinophilic) 
UE NUVELOGY UG ie) crs)|'siets are o'e's.b e's 's sie sins clsjsiv ate BAST steteratee _Neutrophilic .......... oe Ge) emia waieteretare Found in bone marrow only. In 
peripheral circulation in spleno- 
~ medullary leukgemia. 
ick, ehaenaesrn ESTAS) Lcett tala o'er ereieitietaretasvoreiers eee etatere?s Basophilic ....... ee oa CY) anictasclateletoss 14 of 1 per cent. (Virchow). 
pBeduines ees to Increased in leukzemia, 
stain. 
12, 4. -Hosinophilic myelocyte ..........scccscsees OVUM Chee veiceisteattarts y CO) aiealenttetes Found in bone marrow only. In 








peripheral circulation in spleno- 
medullary leukzemia. 





NotE.—The mastcell of Cornhill was described by him prior to Ehrlich’s observations upon the staining peculiarities of these cells, and may 
have been a myelocyte or a large mononuclear, and had best, therefore, be dismissed from the list of blood cells. 


8. Carbol thionin: Saturated solution of thionin in 
50-per-cent. alcohol, 20; 2-per-cent. carbolic acid, 100. 
(Should stand several weeks before being used.) Stain 
for from ten to fifteen seconds. Especially good for 
malarial parasite. 

4. Eosin hematoxylon of Ehrlich: Eosin (cryst.), 0.5; 
hematoxylon, 2; absolute alcohol, 100; distilled water, 
100; glycerin, 100; acetic acid, 100; glacial acetic acid, 10; 
alum (in excess), 50. (Should be made several weeks be- 
fore using.) Alum aids in dissolving hematoxylon. 

5. Miiller’s fluid, see p. 48, footnote. 6. Formalin solu- 
tion for fixing blood, see p.65. 7. Hayem’s solution, see 
p. 40. 8. Pacini’s solution, see p. 40. 9. Polychrome 
methylene blue (methylene blue, 1; potassium carbonate, 
1; water, 100. Keep for several months before using.) 
10. Toison solution, p. 48. 


CHart ARRANGED BY THE WRITER FOR CLINICAL RE- 
PORT ON BLOOD; USED IN THE CORNELL DIVISION OF 
BELLEVUE Hospirat, NEw York CIry. 


RecordeNoOvs.. oc. Ria 


ENICITCNS = syatetetetel feoretcieir Koll isversie ete sis aos 
Red Blood Corpuseles : 
Normally (1 « = ssteo of an inch), 74. 
BIZO, sas sis « Microcytes, 2-5 py. 
Macrocytes, 8-10 vu. 
Normally, biconcave discs. 
Shape .... 4 Poikilocytes, irregular outline. 
_( Crenated, spiculated. 
Normally, pale yellow. 
Colorless, shadow corpuscles 
Vacuolated, degeneration areas—deficien- 
cy in hemoglobin. 
( Normal, 5,000,000. 


Color™. >. 


Number | By Gowers’ instrument....... Tiatofotes 3: 3% 
per cubic By Thoma and Zeiss instrument........ 
millimetre. By Daland’s hemotocrit............++- 

By Oliver’s hemocytometer.......+.... 
Arucleated Normally, not present. 


Fad cells Normoblasts. : 
‘  { Megaloblasts or gigantoblasts. 
Normally uniform. 
Polychromatophia = different intensity of 


stain in cells. 


4 


Staining .. 


AM@POIdeeete tse eens Pete ne : 

Hyaline. + Non-ameboid................; 

| Pigmented. etic: siete setters ate 

fs | Roger eaee 

cellular. oe echh aes 

Kull growno.-ce.c- 

Pig- Pigment motile... . 

Malarial } mented. ) ptm. [ UE terprer cet 
Ee cellular. < Flagellating...... os 
| Non-vacuolated.... 

| Pigment motile..... 

DPEOMENTING se pee ss ca te ete ches Sica ste 

Pigment: motile ......... 

Crescents .... 1 Flagellating........... ae 


: Pigment motile..... taste 
[ Round. bodies. i Flagellating .......5....- 
Hemoglobin : 


Normal, 85 to 95 per cent. 


By Gowers’ hemoglobinometer............ elestetets| st 
By von Fleischl’s hemoglobinometer.......... a ares 
By Oliver’stintometer... fouesiss ch cabic ae: Sarees ae 
By Roy’s specific-gravity method......... waereos a 
Colormindexe(mormial sel )iynetstantertlerceues tere Caterers tratciete 


White Blood Corpuscles : 
( Normal 6,000 to 10,000. 


Number | By Gowers’ hemocytometer........... 
per cubic By Thoma-Zeiss heemocytometer....... 
millimetre. By Daland’s hematocrit............ sere 
By Friedliinder’s instrument........ ota 
Normal. 
Small mononuclear lymphocytes 20-30% 
Large mononuclear lymphocytes 3 
aS Transitional lymphocytes....... 3 
P 100 Polynuclear leucocytes....... .. 60-70 
x Kosinophiles........... roe 2.4 
MOOG Yass, WMastoeliay tases. eh sya ee 0.95 
Myelocy tes. sg... << eevee DOt present, 
| Eosinophilic myelitis........ . 
Present (normal, 250,000 per cubic milli- 
Rlatesey act: metre). 
Absent. 
Plaques... ; Aer 
niet, Present. 
Fibrin..... i Afwents 


67 


Blood. 

Blood. 
Blood* { Present. 
Dust. ( Absent. 


Coagulation time (normal, two to three minutes). 
Gross test. 
Wright’s coagulometer tubes. 
Flame. 
Heat + Copper bar. 
| Sterilizer. 
Alcohol and ether 4a, equal parts. 
Formalin (10 per cent. in 95- 
[ per-cent. alcohol). 


Staining.. + Fixation 


Stain. 
Remarks. 


EBhrlich’s Eyepiece (Fig.598) supplies an important need. 
This instrument is so devised that accurate fields may be 





Fic. 598.—Ehrlich’s Eyepiece for Determining the Relative Values of White and Red Cells in a Dried 
1, Screw for fastening eyepiece to microscope; 2, handle by means of which the 
square aperture (3) may be altered in size; 3, aperture reducible to definite relative sizes by obsery- 


Specimen of Blood. 


ing notches seen on upper margin of square. 


measured off on the dried specimen of blood and the rela- 
tive numerical values of white and red corpuscles thereby 
ascertained. The instrument is constructed like an eye- 
piece, and may be fastened to the microscope in 
place of the eyepiece. A handle projects from one 
side of the instrument, and when this is moved the 
square aperture noted on looking through the eye- 
piece is seen to increase and decrease equally on 
all sides according to the direction in which the 
handle is turned. On the uppermost side of the 
square (see Fig. 598) three notches will be noted. 
When the handle is placed so that the square is at 
its greatest size the dimensions of this square will 
be just sixteen times that of the square formed 
when the first notch is covered. The second notch 
indicates a square four times as large as when the 
first notch is covered; the third notch indicates a 
square nine times as large; and the largest square, 
as stated, is sixteen times as large as the smallest. 

Thus by counting all the red cells in the first or 
smallest square of a number of fields, and all the 
white cells in the fourth or largest square (which 
is sixteen times as large as the smallest) of a num- 
ber of fields, and multiplying the number of red 
cells by sixteen, we get the ratio of red to white 
cells in a dried specimen. 

ALKALINITY OF THE BLoop.—Engel’s (Berliner 
klin. Woch., 1897) modification of the Lowy-Zuntz 
method for estimating the degree of alkalinity of 
the blood places the apparatus among those ap- 
plicable for this purpose in bedside examinations. 
It consists of the following (Fig. 599): 

1. A capillary pipette similar in construction to 
that used in the Thoma-Zeiss corpuscle-counting 
apparatus, but of somewhat larger size. The 
capillary portion is marked off into ten equal di- 
visions. The fifth mark indicates 0.025 c.em. and 
the tenth indicates 0.05 c.cm. 
tion is a mark that indicates 5 c.cm. 

2, A receiver and a stirrer made of glass. 


68 


Above the bulb por- Fic. 599.—Engel’s Apparatus for Determining at the Bedside the Degree of Al- 
kalinity of the Blood. 
quantities of blood; 2, burette for acid solution; 3, litmus paper; 4, re- 
ceiver and stirrer for diluted blood while titrating. 


+ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





3. A burette measuring 5 c.cm., and marked 1, 2, 3, 4, 
5 in equal divisions. 

4, Litmus paper. 

To Make the Test.—Blood from the ear (taken in the 
usual way) is drawn up to the 0.05 mark and distilled 
water to the 5.0 mark. These are mixed by carefully 
shaking the pipette, and then the mixer is blown out into 
the glass receiver. In the burette is placed a 7; normal 
tartaric acid solution. 

As stated elsewhere in this article, a normal solution in 
chemistry is the sum of the atomic weights of the chem- 
ical employed (in grams) in 1,000 c.c. of distilled water, 
The formula for tartaric acid is C,H.sO., and the sum of 
Cus Ones 8+ 6-+ 96 
a eee 
Therefore 75 gm. of tartaric acid in 1,000 c.c. of 
water would represent a 
normal tartaric acid solu- 
tion. Aj;normal solution, 
however, is all that is re- 
quired, which would be: 
1 gm. tartaric acid to 1 litre 
of distilled water. 

This solution is then al- 
lowed to drop from the 
burette into the receiver 
containing the diluted 
blood, which is stirred from 
time to time with the glass 
stirrer. Blue litmus is im- 
mersed from time to time, 
and directly this turns red, 
showing an acid reaction, 
the titration is at an end, 
and the amount of acid 
solution required to accom- 
plish this acid reaction (that 
is, the amount required 
to overcome the alkalies of the blood) is ascertained 


its atomic weights would be 


ra 
= 10, 










Seer 


eats 







Og 









soir OD, 


MSMHaGI AN ampere: 
atin 


1, Capillary pipette for taking and mixing definite 


Blood, 
_ Blood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


















































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Blood. 
Blood-Letting. 





by noting the level at which the liquid stands in the 
burette. 

There is no one alkali in the blood which we can hold 
responsible for its alkaline reaction. It is therefore 
necessary to measure this alkalinity by taking a known 
alkali, say NaHO, as the unit. By ascertaining the 
amount of aj; normal tartaric acid solution required to 
neutralize a known quantity of blood, and then ascertain- 
ing the amount of sodium hydrate ‘neutralized by this 
amount of a; tartaric acid solution, we learn in terms 
of NaHO the amount of tartaric acid required to neu- 
tralize a known quantity of blood. Things which are 
’ equal to the same are equal to one another. 

Thus by experiment we find that 0.5 c.cm. of 4 nor- 
mal tartaric acid solution neutralizes 0.05 c.cm. of blood; 
then 1,000 c.em. of 4; normal tartaric acid solution neu- 
tralizes 100 c.cm. of blood. 

Again, by experiment, we find that 75 gm. of tartaric 
acid neutralizes 40 gm. NaHO (28-+-1-+ 16 = 40). 1 gm. 
of tartaric acid neutralizes (as Ot 40) 588 mgm. of NaHO. 

Since 1,000 c.em. of 4 _ tartaric acid solution neutralizes 
100 c.cm. of blood, 100'c.cm. of blood has an alkalinity 
of 5383 mgm. of NaHO. 

0.5 c.em. of ~; normal tartaric acid solution neu- 
tralizes 0.05 c.cm. of blood. 1,000 c.cm. of -; normal 
tartaric acid solution neutralizes 100 c.cm. of plood. 75 
gm. of tartaric acid solution neutralizes 40 gm. of NaHO. 


C,H.O. = se ee 5 neutralizes NaHO = 23 + 


1+16 = 40. 

Then 1 gm. of tartaric acid solution neutralizes (75 
40) 0.5383 NaHO. 

This is the quantity of tartaric acid in the 7A, normal 
solution (1 gm. in 1,000 c.c. of water). This, therefore, 
is the value in alkalinity—so to speak, in terms of NaHO 
—of the tartaric acid solution employed. 

Now on titration it is found that from 9 to 10 drops of 
such a solution are required to neutralize 0.05 c.cm. of 
blood. 

10 drops equal 0.5 c.em., which equal 0.5 gm. 

0.5 gm. equals 0.266 NaHO. - 

Therefore 10 drops equal an alkalinity of 0.266 NaHO. 

1 drop = 0.0266 NaHO. 

It is perhaps better to bear in mind that 9 or 10 drops 
represent the normal, and to report examinations accord- 
ingly. For example, “6 drops required to neutralize,” 
“12 drops required to neutralize,” etc. It would also 
simplify the proceeding to use a solution of litmus in the 
blood solution instead of the papers. 

The Eyepiece Micrometer (Fig. 600) is of so simple con- 
struction and mechanism that its employment is to be 
recommended for more accurate clinical reports on the 
size of the blood corpuscles. 

The following explanation is taken from the Leitz ad- 
‘vertisement of the instrument: 

Micrometric Measurements.—The scale of the eyepiece 
micrometer is divided into 7; mm. Each of these divi- 
sions represents, according to the objective used, a cer- 
tain absolute linear measure of the object, as shown in 
the following table: 








Absolute length of Absolute length of 
Number | bject represented Number object represented 
of by one division of ra) by one division of 
objective. the eyepiece- objective. the eyepiece- 
micrometer scale. micrometer scale. 
Millimetres. Millimetres. 
1 0.054 ie 0.0026 
2 028 8 0020 
3 O15 9 0017 
4 012 Immersion + 0022 
5 0048 ia 3 ‘0018 
6 os Dad .0014 








When making micrometer measurements it is abso- 
lutely necessary accurately to maintain the tube length 
at 170mm. If this is neglected the measurements be- 
come unreliable or even worthless. 


70 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





The above micrometer values are measured with eye- 
piece II.; in the other eyepieces they differ in an inap- 
preciable degree. 

Example: Let a scale of Hipparchia Janira, as seen 
with objective 6, cover 54 divisions of the scale longitu- 
dinally and 20 divisions transversely. Its actual length 
will then be 54 x 0.0084 = 0.184 mm., and its breadth 20 
< 0.0034 = 0.068 mm. 

Suppose a valve of Pleuwr ostgma angulatum, meas- 
ured with objectives 4, 6, and 7, to cover 21, 74, and 98 
divisions respectively; then the measurements of its 
length represent the following absolute dimensions: 

Objective 4: 21 X 0.012 = 0.252 mm. 

¥ 6: 74 x 0.3004 = 0.252 “ 
vy 7: 98 x 0.0026 = 0.255 “ 

Tables of Magnifications.—The image seen in the micro- 
scope produces upon the eye the same effect as an object 
seen at the normal distance of distinct vision, 7.e., 10 
inches. 

If, therefore, a rule be placed at the foot of the micro- 








Fic. 600.—The Eyepiece Micrometer. 


scope at a distance of 10 inches from the eye, it can be 
compared w ith the microscopical image of a scale di- 
vided into zjy mm. The quotient is the magnification 
of the obicuaye and the eyepiece combined. 

If, é.g., 92 mm. of the rule are found to cover 4% of 
the image of the micrometer scale, it follows that the 
magni ion is #2 = 130. The tables of magnification 
have been compiled in this manner and are sufficiently 
accurate for practical purposes. 

Thus, supposing the same specimen of Pleurosigma 
angulatum to be measured— 

(1) with objective 7 and eyepiece 0, 
(2) with objective 4 and eyepiece IL., 
and supposing the length of its image to be 67 mm. in 
the first and 22 mm. in the second case, then, since the 
actual size of the object is found by dividing the length 
of the image, as seen at a distance of 10 inches from 
the eye, by the magnification of the objective and eye- 
piece combined, the length of our specimen of Plewrosig- 
ma angulatum is: 
(1) 38%, = 0.248 mm. 
(2) 22 = 0.244 mm. 


In all these measurements a tube length of 170 mm. 
must be strictly adhered to. 

(Notrr.—As this article goes to press I learn that Jolles’s 
ferrometer has undergone such simplification as to place 
it among those instruments useful for clinical work. 

The eyepiece spectroscope is also a valuable addition 
to our clinical apparatus. 

Both of these instruments are as yet untested) but 
their simple construction and application commend ‘them 
to the clinician. ) 





BIBLIOGRAPHY. 


As space does not permit of a long list being intro- 
duced, the reader is referred to the very full bibliograph- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Kiood, 
Blood-Letting, 





ical note in von Jaksch’s “Clinical Diagnosis” and to the 
writings of the observers who are quoted throughout 
the article. Charles N. B. Camac. 


BLOOD-LETTING.—This title includes all methods 
of abstracting blood for therapeutic purposes, whether 
they are for a general or fora local effect. The terms 
venesection and phlebotomy are restricted to bleeding from 
the larger veins, for the purpose of influencing the system 
generally ; whilst leeching, wet-cupping, and ‘scarifieation 
are means of abstracting blood from the capillaries, the 
‘effect of which is almost entirely local. 

General blood-letting, or venesection, is of very an- 
cient origin. References to it have been found in history 
prior to ‘the time of Hippocrates, and in the writings of 
this early authority it occupies an acknowledged posi- 
tion as a valuable therapeutic agent. During the many 
years that it has been employed it has been viewed with 
a varying degree of favor, and at times its advocates 
have employed it in all forms of disease and in a most 
extravagant manner. The seventeenth century and the 
early part of the present century mark the periods of 
its greatest use, during which excessive and repeated 
bleedings were constantly employed. The amounts of 
blood removed seem astounding at the present day. For 
a pleurisy 5,520 gm. were abstracted during a period of 
several days; in a case of pericarditis it was found 
necessary to abstract, on different occasions, 721, 720, 960, 
1,200, and then 1,440 gm. before the patient wae relieved ; 
and, in a case of inflammatory rheumatism, twenty 
pounds of blood were taken during the progress of the 
attack. In the early part of the century, medical opin- 
ion went to the other extreme; the practice fell into dis- 
repute and was almost entirely abandoned. During the 
last twenty-five years its use has been revived. Many 
of the older practitioners who had never forsaken its use 
have been more outspoken in advocating its therapeutic 
powers. At medical gatherings, many papers have been 
read and numerous discussions have followed, in which 
venesection has been very generally supported. Its em- 
ployment has now assumed a more rational character. 
The advance in our knowledge of physiology and a 
closer clinical observation have made clearer what its 
effects are upon the system, and we now employ it with 
a definite object in view and restrict its use to a much 
more narrow sphere. 

Venesection exercises what may be termed a mechan- 
ical effect upon the circulation, as well as a general effect 
upon the system. When a certain proportion of the 
blood is removed the tension of the blood-vessels is at 
once lessened, the degree depending upon the amount 
withdrawn. The effect is but temporary, as that which 
is lost is rapidly renewed; but, if any disturbance of the 
circulation exists, it is sufficient to allow the equilibrium 
to be regained, the heart beating more easily and the 
blood flowing more freely through the vessels. 

The general effect upon the system is of the utmost 
importance. Accompanying the lowering of blood 
pressure and loss of blood cells, there is a diminished 
activity of the various functions. The heart’s action is 
quieter, respiration goes on more slowly, tissue changes 
are less active, and there is a lowering of body heat. 
This depression is but temporary. Ina few hours there 
begins a renewal of the blood, tissue changes are ac- 
celerated, the nervous system is improved by a stimula- 
tion of the nerve centres, and general bodily improve- 
ment is the result. At the International Medical Con- 
gress for 1900, in the discussion upon this subject, M. A. 
Robin stated, as the result of many years’ observation, he 
was satisfied that after moderate bleeding of 150 to 250 
gm., polyuria is regularly observed, and the excretion 
of solids is increased. A greater amount of air is taken 
into the lungs, as much as sixty-one per cent., and the 
proportion of oxygen consumed by the tissues is corre- 
spondingly increased. When the bleedings are renewed 
the reaction is slower, and when they are frequently 
repeated, a state of anzmia ensues, with a tendency to 
degenerative changes. 











Inpicatrons.—The indications for bleeding may be 
summed up under three heads: (@) when there is exces- 
sive vascular tension; (2) when it is desired to obtain the 
benefit of its physiological action upon the various tissues 
and organs; (¢) when. it is believed that good may result 
from removing a definite amount of blood, and with it 
a certain proportion of toxic material, from the system. 

There is no difference of opinion as to the value of 
venesection in all conditions in which there is venous 
engorgement. It may be thought desirable to try the 
nitrites and allied drugs for the purpose of “bleeding 
into the arteries,” or to employ hydragogue cathartics 
or diuretics to unload the congested vessels; but if 
these measures fail, all are in favor of bleeding. The 
cause of the obstructed circulation may lie in the heart 
or in the pulmonary tissue. The effect of either of these 
causes is an overfilled and possibly a dilated right 
heart, distended veins, and more or less congestion of the 
various organs. In this condition the removal of blood 
from the venous system affords prompt relief. The 
laboring heart beats more freely, the arteries become 
filled, and the congested veins and organs return to the 
normal. The dyspneea disappears, the dusky hue of the 
skin fades, and the general condition of the patient is at 
once improved. Mitral disease, when compensation is 
failing, and a feeble heart that is suddenly overtaxed, 
are the two conditions that most frequently give rise to 
these distressing symptoms. In such cases, when the 
dilatation is extreme and the force of the heart very low, 
venesection must be prompt to be of service. Among 
these cases may be included many instances of cardiac 
failure that occur during the administration of a general 
anesthetic, when the dilated heart becomes suddenly 
overfilled and unable to empty its cavities. A sudden 
blow over the heart may suffice to cause a powerful con- 
traction, or the withdrawal of blood will relieve the 
pressure and allow regular contractions to be re-estab- 
lished. Of the pulmonary causes of venous congestion, 
emphysema is the most common, and in this condition 
marked benefit will follow the withdrawal of blood. 
Cases of bronchitis and those in which there isa tendency 
to pulmonary cedema afford favorable conditions for this 
treatment. 

Venesection is also of service when the arteries show a 
condition of increased tension, when the pulse is full and 
bounding, and when a condition of general plethora pre- 
vails. In these cases the relief afforded by the with- 
drawal of blood is also very marked, the reduced blood 
pressure relieving the congested organs and often pre- 
venting cerebral hemorrhage. In the convulsions of 
uremia, and especially in puerperal eclampsia, when 
there is the same arterial tension, the value of venesec- 
tion is unquestionable. The relief is immediate, and the 
severity of subsequent attacks is likely to be lessened. 
In puerperal states there should be no hesitation in re- 
sorting to it, if the arterial tension is abnormally high; 
and the fact that a free loss of blood has occurred dur- 
ing labor does not warrant the belief that venesection 
will be any less effective in relieving the tension. In 
these cases much of the benefit is due to the reduction 
of blood pressure, and much also may be explained by 
the favorable influence exerted on the tissue changes 
and by the increased oxidization. In addition, it is also 
suggested that the increased nutritive changes neutral- 
ize the poisons circulating in the blood and convert 
them into harmless products. 

It is difficult to determine to what extent the benefit 
should be ascribed to the actual removal of toxic mate- 
rial from the body (with the blood that is drawn off), 
yet we find that there are many eminent authorities who 
lay great stress upon this explanation. To increase the 
usefulness of the procedure in these toxic cases, it is 
recommended that the bleedings should be very free and 
that the blood lost should be replaced by normal saline 
solution, either administered subcutaneously or injected 
directly into the veins. 

The effect of venesection in lowering temperature and 
allaying the symptoms of inflammation would suggest 


71 


Blood-Letting. 
Blood Stains, 


the wisdom of employing it in the treatment of fevers 
and inflammatory diseases—a practice which was so 
much in vogue at the time when venesection was used 
empirically. This proposition, however, does not meet 
with favor. It is maintained that the relief afforded is 
but temporary, and that the tendency to fatty changes, 
present in pyrexia, is heightened by the repeated with- 
drawals of blood. The symptoms undoubtedly show 
marked improvement immediately after the operation, 
but the greater debility which results and the prolonged 
convalescence prevent its general acceptance. The only 
acute disease in which venesection receives much atten- 
tion is pneumonia. In addition to the benefits derived 
from the lessening of the plethora and the easing of the 
overworked heart, the lessening of the inflammatory 
process and the probable limiting of the extent of the 
consolidation must also be considered as results of 
some value. At all events numerous cases have been 
reported in which venesection has proved serviceable, 
and the subject is therefore worthy of every considera- 
tion. It is evident, however, that if any benefit is to be 
derived from this method of treatment it must be begun 
early before the pathological processes have made much 
advance. When it is resorted to at the outset, in a 
plethoric patient with stlenic symptoms, a full pulse, 
difficult respiration, pain, and fever, the operation acts 
most favorably, and there is every reason to believe that 
it renders the attack less severe. Frequently the vene- 
section is resorted to too late in the disease as a last re- 
sort, and although the distressing symptoms may be 
allayed for the moment, the 
ultimate result is rarely fa- 
vorable. 

METHOD OF PROCEDURE. 
—Formerly, blood was 
withdrawn from the veins 
of the arm, the external 
jugular, the veins beneath 
the tongue, the scrotal 
veins, and the veins of the 
leg; but at the present time 
a vein on the anterior sur- 
face of the forearm is the 
one chosen, unless some 
particular reason exists why 
another should be: selected. 
The veins in this region 
that become most promi- 
nent, when the circulation 
in them is arrested, are the 
median cephalic and the 
median basilic. The former 
is the proper one to select, 
as the median basilic is in 
close relation to the artery. 
The median cephalic is 
external to the tendon of 
; the biceps and away from 
oe g any region of danger. It 

2 will be found, however, 
that the size and promi- 
nence of the veins in front 
of the elbow vary great- 
ly, and generally the most 
marked one is selected re- 
gardless of its name or po- 
sition: 









SS 


(at 


sina 


res 





Fic. 601.—The Superficial Veins of 
the Forearm ; Skin Removed. a, 
Median cephalic; b, cephalic; c, 
brachial; e, basilic; f, median 
basilic; g, anterior ulna; d, me- 
dian nerve. 


tion strict antiseptic pre- 
cautions should be observed 
in the preparation of the site 
and in the selection of the 
knife and dressings. The 
arm is allowed to hang suspended and a firm bandage is 
applied above the elbow, sufficient force being employed 
to compress the superficial veins, and yet not enough to in- 
tercept the arterial flow. The vein is opened either longi- 
tudinally or in a direction slightly oblique to the axis of the 


72 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











In performing the opera- 


vessel, the point of the blade being inserted directly into 
the vessel and withdrawn with a downward cutting mo- 
tion. Before one makes the incision he should place the 
thumb of the left hand below the point of opening, in order 
to secure the vessel firmly. Care must also be observed 
that the skin is tense and in its proper relation to the 
vessel, otherwise the incision through the skin may not 
coincide with the opening 
into the vein, and instead of 
a free flow of blood there will 
be only an exudation of blood 
into the cellular tissue. As 
soon as the blood flows freely, 
the pulse of the other arm and 
the patient’s face should be 
kept under observation to de- 
termine the effect on the cir- 
culation and to detect any 
symptoms of syncope. 
Twenty, thirty, or even forty 
ounces should be removed, 
according to the condition 
and temperament of the pa- 
tient. The quantity taken 
should always be sufficient to 
make a decided impression 
upon the circulation. Fre- 
quently the amount with- 
drawn does not exceed a few 
ounces. This is too small a 
quantity to afford any bene- 
fit to the patient, and as a 
further result venesection is 
discredited. When sufficient 
blood has been removed the 
flow is readily checked by 
applying a compress over the 
incision, removing the con- 
stricting band, and bandag- 
ing the arm, which bandage may be removed in twenty- 
four hours. 

It is often desirable to abstract blood from some promi- 
nent part for the purpose of relieving a local hy perzemia 
or congestion, as in many bruises and ecchymoses, in dis- 
ease about the eye, nose, ear, gums, etc., and in some 
forms of cellulitis. Such local blood-letting is also oc- 
casionally employed to lessen the congestion of deep 
organs by withdrawing blood from the surface of the 
body near to the affected part. In all cases the biood 
flows from the capillaries or superficial vessels, and the 
quantity is very slight in comparison 
with that which is abstracted in general 
blood-letting. 'To accomplish this end, 
leeches, scarification, and wet-cupping 
are the means employed. 

LeEecuinc.—This means of locally ab- 
stracting blood is still frequently employ- 
ed, but not to such an extent as formerly. 
When any large amount of blood is re- 
quired, a number of leeches must be used. 
A single leech will absorb from two to 
three drachms of blood, and this may be 
increased as much more by warm fomen- 
tations applied after the leech has dropped 
off. The leeches may be placed in a wine 
glass which should then be inverted over 
the desired spot. If the area is very lim- 
ited, or if-the blood is to be withdrawn 
from the nasal cavity, gums, or any cav- 
ity, a leech: glass should always be util- 
ized. The leech will bite more freely if 
removed from the water an hour or more 
before needed, and for the same reason 
the part should be thoroughly cleansed. 
| When a leech shows no inclination to bite, 

ae rubbing the skin with sweetened water 
808 Gjace Will sometimes induce it to fasten upon 
pee se the spot. The peculiar bite of the leech 





Fig. 602.—Forearm with Liga- 
ture Applied. Finger at june- 
tion of median basilic and 
median cephalic veins. 




























































































REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


always leaves a permanent scar, and care must be ob- 
served in selecting a site which is not conspicuous. 

SCARIFICATION AND CuPPING.—By these means blood 
is abstracted through small superficial incisions into the 
skin, the flow being augmented by the cupping glass 
when that instrument is employed. 
The incisions may be made with an or- 
dinary knife or lancet, or by means of 
a scarificator. In the latter instrument 
the blades may be adjusted to any de- 
sired length so that the cutis vera of 
the part may be incised without pene- 
trating to the deeper tissues. The cup- 
ping glass may be one of those specially 
constructed for this purpose, or an or- 
dinary wine glass may be made to serve 
the same end. The cavity of the glass 
is heated over a spirit lamp, or by 
burning a small quantity of spirit in 
it, and then the glass is quickly invert- 
ed over the desired part and placed in 
such a way that the air will not enter. As the heated 
air cools its density is increased and suction force is ex- 
ercised upon the incised surface. The glass should be 
removed as soon as it ceases to act and a fresh one ap- 
plied. A cupping glass with a rubber bulb attached, on 
the principle of the ordinary breast pump, is also util- 
ized. 

Dry Cupprne.—Very. frequently cupping glasses are 
applied without an incision being made for the removal 
of blood. This is known ‘as “dry cupping.” The appli- 
cation of the glasses produces a rapid flow of blood to 
the part, and when repeated rapidly over a small area, 
the withdrawal of blood from organs lying below the 
surface is sufficient to relieve them if inflamed and con- 
gested. A single glass may be applied and quickly re- 
applied, but it is more satisfactory to employ a number 
of glasses and apply them at the same time. They are 
applied after the same manner as described for wet cup- 
ping. Dry cupping has the advantage of not making 
any incision and not causing any scar. The therapeutic 
action is somewhat different from that 
of wet cupping, as the counter-irrita- 
tion is much greater and more pro- 
longed. Junod’s boot isan instrument 
prepared on the same principle as that 
of the cupping-glass, its purpose being 
to withdraw blood from the body into 
one of the limbs, in order that relief 
may be afforded to congested organs 
without the permanent loss of any 
blood. It consists of a metallic vessel 
into which a limb may be placed and 
which closes so tightly that air cannot 
enter or escape, except by means of an 
exhausting syringe. As the air is with- 
drawn from the cavity, the blood flows 
into the vessels of the limb which be- 
comes greatly swollen and congested. This appliance 
has never met with much favor, as the constitutional 
effect is not very satisfactory and the local! action is often 
severe. Beaumont Small. 


BLOODROOT.—Saneuinaria. Red Puccoon. “The 
rhizome of Sanguinaria Canadensis L. (fam. Papaverace), 
collected in the autumn” (U.S. P.). Itis doubtful if this 
definition can be complied with, as the aerial portions die 
in early summer, and before fall all traces which would 
indicate the presence of the rhizome have disappeared. 
The plant is a low perennial, with a thick, fleshy, hori- 
zontal root-stock, from which one or two leaves anda 
single handsome white flower appear early in the spring, 
enclosed at the base by several sheathing scales. The 
leaves are kidney-shaped, variously lobed, and grow 
much larger and broader as the season goes on. The 
flower is about 3 cm. across (one and one-fourth inches), 
regular, perfect, spreading; sepals two, falling early: 
petals from six to twelve, rather narrow; stamens nu- 





Fic. 604.—The Scar- 
ificator. 





Fic. 605.—Cupping 
Glass, with Elas- 
tic Rubber Cap or 
Bulb. 





Blood-Letting. 
Blood Stains, 


merous, ovary and capsule one-celled, with two placente ; 
ovules (and seeds) numerous, with prominent caruncles. 
An opaque, orange-colored juice is found in all parts of 
the plant, especially in the rhizome, where it is very 
abundant and dark. Bloodroot is a native of North 
America, and is occasionally cultivated as an ornamental 
plant both here and in Europe. The dried rhizome is 
about 5 cm. (two inches) long, and 1 cm. in diameter, 
slightly flattened, indistinctly annulated, and evidently 
shrunken and wrinkled. It is reddish brown externally, 
variously bent and twisted, and now and then branched. 
It breaks with a short fracture, and displays a pink sur- 
face, finely dotted with 

dull red points; this 

surface becomes dark 

by exposure, and final- 

ly is uniformly brown- 

ish red. Odor slight, 

disagreeable. Taste 

bitter, acrid, nauseous, 

and persistent. Pow- 

der sternutatory. 

The principal con- 
stituent is the alkaloid 
sanguinarine (CaoHis 
NO,), discovered and 
named by Dana in 
1829. When pure it 
is in white crystalline 
needles or tufts, insol- 
uble in water, but eas- 
ily dissolved by alco- 
hol, ether, oils, ete. ; it 
forms with the princi- 
pal acids beautiful , 
salts of brilliant orange 
or red color. The pow- 
der excites violent 
sneezing. Its _ taste, 
when dissolved, is that j=) 
of the rhizome inten- yee 
sified. _Chelerythrine ‘ 
(CoiHi7zNO,) exists in 
smaller amounts and 
yields yellow salts. 
Small amounts of at 
least two other alkaloids exist, with irritant resin, starch, 
citric and malic acids. 

Action.—The several alkaloids of bloodroot have very 
dissimilar actions when used separately, but that of 
sanguinarine is overpowering and determines that of the 
drug. It is amost powerful irritant, locally and system- 
ically. It was formerly used as a caustic for morbid 
growths, and has had many uses as a counter-irritant. 
It is powerfully irritant to the mucous membranes, and 
sialagogue. It is a powerful and even fatal emetic and 
cathartic. Systemically, it irritates both the spinal and 
cerebral centres, producing tetanic convulsions and in- 
toxication or violent delirium. It depresses muscular 
fibre, and this at length greatly depresses both the circu- 
lation and the respiration. 

These properties can be utilized, by small doses, in im- 
proving both appetite and digestion, and in producing 
expectorant effects, the latter either by internal adminis- 
tration, or by inhalation of very.weak preparations, or by 
application to the throat. It was formerly a much-used 
emetic in doses of gr. xv. to Ix., but this use is now 
considered barbarous. It is very little used at the pres- 
ent time, and then chiefly as an expectorant, in doses of 
0.2 to 0.5 gm. (gr. iij. to viij). Its excretion is accom- 
panied by stimulation of intestinal and renal secretion 
and of peristalsis. It is also a stimulating emmenagogue. 
A fluid extract and a fifteen per cent. tincture, each con- 
taining a little acetic acid, are official HAH. H. Rusby. 


BLOOD STAINS.—In criminal trials the medical wit- 
ness is often called to determine whether stains found on 
weapons—as knives, clubs, or daggers—or upon the 





Fic. 606.—Bloodroot. 


73 


Blood Stains, 
Blood Stains, 





clothing of a suspected person, or upon the floor, walls, 
or ground where a homicide is supposed to have been 
committed, were caused by blood or by some other 
coloring matter. So also it is often equally important to 
determine whether stains acknowledged to be blood are 
the blood of a human being or that of one of the lower 
animals. The object of this article is to show how, and 
to what extent, these important questions may be an- 
swered. Such investigations have often served to con- 
vict the guilty, and in other cases triumphantly to acquit 
the innocent. 

The examination of blood stains éalls for the considera- 
tion of: (1) physical characteristics; (2) chemical reac- 
tions; (8) crystalline properties; (4) optical properties; 
and (5) microscopical appearances of blood corpuscles 
and other constituents of blood. 

1. PuystcAL APPEARANCE OF BLoopD Srains.—The 
color of blood stains varies with the amount of serum 
and the absorbent properties of the object upon which 
the stain dries. Generally the more permeable the tissue 
or object stained, the brighter is the color after blood has 
dried upon it. 

Upon polished steel or other metal, blood dries in dark 
brown, shiny scales, however thin the blood may be. 
Upon silk or glass it assumes about the same color as 
upon polished metal. Upon varnished or very hard 
wood, blood stains have also a dark shining surface. Put 
upon soft porous wood, or any soft. tissue, as cotton cloth, 
the blood displays a dull brown color or a rose tint, yet 
even on cloth a thick clot, when dry, presents a brown 
but glistening surface. 

It sometimes happens that upon tissues or objects of 
a brown, maroon, or dark blue color, blood stains are 
quite invisible by full daylight, but they become con- 
spicuous by artificial light, especially if examined by 
light obliquely reflected. This is especially the case 
with dark-colored furniture, wallpaper, or any dark paint, 
on which blood stains easily seen by the light of a candle 
are quite invisible by daylight. 

Stains upon steel or other metallic instruments, if 
quickly dried by exposure to the air, are cracked and of 
a fine red color; but stains on similar instruments, kept 
in a damp situation, are of a dirty brown, tending toward 
a yellow rusty color, surrounded with an ochrey areola, 
yielding no color or albumen in water; even a solution 
of potash extracts only a small quantity of albumen. 

Upon glass, marble, plaster, flint, sandstone, and earth, 
blood stains preserve their ordinary characteristics; but 
upon wood containing tannin they form with the tannin 
an insoluble compound, and water in which such stains 
are macerated fails to yield characteristics of blood. In 
such cases the surface can sometimes be scraped off and 
tested free from the tannin. 

On felt and some kinds of cloth, blood forms shiny 
spots appearing like mucilage. In examining garments, 
searching for blood stains, a small magnifying glass is of 
great service in distinguishing small specks or drops of 
blood. 

2. CHEMICAL REACTIONS.—(a@) Guaiacum Test for Blood. 
—If any red substance is suspected to be blood, place a 
drop on white paper; or if dry, moisten with water and 
then place it on the paper. Let fall upon the stain thus 
formed a drop of tincture of guaiacum. If the stain 
turns blue with no other treatment it is not blood; or if it 
contains blood it also contains starch, a salt of iron, or 
some other foreign substance. If it does not turn blue 
by the action of the guaiacum, drop upon it a watery 
solution of hydrogen dioxide, when, if it is blood, it will 
quickly assume a beautiful sapphire blue color. A par- 
ticle of blood scarcely visible to the naked eye may be 
detected by this test. If the blue color does not quickly 
appear by this test it is not blood. If the stain gives the 
blue color by this test it may be blood; and other tests 
may be applied to determine with certainty that it is. 
The white paper should be tested with guaiacum and 
dioxide before the stain is applied. 

(6) Action of Solvents and Other Reagents.—Stains upon 
cloth may be cut out and suspended in a test tube con- 


74 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 














taining distilled water. The bottom of the cloth should 
dip into the water, but the stain should not touch the 
sides of the tube. Under these circumstances the color- 
ing matter of blood will usually detach itself from the 
tissue and fall in reddish striz to the bottom of the tube. 

When a solution of blood is heated the color disappears, 
but vegetable colors in general are unchanged by heat. 
A solution of blood is made a little darker by the addition 
of a small quantity of ammonia, but the color is not de- 
stroyed. The red, pink, or scarlet infusion of fruit or 
flowers or roots and the juices of fruits are changed to 
green or violet by ammonia, and cochineal is changed to 
crimson. Hypochlorous acid quickly destroys all organic 
coloring matter except blood, which withstands the acid 
much longer. ‘Two minutes are sufficient to destroy 
most colors except that of blood. Stains of colcothar and 
grease and those of rust resist for a long time the action 
of hypochlorous acid, but disappear instantly on contact 
with chloride of tin, which does not act upon the color- 
ing matter of blood. Carbon mixed with the colored 
fluid cannot be readily discolored by any reagent. 

If the stains are upon weapons, from which it is im- 
possible to detach a superficial layer, they may be moist- 
ened with drops of water. If they are upon wood, 
plastered wall, or stone, we may scrape the surface and 
test the materialremoved. If upon the point of a dagger 
or other narrow blade, this material may be placed in a 
tall, narrow vessel. In general, if the material of the 
stain can be scraped off, the fine powder thus obtained 
may be treated with a minute portion of fluid in a test 
tube, watch glass, or on a concave slide or cover glass, 
such as is used with the microscope. The method of 
dealing with minute specks, when these are all that can 
be obtained from a stain, will be described further on. 
If the powder obtained is abundant and contains foreign 
matter, it may be placed in a small gauze bag and sus- 
pended in a test tube as described above. If the stains 
are spread in streaks on the surface of the instrument, a 
plate of glass may be adjusted on a perfect level, and a 
few drops of distilled water placed on the glass; then the 
instrument should be so arranged that the stain touches 
the water while the instrument does not touch the glass. 
After one or two hours the water will be colored by the 
stain; but whatever process we employ, it is important to 
avoid contact of the water with the steel or iron so as to 
form rust. In all cases only a small quantity of water 
should be used, and if the liquid contains much foreign 
matter it should be filtered before using reagents. 

3. CRYSTALLINE PROPERTIES.—Crystals characteristic 
of blood were discovered by Teichmann, and great im- 
portance is attached to this test. To obtain hemin crys- 
tals, digest the stained tissues, or the powder obtained 
from the stain, ina one-fourth-per-cent. solution of com- 
mon salt for twenty-four hours, next allow the fluid to 
dry on a glass slide at a temperature of 80° or 100° F., and 
then apply a drop of glacial acetic acid, heating it over the 
flame ofalamp. As the fluid evaporates a great number 
of crystals appear, in the form of rhomboidal plates with 
angles of 55° and 125°, of yellow, red, or brown color, de- 


pending on the thickness of the crystalline plates. In the 
dog and in man they are long parallelograms. In the 


squirrel they are hexagonal plates; and in the guinea-pig 
they are in the form of tetrahedral crystals. The length 
of the crystals from human blood is from one and one- 
half to three times the breadth. They are generally very 
small, and if obtained from minute stains their obtuse 
angles are somewhat rounded, as are the crystals of uric 
acid found in the brick-dust sediments of urine. 

The microchemical examination of stains to produce 
hemic crystals, or crystals of hematin, or Teichmann 
crystals, when only minute stains are to be examined, is 
so important that we deem it desirable to give the fol- 
lowing directions, which we have translated from “ Précis 
de médecine légale,” by Ch. Vibbert: 

“The Teichmann crystals are so characteristic that 
when once seen they are ever afterward easily recognized. 
The operations for obtaining them are exceedingly simple. 
but require great care and patience. To avoid failure, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


persons but little accustomed to these minute investiga- 
tions should follow carefully the methods here described, 
especially if, as often happens, only minute portions of 
the suspected material are available for these researches. 

“(a) Solution of the Stain.—lf the stain is small and 
no speck or clot that may be removed can be seen, cut out 
the stain, following the edges of it, witha pair of scissors; 
place the stained piece of cloth on a glass slide, and put 











Fic. 607.—Hzemin Crystals. 


on it a few drops of water—just enough to moisten it, for 
it is better to get a solution somewhat concentrated. 
After macerating till the liquid is considerably colored, 
press Out the liquid with a scalpel or needle, and remove 
the cloth, leaving the colored fluid on the slide. Avoid 
spreading the liquid, but dry it slowly, so that it shall 
make a small, deeply colored spot on the glass: not en- 
tirely opaque but somewhat transparent, so that the 
preparation can be examined with the microscope. 

“Tf the stains are very small, several may be taken and 
macerated together to obtain sufficient coloring matter 
for the subsequent manipulations. If the stain is on 
wood, a thin layer of the wood may be removed by a sharp 
knife or lancet, and treated as directed for a fragment of 
cloth; only the maceration should be continued much 
longer. 

“Tf it is not possible to lift the stain from the object, 
a ring of wax may be formed around it, making an in- 
closure that will hold a little water, which is then ap- 
plied to absorb the stain. When the water has absorbed 
the coloring matter, it may be transferred to the slide by 
means of a pipette. 

“(b) Hvaporation of the Liquid.—We may allow the 
liquid to evaporate spontaneously, but the evaporation 
can ‘be hastened by the employment of heat, it being 
necessary, however, to heat the liquid very moderately, 
not exceeding a temperature of 60° C. (140° F.); for 
if the heat is sufficient to coagulate albumen, it prevents 
the extraction of the coloring matter, and of course 
no crystals will be obtained. We generally warm the 
slide over the flame of an alcohol lamp, being careful 
that the temperature does not exceed that which is not 
uncomfortable when the slide is laid upon the back of 
the hand. It is important to heat the liquid around the 
borders and not in the centre, so as to prevent its spread- 
ing over the slide, which would much interfere with sub- 
sequent operations. ; ‘ 

“(c) Action of Reagents.—To the evaporated residue a 
little common salt should be added. Too much is in- 
jurious. It is better to make a solution of 1 part of 
chloride of sodium to 500 or 1,000 parts of distilled water, 
and add one or two drops of this solution. Jt 7s more 
convenient to use this solution in the first place for dssolv- 
ing the stain, instead of using simple distilled water. It 
saves time and nothing is changed. Sometimes crystals 


Blood Stains, 
Blood Stains, 





can be obtained by treatment with acetic acid without 
the addition of salt, there being sufficient chloride of 
sodium in the blood; but it is better to add the salt than 
risk a failure in an important case. 

“At whatever stage the process the chloride of sodium 
has been added, the preparation must be thoroughly dried 
afterward before the acetic acid is applied. This acetic 
acid monohydrate is called glacial or crystallizable. It 
solidifies at the freezing point, or zero Centigrade, and 
does not again liquefy until the temperature is raised to 
17°C. The addition of a small quantity of water trans- 
forms it into acid hydrate, which interferes with this re- 
action. 

“Place a drop of acetic acid monohydrate on the 
preparation and evaporate with heat, which may be in- 
creased and continued, though the evaporation will be 
more successful if the heat does not quite reach the boil- 
ing point. When there is only a small quantity of the 
suspected material, it is especially important to use all 
these precautions. The acid should be taken up with a 
tube drawn out to a fine point, so that only a very small 
drop may be added at a time; place the droplet in the 
centre of the red deposit on the slide, and allow it to 
spread a little, but not to spread beyond the limit of the 
stain; for this purpose the heat of the lamp should be ap- 
plied around the borders at various points, tipping the 
slide as may be necessary to retain the fluid on the red de- 
posit only; a red line is thus formed about the borders 
when the coloring matter becomes thickened, and the acid 
remains on the stain till evaporation is completed. It is 
on this border that the crystals are commonly formed, and 
they are to be looked for by aid of the microscope. 

“It is not common to find crystals after adding only a 
single drop of acid, but it is generally necessary to add 
drop after drop, evaporating each with the greatest care, 
examining the specimen from time to time where the 
red lines are formed one after the other as it is repeatedly 
treated with acid and dried. When this experiment is 
performed under favorable conditions, a multitude of 
distinct crystals are found. Often, however, we find 
only irregular masses of brown or dark coloring matter, 
and the remainder of the preparation filled with coagu- 
lated albumen and foreign bodies which have become 
mixed with the stain. If we have added solid particles 
of chloride of sodium to the coloring matter, we are apt 
to find crystals of this salt formed in cubes, in stars, or in 
small, colorless globules, and even lance-shaped crystals 
of acetate of sodium may be formed. All of these crys- 
tals, arranged together in beautiful forms, may often be 
found. 

“In such cases, we select a point where the coloring 
matter is collected in considerable quantity, and there 
apply another small drop of acid and let it evaporate as 
before. By repeating this operation we sometimes obtain 
a large collection of very small crystals mingled with 
other matter; but when we find crystals in the form of a 
cross or a star, it is very certain that they are chloro- 
hydrate of hxematin, and we may perfect the preparation 
by the addition of small drops of acetic acid. 

“Tf doubt still remains in regard to the nature of the 
crystals, the specimen should be examined by the aid of 
polarized light. The albuminous or saline substances 
allow the field to remain dark, but the crystals of hematin 
appear bright on a dark field. 

“By carefully following the precautions stated above, 
one can almost always obtain crystals of hematin, even 
with a very minute quantity of blood. The reaction is 
successful with very old stains. Many experts have ob- 
tained crystals of hematin from stains of blood ten, 
fifteen, and even forty years old. It sometimes happens, 
however, that it is impossible to obtain crystals when 
the stains are only a few months old. This is especially 
the case when the blood has been allowed to putrefy be- 
foredrying. Contact with perspiration, grease, or tannin 
also seems to interfere with the formation of crystals. 

“Two sources of error are to be noticed in connection 
with this test for blood. Crystals of murexide (purpurate 
of ammonia) have a form very similar to that of crystals 


75 


Blood Stains, 
Blood Stains, 





of hematin, but they are of a bright red, and they ac- 
quire a violet color by contact with a solution of potash; 
again, itis very difficult to imagine how it can be possible 
to obtain crystals of murexide by treating a stain with 
common salt and acetic acid. A mistake may easily 
occur with crystals formed with indigo. Cloth colored 
with this material will sometimes furnish a deposit of 
crystals which will not dissolve in acetic acid and which 
have a form very similar to that of crystals of hematin. 
Their color is blue, it is true, but when the color is very 
deep it can scarcely be distinguished from brown. Des- 
coust, by simply washing with water a piece of flannel 
of blue violet color, obtained crystals having almost ex- 
actly the form and reddish-yellow color of crystals of 
hematin. This isa more serious source of error than 
is generally admitted in books on legal medicine. 

“When a stain to be examined is found on clothing 
colored with indigo, it is important before examining the 
stain itself to examine pieces of the garment which are 
not stained, to see whether they will deposit crystals of 
indigo. The comparison between these crystals and 
those obtained from the stain may remove all uncertainty . 
if, for example, the crystals obtained from the stain are 
very numerous, while those obtained from the unstained 
cloth are very few and of a blue color. If the similarity 
of the two species of crystals is very close we may try 
the guaiacum test. The crystals of hematin will color 
the guaiacum blue, while those of the indigo will have no 
effect upon it. 

“When the crystals of hematin have been obtained 
they may be indefinitely preserved by adding a little 
glycerin and covering the preparation with thin glass. 
The expert should carefully preserve the preparation, to 
serve as a proof of the correctness of his conclusion.” 

4, SPECTRUM ANALYSIS OF BLoop Starns.—One of the 
most important methods of distinguishing solutions of 
blood stains from those of other colored fluids is by the 
use of the spectroscope. The peculiar spectra produced 
by the passage of light through solutions of blood were 
noticed by Hoppe in 1862, and were suggested by him as 
a means of medico-legal research. Stokes, in 1864, and 
Sorby, Lethby, MacMunn, and others have added largely 
to our knowledge of this subject. 

The coloring matter of fresh blood is known as heemo- 
globin, and, according to Preyer, it contains nearly all 
the iron of the blood. By the action of reagents, such 
as acetic, tartaric, and citric acids, the bright red of fresh 
blood becomes changed to brownish red, known as heema- 
tin. This is a permanent chemical change. The same 
change of hemoglobin into hematin takes place when 
blood has been kept for a long time. ‘The fresh blood 
stain is bright red (hemoglobin); the old stain is brown 
(hematin). Hemoglobin and hematin are each capable 
of existing in two states of oxidation, each state produc- 
ing in the spectrum its own characteristic absorption 
bands. If a blood stain is kept in a damp place the 
hemoglobin is rapidly changed into hematin, or both 
hemoglobin and hematin may be decomposed. But if 
the stain is kept dry, it becomes in time of a brown color, 
This change is hastened if the stain is exposed to a strong 
light. This brown coloring matter is methemoglobin, 
which Sorby regards as peroxidized hemoglobin. This 
alteration is much more rapid in an atmosphere contain- 
ing coal gas, or a trace of sulphurous or any other weak 
acid. The change is also very rapid when a stained 
garment is worn next the skin, as the acid perspiration 
hastens the change. If the color of a blood stain be a 
bright red it is evident that it isrecent, but if it be brown 
it is not necessarily an old stain. When fresh blood, or 
a solution from a recent stain, is placed before the slit of 
a spectroscope, two dark absorption bands are seen be- 
tween the Fraunhofer lines D and E, the line near D be- 
ing darker, narrower, and more sharply defined than the 
other (Sp. 1-1, Fig. 609). Ifthe strength of the solution 
is increased the bands grow wider and the orange and 
blue are gradually obliterated. Ifthe strength of the 
solution is diminished the line near E first fades away 
and then the line near D also soon disappears. If the stain 


76 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


has been changed to brown by the action of the air the 
coloring matter becomes peroxidized, and the solution 
then gives a single band between the positions of the two 
above described (Sp. 2-2, Fig. 609). The coloring mat- 
ter giving the single band is known as methemoglobin. 
Alkaline Hematin.—Make a saturated solution of car- 
bonate of potash in alcohol and pour a few drops of 
blood or solution from a recent stain into the solution. 
The color immediately changes, and when examined in 
the spectroscope a broad, lightly shaded band is seen 
covering Fraunhofer’s line D. Caustic potash and caus- 
tic soda in alcohol when added to blood give the same 
spectrum, but different from that produced by aqua 
ammonize or by carbonate of potash. It consists of 
three bands, one in the red, the other two like the bands 
produced by fresh blood. In the addition of a reducing 
agent the spectrum of reduced hematin appears, con- 





FIG. 608.—s 8, Solar spectrum; b b, human blood spectrum; d d, 
didymium spectrum; ¢ c, carmine spectrum; p p, potassium: 
permanganate, 


sisting of two bands similar to the bands of fresh blood, 
but removed farther from D toward the blue part of the 
spectrum, 

In Fig. 608 are shown at s-s the Fraunhofer lines of 
the solar spectrum. Below are shown the spectra of dif- 
ferent colored fluids: J-b, human blood; d-d, nitrate of 
didymium, of a faint pink color, in solution with lines 
similar to those of blood but easily distinguished from 
them; c-c, carmine solution, and p-p, tue spectrum of a 
solution of permanganate of potash with three dense lines 
and one very faint inthe red. All the spectra were pho- 
tographed on the same scale. All the fluids were illumi- 
nated by the electric light, and the right half of the 
spectra shows carbon and other lines produced by the 
flame of the carbon electrodes. Many more might be 
presented, but these specimens are given to illustrate the 
marked distinction, as shown by the spectroscope, be- 
ween blood and other colored fluids. 

Instruments for Spectrum Analysis of Blood Stains.—As 
the absorption bands produced by colored fluids are 
broad and not very sharply defined, an instrument of 
much less dispersive power than that used for colored 
flames is required. The microspectroscope made by R. 
and J. Beck, to be attached to the microscope instead of 
the objective, is very useful when the quantity of colored 
matter is considerable, as it allows the use of the mi- 
crometers in the eyepiece of the microscope to mark the 


Blood Stains, 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Blood Stains. 
G 
VITALI HOHAA Om Oe OO It 













































































“eth aye panels Eevb 





HH | 
Meee ||| Ws) 2. 








aa ge ee aS ae = bee 
c- S BEE aes ess 
ip FP /ATPPertinenl FPPerFPPrl nnnnTno PO PPP Pom tn OP 700 
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a Fig. 609.—Spectometry of Blood. 


17 


Blood Stains. 
Blood Stains. 





position of absorption bands. When the quantity of 
coloring matter is small, ora mere speck of clot moistened 
on the slide is to be examined and tested, the objective, 
as low a power as practicable, is to be retained in the 
microscope and a microspectroscope inserted instead of 
the eyepiece. The Sorby-Browning microspectroscope 
in place of the eyepiece has been used for this purpose, 
but with this instrument it is very difficult to get the light 
from the clot centred in the slit of the spectroscope. 

The microspectroscope made by Zeiss, of Jena, is in- 
serted in the microscope in place of the ordinary eyepiece, 
and the direct vision prism can be turned to one side and 
by opening the slit the object on the stage of the micro- 
scope can be found and focussed; then when the prism is 
replaced the absorption bands are seen. It has also a 
side stage where a comparison specimen of blood or other 
fluid can be placed and its absorption bands compared 
with those of the object on the stage. It also has a 
micrometer scale illuminated by a side light by which 
the positions of the bands can be measured and records 
made, asillustrated in Fig. 609, M, 8. ‘With such a micro- 
spectroscope, under favorable circumstances, the absorp- 
tion bands can be seen in a single corpuscle of perfectly 
fresh blood, but not in a single corpuscle from a dried 
stain. But the bands can often be clearly seen in a speck 
of clot zi> or even 755 Of an inch in diameter when 
moistened with normal salt solution or with glycerin 
water. In the spectrum analysis of blood stains, careful 
comparison with known solutions of blood treated in the 
same manner may be made by placing the known solu- 
tion before the comparison prism, as in the Zeiss instru- 
ment, when any variation between the spectra placed 
side by side can be readily determined. 

For recording observations and results obtained it is im- 
portant to determine the wave length of the centre of 
every absorption band, noting the conditions and treat- 
ment of the stain by which it was obtained. To obtain 
wave lengths, each microspectroscope must have a 
micrometer of its own, with a scale of wave lengths 
carefully adjusted to the prisms and lenses used. Such 
tables and scales are shown in Fig. 609. Spectrum S-S 
shows the positions of the principal Fraunhofer lines of 
the solar spectrum. All the spectra in this figure or 
plate are drawn to the same scale, and the line D-D, 
from the top to the bottom of the page, is used as a start- 
ing point from which measurements are made and by 
which the position of the micrometer is adjusted. The 
didymium line, 6, in Sp. 10-10, is used in the same 
manner for fixing the position of the scale when artificial 
light is employed. 

The micrometer measurements may be reduced to 
wave lengths by means of an interpolation curve, shown 
at B, C, D, E, 6, F, G, constructed as follows: At the 
right hand is a scale of equal parts, numbered from 460 
to 700. These numbers represent in millionths of a 
millimetre the length of all the waves of light which 
require to be considered in the analysis of blood stains. 
Across vertical lines, drawn through the Fraunhofer 
lines in the spectra 8 8, 8 8, horizontal lines are drawn 
from the scale at the right side of the plate at positions 
corresponding with the known wave lengths of the 
Fraunhofer lines. 

a = 718.5 C = 656.2 E = 526.9 F = 486.0 

B= 68644 D= 5892 b = 517.2 G = 430.7 

Through these points of intersection of the vertical 
and horizontal lines the curve B F is drawn. Then from 
points in this curve opposite to the numbers 460, 470 to 
700, vertical lines are drawn, and these enable us to draw 
the scale W L, which serves to determine the wave length 
of any band measured by the micrometer M 8. 

The position of absorption bands thus determined may 
be recorded, and at any future time compared with the 
records of other observers. 

In Fig. 609, Sp. 1-1, at @ and }, are shown the ab- 
sorption bands of normal blood drawn in their relations 
to the Fraunhofer lines as seen in the Sp. S-S, and their 
true positions on the scale of wave lengths, W L. The 
band 2 is seen to be broader and paler than the band a. 


78 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











In Sp. 8-8 are shown the absorption bands of an am- 
moniacal solution of carmine, where @ is shown to be 
paler than >, and also that > has a wave length 517 at its 
centre, while the band 4 in the spectrum of blood 1-1, 3, 
has the wave length 588.* 

The Sp. 9-9 shows the positions of the five bands in a 
solution of permanganate of potassa. In Sp. 5-5 the 
bands @ 6 ¢ are produced by a solution of alkanet, where 
the band a is almost exactly like a in tne blood spectrum 
1-1, but 4 and c are different. If a little alum is added 
to the solution.of alkanet, the band d appears, while a } 
and ¢ remain unchanged; if alum is added to a solution 
of blood, both the bands disappear. At a, in Sp. 2-2, 
Fig. 609, is shown the band of reduced hemoglobin pro- 
duced when hydrosulphate of ammonia is added to a 
solution of normal blood. 

Other reducing agents produce the same effect. One 
of the best is made by dissolving equal parts of tartaric 
acid and double sulphate of iron and ammonia, and then 
adding a little aqua ammoniz. 

An ammoniacal solution of tartrate of protoxide of tin 
may be usedasareducing agent. It is prepared by add- 
ing tartaric acid to an aqueous solution of the protochlo- 
ride of tin, and neutralizing the solution with ammonia. 
The acid should be added in such quantity that after 
over-saturation by ammonia no precipitate is formed, 
but a clear solution remains. 

Sulphide of sodium is highly recommended by Preyer 
as a reducing agent. Dr. Beale recommends, as a de- 
oxidizing solution, protosulphate of iron, with sufficient 
tartaric acid added to prevent precipitation by alkalies. 
A small quantity of this solution, made slightly alkaline 
by ammonia or carbonate of soda, is to be added toa 
weak solution of blood in water. 

Ata, in Sp. 3-3, is shown the band peculiar to acid 
hematin, wave length 640. 

At a, in Sp. 44, is the band of alkaline hematin, 
wave length 605. 

At a, Sp. 6-6, is shown the absorption band of a solu- 
tion of fuchsin, wave length 548. 

Ata, Sp. 7-7, is the band produced by a solution of 
eosin, wave length 517. All absorption bands vary in 
intensity and in breadth as the strength of the solution 
varies, but the centre of the band remains stationary. 

At abe, in Sp. 10, are shown a series of beautiful 
bands produced by a solution of sulphate of didymium. 

This remarkable substance, of a faint pink hue, in 
solution almost as colorless as water, gives a broad ab- 
sorption band a, central ata wave length of 575 millionths 
of a mil'imetre, extending from 571.5 to 578. The line 
bis very sharply defined at wave length 523 of the same 
scale. This substance serves as an index to fix the posi- 
tion of the micrometer scale when using artificial light. 

Besides the substances mentioned above, some other 
red solutions give absorption bands somewhat similar to 
that of blood, but with careful manipulation and ap- 
propriate tests they may be certainly distinguished from 
blood. The coloring matter of the petals of the red 
variety of Cineraria, a variety of chlorophyll, gives two 
bands somewhat like that of blood, but the micrometer 
readily shows that they occupy different positions on the 
scaleof wave lengths. Add ammonia, and the blood 
bands remain unchanged, while those of the Cineraria 
solution are altered or completely destroyed. 

A solution of cochineal in alum: gives the bands a 3, 
Sp. 8-8, Fig. 609, differing little from those of fresh 
blood. Add ammonia, and in both solutions the bands 
become more intense. Now add excess of boric acid; 
in the solution of cochineal the bands shift toward the 
blue end of the spectrum, while in that of blood they 
remain unchanged. 

The other reds likely to be confounded by the un- 
practised eye with blood are lac-dye, alkanet, madder red, 
and munjeet, dissolved in each case in alum. 

But if the spectra be carefully examined side by side 
with blood, or their wave lengths determined on the scale 


* The scale of wave lengths are in millionths of a millimetre. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood Stains, 
Blood Stains, 





by their positions seen on the micrometer, it will be ap- 
parent that the bands produced by these bodies are not 
the same, either in position orin character. Further, none 
of them will stand the action of ammonia, while they 
are all bleached with sulphite of potash, which has no 
action on blood. In the examination of a mixture of 
magenta and blood, the magenta bands may entirely mask 
those produced by blood. The various blood spectra 
may, however, be easily obtained unmixed by adding 
to the solution a trace of sulphite of soda, which com- 
pletely removes the magenta coloring matter, but leaves 
the blood untouched. 

All the supposed fallacies disappear if we successively 
obtain the various blood spectra with the reagents al- 
ready described. 

Examination of a Recent, or Comparatively Recent, 
Blood Stain on a White Fabric.—(1) If you can detach a 
portion of the blood, do so; but if this is impossible, cut 
out a small piece of the stained fabric, and soak it for 
about ten minutes in a few drops of cold distilled water 
in a watch glass. Then squeeze the colored fluid out 
and set it aside for a short time, so that any insoluble 
matters may be deposited. Provide a glass cell about 
one-eighth of an inch in diameter and half an inch high, 
which may be made of a section of barometer tubing 
cemented to a slide with gutta-percha, with a diaphragm 
of tin foil between the slide and the end of the tube. 
With a fine drawn pipette introduce the red fluid into 
this cell, and place it on the stage of the microscope with 
an objective of low power, and illuminate with sunlight 
or other strong light, when, with the microspectroscope 
in place of the eyepiece, if the solution is blood the 
characteristic absorption bands will readily be seen. If 
there is a sufficient quantity of the solution, several tubes 
may be filled. If the tube contains any sediment, it may 
be laid to one side until the solution is clear. The ob- 
jective should be focussed near the top of the tube, a 
little below the surface of the fluid. If the blood is 
tolerably recent, the spectrum of oxidized hemoglobin 
with its two well-defined absorption bands in the green 
will be apparent, as shown in Fig. 609, Sp. 1-1. If such 
a spectrum is obtained, it is evident that it has been 
very little changed by exposure, and that it is probably 
of recent origin. If the spectrum contains two faint 
bands in the green, and an extra band in the red, it in- 
dicates that the stain has undergone a change. Now 
add a trace of ammonia to the solution in the tube, stir- 
ring it with a platinum wire, when you will obtain two 
bands in the green and none in the red. 

(2) To a second tube of the suspected solution add, 
first, a very little ammonia, and then a small quantity of 
Rochelle salt. With this no change will be produced in 
the spectrum, the ordinary bands being visible as before. 
Now add to the liquid in the cell a piece (about one- 
fortieth of an inch in diameter) of the double sulphate of 
protoxide of tron and ammonia ; stir the solution with 
the platinum wire, with as little exposure to the air as 
possible. Cover the cell with a piece of thin glass. The 
two bands seen previously will have disappeared, and 
will be replaced by a single intermediate band, fainter 
but broader than either of the other two, Sp. 2-2, Fig. 
609. This is the spectrum of reduced hemoglobin The 
same effect will be produced by a trace of solution of 
sulphide of ammonium 

The specimen of hemoglobin thus reduced may be 
again and again oxidized by exposure to the air and 
vigorous stirring with the platinum wire It can be 
again deoxidized by further addition of the iron salt, or 
by sulphide of ammonium, if that was previously em- 
ployed for deoxidation 

This deoxidation and reoxidation of the hemoglobin 
is a very characteristic reaction, and serves to distin- 
guish blood from most other substances. If the solution 
of blood is merely covered with thin glass and kept for 
some time in the cell, the reduction of the hemoglobin 
will be effected spontaneously, and without the addition 
of any reagents. 

A question may arise here, whether this spectrum can 








possibly be due to iron. The question is at once an- 
swered by the fact that hydrosulphide of ammonium 
produces the same result, as also does the tin solution 
described on page 78, only that it acts more slowly 
than the iron salt. 

(3) Add to another portion of the suspected solution, 
in a cell, a minute fragment of cztrie acid, stirring it 
thoroughly with a platinum wire. The acid will change 
the hemoglobin into hematin. If previous to the addi- 
tion of citric acid the two bands of oxidized hemoglobin 
were visible in the green, they will disappear, and if the 
solution is tolerably strong a faint band will be visible 
in the red (Sp. 3-3, Fig. 609). Add now an excess of 
ammonia, by dipping the plantinum wire into the am- 
monia solution and stirring the moistened wire imme- 
diately into the liquid in the cell. The band in the red, 
if present, will now disappear, the original bands either 
not being restored at all or restored only to a slight ex- 
tent. This isa most important change to note, since it 
shows that the acid has effected a permanent change in 
the original coloring matter of the blood. Add now to 
the solution in the cell a very small particle of the 
double sulphate of iron and ammonia, and cover the 
liquid over immediately with thin glass. Remove the 
excess of liquid with blotting paper, and in order to ex- 
clude air it is advisable to fix the glass cover on the cell 
with gold size. Turn the cell over and over again, for 
a few minutes. In cold weather the process of oxida- 
tion is slow, and even a quarter of an hour may elapse 
before it is complete. By this means the hematin will 
be reduced, and two well-marked bands will be seen, 
the one nearest the red being the first to appear, and 
both being a little more distant from the red than the 
bands of fresh blood. If the solution be very turbid, 
the precipitate may be allowed to collect on the side by 
keeping the tube for a short time ina horizontal position. 
Preserve and mark the specimen for further examination 
if necessary. 

By exposing this solution of deoxidized hematin to 
the air, assisted by vigorous stirring, we may often 
succeed in bringing back again not only the oxidized 
hematin band, but also the bands of oxidized hemo- 
globin. 

(4) Lastly, add to some of the liquid under examination 
a small quantity of boric acid. If the solution be blood, 
no immediate change will be observed in the position of 
the bands. The above-mentioned method of examining 
blood stains of recent origin requires some modifications 
in special cases. 

Old Blood Stains or Blood Stains on Oolored Fabrics.— 
If blood stains are old, the coloring matter will probably 
be found to be scarcely at all acted on by cold water, 
Either citric acid or ammonia must then be used for dis- 
solving it. If the fabric be white, ammonia should be 
employed in preference to citricacid, but if it be colored, 
test, first of all, which of these two reagents has the less 
action on the dye-coloring matter, and then use that one, 
for the purpose of dissolving the blood, which acts less 
on the color of the cloth. To determine this, place a little 
of the fabric in two watch glasses and apply a solution 
of ammonia to one and a solution of citric acid to the. 
other In general, ammonia should be used in prefer- 
ence to citric acid. but in the case of red fabrics ammonia. 
will generally dissolve so much of the dye stuff that 
subsequent investigations with the colored solution are 
rendered much more troublesome and complicated. 
Hence, if the stain be found on scarlet cloth or other red 
material. citric acid should be used as the solvent. If 
the stain be found insoluble both in ammonia and in 
citric acid, then it should first of all be acted on with 
ammonia solution and a moderate heat afterward applied. 

Proceed then with the solutions in the manner already 
described, examining them with the spectroscope both 
before and after deoxidation with the iron salt. The 
age of a stain does not in general interfere with the 
spectroscope test, as Mr. Sorby has been able to discover: 
hematin with the spectroscope after forty-four years, 
and others have done the same after thirty years. 


9 


Blood Stains, 
Blood Stains, 





The presence of mordants on various materials may 
necessitate occasional alterations in our proceedings. 
More particularly will this be the case if the stained 
fabric has been afterward wetted and the blood by this 
means to a great extent removed. 

What blood remains on the cloth is then very likely to 
be incorporated with the mordant. Insuch cases a proc- 
ess such as the following should be adopted: Digest a 
portion of the stained cloth in dilute ammonia, and 
afterward squeeze out the liquid. Deoxidize the thick, 
turbid, unfiltered solution in the ordinary manner and 
examine it for the deoxidized hxematin bands, using con- 
centrated sunlight, or the lime-light if necessary. 

It is to be remembered that in the case we are suppos- 
ing the hematin is probably chemically combined with 
the mordant; hence filtration, or allowing the deposit 
to subside, is equivalent to removing most of the blood- 
coloring matter. The turbidity of the liquid must be 
overcome in such cases, not by removing the deposit, 
but by increasing the intensity of the transmitted light. 

Examination of Stained Fabrics that have been Washed 
after Staining, and the Treatment to be Adopted in the 
Examination of the Water that was used for Washing 
Them.—Hematin is a very insoluble body. Probably, 
therefore, after an article stained with blood has been 
washed in water, provided a sufficient time has elapsed 
for the change of the blood-coloring matter into hematin 
to be effected, enough will be left on the stained cloth to 
produce the spectra necessary for its identification. But 
it must be remembered that if the stain be perfectly re- 
cent, that is, before any of the hemoglobin is converted 
into hematin, the whole of the blood may then be washed 
out by rinsing in cold water, and no trace be afterward 
found on the stained material. Hot water will not effect 
this removal of the blood like cold water, owing to its 
further action. Hence, if in a criminal case there is 
proof that an article has been washed in cold water, evi- 
dence as to the absence of blood stains is of little value; 
while if, after staining, the article was washed in hot 
water, the probability is there will be no difficulty in 
satisfactorily proving the real character of the stain. 
In many cases, after a stained fabric has been washed, 
the blood stain will be found spread over a considerable 
surface. Under such circumstances a large piece must 
be cut out, and digested with a proportionately large 
quantity of ammonia, or of citric acid solution, the liquid 
being concentrated afterward by evaporation at a gentle 
heat. 

The water used for washing such materials may have 
to be examined. This can be done by concentrating the 
liquid, if necessary, and examining it in the usual man- 
ner If, however, it is found that there is any deposit 
in the water, it should be carefully collected, acted on 
with ammonia, and heat applied if the blood be insoluble 
in the cold solution. 

If the recently stained fabric, however, be washed 
with soap and water, hemoglobin will be rapidly con- 
verted by the action of the alkali into hematin. Soap 
and water, therefore, really sets the stain, and the proba- 
bility is that, after washing, there will be little difficulty 
in detecting it on the fabric itself by the ordinary means. 
It may be necessary sometimes to examine the soap and 
water to see if it contains blood. This may be done as 
follows: Agitate the soap and water with ether and allow 
the mixture to stand until the ether has completely sepa- 
rated. Remove the ether with a pipette, and again and 
again shake the liquid up with ether until the aqueous 
solution is perfectly clear and free from soap This 
liquid must then be concentrated, and examined as usual 
for blood 

Examination of Stains on Leather.—Blood stains on 
leather, or upon any body containing tannic acid, require 
special management on account of the precipitation of 
the coloring matter which is more or less certain to re- 
sult. Proceed as follows: 

(a) Cut off a fine shaving from the stained portion of 
the leather, so that there may be as much blood and as 
little leather as possible on the shaving. Bend this 


80 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


shaving so that the side that is stained may be brought 
into contact with a little water placed in one of the ex- . 
perimental cells, while the leather side of the shaving is 
not wetted. In this manner solution of the blood will 
probably be effected, and enough coloring matter ob- 
tained for experiment. 

Mr. Sorby points out, however, that when a drop of 
blood falls on leather, the serum soaks into the leather, 
and leaves the blood corpuscles on the surface. If the 
leather be then washed, it would probably be impossible 
to obtain the blood spectra by the method just described. 
The following process, recommended by Mr. Sorby, has 
been found to work satisfactorily : 

(o) Digest, for a considerable time, a portion of the 
stained leather in a mixture of one part (by measure) of 
hydrochloric acid and fifty of water. This will effect a 
solution of the mixed compound of the blood-coloring 
matter and tannic acid. Pour off the acid liquid, but do 
not filter it. The solution may appear almost colorless, 
or of a slightly yellow tint. Add to this an excess of 
ammonia, when the color will become either a pale pur- 
ple or a neutral tint, the tint shade being considerably 
intensified on the addition of the ferrous salt and double 
tartrate, which are now to be added. The solution is 
then to be examined in an experimental cell, using a 
sufficiently intense light, such as the lime-light, or direct 
sunlight, to penetrate the turbid solution. Under these 
circumstances the spectrum of deoxidized hematin will 
be seen. If the liquid be too turbid to allow even a 
direct ray from the sun to be passed through it, allow 
the cell to remain for a few minutes in a horizontal posi- 
tion so that a little of the deposit may subside, although 
if this can possibly be avoided it is desirable to do so, 
because it will be found that the removal of the deposit 
at the same time destroys the intensity of the spectrum, 
proving that the greater part of the hematin under these 
a our exists as a compound insoluble in dilute 
acid. 

Before commencing the experiment with the stained 
portion of the leather, it is advisable to make out clearly 
how large a piece of the unstained leather may be treated . 
with a given quantity of the acid without producing too — 
dark a solution, and to take care afterward not to em- 
ploy a larger piece of the stained portion of the leather 
than is justified by these trial experiments. 

Blood Stains on Earth and on Clothes soiled with Earthy 
Matters.—The stained earth is to be carefully collected 
and digested in a considerable quantity of ammonia. 
This is to be poured off, concentrated by evaporation, 
and the spectroscopic experiments conducted as usual 
on the turbid solution, an intense light, such as the lime- 
light or direct sunlight, being used for the purpose, in 
the manner already described. A similar process should 
be adopted in examining stained fabrics soiled with 
earthy matters. This is important to note, inasmuch as 
the coloring matter in a solution of blood will be found 
to be completely carried down by earthy matter when 
shaken up with it. 

General Precautions to be Observed in Conducting Micro- 
spectroscopic Observations.—We now add a few words of 
general advice and a few precautions necessary to be 
observed in examining blood stains by the spectroscope. 

(1) If the fabric on which the blood stain occurs be 
colored, always examine the spectrum produced by the 
coloring matter alone, taken from unstained portions of 
the fabric. Further, it is well to put a little blood on 
an unstained portion, and to examine its spectra when 
dry, and thus fully determine, before commencing ex- 
periments on the stained portion, any possible interfer- 
ence in the blood spectra resulting from the presence of 
such coloring matter. 

(2) On no account decide that an observed spectrum 
from a suspected stain is due to blood unless it exactly 
coincides with bands produced by a known solution of 
blood of equal strength treated in a similar manner and 
examined side by side. It is advisable to have several 
tubes of the deoxidized hematin of different strengths 
for purposes of comparison These solution are best 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood Stains, 
Blood Stains, 





kept in hermetically sealed tubes, so as to have them at 
hand whenever they are needed. 

(3) In all cases examine the spectra both by daylight 
and by artificial light. We prefer artificial light for 
general work, but in every case it is advisable to try 
both means of illumination. Direct concentrated sun- 
light, or the lime-light, should be tried whenever the 
solution is thick and turbid. 

(4) Never be content with observing a single spectrum 
of blood. Remember, further, it is often impossible to 
obtain the unaltered blood spectrum. Hence never 
satisfy yourself that a stain is not blood until you have 
failed to obtain all the spectra produced by the appro- 
priate reagents. 

(5) If the liquid under examination be too strong, too 
much light will be cut off by the solution, and the 
absorption bands will be in this way obscured. If the 
solution be too weak, the bands will be too faint, and so 
likely to be overlooked. Practise in this matter to obtain 
the happy medium. Never (if possible) be satisfied with 
a single examination. ; 

(6) Use extremely minute quantities of the several re- 
agents. Hmatin produced by an acid is not very solu- 
ble in a strong solution of citrate of ammonia. If you 
add too much protosulphate of iron the precipitate pro- 
duced so obscures the field as to mask the absorption 
bands. 

(7) Adjust the width of the slit during the spectroscopic 
examination. Allabsorption bands are best defined when 
the slit is very narrow, while, if the bands are very faint, 
they will often be best seen at the very moment when 
the slit is being completely closed. 

(8) Remember that, with our present knowledge, the 
spectrum microscope affords no information whatsoever 
as to whether the blood is from man or beast, nor from 
what class of animals it is derived; nor, if it be human 
blood, does it enable us even to hazard a conjecture as 
to the locality of its origin. 9. Lastly, unless the 
stain is bright red—an appearance which can be noted 
only on white or nearly colorless fabrics—never venture 
an opinion as to the probable age of the stain. 

Of the certainty of this method of research, Mr. Sorby 
says (Medical Press and Circular, May 31, 1871): “I un- 
hesitatingly say we can distinguish blood (by the micro- 
spectroscope) from all other animal and vegetable color- 
ing matters.” 

5. MicroscoricaL EXAMINATION OF BLooD STAINS.— 
Besides the fluid portion of blood, certain organized bodies 
are found, called corpuscles, consisting of two varieties, 
the white and the red. In the higher animals the red 
corpuscles are the smaller but the more numerous, while 
the white ‘corpuscles are rather larger and somewhat 
granular in structure and of a spherical form. The red 
corpuscles are circular, biconcave discs, of soft viscid 
matter, mostly soluble in water, but only very slowly 
dissolved by serum and the fluid part of the blood. The 
outer part of the red corpuscles is of firmer consistence 
than the interior, especially in the older corpuscles, but 
there is no special envelope or cell wall. By the action 
of water the coloring matter may be dissolved out, leav- 
ing the form of the corpuscle but little changed, except 
that it becomes nearly spherical. 

When blood is spread upon glass, or any hard non- 
porous substance, the corpuscles adhere and retain their 
diameters unchanged, but when blood dries in a clotted 
mass, the red corpuscles shrink and often assume a 
crenated or stellate form. 

If the stain to be examined is a mere film on a steel 
instrument or other smooth, hard substance, as glass or 
varnished wood, it may be laid on the stage of the 
microscope, and with a quarter or one-eighth inch objec- 
tive, with Beck’s patent illuminator above, the light of 
a lamp may be reflected down through the objective. 
In this manner the stain may be examined as an opaque 
object. 

By this method the writer has succeeded in recogniz- 
ing and measuring blood discs, magnified fourteen hun- 
dred diameters, on the blade of a knife which had lain in 


Vou. II.—6 


the forest, covered with leaves, through two winters. 
Generally blood stains form a mass too thick to be ex- 
amined by this method, yet even then the corpuscles 
contracted to dimensions much below normal may be 
recognized as blood by this method of examination. 

If the stain is in the form of shining scales, or if it is 
on cloth, leather, or any porous substance, it may be 
picked off with a needle or pointed instrument, and the 
dust or particles of clot received upon a glass slide and 
moistened witha suitable fluid to separate the corpuscles 
and restore them to their normal dimensions. 

Fluids used in the microscopic examination of blood 
corpuscles should be such as will not destroy them, and 
such as will not increase or decrease their dimensions 
beyond their normal size. For this purpose a fluid 
should generally be used having the same specific gravity 
as blood serum, 1.028 or 1.029. 

Robin's fluid consists of distilled water, to which is 
added chloride of sodium, one per cent., and bichloride 
of mercury, one-half of one per cent. 

Roussin’s Fiuid.—Glycerin, three parts; sulphuric 
acid, one part; with water sufficient to reduce the specific 
gravity to 1.028. 

Hayem’s fluid consists of distilled water, with the ad- 
dition of sulphate of sodium, twoand one-half per cent. ; 
pure chloride of sodium, one-half per cent., and bichlo- 
ride of mercury, one-fourth per cent. 

Professor J. G. Richardson employed water with the 
addition of common salt, three-fourths of one per cent. 

Dr. Thad. 8. Up de Graff, who was very successful 
in distinguishing the blood of man from that of the lower 
animals, employed water with bichloride of mercury, 
one-half of one per cent. 

Many other microscopists use glycerin and water, 
mixed in such proportions as to give a specific gravity 
of 1.028. 

Each of the fluids described has some advantage over 
the others. The fluids containing bichloride of mercury 
are not likely to be infested with fungi when specimens 
are kept for a length of time. Glycerin water interferes 
less with other tests which may be applied after the 
microscopie examination is completed; but in this respect 
it has no advantage over Richardson’s salt solution. 

Filtered serum from the blood of a frog may be em- 
ployed in examining stains supposed to be from mam- 
malian blood. Albumen of egg is also sometimes used. 

In moistening blood stains with any fluid whatever it 
is to be remembered that the substance of the stain ab- 
sorbing the fluid renders it more dense than it was when 
prepared; therefore, if the fluid employed has no greater 
density than blood serum there is no opportunity for the 
blood corpuscles of the stain to enlarge beyond their 
ordinary dimensions in normal blood. As yet no fluid 
has been described which will cause dried blood cor- 
puscles to swell up toa greater diameter than the original 
fresh blood. When by the action of water the red cor- 
puscle becomes spherical, its diameter is diminished. 

When a blood stain is situated upon paper more of it 
remains on the surface than when the stain is upon cloth, 
and, after the paper is moistened, the film of blood can 
sometimes be detached from the surface in small scales 
or lumps. Mingled somewhat with filaments of the 
paper, and with molecular material, we find blood glo- 
bules more abundant than in stains upon cloth. The 
form of the globules is also better preserved, and they are 
often seen in nummular masses, as in fresh blood, and 
we recognize the central depression and dentate bor- 
ders characteristic of corpuscles of mammalian blood. 
These masses also preserve the color which distinguishes 
blood from all colored objects of vegetable or mineral 
origin. ‘ 

Stains upon wood have characteristics similar to those 
of stains upon paper. 

Stains upon woollen goods are somewhat more diffi- 
cult to determine than those on cotton, linen, paper, or 
wood. 

If we use the sulphate of soda solution for the ex- 
amination of fresh stains (not more than six days old) 


81 


Blood Stains, 
Blood Stains, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








upon iron or steel, the fibrin separates and leaves the 
corpuscles floating free in the liquid, and the clot shows 
the characteristic fibrillar arrangement. We find also 
the white corpuscles either isolated or entangled in the 
clot. The white corpuscles are no less characteristic 
than the red by their size, form, finely granular appear- 
ance, and nuclei, which appear near the centre, brought 
into view by the sulphate of soda solution. This solu- 
tion acts upon the white corpuscles almost as quickly as 
pure water, but causes them to swell less. The char- 
acteristics which distinguish white blood globules from 
pus should be noted whenever there is a possibility of 
finding the two together, which is not common in legal 
cases. 

If blood stains have been deposited on rusty iron or 
steel, or have remained long on such instruments even 
if not rusty, the glycerin solution is much to be pre- 
ferred in their examination, as it does not act upon the 
metal; while sulphate of soda or any of the acid solu- 
tions cause the deposit in the preparation of dark gran- 
ules formed of a salt of iron. 

The fine dust obtained by scratching a stain with a 
needle point or by crushing a large particle picked off 
from a shining clot, should be covered with a circle of 
thin glass, and a drop of one of the solutions described 
above should be allowed to run under the cover. If the 
stain is recent, it will be in a condition for examination 
in a few days, or in some cases in a few hours. If the 
stain is old, over six months, a much longer time is re- 
quired to soften it. If the object is only to recognize 
blood corpuscles when the dust-like particles have been 
softened, the fluid may be drawn away by touching one 
side of the cover glass with blotting paper, at the same 
time placing a drop of a staining fluid—as a watery solu- 
tion of eosin or iodine—on the opposite edge of the 
cover. Aftertwoor three minutes the colored fluid may 
be withdrawn in the same manner, and salt solution or 
glycerin water allowed to take its place, when the blood 
corpuscles, if any exist, will be easily distinguished, and 
may be measured by the use of the micrometer. Where 
a stain on paper, leather, or blades of grass is so thin 
that no particles of clot can be removed, Prof. F. B. 
Wyman, M.D., hardens the stain in formalin or in equal 
parts of alcohol and ether for five or ten minutes, then 
stains in a watery solution of eosin, dehydrates with al- 
cohol, clears in oil of bergamot, and mounts the paper, 
leather, or grass in Canada balsam as ordinary sections of 
tissue are mounted. The blood corpuscles of the stain 
are then clearly seen and can be measured. 

If the stains are not very recent, provision must be 
made to prevent evaporation of the fluid used to soften 
them. Takea glass slide witha circular excavation in the 
middle, called a “concave centre,” and moisten it around 
the edges of the cavity with glycerin. Thoroughly 
clean a glass cover an eighth of an inch or more larger 
than the excavation, lay it on white paper, moisten the 
centre with the glycerin solution (sp. gr., 1.028), drop- 
ping into the solution so placed the dust obtained from 
the stain, then invert the slide upon the thin glass cover 
in such a manner that the glycerined edges of the cavity 
on the slide may adhere to the margins of the cover; 
turn the slide face upward, and examine with the micro- 
scope. In the fine dust thus moistened, isolated red and 
white blood corpuscles will often be seen immediately. 
Tf not, lay the slide face downward on a suitable sup- 
port, and examine from day to day until the corpuscles 
become visible and cease to enlarge. They cannot ex- 
ceed their normal size when treated by this method. 

Prof. Joseph G. Richardson, M.D., made a minute dot 
of glycerin, about the size of this period (*), on a thin 
glass cover, and pushed into it a particle of suspected 
blood clot, the smallest that can be seen by the naked 
eye, one-thousandth or one-five-hundredth of an inch 
in diameter, receiving the cover on the concave slide as 
described above. By this method he obtained a strong 
solution of the coloring matter of blood, in which the 
absorption bands peculiar to blood could be seen, if blood 
was present in the stain; and by a little practice the 


82 


bands may be modified by the addition of sulphuret of 
sodium, as advised by Preyer and Sorby. 

By a similar method, using a little more material on a 
cover glass moistened with a very small drop of three- 
fourths-per-cent. salt solution, he was able to see, first, 
the absorption bands of blood with the microspectro- 
scope, then, turning the slide so as to drain off superflu- 
ous fluid, and using the microscope with a magnifying 
power of about two thousand diameters, he was able to 
see and measure both white and red blood corpuscles, 
so as to distinguish human blood from the blood of the 
ox, pig, horse, or sheep. 

In examining a slide prepared by either method above 
mentioned, if the material is blood, we first observe that 
the edges of the solid particles gradually become trans- 
lucent and the fluid around assumes a reddish-yellow 
color, showing that the coloring matter is soluble. In 
this condition of the preparation by use of the micro- 
spectroscope the characteristic absorption bands of blood 
will be seen. 

After a little time, if the amount of fluid applied be 
sufficient, the solid particles are softened, and, as they 
swell up, yellowish-white corpuscles with a slightly 
granular structure are seen; these are the well-known 
white blood corpuscles, which, with a magnifying pow- 
er of one thousand diameters or upward, may be dis- 
tinguished from other organized structures of either 
animal or vegetable origin. After longer maceration 
the characteristic red corpuscles of blood, with smooth 
and sharply defined edges, begin to appear, and after a 
time are found floating free in the fluid under the cover 
glass. If the stain is mammalian blood, some of the cor- 
puscles will be clearly seen as biconcave discs with a 
light centre and a dark edge or border. If any doubt 
remains in regard to the nature of these corpuscles, it 
may generally be resolved by the use of a higher magni- 
fying power. Grains of pollen may be generally distin- 
guished by a roughened edge, or by small points on the 
surface. Spores of fungi are often found mixed with 
blood stains, but in general the texture is different from 
that of blood. Occasionally the biconcave structure of 
red blood corpuscles can be distinguished, as a slight 
motion causes some of them to roll over as they move 
across the field. Unicellular alge, often seen in wet 
preparations, may be distinguished by the granules 
which they contain, having a greenish-brown or reddish 
color. These are grainsof chlorophyll. Spores of fungi 
growing in fluids have generally, if undisturbed, some 
systematic arrangement not found in the positions as- 
sumed by blood corpuscles. 

Erdmann records a case (Zettschrift fir analyt. 
Chemie, ii., 1862, and Gazette Hebdomadaire, quoted 
in Edinburgh Medical Journal, October, 1862, p. 370) 
which shows the importance of employing more than 
one kind of test in examining stains supposed to be 
blood. “The only trace of an assassination at Leipsic 
was a brownish stain found at the spot where the crime 
had been committed. Under the influence of rain, the 
stain had assumed the appearance of coagulated blood. 
An aqueous solution of this stain furnished a reddish 
fluid, which gave with tannin, with ferrocyanide of 
potassium, and with Millon’s solution,* the same chem- 
ical reaction as the aqueous extract of dried blood. Ex- 
amined under the microscope, the brown matter was 
found to contain some corpuscles very similar to those 
of blood. But Erdmann having failed to discover 
crystals of hemin, conceived doubts as to the value of 
the other characters, and repeated with great care the 
microscopical examination. He then discovered that the 
bodies supposed to be blood globules were the spores 
of alge called porphyridiwm cruentum, on account of 
the resemblance of its spores to blood corpuscles.” 

This blood-colored gelatinous alga, porphyridium 
cruentum, growing upon moist ground, is of doubtful 





* Millon’s solution is a strongly acid (nitric and nitrous) solution of 
proto- and pernitrate of mercury. made by dissolving metallic mercury 
in its weight of strong nitric acid with the aid of heat.—Micrographie 
Dictionary. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood Stains, 
Blood Stains, 





occurrence in the United States (Am. Quar. Mic. Journ., 
April, 1879). Thudichum, in “Tenth Report of Med. 
Officer to Privy Council,” 1867, p. 216, mentions a red, 
gelatinous mass, growing upon a human thigh-bone, 
which was macerating at St. Thomas’ Hospital. The 
glass vessel in which it was macerating was similarly 
covered. The microscope showed the red material to 
consist of minute cells in a gelatinous mass, with which 
larger green cells were interspersed. The water filtrated 
from them contained a number of minute bodies in sus- 
pension, It was red, and gave a spectrum very similar 
to that of blood. The plant in question is called by 
Thudichum red saprophytes. 

To avoid mistaking alge or other organized bodies for 
blood corpuscles, the guaiacum test, the heemin-crystal 
test, and the spectroscope should be used. 

The mammalian corpuscle, in its normal condition, is 
a delicate endosmometer, taking in or giving out fluid 
according to the relative density of the liquor sanguinis 
and contents of the corpuscle, allowing rapid variations 
within certain limits. Accordingly, .the corpuscles may 
be either swollen, puckered, or shrunk into a variety of 
figures, flat, tumid, like a shallow circular or oval cup, 
stellate, notched, granulated, mulberry-shaped, crescen- 
tic, angular, lanceolate, fusiform, or comma-shaped, or 
they may possess other figures defying description. In 
certain of the cervide the angular, crescentic, and lan- 
ceolate corpuscles are abundant. In connection with 
disease, deformed corpuscles are also found. 

The recognition of blood stains, and the probable de- 
termination of the animal from which they came, de- 
pend on the use of solvents of the same endosmotic 
power as the serum of normal blood, and on the micro- 
scopic examination and measurement of the corpuscles 
having thenormal form. Inthe blood of birds, fish, and 
reptiles having red blood discs of an oval or ellipsoidal 
form, it is sometimes possible, when they are standing 
on end or are distorted by drying, to see them as circular 
bodies. Time must therefore be allowed for the stains 
to be fully softened and the corpuscles to be isolated by 
the solvent before their origin can be decided. There 
are also some round corpuscles mingled with the elliptical, 
but they are too few in number to mislead a careful 
observer, 

Stains formed by menstrual blood contain uterine and 
vaginal mucus mingled with cells of epithelium. 

At the commencement of menstruation the linen is 
stained of a brown color, changing gradually to red. 
About the third day blood corpuscles are abundant, 
mingled with leucocytes and epithelium. The cessation 
of the courses is marked by the diminution of the red 
blood globules and the increase of leucocytes, rendering 
the flow more nearly purulent. Menstrual blood does 
not differ from any other blood, except that it is mingled 
with mucus and epithelium and an abnormal proportion 
of leucocytes, and that fibrin is almost entirely absent. 
The absence of fibrin is the most characteristic distinc- 
tion of menstrual blood. 

Blood Stains compared with Stains formed by Lochiat 
Discharges.—Medical experts are often called, especially 
in cases of infanticide, to distinguish between stains of 
blood and those formed by the lochiz. These stains are 
to be examined by the same methods as are available for 
stains of normal blood. In the lochial discharge, about 
six hours after delivery, we find about five leucocytes to 
one hundred red blood corpuscles. At the end of the 
first day only about one-third of the organized structures 
are red blood corpuscles. The leucocytes are nearly 
equal in number to the red corpuscles; pavement epi- 
thelium from the vagina is also abundant. 

Among the cells are some spheroidal or somewhat 
polyhedral by reciprocal pressure, united in groups 
similar to the deeper layers of epithelium of the vagina 
or neck of the uterus. The liquid, more or less viscous 
or odorous, which holds these elements in suspension, is 
studded with grayish granules. On the second day the 
leucocytes increase in number and the red globules 
diminish, and little by little the lochiz assume a russet 


tint, which on the third or fourth day passes into a 
grayish white or yellow. 

From the fifth to the seventh day, varying in different 
subjects, the red corpuscles almost entirely disappear, 
and the leucocytes become decidedly granular. Pavement 
epithelium is still found, but less abundantly than during 
the preceding days. The epithelial scales are generally 
imbricated, coming off in patches. The gray molecules 
become more adhesive and abundant, and the fat granules 
diminish innumber. Fibro-plastic, fusiform bodies with- 
out a nucleus, pale and transparent, are also found. 
This composition of the lochize continues without much 
change until the close of the flow. By these character- 
istics stains of lochial discharges can generally be dis- 
tinguished from normal blood. 

The blood of all animals contains certain organized 
structures called corpuscles. In all mammals except a 
few of the camel tribe the red corpuscles, which are the 
most numerous form, are circular biconcave discs of 
which there are in man from four to five million in each 
cubic millimetre of blood. Another form nearly spher- 
ical, called white corpuscles, of which there are about ten 
thousand to the cubic millimetre, havea nucleus and vary 
greatly in numbers in different stages of the digestive 
process and in different conditions of health. 

It is with the red corpuscles that we are principally 
concerned in the study of blood stains. 

In birds, fishes, and reptiles generally the red corpuscles 
are ellipsoidal and have a nucleus. By these differences 








Fig. 611.—Blood of a Snake. 


Fia. 610.—Blood of Lamprey Eel. 


of form it is easy, when using the microscope, to distin- 
guish between the blood of a mammal and that of all 
other animals with two or three rare exceptions. 

In the blood of some of the camelidze we find ellip- 
soidal corpuscles, but those can rarely if ever come into 
consideration in medico-legal cases. In the lamprey eel 
we find circular corpuscles with a nucleus; and these, 
again, are not likely to be mistaken for the blood of man 
or other mammal. On page 85 we give exact reproduc- 
tions of photographs of the blood corpuscles of man and 
of the principal domestic animals, magnified 2,560 di- 
ameters, with a scale in which each division represents 
half a micron or about one-fifty-thousandth (sg$59) of 
an inch. 

We thus see that when viewed by the high powers of 
the modern microscope wide differences are found be- 
tween the blood of man and that of such animals as the 
pig, horse, ox, sheep, and goat. 

In the blood of any single animal there are small and 
large corpuscles giving a considerable range between the 
smallest and largest in the same blood, while the general 
average of the corpuscles in man is greater than it is in 
any of the other animals whose blood is shown in the 
engravings. The accompanying table shows the range 


83 


Blood Stains, 
Blood Stains. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





and general average, measured in microns, for man, dog, 
pig, horse, sheep, and goat: 


TABLE SHOWING VARIOUS SIZES OF RED BLOOD CORPUSCLES 
(MEASURED IN MICRONS) IN MAN AND DOMESTIC ANIMALS. 















































Microns. Man. | Dog. | Pig. Ox. | Sheep.| Goat. 
9 
9, 
9. 
8. 
8. 
8. ar 2 
8. . 1 
iis 5 5 
Me 14 4 
7 21 6 
q. 45 10 ’ 
6. 56 15 1 1 
6. 26 13 1 0 
6. 11 19 0 0 
6. 16 44 29 0 
5. 5 19 16 0 
5. 1 13 20 3 
5. 1 17 if 9 
5. 10 34 30 
4, 6 19 38 
4, 4 8 Th 
4, 4 il 26 2 
4, 3 12 11 
3. 5 3 94 
3 7 63 
3.8 ne 24 
3.00 48 6 
Number of corpuscles*..| 200 200 200 200 200 200 
MAXIMUM Sitesi eiiaeetas 9.31 7.85 8.39 6.77 6.77 4.31 
Minimatiny = ese eters 6.89 5.46 3.85 4.46 3.85 3.16 
IMGaN i itetn ceceeten ees 8.01 6.87 6.07 5.44 4.75 3.69 





* These numbers (two hundred in each column) include all between 
the number in the left hand column opposite to which they are placed, 
and the number next above. 


In any specimen of blood we find corpuscles of vary- 
ing size, but a remarkable uniformity in the average 
measurements of blood from animals of the same kind. 

Some discrepancies appear in the tables of measure- 
ments of blood as given by different authors. The tables 
found in most works on physiology or on medical juris- 
prudence were made when the instruments employed 
and micrometers used were by no means as perfect as the 
microscopes and micrometers now available. The fol- 
lowing table has been prepared with great care. The 
measurements, with two or three exceptions, were made 
by J. B. Treadwell, M.D., with a 34-inch objective, 
magnifying about twenty-five hundred diameters linear, 
and a glass micrometer placed in the eyepiece. The 
blood was spread upon glass and quickly dried. The 
reduction and arrangement of the results as given in 
the table were performed by the writer of this article. 
The standard of measurement was a micrometer ruled 
by Prof. W. A. Rogers, of Cambridge, Mass., and care- 
fully compared with the standards procured at great ex- 
pense by the United States Government. 


MEASUREMENTS OF MAMMALIAN BLOOD. 









































x 
85) 2 | 28) 28 | of |e8| 3/48 
Source of 3¢ z ER | Se ES c= a3 Ea 
blood. Bq 2S | &e| 82 |ae es\sa 
S2| 8 |40| sh] Bb] “| SIs g 
B3| = a |e | ae 
5 men, ages 23 to y 5.773| 7.697] '7.78217.84517.884|7.902 
a9 Yeaieec ees + 11,000] 7.9414] Sal Sirol Stile coaleotalt oes 
5 women, 18 to 55 o+ § | 6.350] 7.825] 7.787|7.878!7.90117.913 
9 BOBS teas 1,000) 7.927) ) g/937| 81152} 8.02617.99317.96317.950 
infants, at birth, » PRY y ; RS 
[mate, 2 fet ooo] 7.9804 | 2881 AR) TReIT em S187 8 
: 6.929] 7.747] 7.828|7.891|7.965|7.988 
Boy, 8 years old.. t 200 7.983 4 9.160 B28 8.191 8.079 8,000 e; 
e 7.005| 7.658] '7.662|'7.'768|'7.85217. 
Man, 70 years old. |} 200) 7.916}| $2581 x torl sus|sa8| 980 
15 persons, as t 3.0001 7 038 J 4.233] 7.658] 7.662)7.768]7.852|7.913 
above ......s.+5 ’ ‘ 10.160| 8.298] 8.191|8.079/8.046 7.983 
Blood stains (hu- t 1.000! 7.910 ; 5.570) 7.700) 7.728 
man) restored.. 8 : 9.687} 8.189! 8.010 





84 


MEASUREMENTS OF MAMMALIAN BLOOD.—Continued. 






































b 
Bs| 8 d|Sal oo. é| 3 
EE| = |e: /22| o£ |o8|eslBE 
wn | Sea lar | ae | do | oo |'o 
Source of o$| S§ | BR) ob] eo |as| aa) we 
blood. Se| % | B8| &y| ae leples| se 
a8] & | "2 | 22] Bie ee 
B'S s a | m + 
a 
c : 4.618] 6.138] 6.445]6.52316.673 
SO COPS, cicero vias 2,500 6.918 | 8.931 7.352 7.305 7958/7198 
Guinea-pig, male, | 5. ‘ -309)|7.249)7.393 
Bene ae | 200) 7.4764} 8-559] 8.608) ‘esoly eaalyese 
Woodchuck, fe-1]| 999) 7.299 : 5.387 7.043) 7.112/7.215)7.279 
WN hoon Gansson or ) ohet as 8.467 7.528 1.374 7,351|7.282 
Muskrat, male ... ¢] 200) 7.2834] 9391] 7.535) TssBlcasly ep 
. 2 rabbits, 1 white, | 499] 6.365 j 4.618) 6.196] 6.227]6.294|6.349|6.354 
1 mixed........ : 8.082] 6.596] 6.48516.409/6.383|6.377 
2 hares, 1 male, 1 400! 5.764 { 4.618] 5.367) 5.377|5.604|5.733/5.756 
female seet, al! 7.120} 6.080| 6.049]5.863/5.779]5.772 
Gray squirrel, 1 5.926| 6.366| 6.627|6.77416.823|6.927 
femble anlese 400] 6.876 | 7-221] P2881 9070117 06017 604 16.006 
Red squirrel, fe- 4.926] 6.227] 6.381)/6.496|6.592 
nial aan 6.607} | S53] Gssl| o:so7le to0|bsae 
Striped squirrel, | 200! 6.753 | 5.887| 6.573) 6.647|6.701|6.747 
female wus .s<s0% i 7.697] 6.981] 6.901|6.815|6.758 
Red fox, male, A: 200! 6.482 ; 5.541] 6.250] 6.408|6.474|6.470 
months ........ a) 0.400) | 7312! 6.674| 6.562/6.54416.494 
Big 2 oth catia 600! 6.101 j 3.849] 5.418] 5.757|5.880|6.028|6.069 
1 of 2 weeks. one : 8.391| 6.520] 6.466|6.246|6.169|6.144 
Ox male, 2 fe- 
’ , 3.916] 5.150) 5.296/5.345/5.34715.406 
reaps ea ear tes ob 1,000 5.436 | 6.774| 5.703| 5.622/5.54315.482)5.461 
mes) 4,618] 5.203] 5.257|5.473|5.493 
Horse, 10 years... ( 5.5084] Geral Sale| BeBsleseale. bio 
Ass, 1 male, 1 fe- | 400) 6.298 ; 5.003} 6.018) 6.138}6.201|6.219)6.259 
malem saan ; 7.687 6.566 6.539 6.377 6.376 6.326 
Mule, 6 years..... 200) 5.4214] 8319] S680] Badslsarale doe 
Cat, 1 adult, 1 kit-1| 499! 5.463 j 2.617| 4.311) 4.3615.268|5.41915.431 
n, 3 weeks. “a : 6.774| 5.780] 5.676|5.573]5.522)5.495 
shee s pales ngs 4 | 3.079) 4.503| 4.588]4.665]4.725]4.744 
bd bane ae tS 4745}) irra) dove] 4809/4 TBD] AcTod| L146 
Goat, 1 male, 1 fe- | 400| 3.567 ; 2.617| 3.394) 3.401)3.467/3.535|/3.546 
maAleee ee 4.080] 4.764] 3.710}3.693|3.638|3.587 
Mouse, house, §| 2.309} 5.772) 5.89115.990)6.037 
common ....... 200] 6.038 | 7004) 6.281] 6.200/6.09416.039 
Mouse, house, 200 6.099 §| 4.618] 5.857] 5.968]6.063]6.089 
long-tailed..... 2 roe ant ie Meare ae 
| : ; of .80315.81415. 
Mouse, field eeceon f 200 5.095 7 ee on oe or 5919 
Rat, male eeccesce f 200 6.500 } 8.005 6.820 6.095 6.694 6.510 
Mole, male....... +] 200] 6.2164] 76 Otee Oe eealeaes 
*Elepbant........ t 100 9.259 | iin oc HN) 9.259 
Woman, 19 years, 100] 7 346 | 3.464| 6.674] 7.012|7.177|7.346 
ANP MIG see. ec ; 9.237) 7.605) 7.628]7. 
P qpiaryed to dently - 8.636] 7.712) 7.639)7 
y oappet eget {| 9.736] 11.082| 11.346 
143 grains, non- 20/ 11.246 - i oalean : 
nucleated  cor- ( | 18.486) 11.661 
PURE nae Se: paoitetee 
uman embryo, i A 
me of nn} 10) 8 089 | 11.611 
ated discs...... 
oe Finke Sais SUDO, 39.5 | 4.772] 5.827] 5.426/5.479)5.489 
see ors br 100] 5.4894) F556] Beaol Sreielecd 





* Measured by M. C. White. 


I was informed by Dr. Richardson that he measured 
from the outside of the dark border of the corpuscle on 
one side to the inner side of the dark border on the op- 
posite side of the corpuscle. If we add one-fiftieth of 
the diameter for the remainder of the dark border we 
should obtain 8.036 microns, which is a trifle larger than 
the average given in the table. This difference may 
possibly be attributed to minute differences in the microm- 
eters used, or it may be owing to what is known as the 
personal equation of the observer. 

Professor Wormley, of the University of Pennsylvania, 
whose extensive and valuable measurements of blood 
corpuscles are published in the second edition of his work 
on “ Microchemistry of Poisons,” measured the whole of 
the dark border of the corpuscle. Professor Wormley 
used a one-tenth inch objective made by Beck, and a one- 
thirty-second inch objective made by Gundlach, mag- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ca tee fpr 


x 





F1G. 614.—Blood of Sheep. X 2,560. FiG.615.—Blood of Goat. 2,560. Fic. 618.—Blood of Horse. 2,560. 


85 


Blood Stains, 
Blood Stains, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





nifying from 1,150 to 2,300 diameters. In the following 
table the measurements of Treadwell and Wormley are 
compared with the measurements made by Gulliver 
twenty-five years ago, and published by him in the 
“Proceedings of the Zodlogical Society of London” 
in 1875. 


AVERAGE SIZE OF RED BLOOD CORPUSCLES, IN FRACTIONS OF 
























































AN INCH. 
Mammals. | By Gulliver. | By Wormley. |By Treadwell. 
WME tere ccotvepteverviels aioicbe ke eines 1-3200 1-3250 1-8200 
AM OKO chee arora sin sisievstert esas 1-3412 1-8382 
MOPOSSUM eis a asiccereiatetar vines ire 1-3557 1-3145 
GUINEA=PIF isis aly elsiete cc 1-8538 1-3223 1-8897 
Kangaroo... 1-3440 1-3410 
Muskrat .. 1-3550 1-8282 1-3487 
DOPseaeee 1-3532 1-3561 1-3672 
Rabbit .. 1-3607 1-653 1-3984 
Rat sa. 1-8754 1-3652 1-3908 
Mouse. 1-8814 1-3748 14223 
Pig ee 1-4230 14268 1-4163 
Ox.... 1-4267 1-4219 1-467; 
Horse . 1-4600 14243 1-4614 
Cat csc 1-1404 1-4372 1-4648 
BK ie. aves 1-8988 14884 
Veqh dads} (OWES sly hhc 1-4586 1-4351 
Wolf (prairie)..... 1-8600 1-3422 
Bear (black)........ F 1-3693 1-3656 
FIVENG Ne siaehiilees ates 1-3735 1-3644 
SQUIFrel TEA) nonce vse ae 1-4000 1-4140 1-8847 
epi cikiesene hoeemranaaa le | oSecig  ndeede 1-3322 . 
Ground squirrel (striped), 
CHIPMUNK cea ces «tee os lew eels 14200 1-3762 
IRACCOOT!.ntcettatadn sie ee ere 1-3950 14084 
Blephant sea. .decectaste ons 1-2745 1-2738 * 
TG@ODATO sreckec nec elele eens <a 1-4319 1-4390 
Hippopotamus.........«.- 1-342! 1-3560 
PUDITIOCCHOB comin sista aialatarerats 1-3765 1-8649 
TAD cetera eouheeieee 1-4000 1-415 
100s RSC FOO Cie 1-4822 1-4143 
OCA Grete casasloucwinateractioss 1-4220 1-3885 
MUON Secrets cntancen atten | Meee release 1-3760 1-4482 
FOR ROR RS AR TA PIC Tren 1-4000 1-3620 1-4036 
SAT as his ish azate atatafe claveis e:tatsl ots 1-4175 1-3966 
SGOD iva ceo actslales sexta eats 1-5300 1-4912 1-5353 
Itc). Saran wagaontodosd lh « Sadeno 1-6445 
CFOBb ateate laine olesinietels isitie 1-6366 1-6189 1-7982 
Sloth Mer suns en usta titet ee 1-2865 
Platypus (duck-billed) ... 1-8000 
Whales erecmen terre sitters eects 1-8099 
CADVDATE fv alee ie nilececies 1-3190 1-3164 
WOOlias siete te cela ach ne 1-8281 
IW OODCHNCKyaircctte aiateteloie' ste De sad 1-3489 
MUSK-CEOr sn we etter 02 sicicie.s 1-12325 
PSO VOL satsatelessieraneveetratrlers 1-3325 
FPOLCHPINEG Ms nine lzcntetelaee aed Ses 
§ Long diam..... _ = 
Llama 7 Short diam..... 1-229 16408 
{ Long diam ..... 2 —3de 
Camel short diam... 1-5876 1-5280 
ROG TOR ater aie sie cletero NA keieere ne 4 Wee oncae 1-3918 
GULLIVER. WORMLEY, 
Length. | Breadth. || Length. | Breadth 
Birds— 
CHICKEN ein eiccs eee > -2102 1-3466 1-2080 1-3483 
TUIKCY ccsmshiee cus tes 1-2045 1-3598 1-1894 1-3444 
DUCK arene seenies cere 1-1937 1-3424 1-1955 1-3504 
PIGEON eee cannes oe 1-1973 1-36438 1-1892 1-8804 
GOOKE Mace sieene celstestiee 1-1836 1-3839 
AJAY one eieele cine eieeialstets 1-2347 1-3470 
WOO mr cctemaatemiestierase 1-2005 1-3369 
SpPalLO Weeds tie cakienione 1-2140 1-3500 
(Oh Usama qo Sade 1-1763 14076 
Reptiles— 
Tortoise (land) ......... 1-1252 1-2216 1-1250 1-2200 
Turtle (green) oa. sci os 1-1231 1-1882 
Boa constrictor ......... 1-1440 1-2400 1-1245 1-2538 
WAIDERAN cet swneemia tee 1-127 1-1800 
NAZAT Parane ctemeaine eis 1-1555 1-27 
Batrachians— 
LOG sonce te tee Risse Sts 5.0 1-1108 1-1821 1-1089 1-1801 
TOAA sen aasauk canes sme 1-1043 1-2000 
Triton Shocen. cake een es 1-848 1-1280 
PTOLCUSS ae tien easel are 1-400 1-727 
Amphiuma tridactylum..| 1-863 1-615 1-358 1-622 
Fishes— 
ED TOUlie asvssate teweisiece elepsie es 1-1524 1-2460 
Perchlicc. torknaesinetue: 1-2099 1-2824 
DiIKGie paca sae een ches 1-2000 1-3555 
WGlicseunechcbceaoteseter 1-1745 1-2842 
TEAMPLC ck teiwrere 16/116 a so ie Circular. | 1-2134 
INCI CIOUIS Jee cise sete wis ecole taste || Matreinied 1-6400 








7 


86 


From these tables it is clearly shown that a careful 
microscopist would not be likely to mistake the blood of 
a goat, sheep, horse, ox, or pig for the blood of a human 
being; or that of any animal having blood corpuscles 
with an average diameter less than 3,55 of an inch or 
0.0063 mm. (6.38 microns). 

Concerning the possibility of distinguishing the blood 
of a dog from that of man, medical experts are in nowise 
agreed, a few contending that they can distinguish a re- 
cent stain of the blood of a dog from the blood of man, 
and they have successfully accomplished the task when 
put to the crucial test of experiment. 

The late Col. J. J. Woodward, M.D., when testifying 
as an expert in the Hayden trial, at New Haven, Conn., 
in 1879, stated that he had measured twenty corpuscles 
from a young dog, forty from another, and fifty from a 
third, in which he found the averages of the corpuscles 
measured from each one of those dogs larger than the 
recognized average size of human blood corpuscles. In 
regard to these measurements Dr. Woodward stated in 
his cross-examination, by the state: “J looked to find big 
corpuscles and I knew that the group around them would be 
large.” The same expert has published measurements of 
the blood of other dogs so large that he inferred that 
there is no safety in attempting to state positively that a 
given stain is the blood of man and that it could not be 
the blood of a dog. 

L. Perier has shown that the blood of new-born in- 
fants often contains giant corpuscles similar to the large 
non-nucleated corpuscles of the human embryo, and 
states that until recently these have not been considered 
as true red corpuscles. 

He also states that these giant corpuscles have a ten- 
dency to collect together, and that in estimating average 
measurements it is important to examine all parts of the 
slide on which the blood is spread. LL. Perier also says 
that he finds in the blood of infants many globulins 
nearly spherical, only about half the diameter of ordinary 
blood discs. If these globulins are not included in the 
measurement it will be easy to obtain large averages for 
the blood of infants. 

Dr. R. U. Piper, of Chicago, finds that the blood cor- 
puscles of new-born infants retain much of the character 
of pre-natal blood, and give an average diameter larger 
than that of the blood of adults. He also finds the blood 
of young puppies giving a larger average diameter than 
that of the blood of adult dogs, but these facts do not 
disparage the value of the microscope as a means of dis- 
tinguishing the blood of man from that of full-grown 
dogs, especially if we can obtain for comparison authen- 
tic specimens of the blood of the particular man and dog 
with which a given blood stain is to be compared ina 
given case. 

Dr. Thad. 8. Up de Graff (in 7’he Microscope, October, 
1883) states that the red blood corpuscle of the dog re- 
sists the action of water and ruptures less readily than 
does the red corpuscle of human blood, because, as he 
thinks, the cell wall or border is thicker in the blood of 
the dog than it is in human blood. 

By a careful study of the micrometric data from which 
the table of measurements by Dr. Treadwell was calcu- 
lated I find as a general rule, to which there are some 
exceptions, that the blood corpuscles of young animals 
have a greater range (as Perier and Hayem have stated) 
from the smallest to the largest corpuscle, and a slightly 
larger average diameter, than have those of adults. This 
is shown in the case of a male pig, two weeks old, in 
the first table giving the range of two hundred corpuscles 
for that and other animals. The same is apparently true 
of the blood of females as compared with the blood of 
males. My own measurements of human blood of in- 
fants and adults, both male and female, tend to the same 
conclusions. ; 

In the measurements given in this table the whole 
of the dark border was measured. The measurements 
were originally taken and recorded in parts of the 
American standard inch, which have been reduced to 
parts of a millimetre by reckoning 1 inch = 25.40098 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood Stains, 
Blood Stains, 





mm. The measurements in the table are given in mi- 
crons, 0.001 mm, 

To secure a fair average two hundred corpuscles were 
generally measured, and often this number was meas- 
ured from several animals of the same class. To show 
how large a number of corpuscles should be measured to 
obtain a fair average, the range of averages is given as 
computed by tens, twenties, fifties, and hundreds; also 
the range of averages of two hundreds as taken from the 
separate animals. 

J. G. Richardson, M.D., of Philadelphia, during the 
progress of the Centennial Exhibition at Philadelphia, 
measured one hundred corpuscles from each of fourteen 
men of different nationalities, using a one-twenty-fifth 
inch immersion objective and a cobweb micrometer eye- 
piece; the microscope thus arranged magnifying eighteen 
hundred diameters. He found the average diameter of 
the fourteen hundred corpuscles to be inch gs4sz or 7.879 
microns. This is smaller than the measurement given in 
Dr. Treadwell’s table, viz., 7.8988 microns. 

While the general consensus of opinion among micros- 
copists is that the blood of man can be distinguished 
with great certainty from the blood of such domestic 
animals as the pig, ox, horse, sheep, and goat, but few 
experts would venture any very positive diagnosis in 
criminal cases between the blood of man and that of the 
dog; though a correct diagnosis has been often given in 
experimental cases. Over twenty years ago Dr. Wood- 
ward published his results in the measurement of the 
corpuscles of dogs, giving averages which could not be 
distinguished from the measurements of human blood. 
Professor Wormley, Dr. Richardson, and Dr. Treadwell 
opposed his conclusions and sought opportunity (which 
was never given) to examine Dr. Woodward’s specimens 
of dog’s blood. At the famous Hayden trial before the 
superior court in New Haven, Conn., in 1879, Dr. Wood- 
ward explained his method of obtaining a large average of 
the blood corpuscles of the dog. He stated that he took 
blood from young dogs, spread on slides, and, looking over 
a slide till he found a collection of large corpuscles which 
have a tendency to collect together, he made his measure- 
ments from that collection. As asample of his work, Dr. 
Woodward stated that on December 14, 1879, he measured 
50 corpuscles from a pup four weeks old, a Newfound- 
land crossed with a setter, and found the average was 326- 
millionths of an inch, or 8.28 of a micron. December 12, 
1879, he measured, selected in the same manner, 40 
corpuscles from a Scotch terrier and got an average of 
320-millionths of an inch, equal to 8.18 microns. From 
a Gordon setter full grown he measured 29 corpus- 
cles and obtained an average of 300-millionths of an inch, 
equal to 7.62 microns. Dr. Woodward, when testi- 
fying under oath, said: “I desire to put myself on record 
as distinctly denying that those measurements of the 
dog’s blood would represent what you would be likely 
habitually to get if, without picking out young dogs and 
without selecting a spot to measure appearing to have 
unusually large corpuscles, you were to measure dog’s 
blood. You would then habitually get smaller figures 
than I have given here. The average of the corpuscles 
of dogs would habitually be smaller than I have given 
here, but I have purposely selected for fixed measurements 
young dogs, for I knew they had bigger corpuscles, and, 
in the second place, in taking an old dog, I purposely 
selected a place on the slide where, to my trained eye, I 
saw there was a group of big corpuscles. My reason for 
doing this is to show that if you pick up a half-dozen 
corpuscles by chance, you may chance on these big 
things. But I have nowhere stated that the average for 
the dog is as large as for man; on the contrary, I would 
like to read my express statement from my printed utter- 
ance, that the general average for the dog, for a great 
number of measurements, will be less than for a great 
number of men.” Dr. Woodward appeared to contend 
that in examining blood stains you might chance to get 
a small speck of dried blood, from a dog, having princi- 
pally these large corpuscles. Thisargument throws doubt 
upon any attempt to distinguish between the blood of 





man and that of the dog unless a large number of cor- 
puscles have been measured. In Figs. 619 and 6201 give 
examples of the blood of man and the blood of a young 
female pug dog, both photographed by me on the same 
negative. They are magnified only 640 diameters in order 
to include a considerable number of corpuscles in the 
comparison. In this case no attempt was made to select 
a place where large corpuscles had collected. I should 
not attempt to distinguish with any degree of confidence 
in a criminal case between the blood of man and the blood 
of a dog. 

As a difficulty in distinguishing the blood of different 
animals by microscopic measurement, Dr. Robert Ryburn 
(Medico-Legal Journal, September, 1892, p. 165) says, the 
trouble in our investigation of this subject lies in the fact 
that the blood corpuscles are living organisms that are 
not possessed of outlines delineated with mathematical 
accuracy. Replying to this objection we refer to Pro- 
fessor Wormley’s statement (“ Microchemistry of Poi- 
sons,” p. 728): “ Ina series of ten spaces ruled on glass 
measured by three observers with different instruments 
the results did not differ more than s5_555 Of an inch; and 
that two independent series of measurements, with high 








Fig. 619.—Human Blood. 640. FIG. eo hed of Pug Dog. X 
640. 


powers, of 20 designated blood corpuscles were abso- 
lutely identical for 16 corpuscles, and for the other 4 the 
greatest difference was only spj559 Of an inch.” Still 
further, Professor Wormley reports the measurement 
of 7 human blood corpuscles, with powers from 1,150 to 
8,500 diameters, by different microscopes, and by draw- 
ing with the camera lucida. The range of averages of 
the different measurements Was gs5q inch to ys45 of an 
inch as measured by the camera lucida. The mean of 
the averages being zs, of an inch; the same 7 cor- 
puscles measured by Dr. Richardson, using a cobweb 
micrometer, gave a final average of zs4, of an inch, differ- 
ing from the former average by something less than gzp\595 
of an inch. To further show the certainty of determin- 
ing the exact limits of the border of the corpuscle and 
that different experts are likely to obtain the same re- 
sults, [ would mention that on a slide of human blood, 
irregularly spread, and dried so that the corpuscles on 
one half of the slide appeared larger than the other half, 
Dr. Treadwell measured, with high powers, 75 corpuscles 
on one side, showing the larger, and 75 on the side show- 
ing the smaller corpuscles. The average of the 150 cor- 
puscles thus measured was y_¢;7 of aninch. The writer, 
using a power of 1,400 diameters and a cobweb microm- 
eter, measured 50 corpuscles on one part of the same 
slide and 50 on the opposite part of the slide, and found 
the average of the 100 to be 3,45 of an inch, differing by 
only gsz}a77 Of an inch from the results obtained by Dr. 


87 


Blood Stains. 
Blood Stains, 


Treadwell on the same slide. The above reported results 
remove, as I think, all objections attributed to the personal 
equation of the observer or the supposed indistinct or 
woolly appearance of the border of the blood corpuscle. 

Prof. Marshall D. Ewell, M.D., LL.D., an excellent 
microscopist, in the Medico- Legal Journal, September, 
1892, gives a report of very careful work in micrometry 
of 4,000 red blood corpuscles. He gives 9.06 microns as 
the average of 100 corpuscles from a boy thirty-six 
hours old, and 8.65 microns for another 100, or 8.85 
microns as the average for 200 corpuscles; also the mean 
of 300 corpuscles from two puppies two days old as 8.22 
microns, and that of 800 from a puppy eight weeks old 
as 8.48 microns. This report sustains the views stated 
above, that young animals have larger corpuscles. Pro- 
fessor Ewell shows by measurements of his own blood, 
taken on six different days, variations from 9.05 to 8.2 23 
microns (the general average being 8.08 microns). This 
shows that for the same individual, while in health, the 
average of 100 or more corpuscles remains substantially 
constant. 

Professor Ewell further says: “(1) There are such 
large discrepancies between the averages obtained from 
the measurement of the fresh blood corpuscles of animals 
of the same species, and between the measurements of 
the same objects by different observers, as to throw doubt 
upon the published results. 

“In the use of the micrometric test no confidence can 
be placed in the results, unless the errors of the microm- 
eter used, with reference to some authentic standard, are 
known. 

“There is no advantage in using very high powers in 
such investigations.” (By this statement he probably 
means that there is no advantage in using powers above 
a one-twelfth inch or a one-eighteenth inch objective as 
he has done. In this view of magnifying powers most 
microscopists at the present day are agreed; but when he 
claims that measuring ruled lines with a one-inch, three- 
fifth inch, and one-fifth inch objective is as good as with 
the higher powers, few experts would agree with him.) 

“Many diseases alter the size of the red corpuscles; 
especially is this so in microcythemia. Fasting dimin- 
ishes both the size and number of the corpuscles. So 
also in the case of various drugs.” 

In view of the foregoing, according to the views of 
Professor Ewell, ¢¢ 7s ¢mpossible in the present state of sci- 
ence to say of a given specimen of blood, fresh or dry, more 
than that tt ts, or ts not, the blood of a manmat. 

As the paper by Professor Ewell has been extensively 
quoted, and as Professor Ewell is now the most promi- 
nent opponent of medical experts on blood stains, the 
above conclusions will be further examined. 

In regard to the micrometric test Professor Ewell’s 
criticism does not apply to comparative measurements of 
blood of different animals where the expert, using always 
the same micrometer, bases his diagnosis on his own 
measurements alone. At present, however, it is easy for 
the expert to obtain micrometers made by skilful work- 
men and carefully rated by comparison with a reliable 
standard. Yet it isa remarkable fact that the measure- 
ments of human blood given by Gulliver, in 1875, zs57; 
Wormley in 1885, ys;5; Schmidt, in 1848, -3,,;; French 
Medico-Legal Society, in 1873, zs:,; Masson in 1885, 
3287} Hans Schmidt, in 1887, ss; Woodward, in 1875, 
so03; Formad, 3555 — made at distant intervals and with- 
out comparison by a common standard—differ by only 
one-half of the difference between the blood of man and 
that of the pig. If Hans Schmidt did not measure the 
dark border of the blood corpuscle it would account for 
the small average which he obtained. 

Another source of difference in measurement is in the 
mode of obtaining and preparing the blood for measure- 
ment. Ifa string is tied around the finger or the circula- 
tion is impeded in any other manner, and the blood is 
obtained by pricking with a needle, and is then spread 
upon a slide, the corpuscles, deprived of a portion of 
serum, will measure less than if obtained from a cut with 
a lancet where the circulation is not obstructed. 


88 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


So also, if the blood is drawn from the prick of a needle 
ina warm and dry atmosphere, the corpuscles begin to 
contract before they can be spread upon a slip of glass. 

None of these considerations enables us to reconcile all 
the discrepancies noticed by Professor Ewell in the writ- 
ings of different authors; but the great fact is shown, by 
the unanimous consent of all microscopists, so far as we 
can ascertain, that less than 3,500 (most writers say less 
than 3,300) corpuscles of human blood are required to 
measure an inch, when placed side by side; while more 
than 4,000 corpuscles of the pig are required to measure 
an inch, and for the horse, ox, cat, sheep, and goat still 
more are required. Hence all authors agree that there is 
a remarkable difference between the average diameter of 
the human blood corpuscle and that of any domestic ani- 
mal except the dog. 

Taking the pig as the representative of domestic ani- 
mals, because its corpuscles are larger than those of the 
ox, horse, cat, sheep, or goat, the following comparison 
between the blood of the pig and human blood is very 
significant : 

To determine the extent of the possibility of mistaking 
the blood of the pig, ox, horse, sheep, or goat for human 
blood, we will examine ‘the table of measurements made 
by J. B. Treadwell, M.D., using a one-twenty-fifth inch 
objective made by R. B. Tolles, and Jackson’s eyepiece 
micrometer, made by Tolles, ruled by Professor Rogers, 
and a stage micrometer ruled, tested, and rated by Pro- 
fessor Rogers. 

In this table the measurements of 3,000 corpuscles are 
given, 200 having been taken from each of fifteen differ- 
ent persons. The measurementsare given maximum and 
minimum by tens, by twenties, by fifties, by one hun- 
dreds, and by two liundreds. Six hundred corpuscles | 
from pigs were measured: 200 from a pig three weeks 
old, 200 from one of two months, and 200 from a pig 
three months old. 

As the corpuscles of the pig have a larger average than 
those of the ox, horse, sheep, or goat, we make our com- 
parison between the blood of man and the blood of these 
three young pigs: 


Microns. Microns. 
Man, smallest ten.......... 7.658 Largest teMniccieaspaes 8.298 
Pig te ae ee teens 5.418 : oO heteee 6. 
Man, Ma twenty...... 7.662 4) twenty ..... 8.191 
Pig, oe a A er 7.768 2 pas ans 25.08 6.466 
Man, “ Hifty:wecmeece 7.768 fs TIty some 8.079 
Pig, om ORs dehrdeowe 5.880 od La Are onc 6.246 
Mans = hundred,.... 7.852 ‘hundred 8.046 
Pig, * Se seats O28: mK 6.169 
Microns 
Smallest: ten from WAN shies woo 0 nis ale ocsis’e1s essinvese ein eae 7.658 
Largest ten from! the Pigs ss << oc cibreiee tee crsie civ eieretere termine 6.520 
DifOTenCe sais o/1d/s/b cleave Meicie biel eleie le cfolore Stele neietere ire nee 1.138 
This equals 0.000045 of an inch = gz4zz inch. 
Smallest twenty from Man. cc deecce cccke crlscisine Clee name 7.662 
Largest twenty from the pigs... vivccies be selec sane 6.466 
DIMOTONCE Ss ..5:05 cs,s:e orosserie 4.08's bala eaielreleqarstaicle nt 1.196 
This equals 0.000047 of an inch = sy37z, inch. 
Smallest fifty from man... < i.eescs eee ce atin wereeeetnee 7.768 
Largest fifty from) the Dig’. 5 scence ccsieccalelererasatetelsion terete 6.246 
) b) bi) 9-) 1 1e: eRe AACR Ne Sanrio ns aoa And sec 1.522 
This equals 0.000060 of an inch = ggg inch. 
Smallest, hundred from MAN 5.1. cslssniciastes wie ne ele 
Largest hundred from the pig........cccceccserevsesceees 6.169 
Difference. (cess lantasalhc a cate csc aelavasee Cee eee eae 1.683 


This equals 0.000066 of an inch = zg}¢y inch. 


We thus see that where only 10 corpuscles are meas- 
ured in man, taking the smallest average of 10 consecu- 
tively measured, this average for an adult man is one- 
sixth larger than the largest average of 10 consecutive 
corpuscles measured from a young pig only three weeks 
old; while the average of the smallest 100 from man, 
taken consecutively, is about one- -fifth, 7g, larger than 
the largest 100 taken from the young pig. 

Professor Ewell says: “Drying the blood éorpuaanten 
in a clot multiplies the difficulty of identification. It has 
never been proven that dried corpuscles can be restored 
to their normal proportions.” 

I would eall attention again to the table on p. 84 of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood Stains, 
Blood Stains, 


ee eeesesesesoseseseseseeeee 


the present volume, which gives the measurements of 
3,000 corpuscles of fresh human. blood, including males 
and females, of all ages, from infants at birth to the man 
of seventy. The measurements are in microns. 








Number of orpeee Aver-|Max.| By | By | By | By | By 
individuals. puscles. | 28°: Min. | 10s. | 20s. | 50s. | 100s. | 200s. 























15 persons as haw \| 4.233] 7.658] 7.662 7.768] 7.852) 7.913 

stated, | ¢ 3000 [7.998 | 4760 81298) 81191] 8.079) 81046) 71983 

Phu ..|{ 1000 F.10j i bis B0 5.880] 6.028] 6.069 
: "757| 5. 

Byoung pigs.|} 600 |6.101}| 3-4| 8:49u] 6 absl Gavel Gciool Grtae 














Here we see that the average of 1,000 corpuscles re- 
stored and measured from stains of human blood is 7.910 
microns, all probably being stains from the blood of 
adults; while the average from fifteen persons (three be- 
ing infants) is 7.988 microns. The maximum, where in- 
fants are included, in fresh blood is a little more widely 
separated from the minimum than in the restored stains 
from adults. So also the range, when taken by tens or 
by twenties, is a little less for restored blood than for fresh 
blood, for the same reason. No closer similarity of re- 
sults could have been expected had all the measurements 
been taken from fresh blood; one set including infants 
and the other being taken from adults alone. The fact 

that there is this difference, as given above, goes to show 
the great accuracy and perfect restoration of dried blood 
corpuscles to their normal dimensions. 

As a further confirmation of the possibility of restoring 
dried blood stains to a condition in which their dimen- 
sions can be properly compared with fresh blood cor. 
puscles, I copy by permission the following table from 
Professor Wormley’s “ Microchemistry of Poisons.” 


EXAMINATION OF OLD BLOOD STAINS. 























7 Fresh 
Animal. Age of stain. Remarks. we 
(1) Human .| 2 months old..} Stain, unknown .| 1-3358 
(2) Human .| 2% “ a foi UIA see or eae ale 1-3236 
(8) Human .| 3 a i Stain cccaeeses ve 1-3334 
(4) Human .| 19 iy es ClOL Ree ence vite 1-3290 
(5) Elephant | 13 a ClOD Perea Metaerttee 1-2849 
(6), Dog..... 4 a Sy Trace of stain, 

unknown ...... 1-3626 1-3561 

(7) Rabbit ..| 18 s * Clots ae woke: 1-3683 1-3653 

AB )i OX cictee,s.0 16 eS Me Siginner crates 1-4544 1-4219 

COWOK . cns s,s 32 oe * ..| Stain, unknown .| 1-4495 1-4219 

CLOOX es 1: AVG VOATS les «tel C1Ob sc cteisteraartiee ele 1-4535 1-4219 

Miiyeputtato.. | 18 Months =* V1 Clot... cececsae. 1-4312 1-4351 

(12) Goat ....| 17 a eames OAL Tce a ciccitrtaee 1-5897 1-6189 

Kis)iIbex::.;.. 18 ne Seda OLOL sce pare vreanaes 1-6578 1-6445 


“In the case of the human blood No. 1, two months 
old, the deposit was in the form of a thin stain on muslin, 
and its nature, other than that it was mammalian blood, 
was unknown at the time of examination. The cor- 
puscles were readily found, and two series of thirty cor- 
puscles were measured. In the human blood two and a 
half months old, fifty corpuscles ranging from 5753 to 

ry; of an inch were measured. 

“The blood stain of the dog, No. 6, was prepared by 
Dr. Frankenberg, and consisted of a single stain so mi- 
nute as to be barely visible to the naked eye; its nature 
at the time of the examination was unknown. In this 
instance only fifteen corpuscles were measured. In the 
ox blood four and a half years old, the corpuscles were 
rather readily obtained, and two closely concordant series 
of measurements were made.” 

Another table, quoted by Clark Bell, Esq., in his 
article on “Blood Stains” in the Medico-Legal Journal, 
September, 1892, p. 157, is worthy of careful study in 
this connection. It shows results of examinations of 
blood dried on knives, glass, wood, cloth, paper, and 
stone, with measurements corresponding very closely 
with measurements of fresh blood. 





I take great pleasure in acknowledging my obligations 
to Professor Ewell, from whose valuable articles on 
micrometric study of 4,000 red blood corpuscles, pub- 
lished in the Medico-Legal Journal for September, 1892, 
I have compiled the following table: 












































S¢/_,/ ¢] 4/28/28 
Source of blood. B3il=8| & 5/28/88 
23/9 5 | SR| ed 
BE|8S| 3 | 2 | eal] ee 
zS/S8| a | & |e" |B 
ROBUSGINEN secttats sitecien ones 650 | 8.03 | 9.98 | 5.08 | 8.28 | 7.95 
Boy thirty-six hours old...... 200 | 8.86 | 11.89 | 5.70 06 | 8.65 
FAG TTI ee Agan sGnnORrCOOe 100 | 7.85 | 9.82) 6.%¢ 60 
Purpura hzemorrhagi¢ca....... 200 | 8.25 | 10.87 | 8.45 | 8.28 | 8.25 
2cases pseudo-leucocythzmia| 400 | 8.04 | 11.04) 6.56 | 8.55 | 8.42 
Tuberculosis, anzemic........ 100 | 8.385 | 10.70} 5.35 950 
PlumbismMesicn seiscees come cess 100 | 8.65 | 10.10} 5.18 
GaStritls ores unica cvewicle tives 100 | 8.82 | 10.18} 6.22 | ... aoe 
2 cases Syphilis.............6 200 | 8.11 | 9.382) 3.97 | 8.11 } 8.11 
YYSINCIAGS ciceniactceneniteeectes TOOT 7.83. eS ULGrRG: OO bie eel sane 
Pernicious anzwemia........... 100 | 7.69 | 9.93 | 6.04 
MENSITUBI DOOM ss cess neces LOO FT B80 5.76 
Whole number measured. .| 2,350 | 8.14 | 11.89] 3.45 | 9.06 | 7.95 














In regard to the alterations of blood in disease, it is to 
be noted that no disease causing smaller average sizes of 
the blood corpuscles of the lower animals can have any 
tendency to cause such blood to be mistaken for human. 
If it was sought to ascertain whether a given stain, with 
corpuscles less than 3-55 Or giz Of an inch, could 
have been obtained from a diseased human being, found 
by examination to have very small corpuscles, such a 
case would be judged by the facts discovered and possi- 
bly be indeterminable. 

If we take 3355 of an inch or 7.987 microns as the gen- 
erally accepted average diameter of human blood cor- 
puscles, and with it compare the average obtained by 
Professor Ewell from blood in disease, we find his largest 
average in plumbism, or lead poisoning, is 8.65 microns, 
or one-twelfth part larger than the normal average. 

Now, if we take the young pig, which, excepting the 
dog, is the domestic animal having the largest corpuscles, 
and to the normal average, 6.101 microns, add one-twelfth 
its diameter, or 0.508 micron, we shall obtain for a pos- 
sibly diseased pig an average diameter of 6.609 microns; 
which is smaller by 1.318 microns than that of the average 
human blood corpuscle. This difference when viewed in 
the microscope with a magnifying power of 2,500 diame- 
ters, the same power used in the photographs reproduced 
in Figs. 612 and 613, is equal to more than two and a half 
divisions of the scale in Fig. 6138. With only 1,000 diam- 
eters the difference would be greater than one division of 
the same scale. Certainly no microscopist of ordinary skill 
would be in any danger of confounding blood of such a 
diseased pig with human blood recovered from a stain. 

The only remaining possibility of mistaking stains from 
the blood of a pig, ox, horse, sheep, or goat for human 
blood, when fifty or one hundred corpuscles have been 
measured and found to average 7.9 microns, or even 7 mi- 
crons, is to suppose it possible that the expert has wickedly 
and purposely measured only the largest corpuscles and has 
not done honest work. Witha magnifying power of 1,000 
diameters, a Jackson’s micrometer measures with great 
certainty spo, Of an inch. Professor Ewell’s filar mii- 
crometer, as he states, is graduated to zoptnay Of an 
inch, and is certainly reliable to s5}55 of an inch, equal 
to one of the divisions on the above scale. Hence no ex- 
pert can have any difficulty in recognizing with absolute 
certainty differences of 1.3 microns, equal 3455 of an 
inch. 

Professor Ewell says that “by selecting the corpuscles, 
it would be possible for a dishonest observer to make the 
average much larger or smaller than the above given [in 
his table] without the possibility of detection; a fact, the 
bearing of which upon the value of expert testimony 
upon this subject is so obvious as to need no comment.” 
I have never claimed, and shall not now claim, that it is 


89 


Blood-Vessels, 
Blood-Vessels, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








any more difficult fora witness to swear falsely in regard 
to blood stains than in regard to any other subject. But 
it would be quite possible on cross examination to ask 
the expert whether, in measuring the corpuscles obtained 
from a stain, he had measured all the well-defined cor- 
puscles in the field of the microscope, or whether he had 
selected the large corpuscles and rejected others which 
were smaller, 

In treating blood stains with solvents of fibrin, to 
liberate the corpuscles for measurement, it has been found 
in many cases that the corpuscles were smaller than in 
fresh blood unless maceration was long continued, old 
stains requiring several weeks before the corpuscles were 
in a condition to be measured. When a biconcave blood 
corpuscle is placed in water, the coloring matter (hamo- 
globin) is dissolved out, the corpuscle swells up, thickens 
at the edges, becomes transparent and spherical. In this 
condition the diameter of the corpuscle becomes less than 
normal. It thus happens in examining blood stains that 
ail corpuscles which have lost their color or have become 
spherical are by some experts rejected and not measured. 
Some corpuscles in fresh blood have much more coloring 
matter than others, and these corpuscles retain their 
color and form (as we think) much longer than paler cor- 
puscles. We are not aware that any fluid used or likely 
to be used for softening blood stains will cause the cor- 
puscles to become larger than normal. In this statement 
the most noted authors agree. 

If the corpuscles obtained from a stain do not recover 
their normal dimensions it is almost absolutely certain 
that their average measurement will be less than normal 
and never greater than normal. Thus, in the language 
of Professor Wormley, we may confidently say: “ Thus, 
then, while the blood of man might on account of contrac- 
tions in diameter of the blood corpuscles be confounded with 
that of some animal having smaller corpuscles, the reverse 
could never occur.” 

From this discussion I claim that it has been proved 
beyond any reasonable question: 

1. That in favorable cases blood stains can be so 
treated that reliable measurements and credible diagnosis 
of their origin can 
b: given,as shown 
in the tables given 
anl in others 
which might be “jia) tissue 
referred to. Internal elas- | 

2. That if error tic membrane } 
occurs on account 
of imperfect res- 
toration of the 
form and diameter 
of the corpuscles 
obtained from a 
stain, proved (by 
(a) the guaiacum 
test; by (0) the 
spectroscope; by 
(c) the production 
of heemin crystals) 
to be blood, the 
error, if any, will 
be to make human 
blood appear like 
that of one of UNO Spears elas 
inferior animals, tic snaioneney 
and never to mis- 
take the blood of 
the ox, pig, horse, 
sheep, or goat for 
human blood. 

3. In general, 
when a stain has 
been proved to be 
blood by the above 
tests, it may be 
decided certainly 
whether it is or is 


Endothelium 
Subendothe- t 


Involuntary t 
muscle 


Elastic tissue 


Fib1 0-elastic t 
tissue 


Vasa vasorum 


90 





FG. 621.—Section of Human Radial Artery. 





not mammalian blood. So, also, a stain from the blood 
of the ox, pig, horse, sheep, and goat may be distin- 
guished from human blood, thus confirming the claim 
of an accused person in many cases that his clothes are 
not stained with human blood. This negative testi- 
mony is certainly quite as important in many cases as 
testimony inculpating a prisoner. 

Lastly, the expert can say, when the average of a suit- 
able number of corpuscles from a blood stain corresponds 
with the average of fresh human corpuscles, that the stain 
is surely not from the blood of the ox, pig, sheep, or goat. 

Such testimony by a skilled microscopist is of untold 
importance in saving the lives of the innocent, and often 
in overthrowing the plea of those who are guilty. Such 
testimony is quite as reliable and important to the wel- 
fare of society as that of the chemist who testifies to the 
presence or absence of poison that might have some re- 
semblance to the many recently discovered ptomains. 

The testimony of the expert might take the following 
form, as recommended by C. H. Vibbert, “Précis de 
médecine légale”: 

“This stain is not composed of the blood of such an 
animal [ox, sheep, horse, pig, or goat] as the accused 
claims. It is like the blood of man, or some animal hav- 
ing corpuscles very nearly the same size as those of man, 
as the dog or rabbit.” 

Or the declaration may take the reverse form, thus: 
“This stain is 20¢ composed of human blood; it might be 
the blood of a horse, ox, pig, sheep, or goat, as claimed 
by the accused.” 

Such declarations are justified, then, and then only, 
when the examination has been conducted with great 
care and the measurements have been made with reliable 
instruments. Moses C. White. 


BLOOD-VESSELS, HISTOLOGY OF.—TxHE ARTE- 
ries.—An artery consists of three coats, which, named 
from their relative 
position, are the 
inner, the middle, » 
and the outer. 
The structure and 
relative thickness 
of these coats vary 
in vessels of large, 
medium, and 
small calibre. A 
medium-sized ar- 
tery, such as the 
radial, shown in 
the accompany- 
ing illustration 
(Fig. 621), has 
been taken as the 
type and first de- 
scribed in detail, 
the structural pe- 
culiarities of the 
larger and smaller 
vessels being sub- 
sequently noticed. 

The znner coat, 
or tunica intima, 
is the thinnest 
coat of the artery 
and consists of 
three distinct 
structures: (@) an 
endothelial lin- 
ing; (0) a layer of 
subendothelial 
connective tissue, 
and (c) an internal 
elastic membrane. 
The _ endothelial 
lining consists of 
a single layer of 
flat endothelial 







5 Adventitia 


cells, each containing a centrally situated nucleus of 
round or oval form. When examined in a transverse 
section of the vessel, in which the cells are seen in profile, 


the endothelial 
plates are  incon- 
spicuous, the nu- 
cleus often being 
the only part of the 
cell readily made 
out. Examined 
from the surface, 
after staining with 
silver nitrate, the 
boundaries of the 
individual cells are 
clearly defined by 
the darkly tinted 
cement substance 
which unites the 
endothelial plates. 
In such _ prepara- 
tions the lining 
cells appear spin- 
dle-shaped or lan- 
ceolate in form, 
their long axes cor- 
responding with 
that of the blood- 
vessel. Careful ex- 
amination of the 
outlines of the cell 
shows these to be 
serrated or sinuous, 
contrasting with 
the more regular 
lines of apposition 
in epithelial tissue. 
The lining cells of 
blood-vessels were 
first described by 
KOlliker and others 
as epithelium; 
later, His applied 
to them the name 
endothelium as 
more appropriate 
for elements de- 
rived from meso- 
derm and closely 
related to serous 
surfaces. In prin- 
ciple, endothelial 
cells are modified 
connective-tissue 
elements. 

The  subendothe- 
lial layer consists of 
bundles of white 
fibrous connective 
tissue interwoven 
with a delicate net- 
work of elastic 
* fibres, and meagrely 
distributed branch- 
ed connective-tissue 
corpuscles lying 
within the lymph 
spaces of the tissue. 


The internal elastic membrane appears in arteries of 
medium size as a structureless, glistening, corrugated 
band that stands out as the most conspicuous structure 
It constitutes the most external layer of 
the latter and forms a sharp line of demarcation between 
the narrow and faintly stained intima and the broad and 
While apparently a homo- 
geneous membrane in the smaller arteries, in vessels of 
large size the internal elastic membrane is represented by 
a number of delicate lamell of elastic tissue, which are 


of the intima. 


more deeply tinted 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood-Vessels, 
Blood-Vessels, 





Endothelium 


Subendothe- 
lial tissue 
Internal elas- 
tic membrane 


Involuntary 
muscle 


Elastic tissue 


External elas- 
tic membrane 


Fibro-elastic 
tissue 


media. 


' 





Foxx: Mm 


Fic. 622.—Section of Human Aorta. 


pends. 


oblique course. 


pierced by apertures of varying size. 
ture in these cases has been appropriately named the 
Jenestrated membrane of Henle, in recognition of the an- 


Intima 


Media 


Adventitia 


The entire struc- 


atomist who called 
attention to its pe- 
cullar arrangement. 
The majority of the 
elastic fibres form- 
ing this reticulated 
network run longi- 
tudinally, but are 
intermingled with 
some oblique fibres 
as well as a limited 
number of branched 
connective-tissue 
corpuscles. 

The middle coat, 
or tunica media, is 
the thickest coat of 
the artery. It con- 
sists of circularly 
disposed lamellz of 
involuntary mus- 
cle intermingled 
with connective tis- 
sue in which elastic 
fibres are conspicu- 
ous. The individ- 
ual muscle cells are 
irregularly spindle- 
shaped, often with 
ragged outlines, 
and possess the 
characteristic rod- 
shaped nuclei. The 
muscle cells of the 
media are shorter 
and thicker than 
the slender and 
more elongated cor- 
responding ele- 
ments in other 
localities. The in- 
dividual cells, held 
together by inter- 
stitial cement sub- 
stance, are grouped 
into illy defined 
bundles, which are 
closely associated 
with small spiral 
bundles of white 
fibrous and elastic 
connective _ tissue, 
the whole forming 
the most compact 
coat of the artery. 
The elastic fibres 
are very numerous, 
and, in ordinary 
preparations being 
almost unstained, 
stand out in mark- 
ed contrast among 
the more deeply 
stained masses of in- 
voluntary muscle. 


The external coat, or tunica adventitia, is composed of 
closely felted bundles of white fibrous and elastic tissue 
arranged in fine wavy masses. 
have a longitudinal direction, while others pursue an 
Connective-tissue cells are present in 
considerable quantity. While looser in texture and ap- 
parently of less strength, the adventitia is nevertheless 
more resistant than either of the other coats, and is the 
tunic upon which the integrity of a ligature chiefly de- 
The walls of the arteries are nourished by a 


Many of these bundles 


91 


Blood-Vessels,. 
Blood-Vessels. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











special system of minute vessels, the vasa vasorum, which 
enter the adventitia and penetrate the media. The vasa 
vasorum do not spring from the vessels which they sup- 
ply, but are usually derived from neighboring arteries, 
the blood flowing through the larger vessels having as a 
rule no direct relation with that within the vasa vasorum. 

The differences distinguishing the coats of a large 
artery from those of a vessel of medium size consist, in 
general, of an increase in the thickness of the various 
tunics, as shown in the accompanying Fig. 622. 

The immediate lining of even the largest arteries con- 
sists of a single layer of endothelial cells; the subendo- 
thelial tissue, however, is greatly thickened not only 
relatively but also absolutely. The subendo- 
thelial bundles of white fibrous tissue are 
coarser, and the elastic tissue is present in 
greater amount and constitutes the fenes- 
trated elastic membrane of Henle. The me- 
dia likewise is thicker, the increase, however, 
being due not so much to the 
greater amount of involuntary mus- 
cle as to the addition of fibro-elas- 
tic tissue, which here bears a much 
greater proportion to the muscular 
tissue. This increase of fibro-elastic 
tissue is responsible for the diminu- 
tion of elasticity and the increased 
stiffness which characterize the 
walls of the larger arteries. The 
clastic tissue of the media in the 
latter vessels is often condensed. to 
form an eaternal elastic membrane, 
which defines the boundary be- 
tween the media and the adventitia. 
The adventitia is also thicker, but the increase in this 
tunic is proportionately less than that affecting the in- 
tima and media. The adventitia of small arteries, in 
relation to the other two coats, is thicker than that of 
the large arteries. 

The small arteries and arterioles, on the other hand, 
differ from the medium-sized vessels by a reduction in 
the thickness of their coats. The subendothelial tissue 
almost entirely disappears, while the involuntary muscle 
of the media is reduced to an attenuated layer of muscle 
cells, with little or no admixture of fibro-elastic connec- 
tive tissue. Theadventitia consists of a few longitudinal 
bundles of fibrous tissue, with often an absence of elastic 
fibres. 

The capillaries are microscopic vessels establishing 
communication between the arteries and the veins. In 


Adventitia 


Capillaries 

{ Nuclei of 
~ endothe- 
‘lial plates 


Connec- 
tive-tissue 
cells 





F1G. 623.—Capillary Blood-Vessels from Mesentery of Dog. X 240. 


the tips of the fingers, the tips of the toes, the tip of the 
nose, the splenic pulp, and the erectile or cavernous tissue 
of the genital organs the arteries communicate directly 
with the veins. A capillary consists of a single layer of 


92 


nucleated endothelial cells united by a small amount of 
intervening cement substance. By reason of the char- 
acter of their thin walls, they are virtually protoplasmic 
tubes admirably adapted to facilitate the distribution of 
nutritive fluids to the tissues or, as in the pulmonary 
alveoli, to the interchange of gases. As the capillaries 
become larger a delicate tunica adventitia is superadded, 
which is formed of a 
delicate network of 
fine fibrils, composed 
of the processes of 
stellate cells lying di- 
rectly upon the vascu- 







} Fibro-elastic 
tissue 


Elastic tissue 
} Involuntary 
muscle 
j Internal elas- 
tic membrane 
| Subendothe- 
lial tissue 
Endothelium 


Fic. 624.—Section of Human Radial Vein. 


lar walls. Each of these stellate cells consists of a 
large elongated nucleus, invested by an extremely deli- 
cate layer of protoplasm. The protoplasm of which 
the cells are composed is always more abundantly and 
distinctly granular toward the centre and around the 
nucleus, whilst near the margin it is quite clear, and 
thins off to a delicate border. The capillaries by their 
union constitute the capillary plexuses, vetéa capil- 
laria, Which are more or less constant in the different 
organs. The forms presented in these plexuses depend 
to some extent upon the disposition of the elementary 
parts, and are also in some degree dependent upon the 
energy of the function. There are in many organs cer- 
tain tissues into which vessels never penetrate,—as the 
transversely striped muscular fibres, the nerve fibres, cells 
of all kinds, gland acini,—and which, therefore, accord- 
ing to their form, trace out definite courses for the capil- 
laries, so that they sometimes present elongated meshes, 
sometimes rounded, narrower, or wider reticulations. 

The mode in which the capillaries pass into the larger 
vessels is interesting. On the arterial side it is found 
that the capillaries, as they become wider, present more 
closely placed nuclei, and are then invested externally 
witha structureless tunica adventitia and solitary muscle 
cells, the whole structure exhibiting the aspect of ar- 
terioles. On the venous side the transitionary vessels are 
less characteristic for a greater length. The first thing 
that is superadded, on this side, to the capillary wall is 
an external, homogeneous nucleated layer, which.may be 
regarded asa sort of connective tissue—the tunica adven- 
titia,—forming a distinctly laminated structure, the vein- 
iol. Besides the finest capillaries, which, bowever, al- 
ways admit the passage of very flexible blood corpuscles, 
some observers have admitted the existence of still finer 
vessels, the so-called vasa serosa, Which no longer allow 
of the passage of blood, but only of its plasma. Hyrtl 
thinks that it is necessary to admit of the existence of 
vessels of this kind in the cornea. 

Among the structural peculiarities of certain arteries. 
may be mentioned the slight development, or even com- 
plete absence, of the subendothelial connective tissue 
in the celiac, the external iliac, the mesenteric, the renal, 
and the uterine arteries of young individuals. The aorta. 


possesses a marked development of the subendothelial. 


~ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood-Vessels, 
Blood-Vessels, 





connective tissue, as well as the presence of longitudinal 
muscle cells within the intima. Longitudinally disposed 
muscle is present in the media of the subclavian artery 
and in the adventitia of the iliac, the superior mesenteric, 
the splenic, the renal, and the dorsalis penis, as well as in 
the umbilical arteries of the foetus. Some arteries, notably 
the vessels within the cranial cavity and the vertebral 
canal, possess coats which are very thin in proportion to 
their calibre. In these vessels, however, it is the media 
and the adventitia that suffer reduction, the intima re- 
maining almost unaffected. 

A typical vein, as shown in the accompanying drawing, 
(Fig. 624) has thinner walls and a larger lumen than the 
corresponding artery; to this rule, however, the pulmo- 
nary veins are exceptions, since they are of the same ca- 
pacity as, or of less capacity than, the pulmonary arteries. 
The constitution of the coats of a vein is less constant than 
it is in an artery, variations in the arrangement, propor- 
tion, and amount of the component tissues being very 
frequently encountered. 

The inner coat, or tunica intima, consists of (a) endo- 
thelial cells, (6) subendothelial connective tissue, and (c) 
elastic fibres. The endothelium is composed of a single 
layer of cells held together by interstitial cement sub- 
stance. The cells are shorter and wider than the corre- 
sponding lanceolated elements of the artery. The sub- 
endothelial connective tissue is very scanty in the majority 
of veins and rudimentary or even entirely absent in the 
smaller ones. The elastic tissue often represented by a 
few longitudinal bundles is less developed and does not 
form a fenestrated membrane. 

The middle coat, or tunica media, is much thinner and 
looser than in the artery, chiefly on account of the ad- 
mixture of connective tissue associated with the circu- 
larly disposed involuntary muscle cells. The élastic 
fibres, so conspicuous in the media of the artery, are very 
few in the vein. 

The external coat, or tunica adventitia, is the thickest 
coat of the vein, reaching often twice or even three 
times the breadth of the media. It consists of wavy 
bundles of white fibrous tissue, usually following a cir- 
cular direction, among which a few longitudinal fibres 
may be found; the greater number of the latter fibres 
are of the elastic variety, Connective-tissue cells are 
present in considerable number. The walls of the vein 
are nourished by vasa vasorum similar to those supply- 
ing the arteries. 

Many veins, especially those of the lower extremities, 
are provided with valves; these are crescentic folds of the 
intima, which are brought into apposition by the dila- 
tation of the pockets formed between the attached portion 
of the valve and the wall of the vessel. The valve con- 
sists of an extension and thickening of the fibro-elastic 
tissue of the intima, covered on each side by endothelial 
cells. The free edge of the valve is thicker than the at- 
tached border. 

The variations in the structure of veins depend largely 
upon modifications of the muscular tissue. The involun- 
tary muscle is best developed in the media of veins of 
the inferior extremities; in the veins of the gravid uterus 
involuntary muscle occurs in.the adventitia as well as in 
the intima. Additional longitudinally disposed bundles 
of muscle are present in the inner part of the media in the 
mesenteric, the iliac, the femoral, and the umbilical veins. 
Involuntary muscle is sometimes encountered in the ad- 
ventitia, in the abdominal cava, the axillary, the hepatic, 
ths external iliac, the superior mesenteric, the renal, the 
splenic, the spermatic, and the azygos major veins. The 
presence of striated muscle in the pulmonary veins and 
cardiac ends of the vene cave is to be regarded as an 
extension of the striped muscular tissue of the auricular 
wall. Robert Formad. 


BLOOD-VESSELS, PATHOLOGICAL ANATOMY OF. 
—TueE CAPILLARIES.—The capillaries are less independ- 
ent structures than the arteries and veins, and the 
pathological changes in the capillary wall are generally 
intimately connected with lesions in the surrounding 














tissues. The important rdle played by the capillaries in 
the different forms of inflammation is discussed in the 
article on Inflammation. 

All tissue proliferation, whether inflammatory or non- 
inflammatory, is almost without exception associated 
with the new formation of capillary vessels by processes 
of budding of pre-existing capillary endothelium, and 
these changes are described in the article on Regeneration. 

Capillary new formation lies at the bottom of tumors 
composed of capillaries, the capillary angiomata and 
teliangiectasias of congenital or acquired origin; they 
form mostly flat tumors of the skin and subcutaneous ° 
tissue, of a bright red colorand a soft feel; the capillaries 
in them have thick cellular walls, and there is abundant 
evidence that new capillaries have beenformed. Similar 
changes occur in capillaries in other tumors (see 7umors). 

Long-continued congestion will result in dilatation of 
the capillaries, capillary ectasis or capillary aneurism; 
this is shown well in passive congestion of the lungs. 

Hyaline degeneration of the capillary walls is frequently 
observed in the brain, especially in paralytic dementia, 
but also in the kidney, the conjunctiva, the lymph glands, 
and in various tumors. Hyaline degeneration of the 
glomeruli is an important alteration in chronic nephritis, 
especially the interstitial form. Hyaline degeneration is 
a rather vague term and the exact origin of hyaline ma- 
terial is not understood. In certain tumors mucoid de- 
generation of the capillary walls sometimes takes place. 

Mallory in his study of colloid or hyaline changes in 
the brain shows that the material is always deposited in 
the vessels; in the larger vessels the middle coat is earliest 
and most affected. The hyaline material has a marked 
tendency to calcification, and in some cases the capillary 
network of the central cortex, the dentate nucleus, and 
the granular layer of the cerebellum undergoes hyaline 
change with calcification; this causes atrophy of the in- 
cluded nervous tissue and leads to the formation of sand- 
like deposits and of stone-like concretions. 

Fatty changes in the capillary epithelium* occur fre- 
quently, especially in the nervous system and in the 
various toxic and infectious states. The lesions in the 
capillaries that may underlie the tendency to spontaneous 
hemorrhage in the hereditary and acquired hemorrhagic 
diathesis have not yet been cleared up; in these condi- 
tions it is difficult to determine whether the hemorrhages 
result from diapedesis or from rhexis. The relations of 
the capillaries to thrombosis and embolism are described 
in the articles dealing with those subjects. 

Calcareous infiltration of the capillary walls occurs in 
the brain of old people; generally calcification is pre- 
ceded by hyaline degeneration. Calcification of the capil- 
laries also takes place in certain tumors, especially psam- 
moma. 

Amyloid degeneration is an important change in the 
capillary walls, observed always in the capillaries of the 
spleen, kidneys, liver, etc., in general amyloidosis. The 
amyloid material appears first in the delicate capillary 
sheath outside of the epithelium, which is soon crowded 
to one side and the lumen closed. 


Tur ARTERIES AND VEINS. 


ABNORMITIES.—Congenital abnormities of blood-ves- 
sels may concern width, thickness of wall, origin, and 
course. Deviations from the normal in these respects on 
the part of the smaller and medium-sized vessels are con- 
sidered to best advantage in connection with the normal 
anatomy of blood-vessels. 

The congenital defects and anomalies of the pulmonary 
artery and aorta are closely associated with defects and 
anomalies of the heart. Among the important irregu- 
larities of the primary vessels is transposition of the aorta 
and the pulmonary artery. This may occur in hearts 
that are not otherwise defective or in association with 
other developmental anomalies of the heart. Transposi- 


*The term “epithelium” is used in place of endothelium in this 
article.—L. H. 


93 


Blood-Vessels, 
Blood-Vessels, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





tion of the ven cave and the pulmonary vein is also 
described. In nearly all cases of this kind the foramen 
ovale is open to a greater or less extent and generally the 
ductus arteriosus is pervious. In some cases the only 
communication between the two circulatory systems was 
through the widely open foramen ovale. Death occurs 
in early infancy. 

The septum between the aorta and pulmonary artery 
may be defective. In an instance of this kind that I ex- 
amined there was an oval defect about 1.5 cm. in its 
greatest diameter between the pulmonary artery and the 
aorta, so that the beginning of the aorta and pulmonary 
artery had a common trunk from which emerged, in the 
usual places, the right and left pulmonary arteries and 
the branches of the arch of the aorta. The ductus arteri- 
osus was patent and large, the aorta distal to the duct 
wider than that proximal to the duct. The foramen 
ovale was widely open. The large veins and the heart 
were normal. 

Instances of aortas with double arches are described by 
Hommel, Curnow, Malacarne, Zagorski, Welch, and Lee 
Shaw. According to Lee Shaw, Hommel, in 1737, was 
the first to record this anomaly. In his case the two 
divisions united after encircling the trachea, and passed 
downward on the left side of the vertebral column. 
Malacarne’s report, as described by Meckel and Quain, 
differs from all the others. Five valves guarded the 
aortic opening of the left ventricle and the arterial trunk 
immediately divided into two branches, which before 
uniting embraced the pulmonary artery, trachea, and 
cesophagus; from each division was given off in succes- 
sion a subclavian, an external, and an internal carotid 
artery. In Welch’s case, the posterior branch passed be- 
tween the trachea and cesophagus, and from each division 
arose a common carotid and a subclavian artery. On the 
posterior branch was found an aneurism from which the 
right common carotid took origin. Lee Shaw’s speci- 
men differs from all of those described except Mala- 
carne’s, in that the two divisions unite behind the cesopha- 
gus. It differs from all in that the right branch is the 
larger, the junction of the two branches is on the right 
side, and the descending aorta passes downward on the 
right side, to the upper border of the eighth dorsal verte- 
bra. This arrangement not cnly resembles the vascular ar- 
rangementin the reptile, butalso more closely follows the 
distribution in the bird than it does that in the mammal. 

Such anomalies of the aorta are probably due to the 
persistence and enlargement of fetal vessels which nor- 
mally become obliterated. From the embryonal aortic 
bulb two vessels arch backward, one on either side of the 
foregut, forming the first pair of vascular arches, and de- 
scend along the sides of the notochord as the primitive 
aorte. As the heart gradually moves away from the 
head, four more pairs of vessels develop, which connect 
the bulb with the descending trunks; making in all five 
pairs of arches, one for each branchial plate. Zimmer- 
man describes an additional pair between the fourth and 
fifth. 

“The bulb, primarily a single cavity from which, 
through two common trunks, one on each side, blood is 
sent to all the arches, is divided by a septum parallel to 
its long axis into two compartments: one becoming the 
pulmonary artery, situated anteriorly, and continuous 
with the fifth pair of arches, the other forming the sys- 
temic aorta, placed posteriorly, and communicating with 
the fourth pair, through which all the arches above re- 
ceive their blood supply. Notwithstanding this separa- 
tion near the heart, both pairs of arches, 7.e., the fourth 
and fifth, ultimately empty into the descending aorta 
which has been formed by the coalescence of the primitive 
aorte. 

“This symmetrical arrangement of the vascular system 
is soon destroyed by the obliteration of certain vessels. 
Even before the last arch is perfectly formed the connec- 
tions between the first pair and the descending aortze 
may be destroyed. However, the fourth and fifth arches, 
lying nearest the heart and soon exceeding the others in 
size, are the chief factors in this transformation. The 


94 


vascular arches on the left side continue to increase in 
size and in greater part become permanent. while those 
on the right gradually become obliterated, except where 
they furnish the supply to permanent arteries. 

“On the left side the fourth arch becomes the arch of 
the aorta and, in the fcetus, is constructed between the 
origin of the left subclavian and the junction of the 
ductus arteriosus, forming the isthmus, which soon after 
the closure of the duct attains the diameter of the ad- 
jacent trunk. The fifth, on this side, forms a part of the 





Fic. 625.—Stenosis of Aorta at Ductus Arteriosus. 
Cruveilbier.) 


(Modified from 


left pulmonary artery and the ductus arteriosus, which 
is occluded soon after birth but remains as a round cord. 
On the right side the fourth arch is permanent for a. 
short distance as the innominate and right subclavian 
arteries, as far as the origin of the vertebral, beyond 
which it diminishes in size and finally disappears. Only 
a small portion of the fifth persists on this side as the 
root of the right pulmonary artery; the distal portion 
becomes obliterated.” 

In Lee Shaw’s case, the fourth arch on the right side 
not only remained patulous, but exceeded the left in size. 
The fourth arch of the left side retained some of its fetal 
characteristics, because it was doubtless unnecessary for 
the isthmus to enlarge after occlusion of the ductus. 
arteriosus, as the blood current could easily pass through 
the right arch. 

Premature obliteration of the ductus arteriosus has. 
been described as causing an abnormal smallness of the 
pulmonary artery. The pulmonary artery may divide 
at a point lower than usual, or arise by two distinct. 
roots, instead of continuing into the aorta as the ductus. 
arteriosus; it may form the left subclavian artery. Sup- 
plementary or vicarious branches distributed to the lungs. 
may arise from the aorta as far down as the ceeliac axis. 

In narrowing or obliteration of the aorta after having 
given off the vessels to the head and upper extremities, 
the inferior parts of the body are supplied with blood 
from the pulmonary artery through the ductus arteriosus; 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood-Vessels, 
Blood-Vessels, 








the descending aorta is said to be given off from the 
pulmonary artery. Now if the degree of constriction of 
the aorta be but slight at the time of birth, the ductus 
arteriosus may become closed. Later in life great nar- 
rowing and even complete obliteration of the aorta may 
take place (Fig. 625). 

The theory usually offered in explanation of the patho- 
genesis of this condition was first broached by Skoda in 
1855. The narrowing is made dependent upon the pres- 
ence in the walls of the aorta of embryonal connective 
tissue connected with the ductus arteriosus; the post- 
natal involutional changes then lead to varying degrees 
of stenosis of the lumen of the aorta. Aberrant vestiges 
of duct tissue may occur in the aortic walls. Throm- 
bosis of the aorta beginning in the ductus arteriosus 
may end in complete aortic obliteration (Rauchfuss),. 

Of 1138 cases of narrowing and closure of the aorta at 
or near the opening of the ductus arteriosus studied by 
Wadstein, atresia was present in 20. In 16.4 per 
cent. the maximum narrowing was above the duct, in 
33.8 per cent. on a level with the duct, and in 44.8 per 
cent. below it.» The narrowing issometimes double. In 
about a third of the cases the aorta was sclerotic, and 
generally more so on the proximal side of the narrowing. 
The most important secondary changes are hypertrophy 
of the left ventricle and the formation of collateral cir- 
culation, the blood reaching the lower portion of the 
body through the intercostals and the abdominal aorta, 
through the superficial epigastric and long thoracic 
arteries and the deep epigastric, and through the anasto- 
moses of the intercostals with the ilio-lumbar and cir- 
cumflex iliac arteries. 

The ductus arteriosus isasarule completely obliterated 
within from one to two weeks post partum. The oblitera- 
tion is accomplished by contraction and endarterial prolif- 
eration. The resulting scar in the wall of the aorta often 
becomes calcified. Incomplete involution of the ductus 
arteriosus may become the occasion for thrombosis; the 
thrombus may project into the aorta and into the pul- 
monary artery and give rise to embolism (Klob). 

Transposition of the large veins occurs in connection 
with cardiac abnormities. There may be two ascending 
or two descending ven cave, in the first case due to 
failure of union of the canals of Cuvier; less than or 
more than four pulmonary veins, which may be inserted 
into the superior vena cava, into the left innominate vein, 
or into the ventricles. Either of the vense cave may be 
absent. An apparent reduplication of the inferior vena 
cava results from the union of the hepatic veins in one 
stem, which may empty into the vena cava above or be- 
low the diaphragm, or directly into the right auricle. 
The union of the iliac veins may take place higher than 
usual, the right and the left iliac vein continuing upward 
on each side of the aorta, sometimes as far up as the liver. 

Coronary Arteries.—Abnormities of the coronary ar- 
teries have been described by Hepburn, Turner, Brooks, 
and others. The most frequent deviation from the normal 
is an increase in number and irregularities in branching. 
Brooks describes the origin of a coronary artery in the 
right anterior sinus of Valsalva of the pulmonary artery ; 
this abnormal coronary anastomosed with the right 
coronary and acted as a vein owing to the greater press- 
ure in the aorta. In another, more complicated case, 
Brooks found an artery originating in the beginning of 
the pulmonary artery, anastomosing with the aortic 
coronaries and the left subclavian artery; it entered into 
intimate relations with a cirsoid mass at the base of the 
pulmonary artery. This vessel also acted as a vein, 
emptying its blood into the pulmonary artery. 

Aplasia or hypoplasia of an organ or part of the body 
is associated with absent or diminished development of 
the corresponding blood-vessels. Abnormal origin and 
course of arteries and veins are of greater surgical than 
clinical interest, because it is exceedingly rare to observe 
that such abnormities cause symptoms. The origin of 
the right subclavian artery to the left of the left sub- 
clavian artery and its coursing in front of or behind the 
cesophagus as it passes over to the right side may cause 











difficulties in swallowing, according to Eppinger. Dif- 
ferences in the size of the radial arteries and in the rela- 
tive depths of their situation frequently give rise to ap- 
parent differences in the pulse on the strength of which 
the existence of aortic aneurism may be erroneously diag- 
nosticated. 

Vascular Hypoplasia.—Congenital smallness of the en- 
tire cardio-vascular system is an interesting condition. 
Morgagni, Meckel, Rokitansky, and Virchow have drawn 
attention to this arrest of development, especially in chlo- 
rosis. The walls of the aorta are thin, the intima is the 
seat of wavy lines, and the lumen scarcely admits the 
little finger at a period when the aorta usually is twice 
or more as wide. The condition is frequently associated 
with arrested development of the reproductive organs 
and of the sexual characteristics of the body. Apparently 
the anomaly is probably more frequent in the female 
than in the male sex. It has been thought that a hypo- 
plasia of the entire mesoblast is present, including the 
blood-forming organs; hence the peculiar anemia which 
is thus explained according to Virchow’s theory. The 
explanation isno longer regarded as satisfactory. “That 
a disorder so common and for the most part so curable 
should depend upon a malformation so grave and so in- 
curable as this aortic and general vascular hypoplasia is 
on the face of it highly improbable ” (Clifford Allbutt). 

The developmental defects in the vessels in heemophilia 
are considered under the latter heading. 

RETROGRESSIVE CHANGES IN BLoop-VESsELSs.—Retro- 
gressive changes of blood-vessels pure and simple are 
not of so much importance as when associated with other 
processes in the condition known as angiosclerosis. 

Atrophy.—In chronic anemia and marasmus simple 
atrophy takes place in the walls of the blood-vessels, 
especially in the muscular coat. Atrophy of individual 
organs is followed by or associated with atrophy of the 
corresponding vessels. When an extremity is removed 
the arteries and the veins that nourished the part decrease 
in size by an atrophy that may be called adaptive; the 


EB 
2 
z 
2 
= 


FIG. 626.—Atrophy of Left Iliac Artery After Thigh Amputation. 
(Two-fifths natural size.) 


vessels become less and less until they carry no more 
blood than necessary for the nutrition of the remaining 
tissues (Fig. 626). In the beginning this adaptation is 
favored by contraction of the arteries and a little later 
by the development of new connective tissue in the in- 
tima, so that the lumen of the arteries is reduced in size. 


95 


Blood-Vessels, 
Bleod-Vessels,. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








Fatty Changes.—Changes in the composition of the 
blood or disturbances of circulation may induce fatty 
changes in the walls of otherwise healthy blood-vessels, 
especially in the epithelial cells and the muscle cells of 
the arteries. Fatty changes are of common occurrence 
in arteriosclerosis. A vessel the seat of fatty change 
presents upon its surface opaque white or yellowish- 
white patches and irregular lines, running longitudinally 
or forming a network, sometimes striated, sometimes of 
a uniform color. The surface is no longer smooth but 
velvety. These appearances are due to fatty granules 
and drops of fat inand between the epithelial cells. The 
change occurs also in the endothelial cells of capillaries. 
Cells may accumulate around and in areas of fatty 
change, taking up the oily detritus, and proliferation of 
cells also occurs. 

Disintegration of the degenerated areas results in small 
defects (“fatty ulcers”) which may become the starting 
point of thrombosis or traumatic and dissecting aneurisms ; 
on supervention of trauma or severe strain the deeper 
layers of the intima are ruptured and the blood current 
makes its way between the layers of the arterial wall. 
According to Paget fatty degeneration of the media is 
responsible for many instances of cerebral apoplexy. 
Fatty changes in the media are Common in various in- 
toxications. Fatty changes are frequently followed by 
calcareous infiltration, the arterial wall becoming rigid 
and inelastic. 

Fatty changes occur most commonly in the aorta and 
the pulmonary artery, and then in the arterioles and 
capillaries, especially of the brain. 

In veins fatty changes in the intima form white spots, 
but the veins are notas frequently affected as the arteries. 

Amyloid Degeneration.—The vascular system is espe- 
cially prone to amyloid change, which takes its beginning 
in the media of the arterioles of parenchymatous organs. 
It also develops in the intima of the larger arteries in 
extensive widespread amyloid change, appearing as fine 
striz and points, which are difficult to recognize with 
the naked eye unless first subjected to the action of 
Lugol’s solution (see Amyloid Degeneration). 

Hyaline Degeneration.—Hyaline degeneration of the 
smallest arteries and veinsand of capillaries is frequently 
observed in the spleen, the lymph glands, the renal 
glomeruli, and elsewhere. The epithelium, at first intact, 
is finally destroyed and the lumen narrowed and occluded. 
In the larger vessels hyaline degeneration appears first 
in the intima, and it formsan early step in the complicated 
degeneration of arteriosclerosis. Hyaline material tends 
‘to become calcified. A good example of a hyaline degen- 
eration of the muscular coat is seen in the pial arteries in 
tuberculous leptomeningitis. 

Calcareous Infiltration.—Calcareous particles in glisten- 
ing granules and as compact masses are frequently de- 
posited in hyaline and fatty areas; it probably does not 
occur as an isolated primary process, and is most fre- 
quent and most extensive in senile arteriosclerosis. 
Gazert found that in a normal aorta the amount of earthy 
material is .45 per cent.; in a sclerotic and calcified aorta 
the calcareous material equalled 8.79 per cent. of the dry 
residue. 

Metastatic calcification as a result of resorption in bone 
is said to involve especially the abdominal vessels, large 
calcareous plates forming which are separable from the 
surrounding tissues, 

In some instances trwe bone has formed in the walls of 
arteries the seat of petrification. Ossification means pre- 
liminary vascularization, absorption of pre-existing cal- 
careous material, and the formation of genuine bone. Von 
Schrotter and Falk describe with illustrations extensive 
ossification of arteries in senile gangrene; Cohn found 
true bone in the aortic valves and in the media of periph- 
eral vessels. 

Desquamation of the Epithelium.—In microscopic sec- 
tions the epithelium of the vessels, both arteries and 
veins, is found occasionally to have separated from the 
intima, the peculiar epithelial cells lying curied up in the 
lumen. This condition is not constant, and the peculiar 


96 





circumstances under which it occurs have not been estab- 
lished. The loosened epithelial cells have been mistaken 
for sarcomatous emboli. 

HYPERTROPHY AND HyPERPLASIA.—Hypertrophy and 
hyperplasia of arteries are observed in connection with 
various forms of tissue overgrowth, ¢.g., the uterus in 
pregnancy, large tumors, and the adaptive hypertrophy 
of one kidney in case of extensive disease or absence of 
the fellow kidney. Obstruction to the blood current and 
increased arterial tension, as in cases of hypertrophy of 
the heart and of chronic nephritis, produce more or less 
hypertrophy of the muscular coat of the arteries. The 
power of the arteries and veins to adapt themselves to 


. new conditions is best shown by the changes that take 


place in the development of collateral circulation. In- 
deed, this is one of the richest fields for the study of 
pathological adaptation. Vessels and vascular systems 
adjust themselves with wonderful precision to changes 
in pressure, in velocity, and in quantity of circulating 
blood. Readjustment is accomplished by virtue of the 
vaso-motor nervous mechanism and the physical proper- 
ties of the arterial walls, aided under special conditions 
by structural changes. The physiological prototype of 
collateral circulation is seen in the changes that occur in 
the fetal circulation after birth. The ease with which the 
important rearrangements to the conditions of extra- 
uterine life are accomplished indicates that the mechan- 
isms for adaptive changes on the part of the circulatory 
system are good; as in almost all pathological adapta- 
tions, the mechanisms are in better working order in the 
young than in the adult and the old. 

The extent of the changes incidental to the develop- 
ment of collateral circulation will depend naturally upon 
the location of the obstruction and upon the size and the 
number of the collateral branches. Formerly it was 
taught that the increased pressure above the obstruction 
was the cause of the development of collateral circula- 
tion; increased pressure is now regarded as a factor of 
little consequence. Nothnagel has shown that there is 
really no rise of pressure in the vessels above the obstruc- 
tion or ligature unless they stand in communication with 
branches below the obstruction. As advanced by von 
Recklinghausen, the increase in the extent of the capil- 
lary bed of the collateral branches, through which the 
blood flows into the capillaries of the obstructed vessel, 
results in increased rapidity of the current; and Thoma 
has demonstrated that increased rapidity of the current is 
followed by a widening of the lumen of the vessels, in- 
creased thickness of the wall, and growth in length. In 
this way the need of the tissues for blood is satisfied. 
The structural changes that take place in the walls of the 
collaterals may be regarded as the expression of a work- 
hypertrophy. And conversely, the gradual thickening 
of the intima of the occluded vessel as far back as the 
nearest collaterals is to be regarded as the result of 
diminished need of work. 

In obstruction to the portal circulation by cirrhosis of 
the liver the dilatation and hypertrophy of the veins 
through which collateral circulation is gradually estab- 
lished may become marked. In exceptional cases the 
cesophageal veins become enlarged to many times their 
normal size and afford so complete escape for the portal 
blood that the congestions and the ascites of cirrhosis 
fail to appear and the clinical picture of the disease is 
masked. . 

INFLAMMATION (ANGEDTIS, VASCULITIS).—Inflamma- 
tion may affect principally the adventitia, the media, or 
the intima (periarteritis and periphlebitis, mesarteritis 
and mesophlebitis, endarteritis and endophlebitis). On 
account of the structure of the venous wall, these dis- 
tinctions are not as marked in veins as in arteries. An- 
geiitis may assume various types, such as productive, 
suppurative, tuberculous, and syphilitic. Angeiitis may 
result from the extension of inflammatory processes in 
the neighborhood (consecutive angeiitis); it may be 
caused by wounds of arteries or veins and by other forms 
of trauma, such as tearing and crushing (traumatic 
arteritis and phlebitis); it develops as a result of infec- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood-Vessels, 
Blood-Vessels, 





tions (pyogenic, syphilitic, and tuberculous) and of in- 
toxications; in angeiosclerosis arteritis and phlebitis 
are observed as consecutive processes, secondary to 
nutritive and mechanical disturbances in the vessel wall. 
Arteritis and phlebitis sustain a double relation to throm- 
bosis inasmuch as thrombosis in an artery or a vein in- 
duces inflammation (thrombo-arteritis, thrombo-phlebitis) 
while angeiitis not uncommonly leads to thrombosis. 
The causes of infectious or toxic angeiitis may reach the 
part of the vascular wall first involved through either 
the vasa vasorum, the lymph stream, or the main blood 
stream within the lumen of the vessel, or they may come 
directly from without. 

It was the custom of pathologists in the early part of 
this century to look upon imbibition and reddening of 
the tunica intima as evidences of acute inflammation; in 
1847 Virchow proved the incorrectness of this view. 

Because the same agent may produce more than one 
form of arteritis and phlebitis, and because the same form 
of angelitis may result from more than one cause, it be- 
comes rather difficult to make at once a comprehensive 
yet simpie classification of arteritis and phlebitis. When 
we omit from consideration periarteritis nodosa and the 
specifically tuberculous and syphilitic varieties, then the 
remaining forms belong to one of two large groups, the 
suppurative and destructive or the productive, the first 
characterized by disintegration and the formation of pus, 
the second by the production of new tissue. 

Suppurative Angetitis ; Suppurative Thrombo-Arteritis. 
—The form of disease of the arterial wall induced by 
thrombosis or by the lodgment of emboli is determined 
by the nature of the thrombus or embolus. In the case 
that pyogenic bacteria are present in their interior, puru- 
lent inflammation is set up in the walls of the artery, re- 
sulting in a more or less extensive and destructive pan- 
arteritis and periarteritis, the final outcome being an 
abscess. This is what occurs in the development of 
metastatic embolic abscesses in the lungs. At other 
times the destructive action of the bacteria in infected 
emboli may be more limited in its extent, thereby pro- 
ducing a local weakening of the arterial wall, at which 
point aneurismal bulging occurs and there results a 
so-called embolic or mycotic aneurism (Goodhart, Ep- 
pinger). Mycotic embolism, the result of embolic sup- 
purative arteritis, is observed most frequently in the 
cerebral arteries. Purulent thrombo-arteritis, with or 
without mycotic aneurism, is liable to result in hemor- 
rhage from the weakening and destruction of the vessel 
wall. 

Suppurative Thrombo-Philebitis.—This may result from 
the extension of a suppurative process about a vein to 
the adventitia, media, and intima, which is more fre- 
quently the case than thrombosis upon the basis of a 
primary mycotic endophlebitis. In either case the re- 
sulting thrombosis undergoes purulent or purulent and 
putrid softening under the influence of the microbes that 
gain entrance into it from the walls of the vein. Begin- 
ning with John Hunter, in 1798, who described inflam- 
mation of the inner walls of veins after blood-letting and 
in the uterine and femoral veins of women in the puer- 
peral period, it gradually became established clearly that 
pyemia commonly depends upon suppurative thrombo- 
phlebitis, the circulating blood being the medium of 
' transference of infected particles from the thrombus to 
various parts of the body, the emboli on lodgment pro- 
ducing metastatic abscesses. Among veins that are liable 
to suppurative thrombo-phlebitis may be mentioned the 
umbilical veins in the new-born, infection taking place at 
the navel; the lateral and other sinuses of the dura mater 
in suppurative mastoiditis and middle-ear disease; the 
mesenteric veins in appendicitis and ulcerative processes 
in the intestines, the process giving rise by extension or 
embolism to suppurative pylephlebitis and abscesses of 
the liver; the subcutaneous veins in the vicinity of the 
foci of infection, etc. Suppuration originating in a diver- 
ticulum of the cesophagus has extended to the superior 
vena cava and given rise to suppurative thrombo-phlebitis 
in this vein. 

Vou, II.—7 








Mycotic and Toxie Endangetitis.—Acute verrucose and 
ulcerative endangeiitis, similar to acute endocarditis, most 
frequently occurs in the aorta and the pulmonary artery 
and is usually associated with infective endocarditis of 
the semilunar valves. It has also been described in the 
larger and medium-sized branches of the aorta and the 
pulmonary artery. The lesions usually assume the form 
of warty eminences, composed of a cellular and vascular 
granulation tissue and capped by thrombotic deposits, 
There is more or less cellular infiltration into the tissues 
of the vessel wall near such warty outgrowths, and at 
times the process assumes more of an ulcerative and de- 
structive type. Osler has described an interesting in- 
stance of multiple mycotic aneurisms of the aorta the re- 
sult of infective endaortitis associated with acute infective 
endocarditis. Schmey has recorded the sudden develop- 
ment of aneurisms, one upon the radial artery and one 
upon the posterior tibial, in a boy of twelve with acute 
articular rheumatism, showing that in all probability the 
microbe or toxin of this disease may also cause this rare 
form of endarteritis. Such aneurisms, although not 
embolic, belong etiologically in the same general cate- 
gory as the embolic-mycotic aneurisms just referred to 
as caused by embolic destructive arteritis. Oliver de- 
monstrated B. anthracis in an ulcerative aortitis. 

It is now recognized that the acute and chronic forms 
of arteritis occur in various infectious diseases—ty phoid 
fever, smallpox, scarlet fever, measles, acute articular 
rheumatism, influenza, pneumonia, syphilis, tuberculosis, 
and leprosy. In the acute forms cellular infiltrations, gen- 
erally circumscribed, are found in the outer coats of the 
vessels together with more or less extensive proliferation 
of the subepithelial connective tissue of the intima. 
Nodular and more diffuse accumulations of lymphoid 
and epithelioid cells occur beneath the epithelium. These 
changes are explained as due to the circulation in the 
blood of the microbes and the toxins of the diseases men- 
tioned. When the endarterial changes result in destruc- 
tion of the living epithelium thrombosis takes place, and 
if it is in a larger vessel a typical verrucose endarteritis 
may be established. The endarteritic lesions are due to 
a direct implantation of micro-organisms upon the intima 
in the same way as infections of the endocardium take 
place; inasmuch as bacteria are often absent, it seems 
that endarteritis may be caused by toxins also. These 
changes occur probably more frequently in the veins 
than in the arteries. Arterial thrombosis in the diseases 
mentioned is often referable to infectious arteritis. 

It is quite evident that there might be more or less 
difficulty in distinguishing between toxic and infectious 
verrucose endarteritis and thrombo-arteritis pure and 
simple. The formation of a parietal thrombus upon a 
rough spot or thickening of the intima might induce 
small nodular outgrowths of new tissue. The presence 
of microbes in the thrombus would indicate that the 
acute and destructive changes in the walls of the vessels 
were primary. 

In many instances of multiple venous thrombosis it is 
not unlikely that an infectious or toxic endophlebitis is 
the primary change in the vessel wall. In typhoid fever, 
diphtheria, variola, influenza, and other infectious dis- 
eases there is found a nodular, sometimes a more diffuse, 
accumulation of lymphoid and epithelioid cells in the 
intima, even more frequently than in the arteries. Many 
of the large cells in such foci seem to have marked 
phagocytic properties (Mallory). The accumulated 
cells, as well as the epithelium, may undergo necrosis 
and become the starting-point of a thrombus. JInas- 
much as bacteria are often absent, it would seem that 
the vascular lesion may be caused by toxins—a toxic 
endangeitis. 

Lancereaux and others believe that there is a malarial 
aortitis which “occurs in the form of gelatinous plaques, 
situated generally in the ascending part of the arch of 
the aorta; the lesion is described as beginning in the ad- 
ventitia with cellular infiltrations which result in atrophy 
of the media and an adaptative thickening of the intima. 
Saccular aneurisms may result. It seems that there 


OT 


Blood-Vessels, 
Blood-Vessels, 


would be great difficulty in distinguishing between ma- 
’ Jarial aortitis and nodular sclerosis from other causes. 

Experimentally aortitis has been produced by the in- 
jection of various microbes—B. typhosus, B. diphtherie, 
streptococcus, etc.—sometimes with and sometimes with- 
out previous traumatism to the artery by means of a 
probe inserted through the carotid. The French espe- 
cially have been interested in this work (Gilbert and Lion, 
Therése, Crocq, Pernice, Boinet and Romary). In some 
cases the lesions were vegetative, in others gelatinous 
plaques due to endarterial proliferation resulted. In- 
filtrations about the vasa vasis were often present. Nod- 
ular thickenings are described by Boinet and Romary as 
following the injection of toxins, of lead, urate of soda, 
and phloridzin, with or without preceding injury. In 
their later stages the lesions would be identical with nod- 
ular arteriosclerosis. 

Metastatic abscesses in the walls of arteries are rare. 
Virchow observed one in the beginning of the pulmonary 
artery; and Eppinger describes an abscess, the size of a 
walnut, in the posterior wall of the aorta just distal to 
the origin of the left subclavian artery. Andral de- 
scribes a case of multiple abscesses, of the size of hazel- 
nuts, in the wall of the aorta, but there is some doubt as 
to the real nature of this case. Spengler describes an 
abscess in the wall of the aorta just above the semilunar 
valves. 

Consecutive Huudative and Suppurative Angetitis.— 
While blood-vessels possess considerable resistance 
against the invasion of suppuration from without, so that 
in large abscesses it is not unusual to find the vessels 
wholly freed from the surrounding tissue and bathed in 
pus, yet periarterial and periphlebitic infiltration and 
proliferation are common consecutive lesions. This oc- 
curs in the vessels at the base of the heart in acute exuda- 
tive pericarditis, pleuritis, and mediastinitis; the adven- 
titia is then the seat of an cedematous, sero-purulent, and 
purulent infiltration. And suppurative and necrotic proc- 
esses around blood-vessels may extend not to the adven- 
titia only, but also to the media and the intima, causing 
necrosis of the epithelial lining and secondary thrombo- 
sis. In this way also may develop suppurative thrombo- 
arteritis and thrombo-phlebitis. The weakening of the 
wall of arteries caused by the purulent disintegration of 
the media sometimes results in another form of aneuris- 
mal dilatation—erosion aneurism produced by a kind of 
hernia of the inner coats at the point of least resistance. 
This result of consecutive peri- and mesarteritis is espe- 
cially frequent in the branches of the pulmonary artery 
that are exposed upon the floor and the trabecule of 
phthisical cavities. The aneurismal bulging takes place 
upon the side of the artery that is least supported by 
surrounding tissue, namely, that toward the lumen of 
the cavity. Frequently an obliterating thrombosis pre- 
vents the formation of aneurism and removes the dan- 
ger of hemorrhage under these conditions. Suppuration 
in a wound, or in an amputation stump, may destroy the 
granulation tissue formed by the intima in the process of 
definitive closure of an artery, cause purulent disintegra- 
tion of any thrombus present, and thus give rise to the 
much-dreaded secondary hemorrhage of the preaseptic 
times. 

Colin and Flexner describe instances of perforation of 
the inferior vena cava in amoebic abscess of the liver. 

On subsidence of acute inflammatory lesions of this 
nature, vascular granulation appears in the walls of the 
vessel, producing more or less extensive fibrous thicken- 
ing of the various coats with narrowing of the lumen; in 
case thrombosis has taken place, the substitution of the 
thrombus by connective tissue may cause occlusion of 
the vessel. Terminal fibrous changes of this kind do not 
differ histologically from the lesions of many primarily 
productive forms of angeiitis. 

Productive Angetitis.—Inflammation of blood-vessels 
resulting in the production of new tissue is a frequent 
form. In productive or obliterating endarteritis and en- 
dophlebitis there occurs a proliferation of the cellular 
elements of the intima, which leads to thickening of the 


98 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


intima, eccentric narrowing of the lumen, and eventually 
to complete occlusion. This process is observed under a 
variety of conditions. The occlusion after birth of the 
ductus arteriosus and the umbilical vein and arteries is 
accomplished by the formation of connective tissue by 
the intima; as the pressure of the blood in these vessels 
fails, a degree of contraction ensues that favors the filling 
of the vasa vasorum; in the narrowed lumen a small 
thread-like thrombus may form which is finally substitut- 
ed by fibrous tissue. Similar changes occur in occlusion 
following ligature, and in the narrowing of the lumen 
of vessels the capillary bed of which has been restricted 
(amputations, indurative processes in the lungs, etc.). 
In these conditions there is usually atrophy of the media. 
A ligated vessel may be occluded by intimal proliferation 
without thrombosis taking place; in many cases a throm- 
bus forms, which is then replaced by granulation tissue. 
In the old and feeble, especially when the arteries are 
sclerotic, the intima may have lost its power of prolifer- 
ating and then there is danger of secondary hemorrhage. 

Productive Thrombo-Arteritis.—The presence in an ar- 
tery of a thrombus, whatever the cause of the thrombo- 
sis may have been, or of an embolus, is sooner or later 
followed by reactive changes on the part of the vessel 
wall, which result in the production of a vascular gran- 
ulation tissue, provided destructive infection does not. 
occur. The plug becomes infiltrated with leucocytic 
phagocytes and with fibroblasts. The amount of new 
tissue and the rapidity with which it is formed will de- 
pend more or less upon the age of the patient and upon 
the previous condition of the walls of the artery in ques- 
tion. The vessels of the aged, the walls of aneurisms 
and of sclerotic arteries are often so changed and degen- 
erated that but slight or no reactive proliferation takes. 
place under conditions that in young healthy arteries are 
followed by vigorous growth of new tissue. The ves- 
sels present in the new tissue result in part from in- 
growth of vascular sprouts from the vasa vasorum, in 
part from the epithelial cells of the intima. In case the 
lumen of the artery is but partially occluded, then the 
tissue replacing the thrombus or embolus gives rise to 
various forms of intimal thickening—flattened elevations, 
projecting ridges and bands, cord-like networks. Com- 
plete occlusion of the artery may be followed by cica- 
tricial obliteration of the lumen, or the new tissue may 
be so traversed by vascular spaces that the continuity of 
the lumen in some measure is restored. (For further de- 
tails concerning connective-tissue substitution of throm- 
bi, see article on Z’hrombosis. ) 

In the healing of wounds of arteries and veins a 
thrombus composed of blood plates and of fibrin first 
forms, which is subsequently replaced by new fibrous 
tissue. 

Productive Thrombo-Phlebitis.—Productive inflamma- 
tory changes occur in the walls of veins after thrombo- 
sis. The process pursues the same general course as 
thrombo-arteritis. It is observed especially in the peri- 
uterine veins, the veins of the lower extremities, the pel- 
vic veins, and the sinuses of the dura, which constitute 
those parts of the venous system that are most frequently 
the seat of thrombosis. The residues of connective-tissue 
replacement of a venous thrombus may be fibrous bands 
coursing across the lumen, the interior of the vein resem- 
bling that of a dural sinus, more diffuse intimal thicken- - 
ings, and great shrinking of the part of the vein involved 
with complete obliteration of the lumen. Such changes 
may occur also in the larger veins, such as the vene cavee.. 
I refer with more detail to occlusion of the superior vena 
cava in the section devoted to tumors of the vessels. 

Obliterating Endophlebitis of the Hepatic Veins.—An 
obliterating, proliferative phlebitis occurs in the main 
stems of the hepatic veins. This process has recently 
been studied by Chiari. In seven cases collected by 
Chiari there were periphlebitic proliferative processes or 
thrombosis followed by productive thrombo-phlebitis. 
Chiari describes three instances of an apparently primary 
obliterating phlebitis of the main stems of this vein, 
which on account of the resulting circulatory disturb- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ances became the cause of death. The endophlebitic 
process was situated in the proximal portions of the 
veins with peripheral extension in one case. The ten- 
dency to obliteration was marked, leading to mechani- 
cal obstruction and fateful secondary thrombosis. The 





Fig. 627.—Obliterating Endarteritis in Chronic Salpingitis. Hsema- 
toxylin and eosin. X 100. 


condition is undoubtedly a peculiar one, possibly of 
syphilitic origin; in one case it was associated with simi- 
lar changes in the coronary arteries. 

Consecutive Productive Angetitis.—Inflammation, acute 
and chronic, generally takes place in the walls of all 
arteries that lie in tissue the seat of inflammatory proc- 
esses. In this case cellular infiltration and proliferation 
extend into the vessel wall from without inward, and all 
the coats may in time become fibrous; the thickening of 
the intima caused by the proliferation of fibroblasts and 
the formation of new fibrous tissue is generally pro- 
nounced and complete obliteration of the lumen may take 
place. In many instances the formation of fibrous tissue 
in the intima of vessels in organs the seat of chronic 
fibrous processes is undoubtedly in some measure the 
result also of obliteration of portions of the capillary 
districts of the vessels (Thoma), the resulting narrowing 
of the lumen partaking of an adaptative nature—a local- 
ized form of secondary angeio-sclerosis. Changes of this 
general character are seen in chronic interstitial inflam- 
mations and fibrotic processes in the parenchymatous or- 
gans, as in interstitial nephritis, orchitis, etc. (Fig. 627). 
They are well marked in the specific granulomatous proc- 
esses, and the resulting arterial lesions need not always 
necessarily present any specific characteristics. The 
acute stages can be studied nicely in the pial arteries in 
tuberculous leptomeningitis. There is leucocytic infil- 
tration of the adventitia, extending into the media and 
intima; the wandering cells are seen making their way 
between the fibres of the media and through the fenestra- 
tions of the internal elastic coat, the nuclei being drawn 
out long so as to pass through narrow spaces; the elastic 
coat at times becomes broken through by the cells which 
may accumulate under the epithelium; simultaneously 
fibroblasts appear, especially in the subepithelial layers 
of the intima (see Tuberculous Arteritis) (Fig. 628). Simi- 
lar changes of a more chronic but non-specific character 
are seen also in the walls of arteries and veins in chronic 
tuberculous areas and cavities in the lungs. Great nar- 
rowing of the lumen and even closure may result from the 
newly formed fibrous tissue in the intima. Quite simi- 
lar changes occur in syphilitic lesions, and it is probable 
that an isolated, primary, histologically non-specific, 
productive endarteritis is often caused by syphilis. In 
productive endarteritis of whatever cause, fibrillar con- 
nective tissue interspersed with elastic elements is formed 
inthe intima. Attimesa distinct, new, elastic membrane 
develops; it is generally thinner than the original elastic 


Blood-Vessels, 
Blood-Vessels, 





layer, the general course of which it imitates, and it 
forms the inner boundary of the new, greatly narrowed 
lumen. But the process is not thereby brought to a 
standstill, as new fibrous tissue may again form and 
completely occlude the vessel. 

The fibrous perivascular changes that develop in con- 
nection with productive angeiitis of diffuse character lead 
to obliteration of the perivascular lymph spaces and se- 
rious obstruction of the lymph flow, which in some tis- 
sues, as for instance the brain, may produce grave dis- 
sete of the function and the structure of the special 
cells. 

Acute endarteritis may in time give rise to fibrous nod- 
ules upon the intima and to more diffuse thickening. 
Fenger describes an extensive polypoid fibrous endarteri- 
tis of the pulmonary artery associated with valvular en- 
docarditis. The polypoid outgrowths, which almost close 
the lumen, sprang from the deeper layers of the intima. 
Willigk described numerous, small pedunculated vege- 
tations. Eriksen noted large radiating scars, producing 
annular stricture, in the stem of the pulmonary artery, 
and Willigk found a stenosis of the right pulmonary ar- 
tery, the lumen being reduced to a diameter of 2 mm. 

Goebel describes a local endarteritis that gives rise to 
small elevations in the intima. The process involves 
only the intima. The resulting thickenings are based 
upon the elastic coat and are composed of a network of 
fibrille and elastic elements apparently splintered off 
from the elastic layer; the nodules are partly vascular. 
As they become polypoid, thrombosis may result and 
cause gangrene, which was the case in an instance of 
spontaneous gangrene in a child, one and a half years 
old, that forms the basis for his study. Goebel found 
similar nodules in medium-sized arteries in three of . 
twenty children examined for this process. The cause 
is obscure; possibly some form of traumatism may be 
the underlying condition. Syphilis was excluded. It 
may be added by way of suggestion that a local toxic or 
infectious endarteritic process might result in such ele- 
vations. 

Elastic Fibres in Endarterial Proliferations. — The 
newer methods of staining elastic fibres, elaborated 
by Tinzer and Unna and by Weigert, have resulted in 
the demonstration 
that they are pres- 
ent to a greater 
extent in the end- 
arteritic prolifer- 
ations than was 
formerly thought. 
Langhans be- 
lieved that the 
pre-existing elas- 
tic layer—the 
elastica interna— 
underwent hy per- 
trophy. Heubner 
found that in ar- 
teriosclerosis the 
inner layer of the 
elastica becomes 
granular, and that 
in the later stages 
of the disease 
four to eight or 
more elastic bands 
appeared in the 
thickening of the 
intima; in syph- 
ilis a new elastic 
membrane formed 
near the lumen in 
the quiescent 
stages; Heubner derived the new elastic elements from the 
epithelial cells. Wendeler pointed out that in syphilis 
each period of growth in the intima closes by the forma- 
tion of an elastic membrane. Dmetrieff shows that in ar- 
teriosclerosis the newly formed elastic fibres in the intima 


‘t Hh 





Fig. 628.—Chronic Endarteritis in Chronic Tu- 
berculous Meningitis. a, Blood spaces. X 
150 diameters. 


99 


Blood-Vessels, 
Blood-Vessels, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





have the same general course as the fibres of the media 
(see Fig. 629). Jores holds that elastic fibres are formed 
in two ways: the one is due to the splitting up of the 
internal elastic layer into several lamella, some of which 
may appear as quite independent bands. This process 
occurs especially in arteriosclerosis and probably to some 
extent under normal conditions. But the new formation 
of fine fibres is by far the most important. Jores favors 
the theory that these fibres are formed by the secretory 
activity of the young connective-tissue cells, although it 
cannot be said that the origin of elastic elements from 
chemical changes in the collogenous intercellular sub- 
stances has been wholly disproved. In intimal prolifer- 
ations Weigert’s elastic-fibre stain shows that the new 
fibres appear first as finer granular lines that surround 
the cells as a fine network. ‘The epithelial cells do not 
seem to play any part in this process, inasmuch as elastic 
fibres never appear between the -individual epithelial 
cells, but are always confined to the subepithelial layers. 
From observations on ligated vessels Jores found that 
new elastic fibres are formed more numerously in vessels 
subjected to the pressure of the circulating blood than 
in parts enclosed between two ligatures or in vessels the 
seat of thrombo-arteritis. Hence he regards the new 
formation of elastic fibres as distinctly compensatory in 
character. ‘The cells in intimal proliferations are gifted 
with greater powers to form elastic fibres, directly or in- 
directly, than the cells of the media. 

Malkoff and Gardner hold that the elastic fibres devel- 
op in the outer layers of the cell bodies. 

In typical endarteritis obliterans there is not much 
change in the elastic elements, which maintain the same 
relation in endarteritis obliterans as in productive throm- 
bo-arteritis. In arteriosclerosis, on the other hand, the 
intimal thickening occurs in layers separated by elastic 
fibres (Falta). 

Obliterating Endarteritis and Spontaneous Gangrene. 
—The occurrence of obliterating endarteritis in an inde- 
pendent, primary form has not been established upon a 
satisfactory basis. Its occurrence as a secondary process 
in indurative processes, in the organization of thrombi, 
and as the result of consecutive and specific arteritis is 
generally recognized since Friedliinder, in 1876, first 
called especial attention to endarteritis obliterans. 
Heubner interpreted endarteritis of the cerebral vessels 
as always a specific syphilitic lesion, but Baumgarten 
showed that not endarteritis obliterans is the specific 
form of syphilitic vascular disease, but gummous arteri- 
tis, in which the changes in the adventitia are equally 
if not more prominent than those in the intima. The 
endarteritis obliterans observed as the case of spontaneous 
gangrene in the middle-aged and the young is regarded 
by von Winiwarter, von Schroétter, Borchhardt, and 
others as a distinct and primary disease. This opinion 
is based largely upon the fact that premonitory symp 
toms, indicative of gradual occlusion of the arteries, may 
exist a long time before culminating in gangrene, the 
more prominent symptoms being pain, cyanosis, and 
coldness. Insome cases the complex of symptoms called 
by Charcot “intermittent claudication ” has been present. 
The arteries more frequently involved are those of the 
foot, leg, and forearm. The endarteritis, which is de- 
scribed as typical, with vascularization of the new tissue 
in the intima and reduplication of the elastic coat, begins 
in the peripheral branches. The adventitia may be 
greatly thickened, and in some cases the neighboring 
veins and nerves were found extensively involved in the 
perivascular sclerosis. In many cases thrombosis or 
pigmentation, the probable result of thrombosis, was 
present, and Thoma, who does not believe there is a 
special form of obliterating endarteritis, holds that the 
endarteritic changes in this form of gangrene result from 
the replacement by connective tissue of thrombi in scle- 
rotic vessels. Zoege von Manteuffel claims that the 
gradual occlusion is brought about by the deposition and 
organization of successive layers of parietal thrombi in 
primarily sclerotic arteries. Von Recklinghausen de- 
scribes hyaline thrombi in the smaller arteries of limbs the 


100 





seat of spontaneous gangrene. Haga regards endarteritis 
thrombotica as syphilitic. Hoegersted and Nemsen find 
that parietal thrombi in sclerotic arteries may result in 
occlusion and constriction of the vessels. Falta has de- 
scribed cases of gangrene in old people as due primarily 
to arteriosclerosis associated with an apparently inde- 
pendent productive process in theintima. Goebel attrib- 
uted spontaneous gangrene in a child, one and a half 
years old, to thrombosis at the bifurcation of the popli- 
teal artery produced on account of the presence of small 
globular elevations composed largely of elastic elements 
and caused by a local endarteritis of obscure origin. 
The conditions that may produce spontaneous gangrene 
not caused either by embolism and secondary thrombo- 
sis or by arteriosclerosis and thrombosis are consequently 
rather complicated. Undoubtedly many instances result 
from arterial thrombosis secondary to the endarterial in- 
flammatory changes that occur in various infectious dis- 
eases (see Gangrene). 

ANGIOSCLEROSIS. —Definition.—It is quite impossible 
to give a comprehensive definition of angiosclerosis, be- 
cause as at present used this term, and the more common 
term arteriosclerosis, undoubtedly include processes of 
different nature. Angiosclerosis is, to say the least, a 
complex process that appears under different conditions 
in varying stages and varying distribution. The general 
idea conveyed by the term is fibrous thickening and oth- 
er changes in the intima consequent upon changes of a 
degenerative nature in the media of arteries and veins. 
When the process affects arteries, and that is by far its 
more prominent, more important, and more frequent lo- 
calization, itis known as arteriosclerosis; and sclerotic 
changes in veins constitute phlebosclerosis. In cases of 
diffuse sclerotic changes in the vessels both arteries and 
veins are often involved, but the arterial changes are the 
more conspicuous both from the clinical and from the 
anatomical points of view. 

The term arteriosclerosis was introduced by Lobstein 
over fifty years ago; he regarded the process as the re- 
sult of nutritive disorders in the vessel wall incident to 
age and use. The word atheroma is used by some as 
almost synonymous with arteriosclerosis, but in reality 
atheroma is applicable only to certain late stages of the 
process, as it affects the aorta and its large branches. 
In the text-books of pathological anatomy of fifteen to 
twenty years ago arteriosclerosis is described generally 
under the heading endarteritis chronica deformans s. 
nodosa, and phlebosclerosis is mentioned sometimes as 
endophlebitis chronica deformans s. nodosa; these terms 
were introduced by Virchow; they are now rarely used. 
Other quite synonymous names are arteriocapillary 
fibrosis, introduced by Gull and Sutton, and arteriofibro- 
sis. Since Thoma’s epochal investigations, the terms 
arteriosclerosis, phlebosclerosis, and angiosclerosis are 
used quite universally. Atheroma should not be used as 
synonymous with arteriosclerosis. 

Pathogenesis and IHistogenesis.—Through the investiga- 
tions and theories of Thoma and his students, angioscle- 
rosis, in some of the phases of its genesis, has been 
placed upon the same basis as certain processes that oc- 
cur in the vessels, especially the arteries, under normal 
physiological conditions. 

The physiological paradigm of angiosclerosis is seen 
in the changes that take place in the aorta immediately 
after birth. At birth there is no connective tissue in 
the intima of the aorta. Immediately after birth the cir- 
culation in the umbilical arteries ceases; a part of the 
territory of the aorta is cut away, the aorta is now too 
large in comparison with the area it supplies with blood, 
and the circulation in it becomes slower. Under these 
circumstances connective tissue develops in the intima 
of that part of the aorta between the ductus arteriosus 
and the hypogastric arteries, and in this way its lumen 
is reduced to a size commensurate with the rate of blood 
current best suited to the needs of the tissues for nour- 
ishment. Later in life similar changes occur normally 
in the carotid, for instance, because from the eighth to 
the tenth year the growth in strength of this artery does 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





not keep pace with that of other vessels; hence it dilates, 
its lumen becomes so large that slowing of the circula- 
tion takes place, and new tissue develops in the intima 
until the current reaches the normal flow (Sack). Simi- 
lar changes take place in arteries after amputation and 
in arteries whose capillary area is destroyed by disease. 
The connective-tissue formation in these cases is there- 
fore spoken of as compensatory, calculated to reduce the 
lumens of the arteries to their proper size. 

From these and other observations the general theory 
is deduced that every slowing of the blood current in the 
arteries and veins of man that is not completely and at 
once remedied by a proportionate contraction of the me- 
dia, leads to a new growth of connective tissue in the 
intima, which narrows the lumen of the affected vessel, 
and thus restores the normal swiftness of the blood cur- 
rent more or less completely (Peabody). It may be said 
here that the compensating endarteritis is regarded as 
the result of mechanical and chemical changes that oc- 
cur in and about the cells of the intima of the part of 
the artery affected; it is not claimed that the compensat- 
ing proliferation is distinctly and purely teleological in 
its nature. In order to explain the new growth in the 
intima, Thoma has elaborated a rather complex theory 
according to which the irritation produced by the abnor- 
mal conditions upon the vaso-motor nerves connected 
with Vater-Pacini’s corpuscles in the adventitia, leads 
to functional disturbances and hyperemia of the vasa 
vasorum and eventually to new tissue in the intima. 
But intimal thickening occurs in vessels that have no 
vasa vasorum when the current is supposed to be slower 
than normal. 

The origin of the new tissue in the intima is traced 
partly to the epithelial cells (Baumgarten, Thoma), 
partly to the connective-tissue cells in the subepithelial 
layer. The latter are probably the more important fac- 
tors in the process. Ingrowth of connective tissue from 
the media and of vessels from the vasa vasorum is also 
mentioned as possible by some writers. 

The weakening of the wall and consecutive local or 
general dilatation that gives rise to compensatory thick- 
ening in the intima are regarded as the result of wear 
and tear, of strain, of heightened intravascular pressure, 
and of toxic and infectious influences. These factors 
may operate singly or in combination. The obliteration 
of capillary areas and the narrowing of smaller, peripheral 
vessels are also held to induce thickening in the intima of 
the larger vessels because of the relative abnormal wide- 
ness of their lumens under these circumstances, but here 
it is manifestly difficult to determine the primary events 
in the process. 

Thoma showed by physical tests upon the iliac arte- 
ries that weakening and dilatation of the arterial walls 
may occur in the early stages of arteriosclerosis without 
evident structural changes in the vascular tunics be- 
ing present. Other investigators describe structural 
changes, especially in the elastic elements, that surely 
give rise to loss of strength and elasticity in the arteries 
affected. : 

Weiszmann and Neumann, Zwingmann, and others 
described tears in the elastic lamelle and granular disin- 
tegration of the elastic fibres of the aorta in arterioscle- 
rosis. Manchot observed similar changes in the aorta in 
the wall of aneurisms. Eberhardt was inclined to at- 
tribute the changes described as artefacts due to the use 
of alcohol not wholly free from water in the staining 
method then employed, in which fuchsin was the prin- 
cipal ingredient. Eberhardt found, however, that the 
changes described occurred to a slightly greater extent 
in the elastic lamelle and fibrous network of the artifi- 
cially distended than in the non-distended carotid ar- 
tery. 

Hilbert found that tears or transverse ruptures of the 
internal elastic coat occur at all ages in the arteries near 
the heart (aorta and carotids); in youth they are rare in 
the external iliacs, but after the fourth decennium they 
are frequent here also. In the renal and similar arteries 

ruptures are rare at allages. Internally to the ruptures 








Blood-Vessels, 
Blood-Vessels, 


may be one or more layers of evidently modified or new 
elastic fibres. In theiliacs he noted amarked separation 
or splintering of. the internal elastic layer in aortic in- 
sufficiency. The ruptures that he describes are attrib- 
uted to momentary increase in the blood pressure under 
sudden physical exertion or mental excitement. They 
occur also in hypertrophy of the left ventricle and in 
cases of probable diminished resistance on account of 
nutritive disturbances. Sclerosis and aneurisms may 
result. 

By means of more improved technical methods, Dmitri- 
jeff has recently studied the changes in the elastic ele- 
ments of the arterial wall in arteriosclerosis. He finds 
that the principal change in the media is a granular dis 
integration of the elastic fibres, which begins first in the 
inner parts of the media in the network between the 
elastic lamelle. The granules appear in chains, and 
stain, some well, some poorly, with acid orcein. Later, 
changes appear in the lamelle, which stain irregularly 
and break up into irregular pieces. The chemical na- 
ture of the elastic elements changes in some way and 
they become basophilous; Unna’s modified elastin, 
elacin, is present. These are the earliest changes in the 
vessels and occur especially in advancing years; Dmitri- 
jeff found them also in the aorta of an eight-year-old 
child that died from scarlet fever. At the same time 
nodules or more diffuse thickenings appear in the intima, 
composed of fibrous tissue and new elastic elements ar- 
ranged either as lamelle or as networks of fine elastic 
fibres; this new formation easily undergoes degeneration 
(atheromatous changes), so that in arteriosclerosis there 
is degeneration of and new formation of elastic fibres. 
Foci of inflammation and proliferation in the adventitia 
and the media also lead to destruction of the elastic fibres 
in their vicinity. Peri-arterial and mesarterial inflamma- 
tory infiltrations about the vasa vasorum were regarded 
as of great importance by Késter, Huchard, and others. 
The etiology of such foci is probably to be sought in 
toxic and infectious influences. Martinand other French 
writers go so far as to advocate that the degenerative 
(atheromatous) changes in the large arteries are the result 
of sclerosis of the vasa vasorum. 

Malkoff, from the experimental study of the effects of 
crushing and stretching of the carotid artery, concludes 
that injuries of various kinds produce changes in the 
walls of the arteries that render the wall less resistant 
and dilatations are produced; but after a time the lumen 
may be narrowed again by a growth of connective tissue 
and elastic elements in the intima and also in the media; 
the lumen may become even narrower than before the 
injury. The experiments were not extended over a pe- 
riod of time sufficient to disclose the ultimate results. 

But in angiosclerosis the compensatory proliferation 
of new tissue in the intima is sooner or later followed by 
more pronounced degenerative changes. The new tissue 
is not able to maintain its integrity in the face of the 
constant strain of the intravascular pressure and of the 
inadequate facilities for nutrition. Hyaline and fatty 
changes take place in the deeper layers of the intimal 
thickening and in the inner layers of the media. Com- 
plete disintegration into fatty and granular débris mixed 
with cholesterin tablets and crystals of fatty acids give 
rise to smaller and larger foci of softening that have 
been termed atheromatous abscesses. By extension the 
overlying tissue may be destroyed, and defects arise in 
the intima—“atheromatous ulcers”—upon the rough 
surface of which fibrin may be deposited. Petrification 
often takes place in the degenerated tissue and calcare- 
ous plates and irregular masses form in the intima and 
inner layers of the media. True bony tissue has also 
been found to develop. It is to this degenerative stage 
of arteriosclerosis, which is seen best in the aorta and its 
larger branches, that the term atheroma is frequently 
applied. In advanced cases the sclerotic, degenerative, 
and petrifying changes are present in varying degrees 
and produce great deformity, unevenness, and changes 
in the normal color of the intima and irregular dilata- 
tions of the vessels. The relation of arteriosclerosis to 


101 


Blood-Vessels, 
Blood-Vessels. 





aneurism and of phlebosclerosis to varicosity of the 
veins is elaborated under these respective headings. 

Etiology.—The etiological relations of angiosclerosis 
are ill defined. So far it has not been possible to pro- 
duce experimentally sclerosis of vessels of animals com- 
parable to the human disease, except possibly the gelati- 
nous nodules in the aorta that French investigators 
describe after the introduction of bacteria and of toxic 
substances with or without preceding injury to the inti- 
ma; these nodules resemble the lesions of nodular arterio- 
sclerosis. Angiosclerosis is rarely observed in animals; 
it has been seen mostly in old cattle and in old horses. 

According to Edgren’s statistical study of arterioscle- 
rosis, syphilis, alcoholism, and old age are the predomi- 
nating factors in its production. Henschen, in his criti- 
cism of Edgren’s work, points out that the source of the 
material for such studies must be carefully scrutinized 
because conclusions based upon the presence of arterio- 
sclerosis in the inmates of institutions that harbor espe- 
cially syphilitics, alcoholics, or old people naturally will 
be one-sided and misleading. Such studies usually take 
no note of the form of arteriosclerosis present. 

Angiosclerosis occurs so commonly in advanced years 
that itis generally regarded as a sort of involutional 
change; this is true especially of the senile form of arte- 
riosclerosis. It is thought that the media gradually 
loses its elasticity; dilatation and the formation of more 
or less new tissue in the intima followed by degenera- 
tion take place. According to Thoma a moderate de- 
gree of thickening of the intimais frequent after the 
thirty-sixth year, especially in the peripheral arteries. 

The period of life at which a well-marked arterioscle- 
rosis appears and the extent that it may assume are de- 
pendent upon the natural, inborn resisting power of the 
muscular and elastic elements of the arterial wall and 
upon the amount of wear and tear to which the vessels 
are subjected. The tendency seen in certain families to 
the early development of arteriosclerosis is explained as 
due, at least in part, to an inherited weakness of the 
arterial walls. This theoretical conclusion has received 
as yet no confirmation in the form of demonstrable ana- 
tomical deviations from the normal in the structure of 
the arteries of such individuals. On the other hand, 
there are cases recorded in the literature of centenarians 
with smooth and normal vessels. 

Changes similar to arteriosclerosis have been described 
in the vessels of children and young persons. Von Schrot- 
ter enumerates several recorded instances; Young de- 
scribed sclerosis of the temporal artery in a child of fif- 
teen months; Meigs of the left coronary artery in a child 
of five months; Gee described aneurisms of the coro- 
nary arteries and atheromatous changes in the aorta in a 
child of seven years that died from dropsy and pneumo- 
nia following scarlet fever; and Chiari observed sclerosis 
of the aorta with typical histological changes in a boy of 
thirteen years, the disease being attributed to abuse of 
tobacco and alcohol. Seitz found seventeen cases of ar- 
teriosclerosis between ten and twenty-seven years of age 
out of one hundred and forty-eight cases of arteriosclero- 
sis examined post mortem. Durante has described an 
instance of calcification of the inner layers of the tunica 
media of the pulmonary artery and the aorta in a prem- 
aturely born infant that lived only a few days. He re- 
gards this as antexample of a congenital atheroma. The 
parental history of the infant was unknown; death re- 
sulted from peritonitis due to infection of the navel. 

It is of course doubtful whether the sclerotic changes 
in the vessels of children and young persons depend 
upon a general primary weakening and loss of elasticity 
and contractility of the media. Special toxic and infec- 
tious influences may be at work in such cases, the sclero- 
sis being the result of inflammatory and other lesions in 
the media. 

Statistics show that men are more frequently affected 
with angiosclerosis than women. Edgren’s statistics 
give twenty-one per cent. of arteriosclerosis in women 
and seventy-nine per cent. in men. Arteriosclerosis ap- 
parently develops later in life in women than in men. 


102 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chronic intoxications and infections of various kinds 
are regarded generally as playing an important part in 
the etiology of angiosclerosis, but so far it has not been 
possible to make any etiological subdivisions of the dis- 
ease. Among the intoxications those due to alcohol, 
lead, and gout are of the first importance. Tobacco is 
regarded by clinicians as not entirely free from delete- 
rious action upon the arteries; Huchard thinks it exer- 
cises a special influence upon the coronary arteries. The 
precise mode of action of these substances can hardly be 
more definitely specified than that under the toxic influ- 
ences degenerative changes and weakening develop in 
the arterial wall, especially the media. Martinotti claims 
to have produced changes in the renal and cerebral arte- 
ries resembling arteriosclerosis by the injection of cam- 
phor, alcohol, and turpentine. 

Of the chronic infections syphilis is the most impor- 
tant. Edgren places syphilis first in the etiology of ar- 
teriosclerosis, which when due to syphilis tends to 
appear rather early in middle life. Arteriosclerosis upon 
a syphilitic basis does not appear to present any special 
features (see Syphilis of the Vessels, page 105). 

Infectious diseases in general appear to exercise a 
harmful influence upon the muscular and elastic parts of 
the walls of blood-vessels. Reference has already been 
made to the toxic and infectious forms of angeiitis and 
to the production of gelatinous plaques in the aorta by 
the injection into animals of bacteria and toxins. The 
closure of the vasa vasorum by inflammatory changes in 
the adventitia and the outer layers of the media would 
surely interfere with the proper nutrition of the inner 
layers of the wall. Thoma has shown that the strength 
of the arterial wall suffers in diseases of the most various 
kinds. 

The overfilling of the vascular system due to exces- 
sive eating and drinking and the increased pressure and 
strain upon the arteries in muscular work constitute 
another group of causes (Osler). According to Huchard 
and Edgren arteriosclerosis is inseparably connected 
with the pathogenesis of increased pressure. The rela- 
tion of angiosclerosis to the intravascular pressure is seen 
in the distribution of the disease in the vascular system. 

Arteriosclerosis sustains a double relation to renal dis- 
ease. An existing sclerosis of the renal and peripheral 
arteries may interfere with the nutrition of the renal 
parenchyma to a degree that parenchymatous degenera- 
tion and connective-tissue overgrowth result. On the 
other hand, a primary interstitial nephritis by raising 
arterial pressure may lead to connective-tissue growth 
in the intima. 

The Forms of Arteriosclerosis.—There is some confusion 
in the classification of arteriosclerosis. The various ana- 
tomical forms often are found connected by transitional 
stages. Thoma recognized two main forms, diffuse or 
secondary, nodularor primary. The former he regarded 
as due mainly to primary changes in the peripheral ves- 
sels and the capillaries and as consecutive to the increased 
peripheral resistance. The latter he regarded as the re- 
sult of primary changes of a degenerative nature in the 
media, and as localized especially in those regions where 
the pulse wave is high and strong. Councilman holds 
that the diffuse form is a distinct disease associated with 
widespread changes in the media, and he distinguished 
a third form, the senile arteriosclerosis, in which the le- 
sions are mainly degenerative, compensatory thickening 
in the intima being but little marked. 

Senile Artertosclerosis.—In this form the process is 
largely one of degeneration and calcification with but 
little thickening in the intima. It represents the general 
atrophy and degeneration of senility as they affect the 
arteries when even connective tissue has lost much of its 
power of proliferation. In this form the heart is not 
always hypertrophied; atrophy of internal organs may 
bemarked. The aorta and its larger branches are dilated 
irregularly, tortuous and elongated, the walls in general 
thinner than normal, stiff, and covered by calcareous 
plates or the seat of cavities containing grayish-yellow, 
grumous material—the detritus of degenerated, necrotic 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Blood-Vessels, 
Blood-Vessels, 





muscular and fibrous tissue. The cavities are sometimes 
called atheromatous abscesses; frequently the thin inter- 
nal membrane is ruptured and rough spots and areas 
arise (“atheromatous ulcers ”) in the tloor of which calci- 
fication may take place or thrombotic material accumu- 
late. In typical cases the aorta and other large vessels 
are changed into rigid calcareous tubes, the inner surface 
being rough, frequently fissured, and covered by fibrin- 
ous masses. The intima has lost its glistening appear- 
ance. The resulting deformities of the affected vessels 
certainly warrant the name arteritis deformans which 
Virchow applied to the disease. 

The relations of senile arteriosclerosis to thrombosis, 
senile gangrene, cerebral softening, and other consecutive 
changes in the body are discussed fully elsewhere. 

Diffuse Arteriosclerosis.—This is the more important 
form, and in it the lesions are widely distributed, embrac- 
ing all the arteries of the body. As pointed out by 
Councilman, contrary to the senile sclerosis, the sub- 
a of diffuse arteriosclerosis are generally in the prime 
of life. 

In twenty-seven cases of this disease studied by Coun- 
cilman, the youngest, a negro, gave his age as twenty- 
three; the oldest was sixty. Most of the cases ranged 
between forty and forty-five; fourteen were white and 
thirteen colored. The negro seems disposed to this dis- 
ease, 

In this disease there is a typical pathological picture. 
Most of the subjects who come to autopsy are strongly 
built, well-nourished, muscular individuals. As a rule, 
there is 110 oedema either of the face or of the lower ex- 
tremities. When cdema is present it comes on in the last 
few days or weeks of life. Heart hypertrophy is always 
present and may reach an extreme degree. In two of 
Councilman’s cases in which there were no valvular le- 
sions whatever, the heart in one weighed 850, and in the 
other 820 gm. The average weight was over 400 gm. 
The myocardium is firm and dark. Close examination 
often shows some degree of fibrous myocarditis, this de- 
pending on the degree of involvement of the coronary 
arteries in the general trouble. The heart hypertrophy 
may be confined to the left ventricle, but in most cases 
it is always associated with so much dilatation that the 
right ventricle also becomes hypertrophied. The dilata- 
tion may be so excessive as to affect the integrity of all 
the valves. Anatomical lesions of the valves are usually 
absent. There may be some extension of the aortic dis- 
ease to the aortic valves or to the aortic segment of the 
mitral valve, but the thickening so produced is not gen- 
erally sufficient to interfere with the functions of the 
valves. Thesupposed inflammatory changes in the myo- 
cardium described by Buhl and referred to by Thoma 
were not found by Councilman. The most marked 
changes are found in the aorta and the large arteries 
given off from this. The large arteries are more or less 
dilated, the dilatation in some cases starting in the aortic 
orifice and extending throughout the aorta and large 
arteries. This dilatation is seldom symmetrical through- 
out, but in addition to the general dilatation there may 
be here and there mere local dilatations. 

The branches of the arch are sometimes relatively 
more dilated than the aorta. There is elongation of the 
vessels as well. The aorta makes lateral curves and the 
normal curves of other arteries are greatly accentuated. 
In addition to the dilatation there is a general diffuse 
thickening of the arteries, which is often relatively 
greater in arteries the size of the radial than in the large 
vessels. In the large arteries the intima is roughened 
by projecting elevations, which are frequently distin- 
guished by differences in color and consistency. They 
may be of a pearly, transparent color and very hard, in 
both color and consistency similar to cartilage. They 
may be of an opaque, whitish-yellow color, and the 
centre soft and pultaceous. On incising such places a 
soft, white, mortar-like mass escapes. We may find 
irregular, ragged excavations, often covered with fibrin, 
showing that the softening has extended through the 
intima of the vessel during life. Similar areas of soften- 











ing and degeneration may be found in the diffusely 
thickened intima. There may be more or less calcifica- 
tion which is usually confined to the projecting eleva- 
tions, but this never reaches the same extent here as in 
the senile form. There are frequently longitudinal folds 
and puckering of 
the intima as 
though due to the 
contraction of the 
vessel after death. 

The two essen- 
tial alterations are 
various degenera- 
tive changes in 
the media and a 
growth of tissue 
in the intima. 
The degenerations 
in the media are 
shown in various 
ways. Sections of 
the fresh artery 
show some fatty 
degeneration, but 
this does not play 
the chief part. The most common change seems to be ne- 
crosis and hyaline degeneration (Figs. 629 and 630). The 
muscle cells lose their nuclei and the whole muscular coat 
is changed into a solid homogeneous mass. The elastic 
fibres between the muscle lamine are frequently broken 
up and disappear; these changes probably appear early 
in the process. In some sections of the dilated carotid, 
for instance, the media as such may not be recognized, 
the whole artery being changed into a dense, thick mass 
of sclerosed connective tissue. This atrophy of the me- 
dia is always best marked opposite the points of greatest 
thickening of the intima. The tissue composing the 
thickened intima consists of thick layers of dense con- 
nective tissue, which not only in consequence of the 
poor nutrition which it has, but also in consequence of 
the pressure to which it is subjected, is particularly 
prone to degenerative changes. The tendency to de- 
generative changes, however, is not so marked here as 
it is in the senile form. 

This diffuse arteriosclerosis that Councilman describes 
agrees best with the form which Thoma has described as 
secondary arteriosclerosis, and in which he considers 





FIG. 629.—Diffuse Arteriosclerosis. Renal ar- 
tery. Weigert’s elastic-fibre stain. I, Inti- 
ma With new elastic fibres; M, media, the 
seat of hyaline degeneration ; no elastic ele- 
ments; A, adventitia with increased num- 
ber of elastic fibres. > 150. 





Fic. 630.—Selerosis of Anterior Tibial Artery. Gangrene of foot 
from thrombosis. I, Fibrous intima; E, elastic lamina; M, media 
with hyaline degeneration and calcification ; A, adventitia; D, be- 
ginning degeneration in intimal thickening. Haematoxylin and 
eosin. X 100. ; 


that the changes in the large arteries are due to the resist- 
ance to the blood circulation that the diseased small ar- 
teries cause. Ina paper on the conditions of the vessels 
in Bright’s disease, which preceded his publication on 
the arteries, Thoma shows that there is an opposition to 
the passage of the blood, which is due primarily not to 
a narrowing of the calibre of the vessels by the thicken- 


103 


Blood-Vessels. 
Blood-Vessels,. 


BREGMANN’S TABLE SHOWING RELATIVE FREQUENCY OF ARTERIOSCLEROSIS IN DIFFERENT ARTERIES. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


THE 


Figures REPRESENT PERCENTAGES. 





Normal. Slight degree. Medium degree. Severe degree. distinction aden 
Brachial «,ccudaudecuses sieve 45 Carotid, internal....... 48 | Aorta, abdominal...... 16:| Wlnar .cicce pases 94 
Tiiac, external... We eseess 42 5 | (Subclavian..meeasc vase AY Cerebral sas ven esate tees 15 | Tibial, anterior......... 92 
Aorta, abdominal........ 36 Ulnar wires serceeninerecs 39 | Carotid, internal....... 13 | Subclavian........ Reese 4 
Aorta, ascending......... 33 2| Tibial, anterior........ 37 | Aorta, ascending....... 18} Cerebralic .cgeeeeee te 87 
Carotid, common......... P| SPlOHIG sancntree wosmente 46) JAXIDATY wesc swe cee 36)| ‘SUPCLAVIAN.« o.\ciccs rene 12 | Carotid, internal........ 87 
Femoral, superficial...... 31 | Tibial,.anterior........ 45: | BPlONIC!: < feeeeiewrycer cas 29 | Tibial, anterior........ IL | "Radial. .85.0 cece 
AXMATY cto ccnb a eee 29 |: Bemoralieccace ace see 44 | Carotid, common....... Boi | POpPLILed ce aeaie ew aeleeeee 10'| Splenic 2) .jeste eee 82 
Carotid, external......... Pe POPLLOBL pestrrectetren tate 44 i) Radial (seen cecm ncn 27 | Carotid, common....... 9 | PoplitealiGcssamecee meen 79 
Poplitedloccuasceceie 21 | Aorta, ascending....... 41 | Popliteal cn sweeten eye a. I BUCTVOTEI iorereivlerots.eratesosstevecs 18 | Carotid, external........ 78 
SpleniGiii-cedescccsseene ISs\ Brachial sesenmecsteceer 40 | Aorta, abdominal...... ZEW SDICMIC 28 cccre reir ecoteietale 7 | Axillary... .cemeeene 1 
Radial Meas oetss. yeti 14 | Iliac, external......... 38 | Iliac, external......... 19 | Carotid, external....... 6 | Femoraly vc .aceseeeren 69 
Carotid, internal......... NS He AM aryeeemeer cio eeeere 345) Cerebral: fa caccw cess SeELSs Redd Bl eee ra cara erkeecieteree 3 | Carotid, common........ 68 
Gerebral st cane dances’ 13 | Carotid, common....... Bll | FOMOLAal ence x dco ninerts Le UUme etcterevopia elaccloteteters 3 | Aorta, ascending........ 67 
Subclaviansncnecrecs cc 2 | SUDCIAVIAN. sac scons se 29 | Carotid, external....... IGS ARTA Vig cee cicet hele ate 1 | Aorta, abdominal....... 64 
Tibial, anteriovsc.csuc.ce. 7 | Carotid, internal....... 2B Brachial cs, <a comneriecete 15 | Wiae external. ok.s..<e 1 | IWiae, externaly.ccneees . 58 
WInar si caccheaieun nce see. 6 | Aorta, abdominal...... 24 | Aorta, ascending....... 18)) Brachial es oe Alcinioces 0' | Brachial...5: ...2 eee 5d 














In this table no distinction is made as regards the kind of arteriosclerosis. 


ing of the intima, but by an increased permeability of 
the vessel walls. With this disease of the vessels there 
is an increase in the connective tissue and destruction of 
large numbers of capillaries, still further diminishing the 
size of the vascular bed, and then comes a disparity be- 
tween the calibre of the artery and the territory to be 
supplied, followed by a compensating growth of connec- 
tive tissue. This endarteritis of distant organs is extend- 
ed in the same way to the aorta. Councilman would 
rather take the view that the changes in the aorta and 
in the minute arteries are due to the same cause; that 
diffuse endarteritis is a disease primarily due to a degen- 
eration of the muscular fibres of the media. On this the 
growth of the intima follows, which is due to the same 
cause acting in two ways: in one, by the well-known law 
of connective-tissue growth, to supply a defect, in this 
case the degeneration of the media; and in the other, 
possibly acting under the law of Thoma, a compensating 
endarteritis to restore the abnormally dilated vessel to a 
normal calibre. Thoma’s assumption that this secondary 
arteriosclerosis is due to an increased blood pressure in 
the aorta from the increased peripheral resistance cannot 
be proven. 

There seems to be good reason for separating the le- 
sions of angiosclerosis from the senile endarteritis and the 
lesions accompanying it. The senile endarteritis is a dis- 
ease of advanced life, seldom occurring before the age 
of fifty. The lesions in the vessels are slow, and there 
is little reaction to the degeneration. Clinically, there 


is absence of the high arterial pressure, which constitutes 
the most obvious clinical manifestation of the disease 
The diffuse arteriosclerosis is a definite 


arteriosclerosis. 





FIG. 
elastic-fibre stain. 


broken up; A, adventitia. > 150. 


disease; the lesions in the arteries and tissues form a 
pathological entity, and the primary lesion to which all 
the changes are due is a degeneration of the tissue of the 
media of both the large and the smaller arteries. 


104 





531.—Nodular Sclerosis of Aorta with Beginning Aneurism. Hzematoxylin and Weigert’s 
. The intima (1D) is thickened, contains parallel, wavy, elastic fibres, 
except at the point of the bulging; the media (M) is thinned, degenerated, the elastic 


ORDER OF FREQUENCY OF NODULAR AND DIFFUSE ARTERIOSCLERO- 
SIS IN DIFFERENT ARTERIES. (Bregmann.) 3 


Nodular Form. Diffuse Form (in Thoma’s 
Sense). 

Abdominal aorta. Radial. 
Common carotid. Ulnar. 
Descending thoracic aorta. Anterior tibial. 
Internal carotid. Popliteal. 
Ascending aorta. Splenic. 
Arch of the aorta. 1 Superficial femoral. 
Cerebral. Axillary. 
Subclavian. External iliac. 
Common iliac. Brachial. 
Coeliac. Subelavian. 
Superior mesenteric. External carotid. 
Inferior mesenteric. Cerebral. 
Renal. Internal carotid. 
Coronary. Ascending aorta. 
Popliteal. Common carotid. 
External carotid. Abdominal aorta. 
Splenic. 
Axillary. 
Common femoral. 





External iliac. 
Posterior tibial. 
Superficial femoral. 
Deep femoral. 

Internal iliac. 

Brachial. 

Anterior tibial (below). 
Ulnar. 

Anterior tibial (above). 
Radial. 


Nodular Arteriosclerosis.—In the nodular or primary 
form of arteriosclerosis there are seen flat, button-like, 
hemispherical, yellowish or yellowish-white projections 
above the intima, especially about the orifices of the ar- 
terial branches. This is generally regarded as the result 
of the greater strain that this part of 
the artery is exposed to. The areas 
consist of new connective tissue 
and new elastic fibres in the intima, 
the underlying media being either 
fibrous, calcareous, or degenerated 
and necrotic: Thoma showed that 
the cast after filling the vessel with 
melted paraffin injected under the 
same pressure as that of the blood 
came out smooth, showing that in 
the tense vessel the intimal nodules 
fill defects in the media. The stage 
of weakening in the intima antece- 
dent to the intimal thickening is lia- 
ble to result in aneurism (Fig. 631). 
The new tissue soon becomes hyaline, 
fatty changes take place, and eventu- 
ally disintegration into fat drops, 
cholesterin, granular detritus gives 
rise to softening. The degeneration 
begins in the outer layers of the sclerotic thickening, 
but may extend inward until the epithelium lining the 
vessel is destroyed and a larger or smaller rough area 
due to loss of substance is formed. Calcareous infiltra- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood-Vessels. 
Blood-Vessels, 





tion may take place. More or less leucocytic and round- 
cell infiltrations occur around softened areas. The ad- 
ventitia may be unchanged, fibrous, or the seat of foci 
of cell accumulations. 

This form is possibly due to local, circumscribed areas 
of degeneration and weakening in the media produced by 
strain, by toxic and infectious lesions. Several French 
investigators have produced apparently similar plaques 
in the aorta of animals by injection into the circulation 
of bacteria, bacterial toxins and other substances, such 
as lead, uric acid, ete., with or without producing trau- 
matic lesions of the vessel wall. In some cases of this 
kind the lesions seemed to be the result of proliferation 
in the intima; in others there were mesarterial and peri- 
arterial inflammatory foci about the vasa vasorum. 

In goitre of all forms, Jones found degenerative and 
sclerotic changes in the arteries of the thyroid and its 
capsule. The changes occurred apart from general arte- 
riosclerosis and were found quite marked in eighteen 
out of twenty cases examined. The vessels were abnor- 
mally friable. The internal elastic coat was granular, 
broken across, and calcified; in one case it had changed 
into a calcareous plate; connective-tissue thickening of 
the intima associated with the formation of new elastic 
fibres had resulted, followed by hyaline degeneration. 

The Distribution of Angiosclerosis.—The relative fre- 
quency of angiosclerosis in the different parts of the cir- 
culatory system has been studied by Bregmann, Sack, 
and others. The arteries are more frequently involved 
than the veins, although the study of phlebosclerosis has 
been rather insignificant as compared with the amount 
of attention paid to arteriosclerosis. ° 

Arteriosclerosis in general is more frequent in the ves- 
sels of the extremities than in the aorta and its branches 
of the first and second order; it is most frequent in the 
arteries of the leg and forearm, beginning first of all in 
the anterior tibial. This is explained on the score of the 
general lateral hydrodynamic pressure to which these 
vessels are exposed on account of posture in addition to 
the general hydrodynamic pressure. 

Arteriosclerosis of the pulmonary artery is exceedingly 
rare as compared with the frequency of the process in 
the aorta. In chronic tuberculosis of the lungs, emphy- 
sema and other diseases resulting in atrophy and destruc- 
tion of lung tissue naturally give rise to more or less 
compensating endarteritis. In Sauné’s thesis are collect- 
ed twelve cases of sclerosis of the pulmonary artery; in 
seven, emphysema was present. It is suggested by 
Laache that the carbonic dioxide may tend to prevent 
the development of arteriosclerosis, although the mode 
of action is not clear at all; probably the more important 
factor is the low pressure in the pulmonary artery as 
compared with that of the aorta (Laache, Frankel, 
Sauné). 

Laache has described an instance of sclerosis with ath- 
eroma of the pulmonary artery that clinically presented 
the symptoms of congenital heart disease (“morbus 
ceeruleus”); there were hypertrophy of the right ven- 
tricle, marked nodular condition of the intima, and dila- 
tation of the pulmonary artery. Apparently the sclerosis 
in this case was due to weakening of the arterial wall. 
Romberg has described a similar case. He found but 
one similar case in the literature, a case of Klob’s. The 
striking blueness of the skin in Romberg’s and Laache’s 
cases—in both instances it led to diagnosis of congenital 
heart disease—is difficult to explain. 

Huchard and von Schroétter describe each a case of 
sclerosis in the pulmonary artery associated with pressure 
upon it by aortic aneurism. Edgren attributes pulmo- 
nary sclerosis in one case to patency of the ductus arteri- 
osus. 

Philebosclerosis.—The early observations on sclerosis of 
the veins were made by Hodgson, Rokitansky, Virchow, 
and others. Lobstein introduced the term phlebosclero- 
sis. Rokitansky described thickening of the intima 
and of the adventitia of the veins involved in varicose 
aneurism; and Virchow called attention to chronic en- 
dophlebitis in long-continued passive congestions; in 





both cases the influence of mechanical causes is quite 
evident. 

According to the careful studies of Sack the localiza- 
tion of phlebosclerosis is determined largely by the same 
factors as arteriosclerosis, and the tendency is to regard 
phlebosclerosis in many cases as a systemic disease, anal- 
ogous to diffuse arteriosclerosis, and due to general nutri- 
tional disturbances resulting in weakness of the middle 
coat. But it may appear as a local disease in consequence 
of local venous congestions, as, for instance, in the portal 
system in atrophic cirrhosis of the liver, and in the pul- 
monary veins in mitral stenosis. As will be seen from 
the adjoining table of Sack, phlebosclerosis attacks espe- 
cially those vascular provinces in which the venous press- 
ure varies greatly in different positions of the body, and 
in which the activity of the voluntary muscles favors 
the venous flow to relatively but a slight extent. Now 
every obstruction to the venous flow hinders also the 
arterial flow, though in a much smaller degree, and un- 
doubtedly phlebosclerosis in some cases precedes arterio- 
sclerosis. Sack showed by the statistical method that 
the two diseases are closely related. There is need of 
further study of these questions. 

The important relations of phlebosclerosis to varicose 
eink ae of the veins are discussed under Varicose 

eins. 


SACK’S TABLE SHOWING THE DISTRIBUTION OF PHLEBOSCLEROSIS. 














2 Number Frequency 
eae with of disease 
examined phlebo- in per- 

; “| sclerosis. | centages. 
Ve JUQularnintoys acc outecie te es 20 7 35% 
Wis DEAGHIAT IS ea sicccncceh rate tele 55 4 7 
Ve COPNALICH fc a's.cleiv.c o109.0.0 06 Fe 6 3 50 
We DESLLAIR Are feclevera elatarse cies. sre wislele fi 4 57 
Vis RAGHIAD So c)< ctvrsswie:s ti maiee mists 52 0 0 
VS WINAE! ccissscitetn sete earls 58 0 0 
Wis WiACAOXbscicc cc clsleceeatiaes ce 61 2 38 
VSfemorali esas snececoeeeedcws 67 51 76 
Vie PODIILCAI ere ctetsieieierenteinen etre tarays 72 65 90 
Vie SDN NOG 2. ca cocince ciinetesees 55 50 91 
Waersapha Dare tec desiainee rete 14 13 93 
Va tibial anton vores viclossictl delet oe 88 24 re 














Sclerotic veins are elongated and of varying calibre. 
They present constrictions and dilatations, the dilatations. 
amounting in some cases to well-marked pouches filled 
and distended with blood. In the severer forms of the 
disease the vessels are curved upon themselves, and if 
superficial, they can be rolled under the finger like a cord. 

The valves are insufficient, either from retraction of 
their leaflets or from adherence to the side of the vein. 
When the vein is cut open its walls show differences in 
thickness, at one point being strong enough, perhaps, to 
gape open like an artery, at another collapsing as a vein 
usually does. At times, portions of the veins show cal- 
cified plates and ulcerous spots, resembling in each case 
those so frequently found in arteriosclerosis. The most. 
marked changes take place in the intima and the inner 
part of the media. The coats are thickened and pre- 
sent points of fatty changes and of coagulation necrosis. 
often infiltrated with lime salts; at other points athero- 
matous débris may have formed. 

SYPHILIS.—Some of the first observations on syphilis 
of the blood-vessels, as it affects the arteries at the base 
of the brain, were made by Virchow and Lancereaux. 
A good anatomical description of syphilitic arteritis was 
given by Allbutt in 1868. In 1874 Heubner published a. 
study of fifty cases of syphilis of the cerebral vessels, in 
which he endeavored to establish a primary endothelial 
proliferation (“arterioma”) as the specific form of arte- 
rial syphilis, the virus acting directly on the intima. In 
this he was opposed by Baumgarten, who, while not 
denying that syphilis causes endarteritis, yet claimed 
that the only arteritis histologically characteristic of syph- 
ilis begins in the lymph spaces of the adventitia, and 
results in a gummatous periarteritis. Kdéster,.Fried- 
liinder, and others supported Baumgarten’s view, and 


105 


Blood-Vessels. 
Blood-Vessels,. 





Friedliinder regarded Heubner’s endarterial proliferation 
as indistinguishable from endarteritis obliterans in gene- 
ral. According to this view the virus acts principally 
upon the adventitia through the vasa vasorum and the 
lymph vessels, the inflammatory process extending in- 
ward. 

Syphilis of the Smaller Vessels.—At the present time 
the general teaching is that syphilis of the smaller vessels 
occurs either as an independent process or as part and 
parcel of a local syphilitic infiltration; von Zeissel and 
other syphilologists state that primary vascular syphilis 
is one of the rare localizations of the disease. In the pri- 
mary form the vessels involved usually present yellowish- 
white or grayish thickening of the adventitia and the 
intima. A smaller vessel, such as a cerebral artery for 


example, may be studded with translucent or whitish, 
circumscribed patches, more or less cartilaginous in con- 
sistency and non-calcified; or a certain length of the 
The 


vessel may be transformed into a whitish cord. 
tendency to fibrous oblitera- a 
tion of the lumen is_ pro- 
nounced, but in the earlier 


Se Beit Oa Re et 2 
’ Se bee REA ESSE = ea Ra = 


Fic. 632.—Gummous Arteritis. Great intimal thickening with small cellular areas—gummata. At a, perivas- 
(From Nothnagel’s ** Specielle Pathologie und Therapie,”’ 1899, xv., p. 147.) 


cular infiltration of intima. 


stages the proliferation in the intima is richly cellular 
and vascular. This is the syphilitic endarteritis of 
Heubner. It is now generally held that this form can- 
not be distinguished either microscopically or macro- 
scopically from certain thickenings of non-syphilitic 
origin. The occurrence of obliterating endarteritis in 
circumscribed form in youthful persons is regarded, 
however—and as unquestionably so when associated with 
gummous nodules—as in the majority of cases the result of 
syphilis. The new tissue in the intima may contain vas- 
cular spaces. The elastic layer is greatly thickened and 
folded. Bands of elastic fibres appear in the thickening, 
and their development is ascribed by Abramow and Haga 
as due to a splitting up of the old membrane by the 
growth of fibrous tissue between its layers. But it is also 
probable that new elastic fibres form; at all events, that 
is not impossible. A reduplication of the elastic layer is 
regarded by Wendeler as marking each standstill of the 
process. The elastic elements do not appear to differ in 
their behavior from that seen in endarteritis obliterans in 
general. 

At other times the vessels are surrounded either with 
nodular, cellular infiltrations or dense cicatricial tissue. 
In the primary syphilitic lesion there is marked periarte- 


106 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


rial infiltration, which is surrounded by an external ring 
of elastic elements, probably part of the walls of the 
perivascular lymph spaces in which the cellular prolif- 
eration takes place. In later syphilitic foci, when the 
granulation-tissue formation is in the recent stage, there 
is cellular infiltration in the adventitia, media, and inti- 
ma. Distinct gummous nodules, either purely cellular 
(lymphoid and epithelioid cells) or with a granular, ne- 
crotic centre and a cellulo-fibrous periphery with giant 
cells, may be found in the vessel wall (Baumgarten’s 
gummous arteritis), most frequently in the adventitia. 
This is the only form of syphilitic arteritis that is histo- 
logically specitic (Fig. 682). 

The gummata develop especially in the adventitia, more 
rarely in the media and the intima. Occasionally a sin- 
gle cross section may show a series of nodules in the 
various layers of the wall. Later, when fibrous transfor- 
mation takes place, all the coats become fibroid, the me- 
dia atrophic. 

Gummous periarteritis and productive endarteritis are 
often more or less intimately associated, especially when 
they occur as consecutive processes in the midst of syph- 
ilitic foci. The different 
appearances so often ob- 
served are explainable in 
a measure by the degree 
and the duration of the 
disease. Syphilitic arte- 
ritis differs from arterio- 
sclerosis by its circum. 
scribed occurrence and by 
the tendency to organiza- 
tion and obliteration; fat- 
ty changes and calcifica- 
tion are not characteristic 
of syphilis. 

Most of the investiga- 
tions on syphilis of the 
.q@ smaller arteries concern 
the cerebral. The appar- 
ent frequency with which 
the cerebral vessels, es- 
pecially at the base, are 
affected by these processes 
is explained as in part the 
outcome of the great in- 
terest that clinicians take 
in all the phases of cere- 
bral syphilis, and perhaps 
also because the basal ves- 
sels are constantly bathed 
in cerebro-spinal lymph. 
The anterior cerebral ar- 
teries—the cerebral 
branches of the internal carotid—are the ones especially 
involved. But syphilitic vasculitis as an independent 
process occurs elsewhere. In the spinal cord both arte- 
ries (Marinesco, Pick) and veins (Lamy, Orlowsky) may 
be involved. The coronary arteries, the arteries of the 
extremities, the splenic, the retinal, the mesenteric, and 
the adrenal (Weichselbaum) may be diseased more or less 
extensively as well. According to Urlich, Palma, and 
Birch-Hirschfeld, syphilitic changes in the coronary arte- 
ries may be primary or consecutive, the left coronary ar- 
tery being affected more frequently than the right. 

In Abramow’s cases there were circumscribed nodules 
in the walls of the arteries of the extremities and of the 
intimal organs, the cerebral being spared. In some the 
appearances described by Heubner predominated; in oth- 
ers, a more diffuse cellular infiltration with gummous 
nodules, especially in the adventitia, the muscular coat 
showing a granular disintegration. The destruction of 
the media by cell proliferation beginning either in the 
adventitia or the intima had resulted in places in aneu- 
rismal dilatations. Some of the appearances presented 
resemble not a little those of periarteritis nodosa. 

Von Zeiss], Lomokowsky, and Haga describe syphilitic 
arteritis of the extremities. In Haga’s case the vascular 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


disease resulted in spontaneous gangrene; this form of 
spontaneous gangrene seems quite frequent in Japan. 
Haga reports thirteen cases, in all of which the vessels 
of the affected extremities presented the same changes. 
The vascular lumen was obliterated either as the result 
of successive intimal thickenings, due to the production 
of a vascular new tissue solely, or from thrombosis. The 
media was thickened. In nine of the thirteen cases 
there were focal accumulations of round cells about the 
vasa vasorum, and in some instances cellular nodules 
were present in the media and the intima (gummous arte- 
ritis). Quite similar changes were observed in the veins. 
Scriba suggests that in some cases this arteritis is the re- 
sult of congenital syphilis. 

Von Zeiss] and Langenbeck describe syphilitic arteritis 


of the brachial artery that was healed by antiluetic treat- ; 


ment. 

Syphilis of the Aorta and Larger Vessels.—Isolated in- 
stances of gumma in the walls of the larger arteries, es- 
pecially the pulmonary, have been described by Weber, 
Wagner, Virchow, and others. Weber describes a gum- 
ma as large as a bean in the pulmonary artery, beginning 
in the media under the intact intima and causing great 
narrowing of the lumen. 

Syphilitie Mesarteritis.—Wagner, Hertz, Backhaus, 
Doehle, Heller, and others describe a primary sy phi- 
litic mesaortitis. _Macroscopically the intima presents 
circumscribed fissured and furrowed areas and depres- 
sions, which occur in groups especially at the beginning 
of the aorta and near the origin of the larger vessels. 
Elsewhere the intima may be smooth and normal or the 
seat of sclerotic changes. The media in such areas may 
be wholly absent or replaced by a thin layer of scar tis- 
sue. Microscopically there is proliferation about the 
vasa vasorum which may show obliterating changes, and 
there may be more or less distinct gummata with necrotic 
centres (Heller, Backhaus) as well as cicatricial areas 
with thickening of the intima and retractions, giving it 
the peculiar linear and irregular pit-like depressions that 
are regarded as characteristic of specific mesaortitis. 
Foci of small-celled infiltration, as well as diffuse fibrous 
changes, are present in the adventitia. These changes 
may be combined with ordinary arteriosclerosis. Back- 
haus states that of ninety-nine syphilitics examined at the 
Kiel Institute, seventeen showed mesarteritis. Doehle de- 
scribes a typical case in asyphilitic woman, aged twenty- 
five. Belfanti describes beginning gummous nodules in 
the aorta with marked circumscribed thickenings in the 
intima. Irregular ulcerations in the aorta with callous 
margins are also recorded as of syphilitic origin. Bol- 
linger has also described a gummous form of endarteri- 
tis. All seem to agree that the presence of circumscribed 
areas of fibrous attenuation of the aortic wall, associated 
with more or less dilatation, may be regarded as the re- 
sult of syphilitic mesaortitis; the changes are observed 
not rarely in rather young persons; there are often dis- 
tinct syphilitic lesions in other organs, and the changes 
in the aorta certainly do not correspond to those of ordi- 
nary arteriosclerosis. It is upon the basis of such lesions 
that aneurisms in young syphilitics probably develop. 
I have seen two cases of multiple, small sacculated aneu- 
risms in the beginning of the aorta that originated in 
fibrous mesaortitis; in both cases were areas of marked 
fibrous attenuation without much compensating fibrous 
thickening in the intima. 

Syphilis is also regarded as playing an etiological role 
‘of a more general nature but of great impor tance in the 
vulgar form of arteriosclerosis. The occurrence of arte- 
riosclerosis and of arteriosclerotic aneurism in young 
‘syphilitics is rather frequent and is generally known. 
On account of the many complex factors that enter into 
consideration in arteriosclerosis the exact role of syphilis 
is hard to define. 

Syphilitie Phiebitis.—Mch that has been said of syph- 
ilis of the arteries is applicable to syphilis of the veins, 
and especially as regards the secondary changes that 
occur in smaller veins in the midst of larger syphilitic 
foci. Dowse briefly refers to obliterative changes in the 


Blood-Vessels, 
Blood-Vessels, 





posterior cerebral sinuses in a gummous pachymenin- 
itis. 

Oedmanson, Winckel, and Birch-Hirschfeld described 
diffuse and circumscribed endophlebitis of the umbilical 
veins of congenital syphilitics. Schiippel has described 
a gummous pylephlebitis in congenital syphilis, and Bow- 
man attributes certain cases of thrombosis of the stem of 
the portal vein to syphilitic periphlebitic changes. Huber 
found intimal thickening with petrification in the veins 
of the extremities of a syphilitic girl twenty-two years 
old. 

In congenital syphilis there frequently occurs an oblite- 
rative vasculitis of the umbilical vessels which was first 
described by Oedmanson. Schiippel has described peri- 
pylephlebitis in a syphilitic infant, and in 1864 Virchow 
observed an ossifying endaortic process in a girl of eigh- 
teen with congenital syphilis. The vascular changes Sof 
the lesions of congenital syphilis in the internal organs 
resemble those of the acquired disease. Reference has 
been made to Scriba’s view that spontaneous gangrene 
may be caused by an arteritis of neon ADy. sy philitic 
origin. 

TUBERCULOSIS.—The older pathologists, such as Roki- 
tansky and Virchow, regarded the blood-vessels as im- 
mune to tuberculosis. The demonstration by Weigert in 
1877 that acute general miliary tuberculosis results from 
the tuberculous invasion of either a blood-vessel or the 
thoracic duct put an end to this theory. So thoroughly 
did Weigert demonstrate this course of events that when 
the tubercle germ was discovered a few years later he 
could say truthfully that it was necessary only to sub- 
stitute bacillus for poison in order to make the report of 
his investigations conform fully to the new require- 
ments. 

Tuberculosis of the walls of blood-vessels may result 
from the extension of the process from adjacent tubercu- 
lous foci. This may occur in the arteries and veins. In 
case the lumen is not closed by productive endovasculitis 
and thrombosis, the infiltration in the vessel wall on case- 
ation and disintegration may give off tuberculous mate- 
rial and bacilli to the circulating blood. This leads to 
embolic or miliary tuberculosis of the corresponding capil- 
lary district. Im the case of the pulmonary vein, the 
general circulation becomes infected; in the case of a sys- 
temic vein, miliary tuberculosis of the lungs results; and 
if it concerns an artery, miliary tubercles may spring up 
in its capillary district. Tuberculous and suppurative 
destruction from without of the branches of the pulmo- 
nary artery exposed in tuberculous pulmonary cavities 
may so weaken the wall that aneurismal dilatations de- 
velop (“erosion aneurism”). Many of the copious hemor- 
rhages in advanced pulmonary phthisis result from the 
rupture of aneurisms of this nature. 

Dittrich, Kamen, and Sigg have described tuberculo- 
sis of the wall of the aorta due to direct extension. In 
Dittrich’s case an adherent lymph gland communicated 
the disease to the thoracic aorta, the intima of which pre- 
sented an oval defect with elevated ridges, a continuous 
tuberculous process traversing the aortic wall. Kamen’s 
case was of similar origin, the vessel presenting a dilata- 
tion with rupture of the wall. In Sigg’s case a tubercu- 
lous lung was adherent to the aorta, which presented a 
bulging corresponding to the caseous replacement of its 
wall, the caseous area being covered internally by a 
thrombus. 

When tubercle bacilli reach the circulating blood they 
sometimes become implanted upon the intima of larger 
vessels such as the aorta. Weigert, Flexner, Hanot and 
Levy, Stroebe and Blumer have described pinhead-sized 
intimal, aortic tuberculous masses. Blumer describes 
two instances of intimal tuberculosis of the abdominal 
aorta; in one of the cases there were several minute 
nodules of characteristic structure. The sclerosis of the 
aorta present in both cases did not play any part in de- 
termining this localization. In all of these cases the 
infection took place directly upon the intima and not 
through the vasa vasorum or the lymphatics of the walls 
of the artery. The tuberculous masses appeared as if 


107 


Blood-Vessels, 
Blood-Vessels, 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





they had been fastened upon the intima. The surface of 
such areas may contain tubercle bacilliin large numbers. 

According to Cadéac tuberculous aortitis is not un- 
common in cattle. Ihave recently studied a tuberculosis 
of the aorta ina dog. 
A large nodule devel- 
oped in the wall of the 
aorta near the heart, 
producing such weak- 
ening that a small 
bulging had resulted. 

The relation of tu- 
berculosis of the blood- 
vessels to general mili- 
ary tuberculosis is 
discussed elsewhere. 
At this time it is suffi- 
cient to say that tuber- 
culosis of the intima 
of blood-vessels or of 
the thoracic duct or 
tuberculous endocar- 
ditis constitutes an es- 
sential, intermediate 
stage in the develop- 
ment of acute general 
miliary tuberculosis. 
It is in the tuberculous areas that result from infection of 
the intima and of the endocardium that the germs muiti- 
ply so freely that masses are thrown into the general cir- 
culation and produce on lodgment in the internal organs 
the numberless nodules characteristic of general miliary 
tuberculosis. There is no satisfactory evidence that tu- 
bercle bacilli multiply in the blood; hence miliary tuber- 
culosis means the setting free into the circulation at one 
time of large numbers of bacilli (Weigert, Benda, Gay- 
lord). 

The vascular changes in tuberculous leptomeningitis 
are interesting and well marked. There is a tuberculous 
endarteritis characterized by the formation of intimal tu- 
bercles and a diffuse subendothelial intimal proliferation 
(Figs. 683 and 684), probably induced by the implantation 
of tubercle bacilli from the blood. From the intima the 
infiltration may spread into the muscular coat and the 
adventitia and the whole wall may undergo caseous and 
hyaline degeneration. Occasionally, though rarely, the 
intimal process so weakens the wall that small, local dila- 
tations take place—a species of mycotic aneurism. Pro- 
liferation in the adventitia may invade the media and the 
intima and the whole wall of the arterial segment may 
undergo degeneration. 
In tuberculous leptomen- 
ingitis the muscularis oft- 
en presents the hyaline 
degeneration described by 
Guarnieri and others. The 
epithelioid cells that con- 
stitute such a prominent 
feature of the intimal pro- 
liferation undoubtedly or- 
iginate from the subepi- 
thelial connective tissue 
rather than from the epi- 
thelial lining, which ap- 
pears to remain intact un- 
til caseation takes place. 
Plasma cells and phago- 
cytic cells are also present. 

In this form of tuber- 
culosis adjacent extravas- 
cular and arterial foci fre- 
quently extend to the veins (Fig. 635). 

Banti describes a case of general tuberculosis in which 
nearly the whole length of the superior vena cava was 
completely filled by a mass of neoplastic tuberculous tis- 
sue which projected into the right auricle.* 





Fic. 633.—Perforation of the Elastic 
Layer by Caseous Intimal Foeus, Infil- 
tration into Media and Adventitia, and 
Beginning Aneurismal Bulging. Note 
beginning subendothelial prolifera- 
tion in opposite wall from tubercu- 
lous leptomeningitis. (Hektoen, The 
pe of Experimental Medicine, 
vol. i. 














634.—Subendothelial Intimal 
Proliferation with Multinuclear 


FIG. 
Giant Cell. From tuberculous 
leptomeningitis. (Hektoen, The 


Journal of Experimental Medi- 
cine, Vol. i.) 


* Migge: Virchow’s Archiv, Bd. 76. 


108 


AcTINOMycosIs.—As actinomycosis spreads through 
the tissues by direct extension, no anatomical structure is 
absolutely secure from invasion, not even the blood-ves- 
sels. In metastatic actinomycosis the fungus gains en- 
trance into the circulation by the direct involvement of 
the walls of the blood-vessels in the vicinity of a local 
process. In the cases in which the point of invasion of 
the vascular system has been directly demonstrated it 
concerns some of the larger veins and cerebral sinuses. 

The meningeal sinuses and veins are frequently at- 
tacked in cranio-cerebral actinomycosis. In many cases 
of actinomycotic phlebitis the generalization of the proc- 
ess is undoubtedly prevented or delayed by consecutive 
thrombosis. 

Ponfick describes an actinomycotic proliferation which 
projected button-like into the lumen of the internal jug- 
ular vein; this invasion became the direct or indirect 
source of secondary foci in the heart, lungs, spleen, and 
brain. 

Ina case of primary pulmonary actinomycosis with 
extension through the diaphragm and into the spleen, 
Arnold Paltauf found the splenic vein infiltrated and 
thrombosed, the thrombosis extending into the portal 
vein; there were metastatic foci in the liver and in the 
brain. Liining and Hanau describe perforation in the 
hepatic vein in a secondary actinomycosis of the liver. 
In pulmonary actinomycosis with extension to the pleura 
and pericardium Habel found the base of the heart and 
the larger vessels surround- 
ed by a spongy tissue; just 
above the entrance into the 
auricle the superior vena 
cava presented a circum- 
scribed area in which the 
normal wall was substituted 
by a nodular mass of pale 
yellow color; the jugular 
veins were thrombotic. 
Abée describes an actino- 
mycotic perforation of the 
inferior vena cava. Begin- 
ning in the csophagus the 
process spread out in the 





prevertebral, mediastinal, 
and peripleural tissue, and 
invaded the diaphragm and 
the spinal column. The 
infiltration between the 
right lung and the dia- 
phragm surrounded the in- 


FIG. 635.— Focal Tuberculous Infil- 
tration with Giant Cell, Extend- 
ing through Wall of Vein with 
Secondary Thrombosis, Caused 
by Extension in Tuberculous 
Leptomeningitis. (Hektoen, 
The Journal of Experimental 
Medicine, vol. i.) 





ferior vena cava in the form 
of a layer, 3 to 4cm. thick, of a reddish, soft tissue rid- 
dled with confluent abscesses. At the point where the 
vein enters the auricle its lumen was materially narrowed, 
the intima roughened, covered by parietal thrombi and 
perforated by numerous yellowish suppurative foci; be- 
low, the vein was partially filled with a large softened 
thrombus. There were numerous metastatic actinomy- 
cotic abscesses in various parts of the body. 
Leprosy.—Leprous nodules sometimes occur in the 
walls of the veins in leprosy of the extremities. 
PERIARTERITIS Noposa.—This remarkable disease was 
described by Kussmaul and Maier in 1866. Cases had 
been observed previously by Pelletan in 1810 and by Ro- 
kitansky, but their descriptions were confined to the mac- 
roscopic appearances. Since Kussmaul and Maier fast- 
ened the attention upon the disease additional instances 
have been recorded, so that the total number of cases now 
is thirteen (von Schrotter). All of the cases have occurred 
in Central and Southern Germany except one—a Russian 
instance (Freund). The disease appears to attack young 
persons mostly between twenty and thirty; it occurs 
also in children. The male sex has so far furnished more 
cases. The symptoms are, generally speaking, those of 
a more or less severe toxic polyneuritis and polymyositis 
with constitutional and digestive disturbances, abdomi- 
nal pain, renal symptoms, etc. In nearly all cases a 
peculiar anemia and general weakness have been re- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blood-Vessels, 
Blood-Vessels, 





corded. The whole course of the disease takes from six 
to twelve weeks, the termination as far as known being 
always fatal. In Kussmaul and Maier’s instance minute 
nodules were present in the skin of the face, neck, and up- 
perextremity. It is quite likely that in the future the dis- 
ease will be diagnosed during life, especially in instances 
with subcutaneous nodules which might be excised and 
examined microscopically. Clinical observation has not 
brought out any common or striking etiological condi- 
tions. Syphilis has been present in some cases and deti- 
nitely excluded in others. 

The vascular lesions consist of nodular, eccentric, and 
more diffuse thickenings of arteries of the general size of 
the coronaries and hepatic and smaller; the swellings are 
grayish and grayish white in color, vary in size from 
pinhead to pea and larger, occur especially at the branch- 
ings, but also in the course of the arteries both when free 
and intraparenchymatous. The distribution and num- 
ber of the swellings, usually present in great numbers, 
vary somewhat in different cases (Weichselbaum and 
Thompson); the favorite locations are the mesenteric 
(including the intraparietal branches of the gastro-intes- 
tinal tract), and the coronary, then the muscular, intra- 
neural, renal, hepatic, 
splenic, bronchial, and 
subcutaneous. Nod- 
ules have also been 
described at the ori- 
gins of the intercostal 
branches of the aorta 
and of branches of the 
crural and popliteal 
arteries. It is note- 
worthy that up to this 
time the veins have 
not been involved (Fig. 
636). 

The histogenesis of 
the arterial lesions, 
which are of an inflam- 
matory nature associ- 
ated at times with 
aneurismal dilatations, 
fibrous tissue forma- 
tion and thrombosis, is 
not agreed upon. 
Fletcher, von Kahlden, 
and Freund regard the 
process as primarily 
inflammatory, due to 
the action of some un- 
known substance, 
which reaches the ad- 
ventitia by way of the 
vasa vasorum. ‘This 
view is supported by 
the presence, in Fletch- 
er’s case, of nodules 
upon the vasa vasorum 
and by the microscopic appearances in the early stages 
of the process (Freund). Accordingly, the inflamma- 
tory round-cell infiltration, which appears to be of a 
non-specific type, begins in the adventitia and extends 
through the media to the intima, producing in the last 
marked cellular accumulations between it and the 
media. As a result of the inflammation the muscu- 
lar coat undergoes a circumscribed hyaline degenera- 
tion, and hyaline material, probably of exudative ori- 
gin, also appears in the subepithelial layers. There 
are not many polymorphonuclear cells in the cellular in- 
filtration, which consists largely of spindle-shaped cells 
with large nuclei. Freund did not find proliferation in 
the intima when the media was normal. Eventually the 
internal elastic coat and the media are so thinned and de- 
stroyed that circumscribed aneurismal bulgings of the 
vessel wall may occur, but the formation of aneurisms 
is not constant because the development of fibrous tissue 
may prevent dilatation. 


FiG. 636.—Periarteritis Nodosa. 
(After Freund.) 











Longitudinal section of a small muscular branch. 
a, Adventitia, greatly infiltrated with cells; b, foci of especially 
dense cell accumulations in adventitia ; ¢, normal media; d, degenerated media ; 
e, external elastic lamina, bulging outward ; f, internal elastic layer; g, remnants 
of internal elastic layer: h, proliferating intima. 


Others, like Weichselbaum and Chvostek, hold that 
the process is primarily an endarteritis, which extends to 
the outer coats. In the case of smaller arteries and of 
vasa vasorum this would seem to be the fact probably. 

It has been suggested that periarteritis nodosa is a pri- 
marily multiple tumor of the nature of lymphoma, begin- 
ning in the adventitia. Circumscribed accumulations of 
cells occur in the adventitia that resemble lymphomata; 
but the singular fact that the process is confined to 
arteries speaks against this view. The subsequent for- 
mation of fibrous tissue is also inconsistent with this 
theory. 

Meyer regarded tears in the media as the essential 
cause, and Eppinger has elaborated the theory that peri- 
arteritis nodosa is the result of the formation of multiple 
aneurisms on account of ruptures of the elastic elements, 
which are congenitally weak and imperfect. Eppinger 
proposes to call the disease congenital aneurism. The 
proliferation observed, in the adventitia and intima, 
which constitutes such a striking feature of the lesions, 
is regarded by Eppinger and the supporters of the 
aneurismal theory (von Schrétter) as secondary ; and the 
thrombi and hard fibrous masses sometimes observed 
are similarly explain- 
ed. Aneurisms are 
not observed in every 
instance of periarte- 
ritis nodosa; in Pelle- 
tan’s, Rokitansky’s, 
Eppinger’s, Weichsel- 
baum’s, and Meyer’s 
cases they were mark- 
ed. In Pelletan’s case 
sixty-three aneurisms 
were present. The de- 
velopment of aneu- 
risms is consistently ex- 
plained on the score of 
more marked inflam- 
matory and degenera- 
tive weakening of the 
arterial wall in some 
nodules than in others 
in which these proc- 
esses were not so rapid. 
Any evidence of a his- 
tological nature of a 
congenital structural 
imperfection of the ar- 
teries in | periarteritis 
nodosa has not been 
furnished. Eppinger’s 
theory does not satis- 
factorily explain the 
relative infrequency of 
involvement of the 
cerebral arteries, which 
would seem to be as 
liable to aneurismal dil- 
atations as other arteries, if not more so. The clinical 
course of the disease is also against this view. 

The histological appearances and the genesis of the 
changes as explained by Freund and others rather favor 
the view that periarteritis nodosa is a primarily inflam- 
matory process in the further course of which aneurisms 
frequently develop; but further studies are essential be- 
fore the question of the nature of this disease can be 
definitely established. Micro-organisms have not been 
found in the lesions. Syphilis has been suggested as the 
underlying condition. Graf finds histologically periarte- 
ritis nodosa resembles not a little Heubner’s endarteritis 
syphilitica; and the appearances described by Abramow 
in two cases of syphilitic arteritis involving many of the 
smaller arteries, except the cerebral, are also decidedly 
suggestive of periarteritis nodosa, the clinical symptoms 
of which were absent, however. The absence, in some 
cases of periarteritis nodosa, of all history of syphilis and 
the freedom of other organs from syphilitic lesions and 


109 


Blood-Vessels,. 
Blue Hill Min. Spring. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








their consequences are also against the specific theory ; 
and it does not appear that the vascular lesions of periar- 
teritis nodosa ever present nodular foci of cell accumula- 
tions with central necrosis such as occur in the gum- 
mous form of syphilitic arteritis. Periarteritis nodosa 
must be regarded, for the present, as a distinct disease, 
histologically and clinically. Syphilitic periarteritis 
should not be included under periarteritis nodosa, as is 
done by some writers like Mott in Allbutt’s “System.” 
Many of the clinical symptoms are evidently due to 
secondary lesions in the internal organs. Although the 
intramyocardial branches of the coronary arteries are 
generally involved, the myocardium itself usually pre- 
sents but slight changes. Whether bronchitis and other 


inflammatory changes in the lungs are directly secondary 
to changes in the bronchial arteries, the pulmonary being 
usually free (von Schrétter), cannot be stated. The mu- 
cous membrane of the gastro-intestinal tract has been 
found to be the seat of multiple ulcers and hemorrhages; 
the ulcers in the stomach being more of the nature of 
erosions while those in the intestines may resemble ty- 





F1G. 637.—Growth of Carcinoma into the Gastric and Portal Veins and the Radicles of the 
The posterior surface of the stomach, 
A, Cut end of gastro-duo- 


Latter, Secondary to Carcinoma of the Pylorus. 
which is turned so that the pylorus is to the left, is exposed. 
denal vein. 


phoid ulcers. These changes are regarded as the result of 
circulatory disturbances in the areas nourished by the 
affected branches, many of which become entirely oc- 
cluded by thrombosis. Enlargement of the mesenteric 
glands is usually present. The spleen may be the seat 
of infarcts, in various stages of absorption, caused again 
by the occlusion of terminal arteries. Pressure of the 
nodules in the intrahepatic branches of the hepatic artery 
on the bile ducts may cause jaundice (von Schrotter). 
Severe changes are produced in the kidneys. Multiple 
ischemic necrosis results from thrombosis of the affected 
arteries. Degeneration of the glomeruli, hemorrhages, 
parenchymatous and interstitial changes develop, due 
either to extension of the vascular changes or to the ac- 
tion of toxic substances in the blood. The changes in 
the peripheral nerves and in the skeletal muscles explain 
well the nervous and muscular phenomena observed clin- 
ically. The pressure of changed arteries upon adjacent 
nerves may cause degenerations, and in Freund’s case 
foci of degeneration in the nerves were found to corre- 
spond to nodules upon intraneural arterial branches. 
The development of nodules upon the intramuscular ar- 
teries gives rise to granular and fatty disintegration of 
the muscle fibres and to waxy changes. 

In Weichselbaum’s case the rupture of an aneurism, 
2 cm. in diameter (the largest so far recorded in periarte- 


110 


ritis nodosa), upon the arteria profunda cerebri gave rise: 
to hemorrhage. 

Tumors.—The primary tumors composed of blood- 
vessels—the various forms of angioma—are described in. 
the article on Zumors. Here is described also the part 
that blood-vessels play in the general dissemination of 
the malignant tumors. Primary tumors rarely develop 
in the walls of blood-vessels. Brodowski has described 
a primary sarcoma of the thoracic aorta, which started 
in the adventitia and extended through the muscular coat. 
and into the intima; the sarcomatous infiltration of the 
intima produced a marked thickening of the latter. 

I have described an interesting pedunculated out- 
growth of the intima of the basilar artery, which at that. 
time was regarded as a fibroma. It is possible, however, 
that the outgrowth in reality was the result of an endar- 
teritic proliferation of inflammatory nature. 

Several instances of myoma, fibroma, and sarcoma. 
have been described as primary in veins (Orth), 

Secondary tumors occasionally occur in the walls of the: 
blood-vessels. Quincke, in “Ziemssen’s Encyclopedia,” 
cites an instance, described by Broca, 
of cancer at the root of the aorta with 
rupture into the pericardium. Fried- 
rich describes metastatic nodules of a. 
papillary cystocarcinoma of the ovary 
in the wall of the thoracic and abdom- 
inal aorta and the renal artery ; here the 
metastases evidently occurred through 
the vasa vasorum. The nodule in the: 
thoracic aorta ruptured into the lumen 
of the vessel. 

Extensive intravascular growth of 
malignant tumors, especially in the 
veins, takes place in the case of sar- 
coma of various kinds, especially of the 
bones, in adrenal tumors of the kid- 
neys, etc. Intravascular growth of 
this kind has extended from the renal 
vein, for instance, to the heart. 

In carcinoma of the stomach I have 
observed an extensive intravenous. 
growth of the tumor resuiting in a 
kind of carcinomatous injection of all 
the veins about the lesser curvature of 
the stomach and of the portal vein 
(Fig. 687). Orth observed the entire 
venous plexus of the dorsum of the 
foot filled with sarcomatous masses. 

Norica and Haret* describe a carci- 
noma of the stomach with metastases 
in the mesenteric, mediastinal, and deep 
cervical glands, followed by carcinomatous invasion and 
thrombosis of the superior vena cava, the two brachio- 
cephalic, subclavian, and internal jugular veins. In 
1885 Oulmont collected nineteen cases of obliteration of 
the superior vena cava. He distinguished two groups, 
namely, obliteration by pressure and obliteration by con- 
cretion. The first group comprised five cases due to can- 
cer of the mediastinum or of the lung, two cases due to 
tuberculous lymph glands, and four cases due to aortic 
aneurism. The second group included five cases of 
thrombosis and three cases of cancerous invasion. Com- 
by and Rendu each report a clinical case in which aneu- 
rism of the aorta was thought to be the cause. I have 
examined post mortem a case of this kind, in which an 
aneurism of the ascending aorta compressed the superior 
vena cava, which was wholly obliterated by the forma- 
tion of fibrous tissue in the intima. The occlusion took 
place gradually and resulted in a great dilatation of the 
subcutaneous thoracic and abdominal veins which for 
years furnished routes for collateral circulation. Le- 
tulle lays stress on occlusion of the large veins of the 
neck and mediastinum on account of propagation of car- 
cinomata of the glands, the thyroid, and the thymus. 





*Bulletins et mémoires de la Société Anatomique de Paris, 189% 
Ixxiv., 861. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. pine ¥ill min, 


Blood-Vessels, 
Spring. 





Gallavardin reports thrombosis of the large cervical veins 
in mitral stenosis. The extensive occlusion described by 
Norica and Haret has been equalled by the case of Reid 
only, which is included in Oulmont’s series. There was 
in Norica and Haret’s case dilatation of subcutaneous 
veins of the right side of the chest and abdomen, show- 
ing that the blood in the superior vena cava was diverted 
into the inferior by way of the azygos vein. This diver- 
sion furnished a sufficient collateral circulation. The 
condition of the thoracic duct was not examined. 
Ludvig Hektoen. 


LITERATURE. 


General. 


Allbutt: A System of Medicine, 1899, vii. 
Orth : Lehrbuch d. path. Anatomie, 1887. 
Von Schrétter: Nothnagel’s Specielle Path. u. Therapie, 1899, xv. 


Abnormities. 
Brooks: Journal of Anat. and Physiol., 1886, xx. 
Dowse: Transactions London Path. Society, xxvii., 11. 
Lancereaux: Traité d’anatomie path., 1881, ii., 948. 
Peacock : Malformations of the Heart, 1866. 
Rauehfuss: Virch. Arch., 1859, xvii., 376. 
Shaw, D. Lee: Aorta with Double Arch. Journal of American Medi- 
ical Association, 1897. 


Retrogressive Changes. 

Mallory, F. B.: A Contribution to the Study of Caleareous Concretions 
in the Brain. The Journal of Pathology and Bacteriology, 1896, 
Prey LO: 

Angetitis. 

Borchard: Beitrage zur primiren Endarteritis obliterans. 
Zeitschrift f. Chirurgie, xliv. 

Bollinger: Endophlebitis verrucosa im Pfortader eines Pferdes. Vir- 
chow’s Archiv, 1872, lv., 279. 

Boinet et Romary: Recherches expérimentales sur les aortites. Arch. 
d’Anat. Path., 1897, ix., 902. 

Chiari: Ueber die selbstandige Phlebitis obliterans der Hauptstamme 
der Venz Hepatic als Todesursache. Ziegler’s Beitrige, 1899, 
Vis J 

Fenger, Christian: Stenose af Ostium pulmonale og Arteria pulmo- 
nalis, forarsaget ved Vegetationer pa Pulmonalklapperne og i Arte- 
rien, oplyst ved et Sygdomstilfalde. Nordisk Medicinskt Arkiv, 
Band v., No. 4. 

Flexner, Simon: Perforation of the Inferior Vena Cava in Amoebic 
Abscess of the Liver. The American Journal of the Medical 
Sciences, May, 1897. 

Haga: Ueber Spontane Gangran. Virchow’'s Archiv, 1898, clii., 26. 

Hunter, John: Transactions of a Society for the Improvement of Medi- 
eal and Surgical Knowledge, 1793. 

Jones: Ueber die Neubildung elastischer Fasern in der Intima bei 
Endarteritis. Ziegler’s Beitraige, 1898, xxiv., 458. 


Deutsche 


Angiosclerosis. 


Councilman, William T.: On the Relations between Arterial Disease 
bel ie Changes. Trans. Assn. of American Physicians, 1891, 
viteay bate 

Dmitrijeff : Die Veranderung der elastischen Gewebes der Arterien- 
wiinde bei Arteriosklerose. Ziegler’s Beitriige, 1897, xxii., 207. 

Durante: Athérome congenital de l’aorta et de l’arterie pulmonaire. 
Bull. et Mém. de la Soc. Anat. de Paris, 1899. 

Eberhardt, Alexander: Ueber den sogenannten kérnigen Zerfall und 
Querzerfall der elastischen Fasern und Platten in ihrer Beziehung 
zu den Erkrankungen des Arteriensystems, 1892. 

Epstein: Ueber die Struktur normaler und ectatischer Venen. Vir- 
chow’s Archiv, 1887, eviii. 

Gazert: Ueber den Fett und Kalkgehalt der Arterienwand bei 
oe und Arteriosclerose. Deut. Arch. f. kl. Med., 1899, 
Lil’, F 

Laache, S.: Om Sklerose af arteria pulmonalis og erhvervet ‘‘ morbus 
coeruleus.”? Norsk Magasin fer Lagevidenskaben, 1900, 1x., 51. 

Malkoff : Ueber die Bedeutung der traumatischen Verletzungen ven 
Arterien fiir die Entwickelung der wahren Aneurysmen und der 
Arteriosklerose. Ziegler’s Beitriige, 1899, Ixxv., 481. 

Peabody, George L.: Relations between Arterial Disease and Visceral 
Changes. Trans. Assn. of American Physicians, 1891, vi., 154. 

Sack: Ueber Phlebosklerosis und ihre Beziehungen zur Arterio- 
sclerosis. Dissertation, 1887. 

Sauné: De l’athérome et de l’artére pulmonaire. Thése de doctorat, 
1877 


dd. 
Thoma: Virchow’s Archiv, vols. xciii., xcy., civ., cV., CVi., Cxi., cxii., 
exiii. 
Syphilis. 

Abramow : Ueber die Veriinderungen der Blutgefasse bei der Syphilis. 
Ziegler’s Beitriige, 1899, xxvi., 202. d is 
Birch-Hirschfeld: Beitr. zur pathol. Anatomie der heredit. Syphilis. 

Arch. f. Heilk., 1875, xvi., 166. 
Bowman: Beitrige zur Thrombose des Pfortader-stammes. Deut. 
Arch. f. kl. Med., 1889, lix., 283. : 
Huebner: Die leutische Erkrankungen der Gehirnarterien, 1874. 
Huber: Ueber syphilitische Gefisserkrankung. Virchow’s Archiv, 
1880, Ixxix., 573. 
Tuberculosis. 


Blumer, George: Tuberculosis of the Aorta. The American Journal 
of the Medical Sciences, January, 1899. 











Gaylord, Harvey R.: Critical Summary of Literature on Tuberculosis 
of the Walls of the Blood-Vessels and the Production of Miliary 
ie The American Journal of the Medical Sciences, July, 


Hektoen, L.: The Vascular Changes in Tuberculous Leptomeningitis, 
Especially the Tuberculous Endarteritis. The Journal of Experi- 
mental Medicine, 1896, i. 

Periarteritis Nodosa. 


Fletcher: Ziegler’s Beitrige, 1892, xi. 

Freund: Deutsche Arch. f. kl. Med., 1899, Lxii. 

Graf: Ziegler’s Beitrige, 1896, xix. 

Von Schrotter: Nothnagel’s Specielle Pathologie u. Therapie, 1899, xv., 


3d. 


BLOUNT SPRINGS.—Blount County, Alabama. 

Post-OFrrice.—Blount Springs. Hotel. 

Access.—Via Alabama and Chattanooga Railroad, also 
vid Louisville and Nashville Railroad to Elyton. 

The springs are about thirty miles northwest from this 
station. The waters of Blount Springs may be classed 
as saline sulphureted. The springs are six in number, 
and are located in a triangular valley 1,580 feet above 
the sea level. 


ONE UNITED STATES GALLON CONTAINS: 

















nee: Sweet Spring 
Solids. R. T.. Spring. No. 4. 
Brumby. Brumby. |Summers. 
Grains. | Grains. | Grains. 
Magnesium carbonate............0008 4.40 3.60 9.40 
Calcium CAnDONRGiw. acciciscssie ccsiels sielere 6.80 4.48 5.7 
Baru CarbOnalerenaneceicuiscm neta mayer Figen 91 
Tron) Carbonate. Gs ceenalsss poses estes 1.92 1.12 3.19 
Sodinmycarhbonates., sccrtescs ces usec nee Seite cinta 
Magnesium sulphate 1.60 2.40 on 
Calcium sulphate... ..3..cs.c8.6 aieteke HAD 1.27 
Calcium phosphate........... Fuss Scie nace Trace. 
IPObASSIUMUeChIOTIOG ssc cninestavicdees a. oiee tear 7.07 
HOdTMCNIOMAGS ccc cisslerectess veteiieene 32.32 30.88 23.21 
Magnesium chloride...............065 6.00 Saisie 2.04 
Moyo b te Eo BS Oe an Ran hucnnaccacosdcoODbaC antc Tone aaa 
Magnesium J0dide.......0.s0tereeee Sere hee 14 
Magnesium bromide................0> Pirie eet 16 
TACHA ayeterateroreratepsietelcisioieerstetcrsieicisiescstete Trace 
PA IULEVLS IA Neatece ous ctetaietatstotcloianersietersislea’ siecle aeafere i stehe Trace 
SUL CAH ele orc tele cfelererisin oteisiatsiste (ols weisielocteiste’e e Rae ene 2.44 
SHC son, GaagenconcobdDAbb COSrObCurle AGns 
TOA esas letinccrewiais osiucWieloastesiel jets 53.04 42.48 55.55 
Gases Cu. in. Cu. in. Cu. in 
CATT OWIC AGI ays arete ae clovatola\e:asofarelersietacei& 6.00 6.00 4.72 
Sulphureted hydrogen...............- 14.96 12.56 30.67 
ORY POMS encase nine sis wrclettiew ccteics See pee t +08 
NitrO@ON Re tutawen tec ohne itecloes oun BGS seas os 








J. K. Crook. 


BLUE HILL MINERAL SPRING.—Hancock County, 
Maine. 

Post-Orricr.—Blue Hill. Hotels. 

AcceEss.— Via steamer from Portland, also by stage from 
Ellsworth, fourteen miles distant. 

The Blue Hill Mineral Spring is located two and one- 
half miles northwest of Blue Hili village, and about six 
hundred feet in perpendicular height above the base of 
Blue Hill Mountain. Its situation assures freedom from 
all surface impurities. The existence of the spring was 
noticed by Dr. Charles T. Jackson in his second report 
of the geology of the State of Maine, published in 1888. 
It was not until recently, however, that improvements 
were made. A handsome and commodious building has 
been erected for the comfort of tourists and visitors at 
the springs, and a large bottling plant established. An 
analysis by Prof. 8. P. Sharples, of Boston, resulted as. 
follows: 


ONE UNITED STATES GALLON CONTAINS: 










Solids. 
Sodium chloride .........scee0e Teese tints! s:2 ielesrale orarriere a ecstat 
Sodium sulphate....sseereseeessvees : 
Sodium carbonate..... EA OD ROAR EN Ot iica: EOE ITIGHOL E 
Calcium carbonate...... Riera Gialetectovete ctatetors sre tiers tatorek iniena arora 1.87 
TTON) GBTDONAtE sou sansiesG aecashio a « pi ature soaeeica ep aaciie 59 
Te tena Sop odbot Sees bbe ADU e ere Cobsog Rais ota bisee Sa 1.07 
Organic matter oi... ccc cece senscscosccscnss Le yadunde Traces. 
Totals .vcseoe BL aS atideectlccn sleaies De aw ae e aie Sodan © S/G) 


Blue Lick Springs. 
Boil. 





This is an excellent table water, and it also possesses 
mild diuretic and tonic properties. It is used commer- 
cially. J. K. Crook. 


BLUE LICK SPRINGS.—Saline County, Missouri. 

Post-OFrFricE.—Marshall. Cottages at spring. 

AccrEss.—Viai Chicago and Alton, or Jefferson City, 
Boonville and Lexington branch of the Missouri Pacific 
Railroad to Marshall, thence eight miles by stage south 
to springs. 

Saline County, Missouri, is entitled to eminent distinc- 
tion as a water-producing district. Thousands of clear, 
pure-water springs of more or less volume are well dis- 
tributed over its surface. They are found in large num- 
bers along the Missouri, Blackwater, and Salt River 
bluffs, and at the base of the minor hills in all parts of 
the county, and are unfailing at all periods of the year. 
The most remarkable natural resources of the county, 
however, are its mineral waters, which for volume, 
variety, and medicinal value are among the finest in the 
country. Not less than two thousand mineral springs, 
some of them of immense flow, are found in the limits 
of the county. Some of these springs will, no doubt, 
take a prominent place among the health resorts of the 
country when they shall have been properly developed. 
At the Blue Lick Springs are more than thirty distinct 
fountains in a pretty valley at the base of picturesque 
wooded bluffs, all within a radius of thirty feet. The 
largest of the group, known as the “Gum” Spring, is an 
immense salt fountain of 57° F., which was formerly the 
site of extensive salt works, but is now the centre of a 
large bathing establishment. Nearby is the “Blue Lick” 
Spring, the most important of the group. Then there 
are numerous black sulphur, magnesian, chalybeate, and 
sweet springs, besides uncounted saline springs. Many 
of these have been analyzed by State Chemist Paul 
Schweitzer, who found in them the following mineral 
ingredients: 

Calcium sulphate. 
Barium sulphate. 
Calcium sulphite. 
Sodium sulphite. 
Ammonium nitrate. 
Magnesium nitrate. 
Calcium phosphate 
Alumina. 

Silica. 

Sulphur. 

Carbonic acid gas, large quantities. 


Sulphureted hydrogen gas, large 
quantities. 


Sodium chloride. 
Potassium chloride. 
Calcium chloride. 
Magnesium chloride. 
Lithium chloride. 
Calcium carbonate. 
Tron carbonate. 
Magnesium carbonate. 
Manganese carbonate. 
Magnesium bromide. 
Magnesium iodide. 
Magnesium sulphate. 
Potassium sulphate. 


Many of these ingredients serve to endow the waters 
with valuable remedial qualities. A complete qualita- 
tive analysis of the Blue Lick Spring, for which the col- 
lection is named, resulted as follows: 


ONE UNITED STATES GALLON CONTAINS: 





Solids. Grains 
Galeilim CAYDOVALCE Sat vivtleiaie'e sate icceleieielole alavera'olsistetnret stsievarare 57.84 
IM ARONOSIUM SUID AKG acre leretarereis/e's planslsiarelcrertiels eiaieortere ots te 26.13 
MAONESINM, ;CHIOTIAE iieiateissorelelore lejelcielereleievavacrmnieiers eveletstsiayeiste 10.94 
Soditina Chloxvide See lioc tetas amtetre cvexteietetotererctetete palette 493.88 
Potassiu Chloride en vce scien sieleteisters otis ainiain tote eicteversters 64 
SLUG olka Tohurele sara ers eiaree acciale aveTecniele esarerers,apataletarate eieleferne tor elets 8.16 
ATINMINAT Sy wep caters cletecie so esn leit aida tate cleetars clei te teicta 10.23 
Ofeanic Miatleretes scene eae ciememittte nsec 2.48 

MTOCAL Si ccale oleriviteliaic's aleve sie@ide is olaielcwintareretalaeiealeleaiotarets 610.30 

Gases. Cu. in 
Free Carbonic acai ai vice a hice cncwils emveeiiebiee sielorelersts 53.22 
Sulphureted Dy Grow@eu 3.) afe ais. miele oveteteislefersiainieiate Not estimated 


It will be seen that the waters are very similar to those 
of the Blue Lick Springs of Kentucky, for which these 
springs are named. 

The water is well adapted for the treatment of con- 
stipation, especially when due to engorgement of the 
portal system. On the other hand, it is also said to act 
beneficially in many cases of chronic diarrheea. It acts 
with advantage in many of the conditions due to a slug- 
gish liver, such as hemorrhoids, jaundice, etc. Being a 
very efficient diuretic, the water is useful in certain renal 
and bladder disorders. Within sixty steps of the Blue 


112 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Lick Spring are three black sulphur springs; two hun- 
dred and fifty yards south is the Sweet Spring, which has 
been found to bea very efficient diaphoretic and diuretic. 
It is entirely free from sulphur and forms a very pleas- 
ant beverage. James K. Crook. 


BLUE RIDGE SPRINGS.—Botetourt County, Virginia. 

Post-OFFiIcE.—Blue Ridge Springs. Hotel and cot- 
tages. 

Access.—Via Norfolk and Western Railroad. The 
hotel is located near the railroad station. 

This resort has a picturesque location in the midst of 
the Blue Ridge Mountains, the elevation being about 
thirteen hundred feet above the sea level. The springs 
yield about one hundred and twenty gallons of water 
per hour, having a temperature of 52° F. the year round. 
The water has been analyzed by Prof. Henry Froehling, 
with the following results: 


ONE UNITED STATES GALLON CONTAINS: 


Solids. Grains 
Magnesium sulphate s..« «essa 0s oie +’ oe « «calls ue aerate 47.01 
Caleitam Sulphate oseictes.0 -sieleiewisieitens a « eielelee eee ener enene 100.13 
Sodium: SuUIPHAte.... ccervles se ses cece sehen slot een 37 
Potassium SulpNate 5.5). sis). scicreosta a cle ole sieivinle ameter eta 65 
Magnesttm Carbonate s:cciciccmccisse «sous semtienaeenmnten 1.61 
Calcinm: Carbonate: ic. cite ows cles «ot eice clalene einer 3.96 
Strontium carbonates. 0. cove cs wee osieeeu enter seieerete 29 
Barilim: Carbonate... casas sis ce vcvjtelsss sdisve viv eet lea 02 
Manganese: Carbonate iio: <)<a.a cca « s10100 00.0 spe nle aioe ieisiaitale 02 
Nickel and cobalt CarbOnaters \.c.cac «cis: aisle clelectetsinisain Trace. 
Iron (ferrous) carbonates. 2.2.0.0 siaeee eee ll 


LOB CarbOMate <ciccicicaisie v/s'e valeierd ove, viseis pec niorete nt tarts 
Copper carbonate 
Sodium ‘CHIOTIAE <5 5:0 oe vet nace «vee v's lovnins aieia) gn eieiae eee 
Lithivuny Chloride: cis. o.cnes sistas els ees sph eee 

Sodium arseniate 





SOGMUM LOGIE. « .i025,0,<:0-+0:eelsieisysis oveiiwiere yelncalndereleieee eaters Trace. 
Sodium bromides, o1.5.. sc <siac.cc eno sscersiee fare teeta terete Trace. 
Calcium Huoride 22 < s's0c c's.at 5 alese o'lelee velele atl te enten enn Trace. 
Magnesium nitrate... aici os0:nlere' ovaletsse a ttelereie isl anene tearm 35 
Ammonium Nitrate... .sicss sic vee. ovis clematis -03 
AlUMINUMY PHOSPHALES..16) oi <1c.0js {clave le c,s/clsate ale eieihiaeereeeterene -02 
AluUMINUNY STCALC ca vrers eicivn co's olelnielote/e ciel aikiatara een enmonays 15 
SUICIC ACI, wis.s.< <2 .s:avlacere'eiese'e wee a srovalbiowistelale a arene eee 1.35 
TOtall 6. o\s:e.0:0 0:07 ofacsine  v'a s-0renidsce. ee 40 eielaieelete aie anne 157.37 
Carbonic: acid combined... <5... cm. sv sue vieieislsivieleeivicteieiels 2.57 
Gases. Cu. in 
Carbonic acid=(free)iivacssnuelleciapale cis yetteeate ennai 38.20 
Sulphureted hydrogen s.% scs.:.ccnlee silos c seteteleietetetets elentane 3.00 


The water is used commercially. It is pleasant to 
drink and bears transportation well. It is useful in 
dyspepsia, especially when attended by acidity, and it 
seems to act as a corrigent or regulator of secretion, be- 
ing efficacious both in diarrhea and in constipation. The 
water also possesses excellent tonic properties. 

J. K. Crook. 


BOCCONIA.—A powerfully medicinal and poisonous 
genus of plants in the Papaveracee or Poppy family. 
“B. cordata Willd.,” more properly Maclaya cordata 
(Willd.) R. Br., of China and Japan, is a stout perennial 
herb, largely cultivated as an ornamental plant, the 
roots of which are used medicinally. It contains at least 
three alkaloids (vide Schlotterbeck), namely, protopine 
in large amount, 3-homochelidonine, and chelerythrine, 
and possibly sanguinarine also. B. arborea Watson, of 
Mexico, and B. frutescens L. and B. integrifolia Kunth. 
of tropical America, are small trees or large shrubs, the 
bark of which is used similarly. These barks are rich 
in alkaloids and resinous matter. The alkaloids have 
been isolated and somewhat studied in the Instituto 
Medico Nacional of Mexico, and names assigned them; 
but apparently insufficient care was taken in comparing 
them with known alkaloids of other members of the 
family, notably of sanguinaria. If they are not abso- 
lutely identical with the latter, they are at least very 
similar in physiological action, as well as chemically. 
These drugs have been very little studied in any way, 
but richly deserve it. The writer has found the leaves 
of B. frutescens highly prized among the Indians of South 
America, but their uses there give little clue to their 
special properties. H. H, Rusby. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Blue Lick Springs. 
Boil. 





BOERNE, Texas, is a town of 800 inhabitants. situated 
in the southwestern part of the State, 30 miles north- 
west from the city of San Antonio. Its altitude is about 
1,670 feet, which gives it somewhat the characteristics 
of a mountain resort of moderate elevation. The soil is 
composed of gravel and sand with occasional streaks of 
adobe, anda substratum of porous limestone. The drain- 
age is good, both on account of the slope and on account 
of the porous character of the soil. 

Dr. I. M. Cline, quoted in Solly’s “Medical Clima- 
tology,” 1897, who has charge of the Texas weather 
service, describes the country in which Boerne lies as 
follows: 

“Between latitude 29° 45’ and 30° and to the 100th 
meridian on the west, the elevation changes rapidly from 
one thousand to two thousand feet, with considerable 
irregularity, and is broken with deep ravines and small 
creeks, and along the western border, as the two-thou- 
sand-foot line of elevation is reached, it is much sculp- 
tured by erosion. The soil between these elevations is 
very irregular in its formation, but is to a great extent 
of the black, stiff soil over the eastern portion, and then 
blends toward the west with black and red sand and 
red loam, with a pebbly soil in some parts; it is also 
crossed here and there by strips of white, sandy land, 
with a growth of scrub post-oak.” 

The monthly mean temperature for eight years, 
arranged by seasons, is given by Solly as follows: 
Winter, 50°; spring, 69°; summer, 79°; autumn, 65°, 
Mean for January, 49°; for July, 81°; for the year, 65°. 
The total seasonal rainfall, based on nine years’ records, 
is given by the same authority as follows: Winter, 5.9 
inches; spring, 9.6 inches; summer, 6.4 inches; autumn, 
4.9 inches. Annual mean, 27 inches. The mean relative 
humidity is from 66 to 72 per cent. Occasionally dur- 
ing the winter months there is a sudden fall in tempera- 
ture during the prevalence of a “norther”; this fall de- 
pends on the velocity of the wind and ranges from 5° to 
25° F., and lasts from a few hours to three or four days. 
The windfall is light, the prevailing winds blowing from 
the south and southeast, the velocity ranging from four 
to seven miles an hour, and occasionaily increasing to 
from fourteen to twenty-five miles during a “norther.” 
“From the fact,” says Miller (“Boerne and Adjacent 
Country,” by Dr. William Miller, Resident Physician), 
“that the wind passes over miles of land covered with 
grass and trees before reaching Boerne, it is not accom- 
panied with clouds of dust or sand,” which, as Dr. Mil- 
ler adds, is a very important matter with persons suffer- 
ing from diseases of the respiratory organs. 

There are a few light morning fogs in the late autumn 
and winter, not exceeding a total of eight days in the 
year. The average number of sunny days is 277, and 
of cloudy 88. The number of days in which there is 
more or less sunshine, and in which an invalid can be out 
of doors, is 355. In Boerne and the adjacent country 
there are no prevailing diseases of a contagious or epi- 
demic nature. The whole of this elevated district is 
above the yellow-fever line (Miller). 

The water supply is chiefly obtained from wells of 
an average depth of thirty-five feet, and the water is 
considered fairly good for drinking purposes. Cistern 
water is also used. About three miles from Boerne are 
the Indian Mineral Springs, so named from the fact that 
they were visited periodically by various Indian tribes, 
who came bringing their sick with them. This water 
is also used as a table water. The analysis made by C. 
F. Chandler, Ph.D., of New York, is as follows: 


IN ONE UNITED STATES GALLON THERE IS: 


Solids. Grains. 
DIOL NOM CHIOKIGGS as... crataoalh tle ele’s(e siaistapisieisls/eias 8. or0 6 0.512 
Equivalent to sodium ChIOTIde...........ccsceescccees 844 
Oxides Of iron And aAlUMINUM 5 <sisecssanviees civdceclss« 093 
BIOTA Ae orale Sa totvcs rtiel Soisiticlals « welshistelasimieis.cty:08 Ba. 45.832 
PVESEEP TORI ecu are elias cs vitor lola gs civ level sieieate oy fale (eteisielalelpier iso 6.435 
Sulphuric acid (SOg) in sulphates...........cseeeeeeees 67.246 
DIOR cre sisaie sie ene ei aetele teenie a aielatelaaniettiateen(s/siaeleisces goss 355 
BOUUIS OP GVADOLATION: . leic'e «oie a setae s ctivieie cies b's alewie'e ole 138.388 


Vou. II.—8 


There are several fairly good hotels and boarding 
houses in the town or near by. Boarders are also re- 
ceived in the ranch houses in the neighborhood. The 
attractions are riding, driving, hunting, and fishing, and 
there are various pleasant excursions in the vicinity. The 
class of diseases which this climate is likely to benefit 
are pulmonary tuberculosis, chronic rheumatism, renal, 
nervous, and malarial diseases. 

When one considers the low relative humidity, the 
equable climate, and especially the very large number 
of sunny days in the year (277), the inference is warranted 
that Boerne is admirably fitted for the open-air treatment 
of pulmonary tuberculosis. While experience has verified 
this conclusion, the fact still remains that here, as in so 
many other climatically excellent health resorts in this 
country, there is lacking the certainty of finding such 
hygienic conditions as the consumptive requires. Climate 
is only one of the factors in the cure of phthisis, and it 
will often prove an illusory one unless those other factors 
are also present, viz., careful medical supervision and 
opportunities for obtaining proper food, well-ventilated 
sleeping apartments, and means for the rest cure. 

Edward O. Otis. 


BOIL.—(Synonyms: French, Fwronele, Clow ; German, 
Blutschwar ; Furuncle.) 

DerFinition.—A. boil or furuncle is the result of an 
acute phlegmonous inflammation of the skin and under- 
lying connective tissue surrounding a skin gland or fol- 
licle, which is followed by suppuration and the extrusion 
of a central slough or core. 

Symptoms.—A boil begins with a certain amount of 
infiltration around a skin gland or follicle, which soon 
manifests itself as a small, somewhat itchy, and slightly 
painful pimple. Very soon the lesion assumes a conical 
shape, becomes more tender, and is surrounded by a zone 
of reddened skin. The boil increases in size with con- 
siderable rapidity until about the third or fourth day, 
when it reaches its full development. The pain likewise 
grows in intensity, becoming a dull ache, and there is 
much throbbing and sensation of tension. All of these 
symptoms are intensified at night. The area of the 
furuncle varies considerably, depending upon the density 
of the skin in the affected part, and the consequent facil- 
ity with which the infiltration may spread. Finally, at 
the apex of the boil a point of suppuration appears, and 
in a week or ten days the lesion matures or becomes 
“ripe.” If pressure is made over a boil before it is quite 
mature a little pus or bloody serum may be made to 
exude; but later, either spontaneously or as the result of 
surgical interference, the core escapes, although not al- 
ways very readily. - The expulsion of the core exposes 
to view asmall cavity which quickly heals, to be followed 
in turn by a purplish discoloration and ultimately by a 
minute scar. Lymphangitis and swelling of the lym- 
phatic glands frequently occur in connection with boils, 
and sometimes constitutional symptoms are marked. 
When a core does not form, as occasionally happens, it is 
called a blind boil. Boils may occur singly orin groups; 
often they come out in successive crops, and keep on 
appearing for long periods, constituting the condition 
known as furunculosis. The so-called “furuncular dia- 
thesis,” especially as seen in children, may produce great 
restlessness, sleeplessness, anorexia, and emaciation due to 
pain and the free discharge of pus. It may be of interest 
in this connection to mention that under the name of “ hi- 
dradenitis suppurativa ” Pollitzer * has called attention to 
a suppurative inflammation of the sweat glands which 
results in their destruction and the production of scars. 
It is the same condition originally described by Verneuil. 

SrruatTion.—While boils may develop anywhere on 
the general surface, except the palms and soles, they 
show a marked predilection for the back of the trunk and 
neck. They also occur inthe armpits and at the borders 
of the lids (styes) and in the external auditory canal, in 
which latter situation they excite great pain. 





* Jour. Cutan. and Genito-Urin. Dis., January, 1892. 


113 


Boldo, 
Bone. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





PaTHOLOGY AND Et1oLocy.—It is now conceded that 
boils are due to the entrance of pus cocci (staphylococcus 
aureus or albus) into the openings of skin glands or hair 
follicles. According to the researches of Bockhardt,* if 
the micro-organisms do not penetrate into the cutis, 
simple impetigo results; if they pass vaguely into the 
cutis through some lesion in the epidermis, a skin abscess 
will occur; but if they pass along the duct of a sweat 
gland or penetrate the lumen of a hair follicle, the proc- 
ess of suppuration is more acute and a furuncle results, 
the suppurating gland or duct representing the core. 
Direct inoculation or experimental cultures show conclu- 
sively the contagious nature of boils, as was pointed out 
long ago by Startin. According to Melsome,t it is not 
possible to obtain cultures in the cedematous area sur- 
rounding a boil; however, when a furuncle is large, or 
is rapidly followed by others in its immediate vicinity, 
the pus cocci pass through the abscess walls and travel 
along the lymphatics, producing swelling of the lymph 
glands, and in severe cases they may even gain access to 
the general circulation and induce septicemia. 

It is said that women are less subject to boils than 
men, and that while boils are not uncommon in infants, 
they are most frequent in boysand young men. Solitary 
boils are often found to be due to some local irritation, 
e.g., chafing of rough or frayed garments, decubitus, 
etc., the irritated skin more readily allowing the penetra- 
tion of pus organisms. A condition of furunculosis of 
the back of the neck is not infrequent as the result of 
infection from the fingers of barbers and the use of the 
dirty implements of their trade. 

Sweaters and other garments worn by young men in 
training and in athletic games frequently become infected 
and give rise to boils in otherwise singularly healthy 
persons. 

It is a matter of common experience that furuncles 
complicate many disorders of a depressing character, ¢.7., 
diabetes, variola, typhoid fever, etc. Severe pruritic dis- 
eases are also often complicated or followed by boils; 
for example, eczema in children. In the hot summers 
experienced in this country the very frequent prickly 
heat is frequently followed by boils, both in children 
and adults. 

The condition known as furunculosis, or recurrence of 
boils in crops, is due to local reinoculation and not to the 
state of the blood, although it is undoubtedly true that 
the nutrition of the soil will have much to do with the 
pathogenetic action of the pus cocci. 

With our present knowledge of the pathology of boils 
it may be readily understood how boils sometimes occur 
quasi-epidemically in families and schools. 

DraGnosts.—A boil is to be distinguished from a car- 
buncle by its conical shape and its single suppurating 
point; a carbuncle, on the other hand, is larger and flatter 
than a boil, has several openings, and is surrounded by 
a much more brawny induration. The difference really 
is one of degree, the carbuncle being, however, clini- 
cally, a much more formidable affection. 

TREATMENT.—In all cases, especially when the erup- 
tion has existed for a long time, it is advisable, in 
addition to the local measures presently to be described, 
to look into the hygienic surroundings and general health 
of the patient. The urine should be examined for al- 
bumin and sugar, and if these are discovered the proper 
treatment for those conditions should at once be adopted. 
All local sources of irritation and possible infection should 
be diligently sought and removed. Old smoking jackets, 
sweaters, etc., should be regarded with suspicion. A 
proper disinfection of barber’s tools should be insisted 
upon. 

Now that the specific character of the furuncle is better 
understood there is less insistence upon the administration 
of Spee of remedies that are supposed to be “ good for 
boils. 

Among such remedies may be mentioned yeast in doses 





* Monatshefte fiir Derm., No. 10, 1887. 
+ Allbutt’s System of Medicine, vol. i., 1896. 


114 





of a half-wineglassful morning and night, and the sul- 
phide of calcium so highly praised by Ringer. It is 
quite possible that the sulphide of calcium may possess 
some germicidal properties, but it must be given in much 
larger doses than those usually recommended. Dilute 
sulphuric acid in ten to twenty drop doses, well diluted, 
every three or four hours, is highly esteemed by some 
physicians. Medicines that improve the general nutrition, - 
thus rendering the individual less susceptible to local in- 
fection, are of undoubted value in furunculosis; for ex- 
ample, iron, arsenic, cod-liver oil, the hypophosphites, 
and the syrup of the lacto-phosphate of lime may be 
prescribed with hope of benefit in suitable cases. 

As regards the direct treatment of the boil itself an 
effort should be made to prevent if possible, or at least 
limit, the suppuration. Very often a boil may be aborted 
by the application of a salicylic acid plaster, as after L. 
Heitzmann’s formula: 


B® Acidi‘salicylici:.’.2. 0... eee 3 ij. 
Emplastri saponis ...............e0: cau ul 
Kmiplastr diachyltn.. ss. metre 2A 


M. S. Spread on cloth. 


Other remedies of this class are iodine, boric acid in 
saturated solution, and ichthyol. Halle and Jamieson 
advise the following application: 


Tincturse 10d1..... cement Zi. 
Aciditannici },. <0: 2a. ce eee 3 SS. 
Pulveris acacis: £2 Hane os ene coer 3 ss. 


A few drops of carbolic acid injected into the apex of 
a boil will often cause it to abort. An electrolytic needle 
will do the same thing. Ifa hair occupies the centre of 
a furuncle it is best to extract it. 

Unna’s mercuric-carbolic plaster often succeeds in 
aborting a boil; but if suppuration has already begun, 
nothing succeeds so well in hastening it. A hole should 
be cut in the centre of the plaster corresponding to the 
apex of the boil. When boils are very painful the com- 
mon practice is to apply a hot flaxseed poultice, but un- 
less it is rendered antiseptic by the addition of carbolic 
acid it is apt to prove mischievous by favoring reinfec- 
tion in the vicinity. The following ointment serves all 
the purposes of a poultice, does not encourage reinfec- 
tion, and allays pain most decidedly: 


BR Pulverisiodoformi< +... se seers 3 
Unguenti vaselini plumbici........... es 
M. S8. Spread on patent lint. 


If the patient exhibits any idiosyncrasy in regard to iodo- 
form, aristol or xeroform may be used in its place. 

The internal administration of appropriate doses of 
phenacetine will usually secure sleep at night. If in- 
cisions are imperatively demanded the parts may be 
rendered insensible by a spray of ethyl chloride. It is 
an absolute necessity, especially where boils are multiple, 
to smear the intervening and surrounding skin with a 
paste made of equal parts of oxide of zinc and vaseline 
and four-per-cent. boric acid. Washing the skin with 
green soap and warm water and mopping on a solution 
of bichloride of mercury 1 to 1,000 often puts a stop to re- 
inoculation. Clean underclothes should be put on fre- 
quently and the patient warned against carrying infec- 
tion to other parts with his fingers. Squeezing and other 
manipulation of a boil should be avoided. After the 
boil has burst the resulting cavity should be treated on 
ordinary surgical principles. W. A. Hardaway. 


BOLDO.—The leaves of Pewmus Boldus Molino (fam. 
Monimiacee). This is a large, much-branched shrub or 
small tree of Chile, evergreen and highly aromatic, the 
leaves opposite, the flowers small, white, panicled, 
dicecious. The leaves usually dry of a brownish color. 
They are coriaceous and very thick, ovate or oval-ovate, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





blunt or emarginate, entire, rough, papillose and stellate- 
hairy. They contain numerous large oil vesicles, and 
have a strong, somewhat turpentine-like odor and an 
aromatic, burning taste. 

Boldo contains about two per cent. of a powerful vola- 
tile oil, with resin, a little tannin, three per cent. of the 
glucoside boldin, and one-tenth per cent. of the alkaloid 
boldine. The statements concerning the properties of 
the constituents are very discordant. According to 
Merck, the hepatic properties reside in the glucoside, the 
dose of which is 0.065 to 0.2 gm. (gr. i. to iij.), and the 
hypnotic properties in the alkaloid, the dose of which is 
0.002 to 0.0065 gm. (gr. x5 to 35). 

The properties of the leaves are very marked, and it 
seems strange that the drug should not have acquired a 
higher repute. Its original use was that of an alterative, 
with special reference to the liver. Marked sedative 
properties were encountered, and it has been considerably 
used as a hypnotic in insomnia. For the latter purpose 
the dose should be 2 to 4 gm. (3 ss. to i.), for the former 
a fourth as much. The drug should be systematically 
investigated. It is now very little used. 

HI, H. Rusby. 


BONDUC.—Bonduc Nut ; Nicker Tree. 

The seeds of Cesalpinia Bonducella (L.) Roxb. and of 
C. Bondue Roxb. (fam. Leguminosae). - 

These plants are not only abundant in India, where 
they are native, but have been very largely introduced 
to most tropical countries. The seeds have the shape of 
a smooth pea, but are one-half or three-fourths inch in 
diameter, and smooth and shining. Those of the C. 
Bonducella are of a peculiar gray lead-color, those of 
C. Bondue yellowish brown. The former especially are 
classical in the medical history of India, the uses being 
numerous and varied, and some of them doubtless ignor- 
ant. Its chief reputation appears to have been in the 
treatment of malaria, and careful trial has shown it to 
possess antiperiodic properties of some importance. The 
seeds contain twenty-five per cent. of fixed oil, which has 
been expressed and used like other fixed oils. They also 
contain about two per cent. of an amaroid, which is a 
white powder, and apparently the active constituent. 
Like all seeds of their class, they are rich in protein. 
The shell contains tannin. The antiperiodic dose of the 
bitter principle is 0.1 to 0.2 gm. (gr. iss. to iij.). 

H. H. Rusby. 


BONE. (HISTOLOGY.)—Bone tissue is closely allied in 
genesis and in many of its structural features to the other 
members of the connective-tissue group, the most evident 
difference between it and other tissues of the same class 
consisting in the solidity and firmness of the basement 
substance. For in this, as in other connective tissues, 
we have to consider the cells and the basement substance 
and the way in which they are arranged to form the dif- 
ferent varieties of tissue. The solidity of the basement 
substance of bone depends largely upon the deposition 
within it of calcium phosphate and carbonate, with small 
amounts of calcium fluoride, sodium chloride, and salts 
of magnesium. These inorganic salts, which form about 
two-thirds of the weight of the bone, are deposited in an 
organic matrix in such a condition of minuteness that 
they are not recognizable as particles even with high 
powers of the microscope. They may be dissolved out 
of the bone with dilute acids, leaving a translucent flex- 
ible material behind, which preserves the shape and gen- 
eral structural features of the bone. 

The soft matrix which is left, after the extraction of 
its inorganic salts, may be converted into gelatin by 
boiling in water. It is sometimes called the cartilage of 
bone, or ossein; but there is no sufficient reason for using 
these names, since the matrix is really, both in chemical 
nature and in minute structure, closely allied to the base- 
ment substance of fibrillar connective tissue. 

The varied gross appearances which different bones or 
different parts of the same bone present have given rise 
to the names compact bone tissue and cancellous bone tissue 





Bolde, 
Bone, 





or spongy bone. But the essential structure of the tissue 
is the same in both, the difference consisting largely in 
the arrangement of the bone tissue proper, and its abun- 
dance in proportion to the marrow spaces or vascular 
canals which it encloses. The compact bone tissue is in 
general found in the outer portions of the bones, while 
the cancellous tissue is situated internally, either entirely 
filling the central portions or bordering the marrow 
cavities. 

Bones are surrounded by a layer of vascular connec- 
tive tissue called the periostewmn, and contain, either in 
large central cavities or in the smaller spaces with which 
they are everywhere permeated, a delicate vascular tissue 
called marrow. We have, then, to consider: 1. bone 
tissue proper; 2. the periosteum; 3. the marrow. 

1. Bone Tissue Proper.—lIf we remove the inorganic 
salts from one of the long bones, by soaking it in dilute 
chromic or picric acid (see article on Histological Tech- 
nique), and then make a thin longitudinal section, micro- 
scopical examination with a low power of these sections, 
stained with eosin and mounted in glycerin, reveals 
a picture like that represented in Fig. 638. The more 
solid portions of the bone show a series of narrow ca- 


















































Fic. 638.—Longitudinal Section of Human Tibia, Decalcified and 
Mounted in Glycerin. ( about 20 and reduced.) 


nals, running in a direction in general parallel with the 
long axis of the bone, and in frequent communication 
with one another by similar short transverse or oblique 
canals. These are the so-called Haversian canals, and 
contain blood-vessels, and, depending upon their size, 
few or many variously shaped cells. Along these Haver- 
sian canals the basement substance will be seen arranged 
in a series of lamellae, while in,and between these lamellee 
lie small, elongated cavities called lacune, in which are 
the bone cells. Transverse sections, however, through 
the middle of a long bone, reveal with more distinctness 
the arrangement of the lamelle of the basement substance 
(Fig. 639). The Haversian canals, which are cut trans- 
versely or obliquely across, are surrounded by a series of 
concentric Jamelle. These Haversian lamellae, with 
their enclosed lacune, together with the canals and their 
contents, form the so-called Haversian systems. Filling 
the larger and smaller irregular areas between the Haver- 
sian systems are other parallel lamella, which run in 
various directions, and which are called intermediary 
systems. Beneath the periosteum, at the external surface 
of the bone, is a thinner or thicker system of lamelle 
called circumferential or general lamelle, which cover 
over large numbers of the Haversian systenis and sur- 
round the entire bone. Sometimes similar but less well- 
defined general systems of lamelle border the marrow 
cavity, but more often the internal surface of the com- 
pact bone is beset with a series of projecting bony 
trabecule, consisting of lamellz similar to those forming 
the systems of the compact bone, and inclosing large, 
irregular spaces. This is the cancellous tissue bordering 
the marrow cavity. In the heads of long. bones, and in 


115 


Bone, 
Bone, 





most short or irregular-shaped bones the cancellous tissue 
occupies the entire central portion. 

If, now, we study more closely the minute structural 
features of the bone, we find in the first place that the 





Fic. 639.—Transyerse Section of a Bone (the Ulna) Deprived of Its 
Earth by Acid. (Sharpey.) Magnified 20 diameters. Haversian 
systems of canals and concentric lamelle. 


Haversian canals, as seen in transverse sections of the 
bone, vary considerably in size and shape. Some are 
large, others small; some are round, others oval, others 
irregular in shape. In many cases, however, the oval 
shape of the Haversian canals and of their systems of 





Fic. 640.—Transverse Section of Compact Tissue of Humerus. Mag- 
nified about 150 diameters and then slightly reduced. (Sharpey.) 
Three of the Haversian canals are seen, with their concentric rings; 
also the lacunz, with the canaliculi extending from them across 
the direction of the lamellze. The Haversian apertures had become 
filled with air and débris (from the grinding), and therefore appear 
black in the figure, which represents the object as viewed with 
transmitted light. 


116 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





lamelle appears to be due to the obliquity of the section. 
In some cases the canals lie in the centre of the systems, 
in others near the side. Sometimes the Haversian systems 
are complex, one set of concentric lamella seeming to 
have encroached upon the space formerly occupied by 
another (Fig. 639). Furthermore, the borders of many 
of the Haversian systems, where these abut on one an- 
other or upon the intermediary systems, appear scolloped 
or jagged. This appearance will be explained below, 
when we consider the growth of the bone. 

Turning now to the bone cells and the spaces in which 
they lie—the lacunse—wwe find that some other mode of 
preparation is necessary than that of mounting sections 
of decalcified bone in glycerin, because the whole ex- 
tent of the cell spaces is not revealed, on account of their 
partial filling by the mounting medium. 

If, however, we take a bone which has been macerated 
and dried, to remove the fat and other soft tissues, and 
prepare thin sections by grinding and polishing them, 
and then mount them in hard balsam, which is melted, 
and, after the section is enclosed, cooled so quickly that 
it does not have time to penetrate far into the tissue, the 
full extent of the cell cavities is revealed. For all the 
spaces are now filled with air, which gives them a dark 
appearance by transmitted light. In a section thus pre- 




















Fic. 641.—Section through the External Table of a Decalcified Human 
Parietal Bone. a, Sharpey’s fibres in their natural position; Db, 
fibres which have been pulled out of the underlying basement sub- 
stance, c. (After H. Miller.) 


pared (Fig. 640), it will be seen that the lacune are 
elongated, mostly fusiform, irregular cavities, lying be- 
tween and in the lamellee, and that from these minute 
branching canals, called canaliculi, pass off, piercing the 
lamelle and forming frequent communications with the 
canaliculi of neighboring lacune. The canaliculi which 
pass out from the lacunz lying near the Haversian canals 
pierce the walls of the latter and open into them. The 
canaliculi of neighboring Haversian systems, however, 
do not, as a rule, communicate with one another. 

In the lacune, as may be seen in carefully prepared 
thin sections of decalcified bone, lie the flattened and, in 
some cases, branching bone cells. To what extent the 
branches of the cells pass into the canaliculi is not yet 
fully established. The bone cells have large nuclei and 
finely granular bodies. 

According to von Ebener, Sharpey, and others, the base- 
ment substance of bone is not homogeneous, but is per- 
meated by exceedingly minute decussating fibrils, similar 
to those of the basement substance of ordinary fibrillar 
connective tissue. Certain of the lamelle, particularly 
those of the circumferential and intermediary: systems, 
are pierced by bundles of delicate fibrils, which pass 
perpendicularly or obliquely through them. These fibre 
bundles, called Sharpey’s fibres, may be seen projecting 
from the inner side of small bits of bone torn forcibly 
away from one another, near the surfaces of decalcified 
bones (Fig. 641) as well as in very thin sections. These 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bone, 
Bone, 








Sharpey’s fibres, as will be seen when we come to the 


development of bone, are the remains of the old fibrillar 


connective-tissue matrix in which the bone is formed. 





Fia. 642.—Cells of the Red Marrow of the Guinea-Pig. 


2. The Periosteum is a fibrous sheath surrounding the 
bones, except over their articular surfaces. It consists 
of moderately dense layers of fibrillar connective tissue 
containing numerous blood-vessels, which ramify in the 
outer portions and finally enter the bone through the 
Haversian canals. There is a considerable number of 
elastic fibres in the inner portions of the periosteum, and 
it contains an abundant system of lymphatic vessels. In 
the growing bone irregular layers of large granular cells, 
called osteoblasts, lie in the inner layers of the periosteum, 
and between it and the bone. The periosteum contains 
a few nerves, which chiefly pass from it into the bone 
tissue. 

3. The Marrow isa complex tissue which fills the large 
central cavities in the shafts of the long bones, the spaces 
in the cancellous tissue, and the larger Haversian canals. 
Marrow tissue varies considerably in its appearance and 
structure in adults and in the young, as well as in differ- 
ent bones in the adult. In the adult the marrow in the 
shafts of long bones consists of blood-vessels and a deli- 
cate connective-tissue reticulum which supports a great 
abundance of fat cells and a varying number of small 
spheroidal cells scattered between the fat cells. Such 
marrow has a yellow appearance from the fat which it 
contains. In the cancellous tissue of both long, irregular- 
shaped, and short bones in the adult, and in all of the 
bones in young animals, the marrow is red in color, and 
contains comparatively few fat-cells. Red marrow con- 
sists, like the yellow marrow, of blood-vessels, lymph 
vessels, and a delicate reticular framework whose meshes 
are more or less filled with cells. These cells are of 
several kinds (see Fig. 642). There are abundant small 
spheroidal cells with nuclei, which are very large in pro- 
portion to the size of the cell body; and between these 
and considerably larger cells, also with large and often 
irregularly shaped and sometimes double nuclei, there 
are numerous intermediate forms. All of the above 
forms are very abundant in red marrow, and constitute 
the marrow cells proper (Fig. 642). Then we find, much 
less frequently, and in varying numbers in different bones 
of the same animal, and in the bones of different animals, 
much larger, usually multinucleated cells, the so-called 
myeloplaxes or giant cells (Fig. 642). These myeloplaxes, 
although always large, vary considerably in size and 
shape, and in the number of their nuceli. The nuclei 
are apt to be collected in a compact mass near the centre 
of the cell, and often present quite bizarre and indescrib- 
able shapes. Finally, red marrow contains, in varying 
number, small nucleated cells, which bodies have the 
color and general appearance of red blood cells, the so- 
called nucleated red blood cells, and small spheroidal cells 
whose bodies contain larger and smaller particles of pig- 
ment, and a moderate number of fat cells. 


Highly magnified. 
a, A large cell the nucleus of which appears to be partly divided into three by constric- 
tions; b, a cell the enlarged nucleus of which shows an appearance of budding into a 
number of smaller nuclei; ¢, a so-called giant cell or myeloplaxe with many nuclei; d, 
a smaller myeloplaxe with three nuclei; e-i, proper cells of the marrow. 





THE DEVELOPMENT OF BonE.—It will be possible 
within the limits of this article to give only a very brief 
general description of the somewhat complex way in 
which bone is formed. It is custom- 
ary to describe the development of 
bone as occurring in three ways, or, 
speaking more correctly, to describe 
three phases of bone development. 
These are intracartilaginous, intramem- 
branous, and subperiosteal. It should 
be borne in mind,, however, that the 
essential nature of the process is the 
same in all. 

Intracartilaginous Ossification.— 
Most of the long and irregular-shaped 
bones in the body consist, at an early 
period of life, of masses of hyaline car- 
tilage, which present, ina general way, 
the shape of the future bone. The 
transformation of these cartilage mass-~ 
es into bones is intracartilaginous ossi- 
fication. This is always associated 
with a certain amount of subperiosteal 
ossification in the manner to be de- 
scribed below. 

If we look at one of the cartilage masses which is to be 
converted into a long bone—at one of the bones of the 
finger or toe, for example (Fig. 643)—at a period when 
the process of ossification is about to commence, we notice 
that at the central portion of the mass the cartilage cells 


(Schiafer.) 











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FiG. 643.—Section of Phalangeal Bone of Human Feetus, at the Time 
of Commencing Ossification. (Schifer.) The cartilage cells in the 
centre are enlarged and separated from one another by dark-looking 
calcified matrix; im, layer of bone deposited underneath the peri- 
osteum ; 0, layer of osteoblasts by which this layer has been formed. 
Some of the osteoblasts are already embedded in the new bone as 
lacunee. The cartilage cells are becoming enlarged and flattened 
and arrayed in rows above and below the calcified centre. At the 
ends of the cartilage the cells are small and the groups are irregu- 
larly arranged; the fibrous periosteum is not sharply marked off 
from the cartilage. 


117 


Bone. 
Bone, 








are larger (Fig. 648) than in other parts, and closer to- 
gether, and that the basement substance between them is 
finely granular from the deposition in it of salts of lime. 


















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Fic. 644.—Longitudinal Section through the Upper Half of the Deeal- 
cifled Humerus of a Fetal Sheep. Magnified about 30 diameters. 
(Schafer.) ic, The part of the shaft which was primarily ossified in 
cartilage, One long, straight vessel (bv) passes in advance of the 
line of ossification far into the eartilaginous head; most of the 
others loop round close to the cartilage. At one or two places in 
the older parts of the bone, elongated groups of cartilage cells (c) 
may still be seen which have as yet escaped absorption ; im, the 
part of the bone that has been ossified in membrane, that is to say, 
in the osteoblastic tissue under the periosteum. The subperiosteal 
layer is prolonged above into the thickening (jp), which encroaches 
upon the cartilage of the head of the bone, and in which are seen, 
among numerous osteoblasts and a few blood-vessels, the straight, 
longitudinal osteogenic fibres (of), and some other fibres (pf ) 
crossing them, and perhaps representing fibres of Sharpey. 


While this preliminary calcification of the cartilage and 
the enlargement of its cells is going on, a shell of bone 
is forming around the middle of the shaft beneath the 
periosteum, and as the cartilage near the ends continues 
to grow and expand at the sides, the entire mass assumes 
somewhat of an hour-glass shape. Now the blood-ves- 


118 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





sels from the perichondrium—which has become a perios- 
teum on account of the above-mentioned shell of bone 
which has been formed around the shaft—begin to ad- 
vance in the central portion of the cartilage, and this be- 
comes channelled out in irregular branching canals in the 
region of the enlarged cartilage cells, so that after a time 
a considerable portion of the central part of the shaft of 
the bone is permeated by a series of vascular canals. The 
general appearance of the bone at this time is seen in 
Fig. 644. 

A closer examination at this period will show: (1) that 
the cartilage cells which lie in the region just beyond the 
advancing vascular canals have assumed a peculiar 
arrangement and are large; (2) that the basement sub- 
stance of the cartilage in the same region is calcified; and 
(3) that thin layers of new bone are beginning to form 
along the edges of the vascular canals in the central por- 
tion of the shaft. 

If we look at a simiiar bone at a somewhat later period, 
we find that while a layer of subperiosteal bone tissue of 
considerable thickness has been formed round the shaft, 
the central portions of the structure are also filled with 
irregular bony trabeculae, between which lie the vascular 
canals or marrow cavities (Fig. 644); and, furthermore, 
that the cartilage cells toward the ends of the bone, in 
the region just in front of the advancing marrow cavities, 
are, as before, large and arranged in rows and lie ina 
calcified basement substance. 

It is now necessary to look more closely at the changes 
in the cartilage which precede the ossification, and to 
study the exact way in which bone tissue is formed along 
the walls of the advancing marrow cavities. 

If we look with a high power at a thin section of a 
carefully preserved and decalcified bone in the process 
of development, confining our attention for a moment 
chiefly to that region which lies along the ends of the 
above-described advancing marrow cavities, and for a 
short distance on either side, we find a condition similar 
to that represented in Fig. 646. At some distance toward 
the end of the bone from the medullary cavities the 
cartilage cells become flattened and are arranged in 
irregular rows, 0; nearer the ossifying portions of the 
bone the cartilage cellsare larger and more closely packed 
together; and finally, just beyond the ends of the ad 
vancing marrow canals, large cartilage cells are seen 
lying in elongated cavities in the basement substance, c. 
Each cavity contains several cells, which, in many cases, 
are separated from one another by narrow partitions of 
cartilage basement substance. Here and there along 
this region it will be seen that the marrow canals with 
their contained blood-vessels have opened into and become 
continuous with the spaces containing the large cartilage 
cells, and the latter have either disappeared or have as- 
sumed some different form. This occurs sooner or later, 
and usually at about the same time, all along this region, 
so that the advancing blood-vessels convert the spaces 
originally containing cartilage cells into vascular canals 
or marrow cavities. 

If we look now at the region near the ends of the mar- 
row canals, we find that these canals contain thin-walled 
blood-vessels, numerous small spheroidal cells, and larger 
cuboidal, ovoidal, or fusiform granular cells, which are 
apt to be arranged along the sides of the canals. These 
latter cells are the so-called osteoblasts, under whose in- 
fluence the bone tissue is formed. 

The exact way in which the bone tissue is deposited 
under the influence of the osteoblasts may be readily seen 
in very thin sections through the zone of ossification, 
which have been stained double with hematoxylin 
and eosin (see article on J7istological Technique) and 
mounted in balsam. A small portion of such a section 
made transversely across the bone is represented in Fig. 
645. Just beneath the osteoblasts which lie along the 
edges of the marrow canals thin crescentic shells of 
strongly refractile calcareous material—the basement 
substance of bone—are formed. These shells grow 
thicker and thicker, and rise up around the sides of the 
osteoblasts. They are pierced by delicate canals, which 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





are to form the canaliculi. Gradually the entire osteo- 
blast, which has become somewhat flattened and jagged 
in outline, is enclosed by the bony basement substance 
and becomes a bone cell. This process goes on around 
the osteoblasts, which lie side by side all along the walls 
of the marrow spaces, so that the latter are presently 
enclosed by an irregular wall or encasement of new bone. 
Upon this, new layers are deposited, so that gradually 
the marrow spaces grow narrower and narrower, and 
finally contain only blood-vessels and a few marrow cells. 
This gradual bony thickening of the walls and narrow- 
ing of the marrow spaces 
may be seen by following the 
tissue in a longitudinal sec- 
tion from the line where ossi- 
fication commences, near the 
distal ends of the marrow 
spaces, toward the centre of 
the bone where the process is 
oldest. 

The fragmentary remains 
of the old base- 
ment sub- 
stance of the 
hyaline carti- 
lage persist for 
some time, sur- 
rounded by the 
new-formed 
laommautei Naya 
they grow 
smaller and 
Smaller as more bone is formed,-and are finally absorbed 
and altogether disappear. 

Thus the ossification of the cartilages advances toward 
their ends, preceded always by a rearrangement and pro- 
liferation of the cartilage cells, and by calcification of its 
basement substance. What the exact purpose is of the 
temporary calcification of the cartilage basement sub- 
Stance just in advance of the ossification line we do not 
know, nor is it certain what becomes of the cartilage 
cells when the vascular canals finally open into the spaces 
in which they lie. Some observers believe that they dis- 
integrate and are absorbed; others, that they become 
osteoblasts, or other marrow cells. Equally uncertain is 
the origin of the osteoblasts, and the consideration of the 
more or less well-founded conjectures as to their genesis 
would lead us beyond the scope of this article. 

After a time new centres of ossification are formed near 
the ends of the long bones, in the epiphyses, from which 
bone formation proceeds in the manner above described. 
At length the zones of ossification in the epiphyses and 
diaphyses approach one another, and are separated only 
by a narrow band of cartilage, which finally itself be- 
comes ossified, and the epiphysis and diaphysisare joined 
to form a single bone. 

Intramembranous and Subperiosteal Ossification vary 
-only in details from the intracartilaginous. In the former 
case, the tissue in which bone is to form is fibrous and 
vascular; osteoblasts appear along the bundles of fibres 
which become calcified, and bone is formed around them 
‘in the above-described manner. Some of the fibrous 
‘bundles persist within the new-formed bone, as Sharpey’s 
fibres. The bone tissue which is at first formed is ar- 
ranged in irregular ‘trabecule, which cross and inter- 
lace as did the connective-tissue fibres which it replaces, 
-and encloses irregular vascular spaces or marrow cavities, 
which become smaller and smaller as successive layers 
-of bone are formed around their sides. After a time the 
-jrregular trabecule and their enclosed marrow spaces be- 
-come covered in by more uniform layers of bone. These, 
in the long bones, are the circumferential lamellx, and in 

the flat bones, such as those of the skull, are the compact 
,external and internal tables which enclose the diploé. 

A pure intramembranous ossification is seen in the early 
stages of the formation of the flat bones of the skull. 
The subperiosteal ossification, on the other hand, occurs 
as above indicated, simultaneously with the intracartilag- 















PSO e 


Fie. 645.—Bony Trabecula from the Lower Jaw 
of a Calf Embryo, with Howship’s foveole and 
giant cells at the ends where absorption is pro- 
ceeding and osteoblasts covering the sides 
where bone is being deposited. (KdOlliker.) 











Bone, 
Bone, 


inous bone formation in the long bones, as well as at a 
later stage in the formation of bones which are originally 
laid down as membranes. 

GrowTH oF Bone.—The growth of bones when they 
are once formed, either in membranes or cartilages or be- 
neath the periosteum, is a somewhat complex process. 
They increase in thickness by a continued subperiosteal 
ossification. The increase in length of long bones goes 
on by the ossification in cartilage until, as above stated, 
the epiphysis is finally joined to the diaphysis. 

The large central marrow cavity of long bones, which 
in the adult bone is itself much larger than the entire 
bone at an early stage of development, is formed by. the 
absorption of the earlier developed intracartilaginous and 
subperiosteal bone. This absorption occurs under the 
influence of large, irregular-shaped, frequently multi- 
nuclear granular cells, called osteoclasts. Around these 
cells, as they lie against the bone tissue, the latter be- 
comes absorbed in some way, so that little pits are formed 
in which they lie. These pits or depressions, which 
are of various sizes 
and shapes, are call- eo N 
ed Howship’s la- wy Call oS 
cune. On the side = ZA 
of the osteoclasts sn ace 
which lie against = er 
the bone there is, i ol 
according to K6l- | |e | 
liker, a shining pa 
striated border. 
The exact nature 
of the-influence by 
which the  osteo- 
clasts induce the 
absorption of the 
bone is not well 
understood. 

Not only are the 
central marrow cav- 
ities formed under 
the influence of the 
osteoclasts, but by 
an absorption of the 
bone in various 
places, and a subse- 
quent new forma- 
tion of it over the 
absorbed surfaces, 
a remodeliing of the 
bone may occur, 
inducing the vari- 
ous changes in 
shape which 
growing bones pre- 
sent. This process 
of absorption and 
redeposition of 
bone goes on, not 
only on the sur- 
faces, but in the 
substance, even of 
compact bone, dur- 
ing early and adult 
life, inducing the 





















































































































































































































































reser 






































































































































iy 


Fic. 646.—Part of a Longitudinal Section of 
the Developing Femur of the Rabbit. 
Magnified about 350 diameters. (Klein 
and Noble Smith.) a, Rows of flattened 
cartilage cells; b, greatly enlarged carti- 


minor chan ges lage cells close to the advancing bone, the 

. > matrix between being partly calcified ; ¢, 
which occur at d, already formed bone; the osseous tra- 
this period. The beculze being covered with osteoblasts (¢), 
intermediary sys- except here and there, where a giant cell 


or osteoclast (f) is seen, eroding parts of 
the trabeculz; g, h, cartilage cells which 
have become sunken and irregular in 
shape. $ 


tems of lamelle, 
above described, as 
seen in transverse 
sections of long 
bones (Fig. 646), are, in many cases at least, the re- 
mains of older lamellze which have been partially ab- 
sorbed; the absorption spaces having been afterward 
filled in by new Haversian systems. What the conditions 
are whose fulfilment determines now an absorption and 
again a new formation of bone, or exactly what the origin 


119 


Bone, 
Bone. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of the osteoclasts is, and what their relation to the osteo- 
blasts, we can, in the present state of exact knowledge, 
do little more than conjecture. 

Consult, for the bibliography of the histology, develop- 
ment, and growth of bone, Quain’s “ Anatomy,” vol. i. 
part ii., tenth edition, and the “Index Catalogue of the 
Library of the Surgeon-General’s Office, U. 8. A.,” vol. ii. 

T. Mitchell Prudden. 


BONE. (PATHOLOGICAL.)—Bone, like all tissues, is 
subject to a continuous waste and repair. New bone is 
constantly formed and the old absorbed; and while in the 
adult these processes may be very slight, under the in- 
fluence of pathological conditions they become very 
marked; hence the conditions known as pathological ap- 
position, absorption, and transformation of bone. Ap- 
position occurs by the formation of bone from the perios- 
teum. The deeper layers of periosteal cells become con- 
verted into large epithelioid cells, the so-called osteoblasts, 
which later become irregular in shape; the intercellular 
substance becomes calcified and thus new bone is formed. 
The new bone may be spread out over the surface of the 
old, and become firmly attached to it, or it may be limited 
toasmall portion of the surface of the bone. In the first 
case the process is called hyperostosis and exostosis; in 
the latter, the processes of new bone are called osteo- 
phytes. 

Absorption or resorption of bone occurs at the medul- 
lary surface and is due to the activity of the large multi- 
nucleated cells known as osteoclasts. Occasionally this 
may occur at the periosteal surface, and we have the 
surface of the bone becoming irregular and porous—osteo- 
porosis. This occurs occasionally in the very aged, in 
the bones of the calvarium, as the result of senile atrophy, 
or it may be secondary to inflammatory exudates, tumors, 
aneurisms, etc., which exert pressure upon the bone. 

Transformation of bone is brought about by a com- 
bination of apposition and resorption. By means of 
these processes the form of bones is changed to meet 
pathological conditions and changes in function. This 
is more particularly true of the size and direction of the 
columns of bone in cancellous structures. If the amount 
and direction of the load to be borne by the bone become 
changed, then will the thickness and direction of the 
columns of bone become changed in the direction of the 
static demand. By reason of this characteristic of bone, 
such great artificial deformities are produced as are seen, 
for instance, in the Chinese’ foot. 

Regeneration of bone is seen*following every fracture. 
Every solution of continuity in bone is followed by the 
formation of new bone, not only sufficient to replace the 
defect, but also enough to form a large mass surrounding 
the fracture (callus). 

In fractures of long bones, one differentiates an internal 
callus formed by the medullary structures, and an ex- 
ternal callus formed by the periosteum. This new bone 
or callus remains intact until the function of the bone is 
resumed. Later on, that portion of the callus which is 
not situated in the direction of the load-bearing lines 
becomes absorbed, and the form of the new bone, just as 
that of the old, becomes changed to meet the static de- 
mands made upon it by the function of the bone—7.e., that 
of bearing a load. 

Osteomalacia is a chronic disease of bone, occurring in 
adults and most frequently in puerperal women; it is 
attended by a progressive softening and absorption of 
bone beginning in the centre and extending outward. 
The process is followed either by fracture or by deform- 
ity of the bones affected. It differs from rachitis in this, 
that while in the latter we have a deficient deposition of 
lime salts in newly formed bone, in osteomalacia bone 
which is already formed is deprived of its earthy mate- 
rial and absorbed. The changes that occur in the bone 
are not due to any active process on the part of the bone 
tissue itself. There are no active changes to be discov- 
ered in the bone cells. The only thing to be found in the 
lacunee is the occasional presence of droplets of fat, which 
is evidence of a passive destruction of the bone cells. 


120 


In the medullary tissue, however, there are to be seen 
evidences of very marked, active proliferative processes. 
This is to be observed in the marrow of the long bones, 
in the medullary tissue of spongy bone, and also in the 
Haversian canals, which latter normally contain very lit- 
tle medullary tissue. This tissue is the seat of a marked 
hyperemia which has converted it into a bright red, 
succulent tissue, free from fat and extremely rich in pro- 
liferating cells. All the medullary tissue seems to have 
the appearance of the red marrow of infantile bone. 
This tissue pushes its way outward at the expense of the 
adjacent bone, first depriving it of its lime salts and later 
causing its complete absorption. 

Thus the compact bone of the diaphysis is converted 
into spongy bone by the enlargement of its Haversian 
canals; the trabeculee of spongy bone are absorbed. If 
the process continue long enough there remains little of 
the bone except marrow and periosteum; so that it has 
been converted into a soft, decalcified, sausage-like mass 
of marrow, that is held together by the periosteum with 
perhaps a thin, paper-like layer of bone beneath. 

The process may be distributed over a period of several 
years with occasional cessation. In such an event the 
medullary tissue loses its signs of active proliferation, 
the hyperemia diminishes, and the tissue appears as a 
yellowish, fatty mags, or as a pale, gelatinous, mucoid, 
semi-fluid material. In the latter event many of the cells 
have undergone mucoid degeneration, and if this has 
been extensive it may have led to the formation of mu- 
coid cysts. This period of quiescence may again give 
place to a renewed activity as before and to a further 
destruction of the bone. 

This process has a certain resemblance, in activity, to 
that of inflammation, but the phenomena that attend 
either acute or chronic inflammation of bone are never 
present. We never find either suppuration or the for- 
mation of new bone. 

The cause of decalcification of bone in this disease has 
been sought for chemically. Some investigators have 
found an excess of lactic acid in affected bones, and also: 
in the urine, and the solvent action of this acid has beem 
brought forward as the chemical agent which brings on 
decalcification. Other observers have failed to find this 
excess. The amount of gluten is diminished in the bones. 
affected. There has been found in the urine a peculiar 
albuminous substance supposed to be derived from the 
organic substance of bone. : 

The bones of the pelvis and of the spinal column are. 
most frequently affected, then come those of the thorax, 
and of the lower and upper extremities. The bones of 
the head are very rarely the seat of the disease; the teeth 


‘are never involved. 


In the non-puerperal cases, the predisposing causes. 
are malnutrition and living in dark, damp houses. 

Osteomalacia has been observed in animals who are 
badly fed and stabled in dark, damp places. 

Osteomalacia is a comparatively rare disease. It is. 
rarely seen in England and America; it is more frequent. 
in Germany than in France. In some parts of Germany 
the disease is more frequent than in others; thus in the 
Rhine valley and in Southern Germany the disease is 
more common than in other districts. 

The preponderance of puerperal females affected is. 
very striking. Thus of one hundred and thirty-one cases. 
gathered together in the report of Letzmann, in 1861, 
eighty-five were in women who became ill either during 
pregnancy or during the puerperal period. Repeated 
pregnancy and prolonged nursing in poorly nourished 
women predispose to the disease. 

In all of these puerperal cases the disease began in the 
bones of the pelvis, and in many it was limited to that. 
region. It is therefore highly probable that the great. 
circulatory changes in the pelvis attending pregnancy 
have a decided influence on the causation of the disease. 
Fehleisen regards the disease as a reflex trophoneurosis. 
of the blood-vessels of bone, causing a dilatation and 
proliferation of the marrow at the expense of the bone, 
and having its origin in the ovaries. The removal of the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bone, 
Bone, 





ovaries has been practised as a curative measure with 
some, though not universal success. 

Of forty-six non-puerperal cases, thirty-five were in 
women and eleven in men. These cases are, as a rule, 
more rare than the puerperal. 

Rachitis or rickets is a disease occurring in children, 
It is caused by improper food and bad hygienic surround- 






ZB 


Te 
crt ety 


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* [Sto fon Gi 
Pkece =| 
Leereonsde 


J 


Fig. 647.—Section through the Line of Ossification of a Normal Femur 
from a Healthy Child. a, Hyaline cartilage; b, zone in which the 
cartilage cells are hypertrophied ; c, cells arranged in columns; d, 
columns of hypertrophic cartilage; e, zone of temporary calcifica- 
tion; f, zone showing beginning of medulla; g, first bony forma- 
tion; h, spongy bone; 7, blood-vessels; k, osteoblasts. (After 
Ziegler.) 


ings, and is attended by a disturbance in growing bone 
whereby the reabsorption of bone is increased, the calci- 
fication of incompletely formed bone is diminished, and 
the formation of so-called osteoid tissue is excessive. It 
has been aptly and briefly described by Jenner as “an 
increased preparation for ossification but an incomplete 
performance of the process.” The disease is most marked 
in the epiphyses of long bones and the margins of flat 
bones. : 

During the formation of normal, healthy bone there is 
always going on an absorption of already formed bone, 
which, however, remains confined to certain limits. In 
rickets the extent of this reabsorption is increased, so 
that in severe cases a large part of the bone may disap- 
pear. As a result, in the long bones the cortical layer 
becomes more or less osteoporous, and the columns of 
bone in the spongy portions become thinner and many of 
them disappear. This reabsorption of bone is lacunar, 
and, as in the case of normal bone, is due to the action of 
osteoclasts. 

The most striking change is that which occurs in the 
epiphyseal ends of growing long bones. If one examines 
a section of the end of a normal long, growing bone (Fig. 
647), a straight line may be seen where the white epiphy- 
seal cartilage is joined to the cancellous shaft. The new 
bone is formed by a pushing of the medullary tissue from 
the cancellous bone into the epiphyseal cartilage. The 





two are joined by a straight, blue, semitranslucent band 
about 1 mm. broad, that is made up of hyperplastic car- 
tilage, called the zone of growing cartilage. 
Microscopical examination shows that in this area the 
cartilage cells have become greatly increased and are ar- 
ranged in columns running parallel with the long axis of 
the bone. After these columns have acquired a certain 
height, there occurs at their base a deposition of calcare- 
ous material, which marks the cessation of the growth of 
cartilage. Ina short time this calcified cartilage is de- 
stroyed by the pushing upward of the neighboring medul- 
lary tissue. These “buds” of medullary tissue, consisting 
of growing blood-vessels surrounded by a thin layer of 
medullary cells, push up between the columns of cartilage 
cells, gradually “eating” away the calcified, cartilaginous 
ground substance. The cartilage cells eventually disap- 
pear and are probably converted into medullary cells. 
Thus there are formed primary medullary canals bounded 
by the remains of the calcified cartilaginous ground sub- 
stance, and it is this latter which then becomes converted 
into bone. This is brought about by the deposition with- 


in this substance of cells from the medullary canal which 





Fig. 648.—Longitudinal Section of the Line of Ossification in the 
Femur of a One-Year-Old Child Suffering from Rickets. (After 
Ziegler.) a, Hyaline cartilage; b, cartilage in the first stage of 
hyperplasia; c, zone of the columns of cartilage cells; d, columns 
of enlarged cells; e, vascularized marrow extending into the carti- 
lage zone; f, calcified cartilage; g, osteoid tissue ; h, remains of car- 
tilage ; i, columns of osteoid tissues; k, columns of osteoid uncalci- 
fled tissue, surrounded by true bone; J, vascular marrow tissue. 
(X 37 diameters.) 


go to form the osteoblasts. The cartilage has formed the 
framework on which the growing bone has climbed, and 
is itself eventually absorbed. 

In rachitic bone, the blue transition zone of hyper- 
plastic cartilage is much wider, while its outline, both 


121 


Bone, 
Bone, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








above, below, and at the circumference, is enlarged and 
irregular. It is this which forms the irregular enlarged 
ends so characteristic of the disease. The zone of hyper- 
trophied cartilage cells as well as the columnar zone is 
enormously enlarged. There is also a more or less com- 
plete absence of the zone of calcification of the cartilag- 
inous groundwork, and in addition there is a great ir- 
regularity in the formation of the vascular, medullary 





Y 


ris 
a, os “y 
1, %, st se 7 ch agape as yt ice a st / 
4 eg 


KZ 7 Mehe 














(After 


Fic. 649.—Necrosis and Inflammatory Hyperplasia of Bone. 
Boyce.) 1, Spongy new bone; 2, remains of shaft; 3, sequestrum. 
(Slight enlargement.) 


canals. These have pushed their way into the cartilage 
in an irregular manner as though unrestrained by the 
presence of a firmly calcified groundwork. 

The persisting columns of cartilage are gradually con- 
verted into an “osteoid” tissue, made up of cells derived 
from the medullary tissue and a fibrillar, uncalcified 
groundwork. This osteoid tissue will show in numerous 
places islands of persisting cartilage. The zone of os- 
teoid tissue may attain a length of 15 mm.; it is a firm, 
elastic connective tissue, but it bends under pressure. It 
differs from bone in that the cells have not the same regu- 
larity of arrangement, and in the absence of earthy ma- 
terial in the groundwork. 

At a varying distance below this zone we finally come 
upon a zone in which columns of osteoid tissue are be- 
coming converted into bone by the calcification of the 
groundw ork. 

Inflammations of bone occur in the periosteum, in the 
marrow, or inthe joints; that is, always in those portions 
of the bone which’ are well supplied with blood-vessels. 
They are as a rule due to hematogenous infection or to 
trauma, although occasionally they may be brought about 
by extension from neighboring tissue. If the inflamma- 
tory process is of any considerable degree, or lasts for a 
considerable time, it is always followed by changes in the 
bony substance itself. This, asa rule, is of a retrograde 
character, 7.¢., leading to destruction of bone. If the in- 
flammation is of a highly infectious, purulent character, 
the connective tissue affected becomes dissolved, the ves- 
sels become thrombosed and are destroyed, and the bone 
becomes necrotic. If the inflammation is less severe in 
character, if it is accompanied by considerable cell infiltra- 
tion and the formation of new vessels (granulation tissue), 
there follows a gradual solution of the neighboring bone or 
cartilage, an ulceration, or, as it is usually called, caries. 
As long as this inflammation keeps up, so long is there a 
gradual absorption of the neighboring bone or cartilage. 
If in the beginning of the inflammation there occurs 
necrosis of a certain portion of bone, there follows in the 
later stages, at the surface of this necrosed portion, a 
gradual absorption which has its greatest intensity at the 


122 





border between living and dead bone, so that eventually 
the two become separated and there is formed a seques- 
trum. If the latter isnot very large it may in the course 
of time become completely absorbed by the neighboring 
granulation tissue. Large sequestra, however, offer a 
great deal of resistance to this absorptive process and 
may remain for years. As long as the sequestrum is 
present so long will the inflammation keep up, even 
though the infection has been overcome. <A piece of 
dead bone acts as a foreign body and is a sufficient irri- 
tant to keep up this chronic form of inflammation. 

In addition to this destructive process in bone accom- 
panying inflammation, every such process lasting for any 
considerable time is accompanied by a hyperplasia, which 
manifests itself partly in the vascular soft parts and 
partly in the bone itself. This occurs both in the imme- 
diate neighborhood of the inflammation and in surround- 
ing portions of the bone. It leads to those processes 
which have received the names of hyperostosis, exostosis, 
osteophytes, and parostosis. The most excessive hyper- 
plasia of bone occurs in those cases in which a large se- 
questrum remains as a source of irritation for months and 
years. 

Of acute infections, osteomyelitis is the most severe 
acute inflammation of bone with which we have to deal. 
It occurs most frequently in young individuals, as a 
rule in one of-the long bones, and is accompanied by 
fever, by a destruction of more or less of the bone, and 
by the formation of an abscess. The infection is either 
primary or secondary to one of the acute infectious dis- 
eases. Asarule, the immediate cause is the staphylo- 
coccus pyogenes aureus or albus. The process may 
begin either in the periosteum, or in the marrow of 
the bone. It very soon leads to the formation of pus 
and to the destruction of ,bone. In severe cases it may 
lead to the suppuration of the marrow of the entire 
diaphysis and to an extension into the cortex of the 
bone through the Haversian canals. It may occasionally 
break through the periosteum. If the inflammatory 
process is near a joint, the pus may be poured into 
the cavity thereof. Through the formation of septic 
thrombi in the veins, we may have multiple metastatic 
abscesses and death by pyemia. Wherever we have had 
a suppurative inflammation, there is of course a death 
of more or less bone, but the extent of this necrosis de- 
pends upon that of the suppurative process. If this has 
been very slight, the necrosed pieces of bone may become 
absorbed, so that they may not be discovered. In more 
severe forms we may have a sequestrum comprising the 
entire diaphysis. According to the extent and seat of 
the necrosis there may be distinguished a total, a partial, 
a central, and a superficial necrosis. Very soon after the 
setting in of the suppurative process there will be formed 
at the border, between the dead and the living parts, 
a zone of granulation tissue. This leads eventually to 
the separation of the sequestrum. When this has become 
complete there will be present, within the bone, an abscess 
cavity containing a sequestrum. This cavity very often 
connects with the surface of the bone by means of an 
opening or fistula. The walls of this fistula are also 
covered by a layer of granulation tissue from the surface 
of which pus is being poured out. In the neighborhood 
of these areas of granulation tissue there will have oc- 
curred more or less hyperplasia of bone which leads to a 
thickening. If the bone has been destroyed in its entire 
thickness in the beginning, then this hyperplasia occurs 
of course only in the periosteum, which thus surrounds 
the sequestrum with a firm, bony capsule. In cases of 
partial necrosis, however, new bone is formed both from 
the periosteum and in the interior of the bone. Small 
sequestra may in the course of months be absorbed; large 
ones constitute an irritant sufficient to maintain an in- 
flammatory process for years, and they can be gotten rid 
of only by operative procedure. After the removal of the 
sequestrum the wound cavity is closed by means of gran- 
ulation tissue, which later may be replaced by the for- 
mation of true bone through the activity of the periosteum 
or of the bone marrow. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Tuberculosis of bone gains entrance either through the 
marrow, the periosteum, the joint, or the surrounding 
soft parts. The most frequent method of development 
is that of a small tuberculous nodule which forms in the 
marrow of an epiphysis. This undergoes caseation and 
softening and eventually breaks through the bone to the 
surface, thus either entering into the joint or breaking 
throughthe periosteum. The process is of course always 
accompanied by caries, at times of considerable extent. 
A notable example of this is seen in tuberculosis of the 
spine, where the bodies of one or more vertebrae may be 
destroyed. This of course leads to the extensive de- 
formities that we see in this disease (Pott’s disease). 
After such a bone abscess (for this it really is) breaks 
through the periosteum, there are formed collections of 
pus in the surrounding tissues, particularly between the 
muscles. These sometimes reach an enormous size, and 
_ may through the influence of gravity dissect their way 
for a considerable distance through the body before 
reaching the surface. 

In miliary tuberculosis, we have numerous tubercles 
in the bone marrow. Occasionally the tuberculous proc- 
ess affects the long bones of the hand or the foot in a very 





Fic. 650.—Severe Tuberculous Coxitis. The disease has broken 
through the cartilage ata. In the region of the neck is a seques- 
trum about the size of a cherry stone lying free in an abscess cavity 
connected with the joint by means of the fistulab. (After Krause.) 


slow and chronic form, leading to resorption from the 
internal surface and apposition at the periosteal surface, 
and in this way producing certain peculiar spindle-shaped 
swellings that have been termed spine ventose. This 
may be followed by the occurrence of necrosis and the 
formation of sequestra and fistulz, but in most instances 
the swelling eventually disappears. 

Syphilis occurs in bone in three forms: 

(1) Gummatous formations affecting both the perios- 
teum and the marrow. In the periosteum, the process is 
accompanied by a destruction of bone, of such a charac- 
ter that sharply defined defects are produced—the so- 
called caries sicca. This occurs more especially on the 
calvarium. Occasionally one finds in the neighborhood 
of these bony defects new growth of bone. 

(2) Hyperostosis. This occurs either in the form of 
hard, ivory-like thickenings in the compact bone, or in 
the formation of irregular exostoses or osteophytes. The 
latter form is found more especially in the tibia. 

(3) Congenital syphilitic osteochondritis. This in its 
severe form is accompanied by the formation of irregular 
growths in the zone of growing bone, growths which have 
undergone a fatty and calcareous degeneration, and which 
may have the character of true gummata. In the lighter 
forms we have simply a calcification of the zone of car- 
tilaginous hypertrophy at the epiphysis, marked by a 
sharp, yellowish-white line, and accompanied by a slight 
sclerosis of the neighboring bone. This affection is al- 
ways present in congenital syphilis, but may disappear, 
~ that a few weeks or months after birth it may not be 

ound. 

Actinomycosis of bone begins, as a rule, in the marrow 
by the formation of granulation tissue, which causes an 
absorption of bone from the inside and is accompanied by 





Bone, 
Bone, 





an apposition of bone on the periosteal side. In this way 
we may have large projections from the surface of the 
bone which, in decalcified and macerated preparations, 
will show on the inside the formation of a number of 
cysts. At times the actinomycotic process pushes 
through the bone to the periosteum, destroying this with- 
out being accompanied by the apposition of new bone, so 
that there will be produced a caries in the form of an 
osteoporosis. 

Sarcomata are frequently found in bone. They occur 
either in the marrow (myelogenous sarcomata) or in the 
periosteum (periosteal sarcomata). Those that occur in the 
marrow of the bone produce, by the absorption of bone 
from the inside and apposition of bone from the outside, 
enlargements of the bone which attain at times enormous 
size, and in which we have the tumor mass surrounded 
by a more or less well-developed capsule of bone. Later 
on, even this capsule becomes either partially or totally 
destroyed by the pushing of the tumor through the bone. 
The tumor is as a rule of the round-celled variety, 
containing usually a large number of multinucleated 
giant cells. These giant cells may at times attain such 
enormous size as to be visible to the naked eye. Occa- 
sionally, however, they may be entirely absent. These 
sarcomata are exceedingly apt to recur after an excision 
or amputation. Periosteal sarcomata have, as a rule, a 
very considerable framework of bone in which the sarco- 
matous masses are enclosed, so that they are more aptly 
termed osteo-sarcomata. Occasionally also they have in 
addition a certain amount of cartilage, when they are 
called osteo-chondro-sarcomata. They are, as arule, of 
the spindle- or small round-celled variety without giant 
cells. They are exceedingly apt to form metastases, 
especially in the lungs. Simon Pendleton Kramer. 


BONE, PLASTIC SURGERY OF THE.—Defects in 
bone heal so slowly and imperfectly that it is no won- 
der surgeons of very early times tried to assist nature 
in their repair. There is some reason to suppose that 
such efforts were successful in India more than five hun- 
dred years ago, while a Peruvian skull antedating no one 
knows how long the discovery of America has, accord- 
ing to McGee, been found with a silver plate sunk in its 
substance to protect the opening made after trephining. 
The condition of the bone shows that the plate rested in 
it for a considerable time before death. 

Despite this long history, and the very numerous ex- 
periments which have been carried out in recent years 
with the aid of a fuller knowledge of asepsis, the sub- 
ject of repairing large defects in bone is still very im- 
perfectly understood. 

The indications for bone transplantation or some 
similar procedure are: 

1. Toafford a protection to underlying organs, notably 
to the brain after extensive removal of the cranium by 
accident or operation. 

2. To preserve the normal contour of the parts—for 
instance, after loss of the bridge of the nose or half of 
the lower jaw. 

3. To maintain the continuity of a bone so that the 
power of a limb shall not be lost. 

4. To shorten the time of recovery, for a deep cavity 
in a bone—for example, in the head of the tibia—heals 
very slowly and often imperfectly. 

In considering this subject of plastic operations upon 
bone, it is well to remember that osseous tissue has only 
a slight regenerative power, while the power of the 
periosteum to form new bone is very great indeed. This 
is constantly illustrated by the repair of comminuted 
fractures, the injured bone being restored to something 
like its former condition, though many fragments may 
have been lost. One must therefore accept with great 
caution accounts of the incorporation into the structure 
of a bone, of bone chips or decalcified bone which sur- 
geons have introduced into a bony gap to hasten re- 
covery. The new bone under such circumstances may 
have come from periosteal flaps which were not destroyed 
by the accident. 


123 


Bone. 
Bo ne, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





The integrity of the periosteum is of chief importance 
in the maintenance of osseous tissue. If, therefore, a 
flap of bone and periosteum can be so cut as to remain 
attached to the soft 
parts, it may be nour- 
ished through the 
pedicle until it unites 
in a new situation. 
Many useful opera- 
tive procedures have 
been founded upon 
this principle, but 
the field is a limited 
one, because super- 
fluous bone, which 
may be utilized for 
the bone flap, will 
often be wanting in 
the immediate neigh- 
borhood of the bony 
defect. 

Such an osteoplas- 
tic resection of bone 
has been performed 
upon the skull, upon 
the bones of an extremity, to restore a deficient nose, to 
supply an arterior plate to the trachea, et cetera. 

Osteoplastic Resection of the Skull.—This operation has 
been devised to give the surgeon more space than can 
be safely obtained by trephining. As practically the 
whole bone is replaced, the flap may be made very large 





Fig. 651.—Osteoplastic Resection of the 
Skull by Means of a Gigli Wire Saw. 
(Gigli.) 


NSS 
ra 


ae 
pteee 






SONI 


NY 


Fic. 652.—Osteoplastic Resection of the Skull by Means of a Cranio- 
tome. (Codivilla.) 


without risk of leaving the brain unprotected. The 
operation, which may be carried out in various ways, 
aims to cut through the bone and soft parts on three 
sides of a rectangle, or three-quarters of a circle, and 
then to break the bone on the fourth side without in- 
juring the soft parts or disturbing the vitality of the 
large bone flap. It has been many times successfully 


124 


carried out in the past few years. 
Fig. 651 shows the method of cut- 
ting a flap by means of a Gigli wire 
saw which is passed through very 
small trephine openings and saws 
the bone from within outward. 

The bone flap may also be cut by 
chisels or by a craniotome. 

When the operation upon the 
brain is completed, the operator has 
only to bend back into its original 
position the flap of skin and bone 
and to fasten it there by a few sut- 
ures. Primary union usually re- 
sults. 

One of the first operators to make 
use of a flap of skin and bone was 
Koenig, whose rhinoplasty, carried 
out by means of a flap cut from 
the forehead and twisted downward 
and stitched in position to make a 
new nose, is too well known to need detailed description. 
In a similar manner, other surgeons have successfully 
operated to close defects 
in the skull, by taking a 
flap of the skin and the 
outer table of the bone 
and swinging it around 
over the defect. If the 
skull is thin it is difficult 
to split it in this manner; 
but the periosteum can 
always be obtained. 

Osteoplastic operations 
upon an extremity, a pedi- 
cle being employed to 
keep up the nutrition un- 
til the flap unites in its 
new position, were de- 
scribed in 1856 by Jordan 
and Nélaton. Since that 
time they have many 
times been successfully 
carried out. The flap may 
either be twisted on its 
pedicle as is done in Koe- 
nig’s rhinoplasty, or it 
may be cut from the dis- 
tal fragment of a defect- 
ive bone, and retracted so 
as to fill the gap between the fragments, as is shown 
in Fig. 653. 

A defect in the femur, several inches in length even, 
may be closed in a similar 
manner by a flap of mus- 
cle and periosteum. The 
steps in‘the process, as de- 
scribed by Ap Schulten, 
are the preparation of the 
cavity in the bone consist- 
ing of free exposure, ir- 
rigation, and tamponade 
with sterilized gauze. 
Three or four weeks later, 
when the cavity is lined 
with healthy granulations, 
it is cleaned, the site of 
the proposed flap is ex- 
posed by longitudinal and 
transverse incisions, and 
a tongue-shaped flap of 
muscle and periosteum is 
cut, with its base upward 
whenever possible, al- 
though this is not abso- 





Fig. 653.—Osteoplastic 
Resection of the Tibia 
with Retraction of 
Skin and Bone Flap. 
(Mueller. ) 





Fig. 654.—Closure of a Defect in the 
Femur by a Plastic Operation. 
Skin and fascia reflected; flap of 
muscle and periosteum marked 
out. (Ap Schulten.) 





Fic. 655.—Later Step in Same Oper- 


lutely necessary. The 
edge of the bony cavity 
is cut away at the place 


ation. Flap stitched in position to 
close the defect in the femur. 
(Ap Sehulten.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








at which the flap is to be bent over it, and a couple of 
stitches are inserted to hold the flap in position. The 
drawings (Fig. 654 and 655) sufliciently illustrate the 
method of procedure. 

From the plastic operation already described it is only 
a short step to one which splits a bone in order to utilize 
the two portions to make up for the lack of its fellow. 





Fic. 656.—Splitting of the Second Metacarpus and Utilization of One 
of the Parts as a Substitute for the Metacarpus of the Thumb. (K. 
Cramer.) a, Remains of the metacarpus of the thumb. 


This has been successfully performed upon the meta- 
carpals and metatarsals, and the ulna has beeen success- 
fully split to piece out the radius. 

The use of a less important bone for its fellow, as of 
the fibula to make good a defect of the tibia, is founded 
upon the same principle as the operations hitherto de- 
scribed. One of the well-recognized operations for cleft 
palate consists in chiselling free a strip of bone along 
either margin of the cleft, and by stitching them in the 
middle to convert one large cleft into two smaller ones, 
which can later be closed by a plastic operation upon 
the soft tissues. . 

This osteoplastic principle has recently been employed 
in a most ingenious way to close a defect in the anterior 
wall of the trachea. Schimmelbusch cut a flap from the 
sternum of a child aged thirteen years, and inverted it, 
so that the skin surface was directed toward the lumen 
of the trachea. The bony surface turned outward was 
covered with skin from the neck. The wound healed 
nicely and the plate of bone prevented the sinking in of 
the anterior wall of the trachea during inspiration, and 
consequent suffocation which is noticed when such a de- 
fect isclosed by skin only. Konig operated successfully 
upon a seven-year-old child, taking a skin-and-bone flap 
from the clavicle. The bone sloughed out, but the 
periosteum lived and became stiff enough to keep the 
lumen of the trachea intact. Auc describes a similar 
operation, or rather séries of operations, successfully 
carried out by Sklifossowsky under less favorable cir- 
cumstances upon a boy aged fourteen years. There was 
stenosis of the trachea and larynx which had first to be 
overcome by plastic operations, the skin of the neck be- 
ing utilized to cover the posterior defect in the tracheal 
lining. Then the sternal skin-and-bone flap was em- 
ployed, as in the operations mentioned above. With 
this variation: the flap of bone was loosened and the skin 
flap was wrapped around it like a blanket and stitched 








Bone, 
Bone, 





there. When the wound had so far healed that the bone 
was completely surrounded by skin, the flap was turned 
upward and stitched in the tracheal gap. Necrosis of 
the bone flap was thus guarded against. 

The use of a bone flap to heal a defect in bone is 
limited by the length of the pedicle and the supply of 
suitable bone in the neighborhood. It is obvious if a 
piece of bone can be transplanted without a pedicle, the 
field of this branch of surgery will be much wider. 
There will then be three sources of bone available, viz., 
other bones in the patient, the bones of other individuals, 
and the bones of animals. It seems certain that bone 
grafts from all three sources have healed in their new 
beds. Not only do the histories of these patients show 
that bone so transplanted may become part of the bony 
structure of the individual operated upon, and not 
simply remain as a foreign body which is tolerated by 
the surrounding tissues, but the z-ray affords the sur- 








Fig. 657.—Radiographic Photograph of the Actual Condition of the 
bh After the Osteoplastic Operation Described in the Text. 
Dubar.) 


geon a means of actually demonstrating that the im- 
planted fragment may persist and carry out the functions 
of the bone for which it is a substitute (Fig. 657). 

Dubar resected the wrist of a girl aged nine years for 
tuberculosis, and inserted in place of the carpal bones 
that were removed, five fragments from the lower ends 
of the femurs of a puppy aged eight days. The wound 


125 


Bone, 
Bone-Setting, 





healed primarily. The limb was kept in a plaster-of- 
Paris splint for six weeks. All the motions at the wrist 
were preserved. Three years later a small focus of 
tuberculosis in the fifth metacarpal bone was curetted 
away. It did not communicate with the wrist. Two 
years afterward a similar lesion in the fourth metacarpal 
bone was treated in the same manner. After both of 
these lesser op- 
erative efforts 
the wounds heal- 
ed perfectly. 
Six years after 
the operation 
upon the wrist 
a radiograph 
was taken (Fig. 
657). Thisshow- 
ed that the frag- 
ments of puppy 
bone had held 
their positions 
and had actually 
increased in size, 
fixed in the 
midst of new- 
formed fibrous 
tissue, 
Kronacher in- 
serted a piece of 
calf bone steril- 
ized by boiling, 
to make good 
the defect in the 
first phalanx of 
the forefinger. 
The wound was 
drained and 
healed by gran- 
ulation. The 
finger was kept 
in plaster of 
Paris for more 
thn titre e 
months, and 
was finally stiff. 
New bone form- 
ed around the 
old, as was 
shown by a ra- 
diograph, and 
the length of the 
phalanx was 
nearly normal. 
The new bone in 
this instance 
may have come 
apparently from 
undestroyed 
periosteum. 
Lane used a 
rabbit’s femur 
to make good a 
congenital de- 
fect in the mid- 
dle of the ulna 
of a child, split- 
ting the femur and applying the two halves like splints, 
one to either side of the ulna. In a similar manner he 
supplemented a defect in an adult ulna resulting from 
an inflammation of the bone. The results were satisfac- 
tory, both patients obtaining perfectly useful limbs. 
Ricord removed a large osteosarcoma from the forehead 
of a woman and utilized the coccyx of a dog to fill the 
gap in the skull. Five years later the patient died of 
metastatic growths similar to the original tumor. There 
was no recurrence at the site of the original tumor and 
the coccyx was still in place and unabsorbed. 
He also made use of the fourth metatarsal of a woman 





Fig. 658.—Radiograph of Arm, Showing Suc- 
cessful Transplantation of Piece from Tibia 


to Take Place of Humerus. 
of bone transplanted. 


a-b, The portion 
(Klapp.) 


126 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





to correct a nasal deformity in the same patient. The 
operation was in every way successful, and five months 
later the bone was solid in its new position. Seventeen 
months after the operation its place had been taken by 
solid elastic tissue, which was firm enough to still hold 
the skin over the nose in correct position. 

Bramann cut a piece from the tibia of a patient and 
used it to splice a defective humerus in the same indi- 
vidual. The operation succeeded. 

But the most striking success which has thus far been 
recorded of bone transplantation is perhaps the case of 
which the radiograph is here reproduced (Fig. 658). 

In this instance Klapp removed the greater portion of 
the humerus of a woman aged thirty years for a sarcoma. 
which had so eroded the shaft of the bone as to bring 
about a spontaneous fracture. The periosteum was also: 
removed. To fill this defect the operator chiselled a 
piece from the anterior part of the patient’s own tibia. 
nearly as long as her humerus and transplanted this long. 
strip of bone, to which the periosteum was still adherent, 
to the arm, inserting its ends in the upper and lower ex- 
tremities of the humerus, which still remained in their 
normal positions. The most careful asepsis was observed, 
but a suppuration took place in the arm, and a consider- 
able part of the scar had to be reopened in three weeks. 
The wound then healed by granulation, and some weeks 
later a sequestrum a little over an inch long and not 
quite an inch broadcame away. No further suppuration 
took place, the wound healed, and bony union took place 
between the remains of the humerus and the trans- 
planted piece. This was shown by the fact that the 
patient could hold a three pound weight out at arm’s. 
length, as well as by the radiograph. The arm was not 
quite so strong as the other, but sufficed for the ordinary 
duties of the house. The accompanying radiograph was 
made nearly two years after the operation. 

Though these are isolated examples of successful bone 
transplantation, and the failures have doubtless been 
many times more numerous, yet a few well-authenticated 
successes are sufficient to encourage surgeons to con- 
tinue their efforts until the conditions under which suc- 
cess is to be obtained are better known. When they are 
thoroughly understood, a bone graft may be performed 
with better hope of success. A priort there seems to be 
no reason Why a graft of bone from one individual to 
another of the same species, or a graft from one part of 
the human body to another, should not grow as well as 
a graft of skin, or of the thyroid gland. In transplanta- 
tion of bone from man to man, the possibility of the 
transmission of disease ought not to be overlooked. 

The operations thus far described are difficult of per- 
formance and they by no means promise any certainty of 
result. Is it not possible to close a defect in bone by 
some simpler method? For this purpose both organic 
and inorganic material have been used. 

Filling Defects with Organic Material.—1. With blood 
clot. 

The most accessible organic substance with which to 
fill a bone cavity isa blood clot. Schede proposed in this 
manner to shorten the time of healing. The method is 
practicable, if the asepsis is perfect, though the length 
of time required for the organization of the clot is greater 
than the early advocates of this plan supposed, and the 
final results are little if any better than those obtained 
by allowing the cavity to close by granulations. In 
suitable cases a still better plan is to cut away the edges 
of the cavity to such an extent that the skin and peri- 
osteal flaps may cover the bottom of the defect. 

2. With decalcified bone. 

Senn suggested decalcified bone as a suitable material 
to use in filling a bone cavity. It is of course easily 
sterilizable, and is well tolerated by the tissues. Little 
by little, if asepsis is perfect, the decalcified bone may 
be absorbed and its place taken by tissue of new forma- 
tion, either bone or connective tissue as the case may be. 
Under such circumstances the permanent result is not 
better than a strong scar formed by granulation. If the 
decalcified bone is in a badly nourished portion of the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Bone, 
Bone-Setting. 





body, it may resist absorption a long time, as shown by 
the following unique case narrated by C. L. Gibson: 
Decalcified bone chips prepared according to the direc- 
tions of Senn had been packed into the cavity left in the 
head of the tibia after evacuation of a cyst. The skin 
healed and function and appearance were normal for 
four and one-half years. Then the scar became inflamed 
and some chips made their way out through the skin, 
leaving a sinus. The whole cavity was opeued and the 
chips and loose granulations were curetted away. There 
was no perceptible change in the bone chips, nor was 
there any new formation of bone. 

8. With calcined bone chips; with sterilized bone 
chips; with aseptic live bone chips. 

The fate of an implanted bone chip has provoked a 
long and bitter discussion, carried on over a period of 
some years by Barth and David. The former claims, as 
a result of numerous histological examinations of speci- 
mens obtained from animals and man, that a transplanted 
bone fragment always dies and is succeeded by new- 
formed bone; while David claims that at least a part of 
the transplanted bone does not lose its vitality, but after 
a period of inactivity it becomes revascularized and lives 
again as truly as before its transplantation. It would 
seem that so well defined a problem as this might be 
easily settled, but the discussion has gone on for some 
years, without any definite conclusion, although several 
other investigators have studied the subject and have 
written upon it, some taking one view and some the 
other. Those who are interested in the details of this 
question, will find them fully discussed in the Archiv 
fir klinische Chirurgie, 1896-99, an especially full article 
giving a résumé of those preceding it being one by Fis- 
choeder in vol. lviii. of that magazine, p. 840. 

One or two experiments are worth a passing notice. 
Morpurgo and Martini introduced plates of bone, freed 
from organic substances, into pouches made in connec- 
tive tissue. There usually followed a growth of the liv- 
ing tissues into the calcic substance, exactly reproducing 
the bony structure. The experimenters looked upon this 
as a new formation of bone from connective tissue, under 
the influence of the lime salts. Zworykin went one step 
farther and was able to cause ossification in the heads 
of rabbits by the introduction of chemical mixtures of 
lime salts, simulating the mixtures found in normal 
bone. 

It makes little difference to the surgeon, and less to the 
patient, whether the bone which fills in the gap in his 
skull is the implanted bone which has retained its vital- 
ity, or bone of new formation which has gradually eaten 
up the implanted bone, using its lime salts for the new 
bone cells. Indeed, in practical use calcined bone, which 
all must admit to be dead, is said by many surgeons to 
be better than chips of living bone. The bone for the 
purpose should be of a spongy character. The scapula 
of the calf answers very well for implantation in the 
skull. 

Filling Defects with Non-Absorbable Material.—lf the 
success of these implantation experiments depends not at 
all on the fact that the bone is alive, and altogether on 
the aseptic operation, and on the non-irritating qualities 
of the implanted foreign substance, why confine one’s self 
to organic material ? 

Teeth may be filled with gold, silver, cement, etc., 
and no harm follows. Bullets and other foreign sub- 
stances remain encysted for years. Why not fill bone 
cavities with some non-absorbable material? Theoreti- 
cally this is possible, and practically it may be done pro- 
vided the cavity is not a large one and asepsis can be 
secured. Stachow has made many experiments in this 
direction, and has reached the conclusion that a copper 
amalgam is the material best suited to this purpose. 
Plaster of Paris, cement, gutta percha, and other sub- 
stances have been used with a limited success in man as 
well asin animals; but the chances of future suppuration, 
even long after the healing is complete, are very great. 
In certain situations hard foreign substances are well 
tolerated and are very serviceable. Thus Weir and 





others have used celluloid for supplying the nasal bridge, 
although the boat-shaped piece of celluloid is merely 
slipped under the skin and does not come in contact with 
the bones. The same may be true when a celluloid plate 
is inserted to cover the defect left by trephining, or after 
resection of the lower jaw, as described by Berndt. It 
was at one time the fashion to preserve a trephine but- 
ton in salt solution, and to replace it before closing the 
wound. Experiments upon animals showed, however, 
that whereas the button might become firmly fixed in 
position, adhesions between it and the dura are almost 
sure to follow, even though the operation is of the simplest 
character. Foreign substances with a smooth surface do 
not offer such opportunities for firm adhesions, and hence 
celluloid plates are preferable. Most of the best-known 
continental surgeons early reported successful cases in 
which celluloid was thus employed, and with the back- 
ing of Fraenkel, Hinterstoisser, von Eiselsberg, Billroth, 
Winiwarter, WO6lfler, and others, the procedure soon be- 
came generally known and practised in both Europe and 
America. 

Monara prefers to use a thin plate of cartilage. He 
says that if its smooth surface is directed toward the 
brain, no adhesions between the membranes and the car- 
tilage will result. 

A hard’ foreign substance may be used as a guide to 
the periosteum in its attempt. to form new bone. C. 
Martin made a skeleton of platinum-iridium wires the 
shape of the bone that was lost and succeeded in getting 
the periosteum to grow a new bone almost the shape of 
the old. Immobility is essential to the success of such 
procedures, and hence they yield better results in the 
forearm and leg than in the upper arm and thigh, since 
the sound bone acts as a closer splint than any external 
apparatus can possibly do. In Martin’s successful cases, 
the supports remained permanently incorporated in the 
regenerated bones. As such apparatus usually needs 
fitting during the operation, the vise, files, pincers, and 
whatever other tools are required should be sterilized, as 
well as the instruments needed for the operation upon 
the patient, This is equally true when celluloid or other 
solid material is introduced. Edward Milton Foote. 


BONE-SETTING.—In every country there is a class 
of irregular practitioners who make a living, and some- 
times also quite an extensive reputation, by their success 
in restoring functional usefulness to crippled limbs. 
These individuals are, as a rule, most arrant quacks, 
knowing absolutely nothing of anatomy, or of the 
pathology of the conditions which they are called upon 
to treat, and yet they are often successful to a remarkable 
degree in curing certain joint affections which may have 
baffled the skill of the most experienced and able sur- 
geons. These men are known as bone-setters, from their 
invariable assertion, made often through honest igno- 
rance, that “the bone is out of joint, and only needs to be 
set.” It is true that they frequently inflict most serious 
injury, which may lead to loss of limb or life itself, yet 
it is also undeniable that they sometimes restore a limb 
which might otherwise- remain permanently crippled, or 
even be sacrificed as a useless incumbrance. Such being 
the fact, it is not the part of wisdom to seek to ignore 
the existence of bone-setters, or to allow their failures to 
blind our eyes to their successes; but we should rather 
study their methods, to learn wherein lies the secret of 
their triumphs, and then we may with benefit and with- 
out any loss of dignity imitate their treatment in suitable 
cases, easily avoiding, through a knowledge of anatomy 
and pathology, the pitfalls into which they, in their 
ignorance, so often plunge. 

Dr. Wharton P. Hood! was the first to study intelli- 
gently the methods employed by bone-setters, and it is 
to him that most of our knowledge of this art, for art it 
is, though no science, is due. He defines bone-setting as 
“the art of overcoming, by sudden flexion or extension, 
any impediments to the free motion of joints that may 
be left behind after the subsidence of the early symptoms 
of disease or injury; perhaps, indeed, more frequently 


127 


Bones, 
Bordighera, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of the latter than of the former.” The cases that most 
frequently fall into the hands of bone-setters, and are 
cured, to the joy of the patient, but to the discredit and 
loss of reputation of the regular practitioner, are those 
of slight fibrous ankylosis, of a degree sufficient to limit 
motion and impair the functional utility of the limb, yet 
not such as apparently to demand forcible rupture, an 
operation so unreasonably dreaded by many surgeons. 
In such a case, perhaps, some feeble attempts at passive 
motion are made. The joint is flexed cautiously and 
slowly, until the patient complains bitterly of pain; then 
the operator desists, orders the limb to be kept at rest, 
and bathed with lotions to subdue the inflammation ex- 
cited by the strain put upon the adventitious bands, A 
few days later, when the heat and swelling have disap- 
peared, the same manipulations are repeated, and fol- 
lowed again by inflammation and its treatment. After a 
number of repetitions of this sort the patient sees that he 
is no better than before, and refuses to submit his joint 
to any further manipulations. Then he becomes dis- 
couraged, limps around with the aid ofa cane or crutches, 
and tries to bear philosophically the thought that he is a 
cripple for life. But at last some friend tells him of a 
wonderful cure performed by a bone-setter in a case ap- 
parently similar to his own, and in desperation he sends 
for the quack. The latter assures him that the bone is 
out and only needs to be replaced. He orders the joint 
to be enveloped for a time in flaxseed poultices, probably 
a procedure that contributes in no way to the success of 
the operation, and then on the appointed day meets his 
patient, seizes the limb, and with a quick motion flexes 
and extends the joint to its full extent, breaking up all 
the adhesions, and the patient finds that he is cured. 
The pain of the operation is but little greater than that 
inflicted by the regular practitioner in his feeble and in- 
effectual attempts to restore motility, and the resulting 
inflammation is usually slight or nil. The quack says 
that the bone is restored to its place, pockets his fee, and 
retires with glory. 

This is no exaggerated picture, but is a true tale of 
what actually occurs in not a few instances, as many 
practitioners will sorrowfully admit. The good that 
bone-setters do is in these cases of partial ankylosis, and 
it is because they are unable to discriminate between the 
different conditions in which joint motion is impeded 
that they so often inflict irreparable injury. No surgeon 
would attempt forcibly to move an articulation which is 
the seat of strumous or tuberculous inflammation, yet this 
is what the bone-setter does with dire result. In most 
of the joints which can be benefited by forcible move- 
ments there is a tender spot, usually about the inner side, 
for which the bone-setter always feels, and the discovery 
of which is to him a sign of ultimate success. The mo- 
tion of the joint is not absolutely abolished, but is limited 
in certain directions, and any attempt to pass this limit 
causes pain. .The skin over the articulation is not hot, 
and all the other signs of inflammation, except perhaps a 
slight serous effusion, are absent. The following is an 
enumeration of the location of these painful spots, to- 
gether with Mr. Fox’s explanations of their occurrence, 
as given by Mr. Edward Cotterell in a very practical 
little work treating of the minor injuries of the limbs.? 
1. “Over the head of the femur, in the centre of the 
groin, corrresponding to the ilio-femoral band of the 
capsular ligament (which is most severely stretched when 
the thigh is over-extended, as when the trunk is flung 
violently backward, the commonest cause of a sprained 
hip). 2. For the knee joint, at the back of the lower 
edge of the internal condyle; in other words, at the 
posterior border of the internal lateral ligament, where 
it blends with Winslow’s ligament, and where the semi- 
membranous tendon isin intimate relation with it. These 
parts suffer most because, as Mr. Morris says, ‘ during 
extension they resist rotation outward of the tibia upon 
a vertical axis, and a sprained knee is almost always caused 
by a twist outward of the foot.’ 3. For the ankle, on 
the front of the external malleolus, the apex of the 
plantar arch, and the tip of the fifth metatarsal bone. 4. 


128 





For the shoulder, at the point corresponding to the 
bicipital groove, because in nine cases out of ten a man 
sprains his shoulder to prevent himself from falling; his 
hand grasps the nearest support, the body is violently 
abducted from the arm, the long head of the biceps is 
called upon to exert its utmost restraining power, the 
bicipital fascia is overstretched, and the tendon very 
often misplaced. 5. For the elbow, in front of the tip 
of the internal condyle; the fan-shaped internal ligament 
has itsapex at that point, and it is most stretched in over- 
supination with extreme extension of the forearm. 6. 
For the wrist, the styloid process of the ulna, and the 
annular ligament in front of the wrist.” 

The injuries or diseases most likely to give rise to the 
slight degree of ankylosis which is amenable to the 
bone-setter’s manipulations are rheumatism and gout, 
displaced tendons or cartilages, sprains, prolonged im- 
mobilization during the treatment of fractures, neuro- 
mimetic joint affections treated improperly by rest and 
mechanical support, and ganglions. 

The bone-setter’s manipulations consist in first locating 
the painful point, upon which the thumb is firmly pressed 
during the remainder of the operation; and then, while 
the operator steadies the proximal segment of the limb, 
the distal segment is grasped and rotated as much as pos- 
sible on its axis in order to overcome, as far as may be, 
muscular resistance, this being accomplished, the joint 
is sharply flexed or extended in the direction of great- 
est resistance, and then the reverse movement is made 
until all the adventitious bands are broken, or until 
the “bone is put back,” in the bone-setter’s own phrase- 
ology. The rupture of these bands of adhesion is often 
accompanied by a loud report. For a description of 
the special manipulations required for each joint, the 
reader may consult the work of Wharton Hood, above 
referred to. 

It should not be forgotten that most of these stiff joints 
may be prevented by a proper attention to the treatment 
of minor injuries of the articulations, and this is one of 
the principal lessons which we may learn from the bone- 
setters. If surgeons would never dismiss a case of frac- 
ture or sprain until joint motion were perfectly restored, 
the occupation of the bone-setter would be less lucrative 
than it now is. 

1 On Bone-Setting (So-Called), and Its Relation to the Treatment of 
Joints Crippled by Injury, Rheumatism, Inflammation, ete. By Whar- 
ton P. Hood, M.D., M.R.C.S8., London and New York, 1871. 

2On Some Common Injuries to Limbs: Their Treatment and After- 


Treatment, Including Bone-Setting (So-Called). By Edward Cotte- 
rell, M.R.C.S., Eng., L.R.C.P., Lond., London, 1885. 


BONES, TEETH, AND CARTILAGE, CHEMISTRY 
OF.—The bones of vertebrates consist essentially of an 
organic basis of ossein and the so-called bone earths made 
up of inorganic salts. Elastin, fat, proteids, and nuclein 
are also present. Ossein is identical with or very similar 
to the collagen of connective tissue. In the bone earths 
calcium predominates in the bases, but small quantities 
of magnesium are also present and, according to some 
authors, traces of potassium and sodium. These bases 
are for the most part in combination with phosphoric 
acid, but some carbonic acid is found, and traces of chlo- 
rine and fluorine. The sulphuric acid mentioned by 
some writers is probably derived from some of the organic 
constituents and does not properly belong to the bone 
earths. There issome difference of opinion as to how the 
bases and acids are combined, but according to Gabriel 
the simplest expression for the composition of the ash is 
[Cas(PO,)2 + CasHP3;01; + Aq] in which two to three per 
cent. of the lime is replaced by magnesia potash and soda 
and four to six per cent. of the phosphoric acid by car- 
bon dioxide, chlorine, and fluorine. Asage advances the 
bones become richer in ash and poorer in water. Hoppe- 
Seyler gives the following composition for undried bone 
without separation of marrow or blood: Water, 50 per 
cent. ; fat, 15.75 per cent.; ossein, 12.40 per cent.; bone 
earths, 21.85 per cent. The composition of the bone 
earths is given as follows by Zalesky in parts per thou- 
sand: 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bones, 
Bordighera, 








Man Ox 

Calcium phosphate, CagPoOg....cccccescccvecsvccens 838.9 860.9 
Magnesium phosphate, MggPoOg.........ceeeeeeeees 10.4 10.2 
Calcium es 1 with COg,FI, ‘and Ce eearate ane 76.5 73.6 
Mem MMPI Ve iver ctv olga lo:0is Giaccieis cpl acaitie ace eis 'siveleic’e od 57.3 62.0 
Meee CRI NSEA MME Pne cio ‘era a 0i2\cjclc'e Yee, chm. oi e7eye. ea -wicteyeceiaveretéieleia: 6ys)e 1.8 2.0 
PE PIRECEMMME TEE eta? ct cis 6's, aro, cs 5) 50:5) 0°41 oe: 855, 0 e701) Siayeia eave & aietae ble 2.3 3.0 


Bone marrow is composed chiefly of fat (96 per cent.), 
containing the fatty acids of ordinary adipose tissue in the 
proportion of palmitic acid 22, stearic acid 10, and oleic 
acid 63 per cent. of the total fatty acids. Proteid is pres- 
ent in small quantities, especially in the red marrow of the 
spongy bones. It is principally in the form of globulin 
and nucleo-albumin, with traces of albumin. Among 
the extractives of marrow are lactic acid, hypoxanthin, 
and cholesterin. 

The teeth consist of crusta petrosa, dentine, and enamel. 
The crusta petrosa is a true bony structure and resembles 
ordinary bone in composition. Dentine is very similar 
in composition, but contains less water. Enamel is an 
epithelial structure containing scarcely any water but 
rich in lime salts. Its organic constituents differ from 
the ossein of bone and dentine in not yielding any gela- 
tin on boiling.. The following composition is given for 
the teeth by Hoppe-Seyler from analyses by Aeby: 








Constituents. Dentine. | Enamel. 
COE OG) Sitter as sree setrcescnsbeseseseces 72.06 96.00 
TEL ocd. oh COCR RGL ICED SABO ESAT AC aaa 75 1.05 
STANTS SU DR UBTICES ies 9.0.6 < cise cies 9010.0. 0's 010.8 0ie(e's.9.0:8 27.70 3.60 





Cartilage.—The organic basis of cartilage was formerly 
known as chondrigen and the gelatin-like substance ob- 
tained from it on boiling was known as chondrin; but it 
is now recognized that the so-called chondrigen is a 
mixture, containing the following as its chief constituents. 

1. Collagen, resembling closely that of connective 
tissue. 

2. An albuminoid substance, resembling elastin but 
richer in sulphur. 

3. A mucin-like substance, known as chondro-mucoid 
and capable of decomposition into a proteid and chon- 
droitic acid. 

4, Chondroitic acid or chondroitin-sulphuric acid, pres- 
ent in combination in chondro-mucoid and also uncom- 
bined. Schmiedeberg ascribes to chondroitic acid the 
formula Or sHezNSOx1:. 

The inorganic constituents of cartilage are characterized 
by the abundance of sodium which in adult mammals is 
principally combined with sulphuric acid. In mamma- 
lian embryos and in lower vertebrates the sulphuric acid 
is largely replaced by chlorine. The composition of car- 
tilage is summarized by Hoppe-Seyler as follows: 








Costal | Articular 
In 1,000 parts. Cartilage. | Cartilage. 
SUM ET URI ierecinietsiot'citic-s.e clove «.alriniaisacieleiece'ae cis vivie-oves 676.6 735.9 
BROT CIM mn oRtc aa a) fia, ois'cia.e.nleie-a.0,0ig v'els, ie oct a nielvinis 323.3 264.1 
ITAA UR Semettere ieiere cie/ersiaicle) tinis’o.e @siieitia'sieare edie oe 3 301.3 248.7 
MEO AILIOM ste eels viois it cies c's. a\e‘alc ocicielele o's vicle'ee 22.0 15.4 
Salts in one hundred parts of ash : 
Ee MISILITESESUILENISSUCG Sieotniattia ayo.clr'a'c e cinlersjels ec ¢'e'b 9, sities dieeee 26.66 
MALTESE PMB aie eisres cistelciere Oreies cis csisie’e sibel eiicive.s ounce 44.81 
UMEMITCLLOTI IG cae cictel dee cise sive cies siveisie osleie civ oveiecreeunee 6.11 
MMs LITRE LORDS cic ierayalate ares stein ovis 'e ert'e 2 08 sl atosdie'sin sare cele’ 8.42 
RRICLUEITE DUGNDRAUCs ares eirisisrae'e sine oieeyna'bs let 6.0 9 ees'sielo'a os 7.88 
MIA OTIGMLUINIG DHOSDUALOL ences cekccis scenes ecclee vite ceneeive 4.55 


Wesley Mills. 
William 8S. Morrow. 


BORAGE.—The leaves and flowering tops of Borago 
officinalis L. (fam. Boraginacee), A European or Oriental 
plant, occasionally cultivated in flower gardens in the 


Vou. Il.—9 


United States. It has a succulent, branched, hairy stem, 
half a metre or so high (twenty inches), with rough, 
coarse-looking, entire leaves, and terminal one-sided 
cymes of pretty blue flowers. Borage has been a domes: 
tic medicine in Europe for years. Its odor is slight, at 
least when dry; taste, bland and mucilaginous. It con 
tains no more active principles than mucilage and nitrate 
of potassium, and its medical qualities are only those of a 
mild demulcent. W. P. Bolles. 


BORDIGHERA.—A marine health resort on the Medi- 
terranean ceast of France, 10 miles east of Mentone and 
3 miles west of the Italian boundary. 

“Bordighera is a conspicuous object nearly all along 
the western Riviera, as it is seen glittering in the sun- 
shine, its houses clustered together on a promontory that 
projects far out into the sea. It is the only health resort 
on this coast that occupies a position on a promontor y; 
all the others being built round bays or depressions in 
the coast. It is naturally, therefore, much exposed to 
winds, that is to say, to all those winds that can reach 
it in blowing across the sea; the east, the southeast, the 
southwest, and the west winds can all blow freely upon 
this promontory. But it is well protected by mountains 
to the north, northeast, and northwest, whence the cold- 
est winds come. Moreover, it must be remembered that 
all the winds that reach it must, on account of its posi- 
tion, come to it from the sea, and impregnated with saline 
emanations. And this is the sole distinguishing charac- 
teristic of the climate of Bordighera as compared with 
that of neighboring stations; the predominating influence 
of sea air rendering it essentially bracing and tonic” 
(Burney Yeo). 

Bordighera is a small town of 2,500 inhabitants, and the 
portion devoted to invalids is called the “new town,” or 
English quarter, and is on level ground to the west of 
the promontory. The hotels and villas are surrounded 
by groves of olive, lemon, and palm trees. The latter 
grow toa great height and are said to be more plentiful 
than in any other part of the Italian Riviera. “It is said 
that there are more palms in the neighborhood of Bordi- 
ghera than in the whole of Palestine ” (Dean Alford). The 
natives have a monopoly of supplying the Vatican with 
palm leaves for Palm Sunday. Dense olive groves also 
cover the plain upon which the new town is situated. 
The drainage of the town is primitive, but the place is 
said to be healthy, and the hygienic conditions are con- 
sidered good. The water supply is obtained from wells, 
and from a spring in the flank of Monte Nero (Goodchild). 
During a residence of fifteen years Dr. Goodchild has seen 
no case of typhoid fever or diphtheria among the mem- 
bers of the English colony. 

The average monthly temperature for the months from 
October to May inclusive is as follows: 


MEAN TEMPERATURES, 1876-79. 


October Seaseeccacite sas aes 63,5258 | MODIMELY! cle sve lcleure s vieheters 49.1° F, 
NOVEMIDER Sire rates atenie oie0 Do oe Mom ARCH sermeisre etcielevenisiacrniere 50.5° F 

DCCEMDOLR vere e vara re cere ne 49:09 BOCA DTU Se cicce cs eceetacivssec 55.12 F. 
SATAY ie se cremeree vinicicreictels AD.GObPESISMaAY, sinverteciasaleoaeeres cates 61.0° F 


The temperature averages about three degrees lower 
than that of Mentone, according to Dr. Goodchild, and 
the rangeissmaller. The relative humidity approximates 
to that at San Remo, which has a yearly average of 66.7 
per cent. The rainfall also is about the same as at San 
Remo, at which place the number of days on which rain 
falls during the season is thirty. “At Bordighera the 
mistral is the west wind, being turned completely in that 
direction by the mass of mountains behind Monaco, and 
from being forced to blow over the sea it loses somewhat 
of its dry and cold character” (Burney Yeo). “The 
soil upon the hillsides is limestone and conglomerate, but 
upon the flat it is composed of old sandy sea beaches, in 
which the water rapidly finds the sea level. About a 
couple of acres near the English church possesses a soil, 
however, in which there is a small admixture of clay and 
which is somewhat damp in consequence” (J. A. Good- 
child, M.D.). 


129 


Boric Acid. 
Boston. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





The climatic characteristics of Bordighera can be sum- 
marized as those of a Mediterranean health resort, afford- 
ing pure sea air, a mild equable winter temperature, a 
comparatively low relative humidity, and, in common 
with the other resorts of the Riviera, a large amount of 
sunshine. Thus, an outdoor life in a mild bracing sea 
air is afforded. The variety of level shady walks among 
the palms and olive trees, and the attractive excursions 
in the neighborhood add a charm and interest to the in- 
valid’s life there. 

The class of diseases which are likely to be benefited 
by this climate are those requiring a warm, moderately 
moist sea climate. As has been said before (vide note 
upon Algiers), a climate of this character is not an espe- 
cially curative one for phthisis, and all that can generally 
be expected of it in this disease is to ameliorate symp- 
toms and prolong life. Strumous cases, especially in 
children; patients with ansemia, diabetes, or albuminuria ; 
convalescents from acute diseases; the weak and debili- 
tated; sufferers from chronic bronchial catarrh, from 
catarrh of the stomach and intestines, and from various 
other conditions of constitutional feebleness, find here a 
suitable climate—* cheering to the mind and invigorating 
to the body.” 

Bordighera is not suitable for the febrile and for those 
who are very nervous and sensitive. The accommoda- 
tions are said to be very comfortable, although somewhat 
limited. “English tastes are consulted, as nearly all the 
visitors are English or Americans ” (Ball). 

Bordighera may be reached vii Marseilles, or by way 
of Turin and Savona. By the former route it is thirty- 
three and a quarter hours distant from London. 

Edward O. Otis. 


BORIC ACID.—Boric acid (H;BOs;), often called by 
the older but less correct name of boracie acid, is official 
*n the United States Pharmacopeeia under the title Actdum 
Boricum, Boric Acid. It is described as “transparent, 
colorless scales, of a somewhat pearly lustre, or, when in 
perfect crystals, six-sided, triclinic plates, slightly unctu- 
ous to the touch, odorless, having a faintly bitterish taste, 
and permanent in the air. Soluble, at 15° C. (59° F.), in 
25.6 parts of water, and in 15 parts of alcohol; also solu- 
ble in 10 parts of glycerin. Addition of hydrochloric 
acid increases its solubility in water. An aqueous solu- 
tion (1 in 50) of boric acid colors blue litmus paper red ” 
(UGS:3P2). 

Boric acid is a very feeble acid chemically, and 
physiologically lacks the ordinary acid qualities of sour 
tasteand tendency to irritate. Evenasaturated aqueous 
solution is tasteless, and without irritant action on even 
so sensitive a part as the conjunctiva. Constitutionally, 
also, in all ordinary applications, the drug is harmless; 
but yet poisoning and even death have followed, in a few 
cases, a very extensive use of the acid. The essential 
symptoms in such cases were nausea, vomiting, hiccough, 
feeble heart action, and fall of temperature, with the 
development of an ci ‘-nematous rash, affecting particu- 
larly the legs. 

Boric acid is useful in medicine by reason of its power 
to arrest the multiplication of microbes. But yet this 
same power has been overrated. The experiments of 
Sternberg,* the most precise with which the writer is 
acquainted, assign to the acid the power of preventing 
the development of the micrococcus of pus in a one-half 
per cent. solution; but in the matter of permanently 
sterilizing such organisms—quite another story—the ex- 
periments record complete and repeated failure even in 
saturated (four-per-cent.) aqueous solution, and this not 
only in the cases of the micrococcus of pus and that 
of septicemia, but also in the case of the common bacte- 
rium termo. 

Boric acid, therefore, must be regarded, in the present 
state of knowledge, as a fairly efficient antiseptic—con- 
venient withal, because odorless, tasteless, unirritating, 
and non-poisonous in ordinary application—but must not 


* American Journal of the Medical Sciences, April, 1883. 


130 


be relied upon as a germicide in the proper understand- 
ing of the term. Probably because of its antiseptic ac- 
tion, boric acid, locally applied, tends to abate the ca- 
tarrhal process, and is, for such application, peculiarly 
agreeable because non-irritating. As a collyrium in 
conjunctivitis, a gargle in pharyngitis, or an injection in 
cystitis, solutions of boric acid are, therefore, often effica- 
cious, and at least innocent of harm. For an application 
to catarrhal surfaces, or for antiseptic purposes to wound 
surfaces, boric acid may be used in aqueous solution rang. 
ing from one to four per cent. in strength—the latter being, 
indeed, at ordinary temperatures, a saturated solution. 
A stronger solution, if wanted, is obtainable by using 
a mixture of equal parts of boric acid and borax, which 
dissolves to the extent of sixteen per cent. of water at 
ordinary temperatures. A convenient and efficient wound 
dressing may be made by soaking lint in a hot saturated 
aqueous solution of boric acid, and then allowing it to 
dry. <A boric-acid ointment also has been recommended, 
where, to a melted mixture of one part each of white 
wax and spermaceti and six parts of vaseline, is added a 
proportion of from two to four parts of a saturated solu- 
tion of boric acid in glycerin. Also the substance boro- 
glyceride (see Boroglyceride) affords a means of applying 
boric acid in strong solution. Boric acid has also been 
given internally in doses of 2 gm. (gr. xxx.) frequently 
repeated, with no poisonous effect, and with asserted 
benefit in dyspepsia with fermentation of the ingesta, in 
chronic cystitis, in diphtheria, and in other diseases prob- 
ably determined by the multiplication, within the system, 
of microzymes. Edward Curtis. 


BORLAND MINERAL WELL.—Pleasants County, West 
Virginia. The well from which the Borland Mineral 
water flows is situated on the bank of Blue Creek, 6 
miles from Salama, on the Ohio River Railroad, and 30 
miles northeast of Parkersburg. At present there is no 
hotel in the vicinity, but nearby farmhouses accommo- 
date a limited number of guests who wish to use the 
water from the well. The surrounding hills and valleys 
present some very pleasing landscapes. The water rises 
from a flowing well, being forced upward by the natural- 
gas pressure from a depth of three hundred feet. An 
analysis by Prof. T. G. Wormley, of Philadelphia, showed 
the following mineral ingredients: 


ONE UNITED STATES GALLON CONTAINS: 


Solids. Grains 
SOdIM CHOMIME. ¢ sc fics seveisie oss slereieversisiels lero wsisietalel neler ieee 240.07 
Sodium bicarbonate: «<<. \sii. «is sss s\eie.eicie.e viesiein\e ett le lalate 112.16 
Sodium sulphate. os scp siev ac vjcle's wie exe v.sreleieisreisie Me ener 37.84 
Magnesium DrOmide sy. sons seccseccecs selsisleceleneretteiae 28 
Potassium sulphate........... PoC Aid ssarevele ele o/dielere eer teers 22.62 
Magnesium I1OdIdes, «.<:40j0)+ «race's ojo ciere oreisiove ete siareiete siemens OR 
Magnesinm \Chloride? Jess sieewleuie ties araireeaeleetaetetee teres 2.13 
Calcium: bicarbonate... 5s 2%) ese slclume > sve oe seinem 12.59 
Magnesium bicarbonate % ....035 2 css sic vies be > entesien eration 3.12 
AlUMINUM PHOSPHAL!S ss acta’ ccscssrstelcleisie ie wivieleuelon eimai P 
Aluminum and dron’ carbonate cic. «- «es sess sleet 64 
MANGANESE 5 vo:ciccaie,o cleissesclelois stovereletesnnareceleraie ettaleiniettratstetn annem Trace. 
BLIGE io sides eSeretes aeeevelore clones ele nloteseserele eleleceiotenietetere atietene 
Organic matter .'. cccilecs accieveividiodlae eteisniiee casa celts Trace 

TOCA sera arave a sister elate's ciate’ ccacsi@ielerelete' sieteiate ce stein a aie einen 432.28 
Suiphureted hydrogen............s++0 A perceptible quantity. 


This water is quite a strong muriated, alkaline saline. 
It is a very efficient antacid laxative, with diuretic and 
diaphoretic properties. It also derives a certain tonic 
and restorative influence from the presence of iron, phos- 
phorus, and manganese. In addition to its table value it 
has been found to possess excellent therapeutic properties 
in chronic affections of the stomach, bowels, liver, and 
kidneys. It acts with great efficacy in renal dropsy. 

James K. Crook. 


BOROGLYCERIDE.—Under this title there has been 
introduced into medicine a compound formed by direct. 
reaction of boric acid upon hot glycerin. In this reac- 
tion tribasic boric acid replaces the three hydroxy] equiva- 
lents of the molecule of glycerin, forming glyceryl borate, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Borie Acid, 





C;H;BOs, with evolution of water, as per the follow- 
ing equation: C;H(OH); + HsBO; = C;H.BO; + 3H,0. 
Boroglyceride is a solid, vitreous body, transparent, and 
of a light amber color. It has little odor, and a slightly 
sweetish taste, with a faint astringent twang. 
hygroscopic, rapidly becoming sticky on exposure to the 
atmosphere. It dissolves freely in glycerin, and, melted 
into an equal weight of that fluid, forms a permanent, 
viscid, clear solution. The solubilities in water and al- 
cohol have been stated very variously. A sample tested 
by the writer broke up into opaque, granular flakes by 
treatment with cold water, but finally dissolved in ten 
times its weight of that fluid; and in cold absolute alco- 
hol it dissolved slowly but completely, in even less than 
its own weight, forming a clear, syrupy solution. 
Boroglyceride is reported to be strongly antiseptic, 
and was originally proposed by Barff, before the Society 
of Arts of London, as an agent for the preservation of 
food-stuffs. Taken internally it has seemed to be as in- 
nocent as the two substances of which it is compounded. 
It has so far been used in medicine locally only, being 
- applied—generally in glycerin solution—as a dressing to 
wounds, ulcers, catarrhal mucous membranes, etc. It is 
claimed to be at once antiseptic, astringent, and healing, 
while inodorous and practically unirritating. It is most 
commonly employed in fifty per cent. glycerin solution, 
or in ointment made by mixing one part of such glycerin 
solution, while hot, with three parts of vaselin. What 
amounts to a fifty-per-cent. glycerin solution of boro- 
glyceride is official in the United States Pharmacopeeia, 
under the title Glyceritum Boroglycerint, Glycerite of 
Boroglycerin. In this case the solution is made directly 
by treating boric acid with hot glycerin in proper propor- 
tion. The preparation is a colorless, glycerin-like fluid. 
Asa preservative, boroglyceride has been recommended 
in solutions ranging from two per cent. to five per cent. 
in strength. Edward Curtis. 


BORNEOL.—Borneo Camphor ; Dryobalanops Camphor. 
(CioH,;,—OH). A camphor-like body occurring in the 
wood, and in lumps in the cavities thereof, of Dryobala- 
nops aromatica Gaertn. (fam. Dipterocarpacee), in a 
number of Coniferw, in valerian, rosemary, and several 
other aromatic plants. The article is not exactly the 
same, differing especially in its optical properties, from 
these different sources. That commonly sold is artifi- 
cially made from ordinary camphor by the action of so- 
dium. This differs from ordinary camphor in its much 
higher melting and boiling points, and in not crystallizing 
upon the sides of the glass containers. It is crystalline 
and soluble in alcohol. It is used externally as a disin- 
fectant to sores. H. H. Rusby. 


BORRAGINACEA.—A family of some eighty-five gen- 
era and nearly fifteen hundred species, most widely dis- 
persed, but mostly in warm temperate climes. Except 
for ornamental purposes, especially the heliotropes and 
forget-me-nots, the family is but little utilized. Its chief 
use at present is to yield the coloring matter alkanna red. 
Historically, it is of considerable interest in medicine, the 
borage, comfrey, lungwort, eritrichium, vipers bugloss, 
and other drugs having formerly enjoyed a high, though 
ignorant repute. Although some of their alkaloids are 
quite active, they occur in inconsiderable proportions. 

H, H, Rusby. 


BORTHWICK MINERAL SPRINGS.—Also known as 
the Otfawa Mineral Springs. 

Post-OFFICE.—Ottawa, Canada. 

Access.—By carriage drive from Ottawa. 

Awnatysis.—By I. Baker Edwards. 


ONE PINT CONTAINS: 


suiias. Grains. 
COMIGTICE OL SOGLUIN, vectaticiaceiercers even malcieinateelsclesisiersi tie 6 98.081 
OHIOTIAG Ol DOLASSIUTI Ss cicrerseielerecieteYelelovaistsiers ie iclevctarcle's eisteve 1.310 
TOTIAS Of CAICLUININ cots tlete's siete alerosib ce sents alcineie eisietelo 8 1.832 











Boston. 
Solids. Grains 
Chloride: Of MAPNERINMN Feces ceases sles cie ces Seishin cweiae 2.7138 
Bromide and iodide of magnesiuM..................05 351 
SulpNateOf CALA ois ck clerelaietacle eee aca'estie.cieie a alcle% ofieve 2.019 
Sulphate of maonesiuineey cnc. reese: ste secre eels one 2.450 
It is Trony stron tlumisant asides delta teteaissslesiste sis'ss caven slvwe's Traces. 
Total gacktacpiante cecal Aten ie siies sa vicmionnnecatstss 108.756 


This is an unusually pure saline water, containing a 
large percentage of iodine and bromine. A small amount 
of purgative salts is also present, forming an excellent 
combination. There is no aération with carbonic acid. 
These waters are extensively used by the residents of 
Ottawa and vicinity. Their reputation is steadily in- 
creasing and their sale has assumed enormous proportions. 

Beaumont Small. 


BOSTON.—Massachusetts. Although this and vari- 
ous other cities which wili be mentioned in the HANDBOOK 
are not health resorts, yet it frequently happens that an 
invalid is obliged, from reasons of necessity, to spend more 
or less time in them, and it isa satisfaction to know some- 
thing of the climate and weather which may be expected. 
Further, as Dr. Huntington Richards, the previous editor 
of this department, says: “ One can better form an opinion 
of the climate of any health resort he may have under 
consideration, if he compares it with that of the place in 
which he resides or with that of some place with which 
he is familiar.” For these reasons, then, the climatic 
tables and general weather conditions of the principal 
cities of the United States will be given. 

The climate of Boston is characterized by great vari- 
ability and range, from a possible maximum of 101° F. 
in July to — 13° F.in January. Theeast winds, although 
not the prevailing ones, as the climatic table indicates, 
are still frequent enough to form one of the peculiar 
characteristics of this climate. They are damp and chilly 
in winter and early spring, and render outdoor existence 
exceedingly uncomfortable. 


“A chill no coat, however stout, 
Of homespun stuff can quite shut out— 
A hard, dull bitterness of cold.”’ 


In the summer, on the contrary, they modify the heat 
and are very refreshing. Ask any inhabitant what is 
the one striking climatic peculiarity of Boston, and he 
will immediately reply, “ The east wind.” 


CLIMATE OF BOSTON, MASS. LATITUDE, 42° 21’; LONGITUDE, 7194’. 
PERIOD OF OBSERVATION, FROM 13 TO 25 YEARS. ELEVATION OF 
PLACE OF OBSERVATION ABOVE SEA LEVEL, EIGHTEEN FEET. 























Data. Jan. | Mar. | July.| Year. 
Temperature (Fahrenheit Scale). 
AVCrage OL DOTMAl «an cncecusieatitos sts 27.0°) 34.2°| 71.3°! 48,.2° 
AVGYASS GALLY, TANGLE ce vinsnic ceisler vos 17.2 | 16.5 | 17.9 
Mean of warmest (average maximum) ..| 35.3 | 42.2 | 80.8 
Mean of coldest (average minimum).....| 18.1 | 26.7 | 62.9 
Highestior Maximum sees ashe css hoe 70.0 | 72.0 |101.0 
HOWeSt OM MINIM UMiget wote ns evivieeetciee © -13.0 |—7.5 | 46.0 
Humidity. 
Mean relative (average) ........sesseee0. 71.8%] 69.4%] 70.8%] 69.6% 
Wind. 
Prevailing direciorr. steers es sie esc cris ces N.W.|N.W.| W. WwW. 
Average hourly velocity in miles......... 14.2) 11.3] 8.5 
Weather. 
Average number of Clear days........++- 8 Soiree LOs 
TAL P CS eR Be eet on a ade ccraaesicrce's 13 sisithe. 1b, AD 
Smallest re id ti IRE aa 4 3 
Average A fairey) ers ee es 10.6 | 9.5 | 13.7 |184.6 
Largest es + ran chbonee cece 15 20 
Smallest Si i: Be aisigaanaeire ib 3 
Average - CLOUDY sul oweeouts tas 12.4 | 12.5] 9.4 |185 
Largest g > Sada nts sas om se 23 
Smallest hey os FAS Aavassaricice’ 3 
Average number of rainy days, .01*inch 
ANG OVER. Alu cow cae seine nove Ceswnanee ss 2.2 )138.7 |) 11 {180 
Smallest number of rainy days aeeistanetele e6 4 Age 6 
Targest eye adie. CPP cod hose naa 18 17 








131 


Boswell Springs. 
Bournemouth. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





The cold season begins in November, although it is 
occasionally mild even to Christmas, and continues 
until April; snow is for a great part of this time upon 
the ground, although not always continuously. March, 
on account of the high cold winds, is one of the most 
disagreeable months of the year, and June one of the 
most delightful, although the latter part of the month 


may be uncomfortably hot. In the summer, the heat, 
oppressive at times on account of the dampness, is not 
continuous, and in the writer’s experience, froma climatic 
point of view, the spring and summer are the best seasons 
to spend in the city, and January, February and March, 
the months to be avoided by achange toa milder climate. 
Fashion, however, has it otherwise. The writer recalls 
the case of a family whose members had come on from 
St. Louis, in search of an Eastern seaside resort, but who, 
on arriving in Boston, had found the place so comfort- 
able that they decided to remain there the whole summer. 
The excursions by water are numerous and very de- 
lightful, and the country around is easily accessible and 
attractive. Boston is noted for its beautiful suburbs. 
Edward O. Otis. 


BOSWELL SPRINGS.—Douglas County, Oregon. 

Post-OFFIcE.—Boswell. Hotel. 

AccEess.—Boswell is a flag station on the Southern 
Pacific Railroad (Shasta Route), 163 miles south of Port- 
land. The location of the hotel is one hundred feet from 
the railroad. 

The situation is on Elk Creek, about 45 miles from the 
coast and 350 feet above tide water. The surrounding 
country is made up of hills and valleys. There are two 
springs at the resort. 

A partial analysis of the stronger spring, made at the 
University of California, showed the presence of two 
thousand grains of solid matter to the United States gal- 
lon, made up chiefly of the following ingredients: Iron, 
bromine, potassium, calcium, magnesium, sodium. 

The weaker spring was analyzed by Philip Harvey, of 
Portland, Ore., who gave its contents as follows: 


ONE UNITED STATES GALLON CONTAINS: 


Solids. ® Grains. 
Soditim: :CHIOTIAG, Vo aires cielercdios clecels wtatctesle ota as haie senate 173.00 
MATES UI CHIOLLGET. cycivaverere oltisiaisleieisialate staisvartve) eleeetcietorayere 145.00 
Calcium (CHIOTIAE) er.cta c's onic sivietaiese ss sieiersiniisieieeihs + Dracies 115.00 


Tron carbonate { 
Ta ees [ter te reece eee ee reece eee 


TOtALS ca ciantast catele aisles aistate ale ature ides ei atate ele etetaietatonaatale 433.00 


Small quantities. 





Both springs are heavily charged with carbonic acid 
and sulphureted hydrogen gas. The waters are evidently 
of the muriated-saline-chalybeaté variety. They have 
been found usefui in constipation, chronic malarial infec- 
tion, dyspepsia, functional liver complaints, and other 
disorders. J. K. Crook. 


BOTHRIOCEPHALUS LATUS. See Cestoda. 


BOULDER.—Colorado. A town of 4,000 inhabitants, 
situated at an elevation of 5,800 feet above sea level, in 
the heart of the Rocky Mountains, 30 miles northwest 
from Denver. “The town is situated close to the foot- 
hills near the entrance to the Boulder Cafion” (Solly). 
The soil is dry and porous, except in areas of clayey soil. 
The water supply comes from a reservoir on Boulder 
Creek, five miles above the town, and also from wells, 
springs, and the creek itself. The hotels are said to be 
fair (Solly). 

Although the meteorological data for Boulder itself are 
very incomplete, so far as the writer has been able to 
learn, they cannot be very different from those at Denver, 
thirty miles away (see article on Denver). Solly gives 
the mean monthly temperature for Boulder, from obser- 
vations extending over a period of one year and a half, 
as follows: Winter, 30° F.; spring, 49° F.; summer, 65° 
F.; autumn is not obtainable. The average number of 
cloudy days during the winter is 13. 


132 


Boulder is one of the many representative places in the 
great high-altitude, health-resort belt of the Rocky Moun- 
tains, extending from Wyoming south along the eastern 
base of the Rocky Mountains, through Colorado into New 
Mexico, and then turning southwest into Arizona. “In 
this belt no particular spot is materially better than an- 
other, so far as climatic conditions are concerned ” (Re- 
port of the Committee on Health Resorts. Transactions 
of the American Climatological Association, 1895), 

Boulder, like many other localities in this belt, would 
seem to offer an almost ideal climate for the high-altitude 
treatment of phthisis: almost constant ‘sunshine—but 
thirteen cloudy days on an average during the winter, 
clear bracing air, low relative humidity, nights that give 
invigorating sleep and rest, and grand mountain scenery. 
But it is well to repeat what has been before said, that 
climate is but one factor, although an exceedingly im- 
portant one, in the treatment of phthisis, and in order to 
obtain the greatest advantage from any climate, however 
ideal, there must be at hand proper hygienic conditions 
and wise medical supervision. Phthisical patients in 
health resorts require, as a rule, constant guidance and 
restraint; they must know when to practise the rest cwre, 
and when it is safe to take exercise and how much. 

Edward O. Otis. 


BOULDER HOT SPRINGS.—Jefferson County, Mon- 
tana. 

Post-OFFIcE.—Boulder. Hotel and cottages. 

These springs are located within two miles of the town of 
Boulder, about midway between Butte and Helena. They 
are reached by both the Northern Pacific and the Great 
Northern Railroad. The springs are numerous, and some 
of them havea large outflow of water. The surrounding 
country is of a rugged, mountainous character, the loca- 
tion of the springs being 4,904 feet above the sea level. 
The following analysis, supplied by Mr. George B. Beck- 
with, manager of the springs, was made at the Columbia 
School of Mines, New York City: 


ONE UNITED STATES GALLON CONTAINS: 


Solids. Grains. 
Sodium CHLOLIGE 6 :..0:<.<.+ olsig:< 9. 0,sth,sve eis cineie: aietec cltreieeee teen 4.70 
Sodium sulphate... 6s cic sce pegs sve cle efors siccatelersieleuleoneeteeeaate 4.30 
Sodium Carbonate s.:io ii. isc /aisterersteie olae'sce aetna en 2.60 
Calcium) CarbOnates..c< ii stsic cleje om sicieteie elelelee ciate Catajereietasiete 1.30 
Magnesitim, GarPOnate \a\.c.cs.e0..00% esos sinjes'e cfeleita pletlaeaneeene 3.60 
Bul PDULs «2 s.06 a'oe oe wale ce eae. vro ale/alahevescye ete ce. or areldiaec teeta teeta 4.80 
TY OM «\5:0:5%5.4's:510:0 oinleleie.e.0(6.0'¢,0 ocer¢) olehe,olelpserecojelere-elelealeraverete aaa ae 2.90 

MTOtAL si cec cree clsice scree ovine uel avoielsaveleteiayevere eteltiaa gianna 24.20 


The temperature of the springs ranges from 125° to 
187° F. The water is said to be very palatable as a 
beverage. The hotel is heated by the water of the 
springs, and bathing facilities are abundant. The dis- 
eases especially benefited here are rheumatism, indiges- 
tion, chronic constipation, renal, cutaneous, and hepatic 
diseases, and metallic poisoning. J. EK. Crook. 


BOURNEMOUTH, England, is a city of 17,000 or more 
inhabitants, and is situated on the south coast of Eng- 
land, in Hampshire, 374 miles from Southampton. “It 
is built ona flat, pine-covered heath which abuts abruptly 
on the sea in the form of great brown sandy cliffs.” 
“The East Cliff, the West Cliff, the Valley, and the Coast 
are the four natural divisions of Bournemouth.” The 
East Cliff, over a great part of its extent, slopes land- 
ward and thus has a westerly and southwesterly as well 
as a southerly aspect; it is the older residential quarter 
of Bournemouth. The West Cliff is more elevated and 
exposed than the East, and is the newer part of Bourne- 
mouth; it contains the larger number of boarding houses. 
The Valley of the Bourne affords the maximum of natural 
protection from the wind which the place can claim. The 
lower part is an attractive public garden, and the eastern 
slope, which is covered with pines, affords a perfectly 
sheltered, sunny and quiet promenade and resting place; 
the well-known “ Invalids’ Walk” is to be found here. 
The Coast is in the form of rugged high cliffs, bright 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Boswell Springs, 
Bournemouth, 





with green and yellow gorse, and broken by deep irregu- 
lar chines, Pines, much resembling those in our South- 
ern States, are everywhere to be seen. On the East Cliff 


Fie. 650.—Invelids’ Welk, 


they are so abundant, fringing the streetsand level walks 
and sheltering the houses, “that this portion of the city 
has been well described as a town in the wood.” The 
heath all around Bournemouth is aiso covered with pine 
woods. The aromatic emanations from the pines are sup- 
posed to impart salubrious properties to the atmosphere. 
Beneath and about the pine trees the furze, rhododen- 
dron, and holly flourish in great luxuriance. 

The sea lies full to the south, and on the eastern horizon 
are the Needles and Alum Bay, in the Isle of Wight. A 
pier 838 feet long extends into the sea and has specially 
constructed shelters for invalids. The soil, consisting of 
a greenish sand, is highly absorbent and very dry. 

The principal facts relating to the meteorology of 
Bournemouth are exhibited in the following table: 


METEOROLOGICAL MEANS 








of rain or occasional cold- winds or dust. The town 
possesses a good drainage system, and the water supply 
is above suspicion. 





Cournemouth, England. 


The general opinion of local practitioners, as expressed 
broadly, is that “most cases of pulmonary tuberculosis 
improve at Bournemouth.” At the same time the climate 
of Bournemouth cannot be represented as equal to the 
best of the foreign climates, such as the Riviera or the 
Alpine stations. Dr. C. Theodore Williams’ results are: 
“Twenty patients, each one winter at Bournemouth; six 
much improved, seven improved, two stationary, and 
five worse.” 

The special features of Bournemouth as a health resort, 
as summarized by the report of acommittee of the Royal 
Medical and Chirurgical Society of London, 1895, to 
which the writer is indebted for the above account, are 
as follows: 

“Bournemouth is distinguished by the general beauty 


FOR TEN YEARS, 1881-1890. 


















































Jan. Feb. | Mar. | April. |. May. | June. | July. | Aug. | Sept. | Oct. Noy. | Dec. | Year. 
Mean temperature (Fahrenheit) at 9 a.m ...| 40.30° | 40.70° | 42.80° | 49.80° | 56.10° | 61.50° | 64.80° | 63.60° | 58.80° | 51.00° | 4¢.30°) 41.00° | 51.40° 
Mean minimum temperature ..........0000+ 34.40 | 34.50 | 34.90 | 38.50 | 44.60 | 50.80 | 54.20 | 52.60 | 49.70 | 42.90 | 39.80 | 34.60 | 42.60 
Mean maximum temperature ...........05- 44.70 | 45.80 | 48.50 | 44.90 | 62.00 | 68.20 | 71.00 | 70.90 | 65.80 | 56.30 | 51.00 | 45.00 57.10 
Mean relative humidity ............. Sion 85.00 | 89.00 | 80.00 | 68.00 | 69.00 | 69.00 | 69.00 | 70.00 | 81.00 | 81.00 | 87.00 | 85.00 77.70 
Ai GHtE POULEIT AUN aries ole cc's: 'ee.e beaten Waiters CL: 1.85 1.83 | 1.61 2.18 1.17 2.07 1.84 2.46 3.14 3.36 2.53 | 27.26 
Mean number of rainy days........ Sis prater elas 14.80 | 10.50 | 11.50 8.70 | 10.80 | 11.30 | 14.80 | 15.00 | 11.50 | 18.80 | 17.20 | 14.70 | 158.30 












































From the above we see that the mean temperature for 
the whole year is 49.7° F., or, at 9 a.m., 61.4° F. The 
mean minimum temperature is 42.6° F. and the mean 
maximum 57.1° F. The mean relative humidity at 9 
A.M. is 77.7, the lowest recorded in England. The mean 
total rainfall is 27.26 inches, and the mean number of 
rainy days 158.3. Onan average it has been estimated 
that there are about two days a week during the winter 
season when patients cannot go out safely in consequence 


of its position, which combines the attractions as well as 
the wholesome influences of sea and heath. Asa whole, 
compared with England, it possesses a mild, bright, and 
fairly dry climate. The atmosphere is naturally pure, 
sunny, free from fog, redolent of the pine, of low relative 
humidity, and comparatively undisturbed by high or cold 
winds. The soil is dry and warm, permitting patients 
to sit with comparative safety in the open air; and it sup- 





ports an abundant and luxuriant growth of non-decidu- 


133 


Bowden Lithia 
Box. {Springs. 








ous trees and shrubs. The town area is very large in re- 
lation to the number of houses and inhabitants.” On the 
other hand, “like other places on the south coast, it is 
subject to frequent and uncertain spells of bad weather, 
in the form of wet, cold, or both combined, and to even 
more dangerous, because deceptive, visitations of high 
east winds in the early spring.” 

“The kinds of cases which have been benefited by a 
residence at Bournemouth are chiefly as follows: 

“(1) Cases of pulmonary tuberculosis which would do 
well at any good health resort. (2) Pulmonary tubercu- 
losis in the incipient stage. (8) Quiescent pulmonary 
tuberculosis when the patient can spend a number of 
hours continuously in the open air. (4) Patients in the 
last stage of phthisis often enjoy an extension of life 
here. In general, cases that can take advantage of out- 
door life do well, while those who are confined to the 
house do badly. (5) Chronic bronchitis without fever, 
and particularly recurrent bronchial catarrh with a mod- 
erate amount of expectoration, asthma, whether neurotic 
or catarrhal, the different parts of the town being tried 
if necessary. (6) Chronic Bright’s disease, particularly 
of inflammatory origin. (7) The subjects of chronic ma- 
laria. (8) Sufferers from chronic gastric catarrh with 
emaciation. (9) The victims of nervous over-work, 
particularly with insomnia, provided they do not settle 
too close to the sea. (10) Delicate persons generally, in- 
cluding more especially elderly and aged people, and 
feeble and rickety children.” 

“The cases, on the other hand, which do not do well 
or even badly, are: (1) Persons confined to the house, 
applying chiefly to consumptives. (2) The subjects of 
pulmonary tuberculosis in its active stage, especially 
when attended with much fever and profuse expectora- 
tion. (8) Those suffering with dry irritable catarrh of 
the larynx and bronchi. (4) Sufferers from neuralgia.” 

The accommodations are good and abundant and of 
every variety. From a personal visit the writer was im- 
pressed with the beauty of the place, its clear, bright 
atmosphere, the abundant sunshine, its luxuriant vegeta- 
tion, and the striking effect of the great number of pines 
everywhere. The sea view from the cliffs is most attrac- 
tive, and there are many pleasing excursions inland over 
the thickly wooded heath. For an outdoor life one can 
hardly imagine a more attractive place of residence. 

Edward O. Otis. 


BOWDEN LITHIA SPRINGS.—Douglas County, Geor- 

ia. 

2 Post-OFFIcE.—Lithia Springs. 
tel. 

Accrss.—Via Georgia Pacific Division of the Piedmont 
Air-Line. These springs are located in Douglas County, 
17 miles west of Atlanta, 300 miles distant from the 
Atlantic coast and at an altitude of 1,200 feet above 
the sea level. The surrounding country is of a some- 
what rugged, broken character, interspersed with forests 
of pine, oak, maple, and cypress and watered by streams 
skirted by haw and holly. The temperature rarely 
reaches 90° F. in summer or extends below 40° above 
zero in winter, while the nights are proverbially pleas- 
ant. The surroundings of the place are exceptionally 
charming, the Shoals, the Ruined Mill, Chapel Hill, and 
the Dome Rock, showing the mighty action of some 
great sea in prehistoric times, the Mill in the Glen, the Old 
Distillery, and the Sweetwater Creek being also among 
the numerous features of interest. The hotel is a first- 
class modern structure, capable of accommodating five 
hundred guests, and all of the appointments are of a 
superior order. While people have resorted to these 
springs for about sixty years, only recently have they 
become very extensively known. 

The use of the Bowden lithia waters is particularly 
recommended in kidney and bladder affections, calculi, 
gravel, cystitis, etc., and in gout and rheumatism. The 
external use of the water in bathing, for which there are 
excellent facilities, is said to be beneficial in skin affec- 
tions, chronic ulcers, glandular enlargements, etc. The 


Sweetwater Park Ho- 


134 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


waters are used commercially, and may be found in most 
of the principal cities of the East and South. 
Following are analyses of the waters: 


ONE UNITED STATES GALLON CONTAINS: 











arabe ets 
X pring. pring.) | Dorem 
Solids. Pratt, Pratt, 1890. 
1887. 1889, 
Grains. | Grains. | Grains. 
Carbonic acid as bicarbonates........ 9.85 WW sataeee 9.91 
Lithium bicarbonate ........secsseees 2.85 1.67 4.45 
POtAsSl UM DOM Cee ace are cial tale ate) ohare leel] Mmreroletsiee B28: Wi Mementte 
Potassium SUIPNHAte...c cece cesciacec ceil) sjeesice lumen 1.73 
Potassium HicarboNater: «..). 010+ icesve0e 3.86. || ocean arene 
Magnesium bromide ..........s..2.+. 1.69 15.23 1.47 
Magnesium bicarbonate.............. 10.82)" <cisctae stn terete 
Magnesium sulphate.............0005. 4,41. | <5 ee 
Magnesium iodide (iodine)........... Traces 73 Traces. 
Calcium bicarbonate. 6c. secveces 14,18. | ese 17.25 
Calcium sulphaters. a. ccs steeneceeeel seeense 20.21 12.15 
Calcium phosphate.......ssscevscceee 64 [) costen Oi) eee 
Strontiumisulphates. ss ascccsmee cies: 1.02 28 1.22 
KELTOUS. DICALDONATOS. cele aise 'eie oieleie'e see wel |, asurer 21 
Sodium sulphatelrncvneceauiccse cee dine 16.25" |) sestiee 8.08 
Sodium! Chloride. :: .cec veuvcies sa closes 133.71 124.49 121.78 
Sodium phosphates ove coe ec heros lameeserroiete Bo! Je ea 
Aluminum sulphate............see0- 1.33 2.61 
Silicic'acid (SOLE) i casemate clatinere tne 1.12 1.96 
13{0) i (at: ¥ 61 Fs Are RD TOLIROOODO CE OGURA moctOndc: all) arroonc 
Manganese........ Sinia aie Seercisiete exe slonton Traces: |) Waster 
PHOSPHOLIGC: ACTA: 5, cease ese were vcctiae ee cll mo Biatorensts anal ES 
Rubidium (spectroscopic analysis)....| Traces. | ...... 
HIIOTING Ger. cas ea citeoeiente dacorleo ane TYACES. wi) Sarees 
TOSS On AQNIMOMNE 35 isveyeveicte sities oe aleitoele oil ieeaie!enak geal | RSet 
Total irtcoie nov ceras says. Cepeetiig a ate 200.94 173.36 185.74 


James K. Crook. 


BOW LEG.—(Synonym: Genu Varum.) In the pop- 
ular sense bow leg includes all the deformities which 
cause separation of the knees when the ankles are in 
contact with each other; but, strictly speaking, bow leg 
implies an outward bending of the tibia and fibula, and 
genu varum a deformity in which the greatest distortion 
is at the knee, the opposite of genu valgum. In most 
instances simple bow leg is associated with slight out- 
ward deviation of the knee, and genu varum with a cer- 
tain degree of bending of the bones of the leg, so that the 
two terms are properly synonymous. 

Erro.ocy.—Bow leg is the most common of all dis- 
tortions, constituting about ten per cent. of the cases 
treated in orthopedic clinics. It is essentially a deform- 
ity of childhood. It may be congenital, and it is not un- 
common in vigorous infants who stand at an early age. 
But in most instances it is an effect of rachitis, usually 
of a mild type, and it develops therefore soon after the 
child begins to walk, although the tendency to deformity 
may have been acquired before this time. It may be ac- 
quired in later life, as an effect of occupation, or injury 
or disease, but this type is comparatively uncommon. 

Symptoms.—The essential symptom of bow legs is the 
deformity. In the genu varum type, the femur is ab- 
ducted and rotated outward while the tibia is rotated in- 
ward; and in simple bow leg also there may be a spiral 
inward twist of the tibia, so that in-toeing, “ pigeon toe,” 
may be one of the effects of the deformity. 

In the more extreme cases, in which there is laxity of 
the ligaments at the knee joint, the patient may suffer 
from discomfort and weakness, but this is unusual except 
during the stage of active rachitis. 

TREATMENT. —There is a strong tendency toward spon- 
taneous recovery, the “outgrowth” of deformity. But 
although the distortion may be entirely cured by the 
natural process, it is far more often simply modified and 
made less noticeable. This may be inferred from the 
fact that bow leg in the slighter degree is so common in 
later life. According to the writer’s observations, about 
one adult male in five has noticeable deformity of this 
character, a proportion that is apparently not exceeded 
among children. Thus, although bow leg may cause no 
physical discomfort, it is, from the esthetic standpoint, 
of sufficient importance to merit treatment in all cases. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 2OWween Elna 





Fig. 660.—Bow Legs of the Genu Varum 
Type. 








It may be easily 
overcome in infancy 
by systematic man- 
ual correction. It 
may be prevented in 
rachitic children by 
the avoidance of at- 
titudes that induce 
the deformity, espe- 
cially standing when 
the bones are weak. 
In the slight degree 
of deformity in walk- 
ing children, the 
tendency toward dis- 
tortion may be coun- 
teracted somewhat 
by making the sole 
of the shoe slightly 
thicker on the outer 
border. If the de- 
formity is more 
marked, or if it is in- 
creasing, or if the 
bones are abnormally 
flexible, a brace 
should be applied. 
This consists essen- 
tially of a light bar 
of steel, reaching 
from the internal 
condyle of the femur 
to the sole of the shoe. 
This is suitably pad- 
ded at the points of 
pressure and is pro- 
vided with a laced 
band which is passed 
around the limb at 
the point of greatest 
deformity, thus sup- 
porting it and exer- 
cising slight correct- 
ive force. If the 


distortion is most marked at the knee, the bar should be 
prolonged to the upper third of the thigh, and a second 
band should be applied about the knee. <A jointed brace 


is less effective than is the simple form 


that has been described. 


The function of a brace is principally 
support. The correction of the deform- 


leg may be uni- 
lateral, or it may 
be combined 
with knock- 
knee. 

Anterior Bow 
Leg. — Anterior 
bow leg is a de- 
formityin which 
the tibia is bow- 
ed with the con- 
vexity forward. 
This distortionis 
usually symp- 
tomatic of pro- 
nounced rachit- 
is; it is often 
combined with 
knock-knee, or 
with general dis- 
tortions of the 
limbs, “cork- 
screw” deform- 
ity. Theantero- 
posterior diam- 
eter of the tibia 
is increased and 
its crest is prom- 
inent and _ pro- 
jects sharply be- 
neath the skin. 
As the weight is 
thrown upon the 
anterior part of 
the foot, the heel 
projects and the 
gait is awkward 
and shufiling. 
The distortion is 
not usually 
amenable to 
treatment by 
braces, and in 
the more ex- 
treme cases a 
cuneiform oste- 
otomy may be 


Box. (Springs, 





eat 








Fig. 661.—Bow Legs in Which the Principal Dis- 
tortion is Below the Knees. 


required to restore the normal contour. 


Royal Whitman. 


BOX.—The leafy twigs of Buaus sem- 


ity is hastened by daily systematic 
manual straightening, and cure is accom- 
plished by the natural transformation 
of the internal structure of the deformed 
part which begins when the static con- 
ditions are changed. In older subjects, 
when the bones are more unyielding, 
operative treatment is indicated. 

Osteoclasis or osteotomy may be em- 
ployed. As a rule it is sufficient to 
straighten the tibia at the point of great- 
est deformity, but in exceptional cases 
both the tibia and femur may require 
treatment. By far the most satisfactory 
method is partial osteotomy, combined 
with forcible correction. A small sharp 
osteotome is inserted directly over the 
point of greatest deformity on the con- 
cave side of the tibia, and when the 
cortex on its inner surface has been di- 
vided the fracture is completed by man- 
ual force. The fibula may be bent or 
broken as it is more or less resistant. In 
all cases the distortion should be slightly 
overcorrected, and the limb fixed in this 
position until union is complete. 

Other Varieties of Deformity.—Bow 








Fic. 662.—Braces for Bow Legs. 
(Bradford and Lovett.) 


pervirens L. (fam. Buaacee). The box is 
a slow-growing evergreen shrub, rather 
variable in habit, but usually compact, 
with a very short trunk, and numerous 
leafy branches. The leaves are opposite 
and crowded, 2 or 8 cm. long, elliptical or 
oval. They are dark green and shining 
above, pale beneath, thick and leathery. 
The bark of the younger twigs is green, 
that of the old trunks gray and tubercu- 
lated. 

Box is a native of the southern part of 
Europe and the East. It is frequently 
cultivated for ornament there, and has 
been a favorite bordering plant for flower 
gardens in the United States, where it 
grows fairly, but very slowly. It sel- 
dom blossoms in New England. All 
parts of the plant are bitter; the leaves 
and twigs are the most available for 
medicinal use. By far the most impor- 

~tant product of this valuable shrub is 
its wood, which for many purposes is 
unequalled. 

The bitterness of box is due to the 
alkaloid buaine, discovered by Fauré in 
1830. It is a white, amorphous powder 


135 


Bradford Mineral 
Brain. (Springs. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of a persistent bitter taste. It is very insoluble in water 
(scan), but dissolves rather freely in alcohol, and more 
freely in chloroform. A second alkaloid, paraburin, was 
found by Pavia to accompany the buxine in box; and 
it is still probable that some other principle may be 
found to explain the poisonous qualities it has been 
occasionally observed to have. 

Usrs.—Box has had some reputation as a febrifuge and 
tonic; in large doses it is purgative and emetic. It is 
suspected of being sometimes used to replace hops in 
beer; but it is little employed in medicine to-day. The 
alkaloid buaine (bebeerine), either from box or bibiru, 
has been offered as a substitute for quinine in intermit- 
tents, but is much inferior; in the same large doses it 
deranges the stomach and digestion; in small doses it, 
showever, is an excellent tonic. Buaine has been found 
in several plants of entirely different orders, and is prob- 
ably, like berberine, a rather extensively distributed 
alkaloid. The bebeerine of bibiru (Nectandra Rhodiet 
Schomb.), the pelosine of pareira (Chondodendron tomen- 
tosum R. et P.), as well as of the false pareira, have 
been shown by Fliickiger and others to be identical with 
this alkaloid, although it is not quite certain that the 
physiological effects of buxine from all these sources are 
the same. The sulphate and hydrochlorate of buxine 
are in the market. Dose, as a tonic, from 5 to 10 cgm. 
(0.05-0.10 = gr. i. ad ij.); as a febrifuge, eight or ten 
times as much (0.5-1 = gr. viij. ad xvi.). 

W. P. Bolles. 


BRADFORD MINERAL SPRINGS.—Merrimac County, 
Ney gale 

Post-OFFICE.—East Washington. Hotel. 

Accgss.—From Boston via the Lowell Railroad to East 
Washington; thence one mile to hotel at springs. Stages 
await trains during the season from May 15th to October 
15th. 

This spring became known to the white settlers in 1770, 
and since early in the present century its waters have 


supercentral f. 
precentral f. 


superfrontal f. 
medifrontal f. 


subfrontal f. 
subfrontal g. 


presylvian f. 


3 
preoperculum 


9 


orbital f. 


presylvian f. 
olfactory bulb 


1 
meditemporal f. 


postoblongata 


Fig. 663.—Left Side of the Brain of a Male Child at Birth; 478. 1. 








chloride, sodium carbonate, calcium carbonate, magne- 
sium carbonate, calcium phosphate, iron oxide, aluminum 
oxide, organic matter, sulphur, carbonic acid gas. 

We are unable from this analysis to assign the water 
to its proper class, although it is probably a sulphureted 
chalybeate. The spring yields twenty-one hundred gal- 
lons hourly. The water is clear and sparkling, and emits 
an odor of sulphureted hydrogen gas. It has been suc- 
cessfully used by the residents of the neighborhood in the 
treatment of certain cutaneous diseases, especially eczema. 
It is said to be a very efficient diuretic and tonic, and 
seems to be well adapted for rheumatism and diseases of 
the alimentary tract, and for conditions in which the 
urine is scanty and high-colored. Asa douche in nasal 
catarrh and in catarrhal states of the vagina and uterus 
it has been found useful. There are bathing facilities 
for guests who wish to take hot or cold sulphur baths. 
The surroundings of the place are very attractive, and 
ample amusements and diversion are afforded the visitor 
in the way of bowling, shooting, fishing, driving, etc. 

James K. Crook. 


BRAIN. (AnatomicaL.)—I. Inrropucrion. § 1. 
Scope of this Article.—The development of the brain, its 
growth, histology, functions, blood-vessels and surgery, 
and the methods of its removal, etc., are presented under 
appropriate titles. In this article the organ will be con- 
sidered mainly from the standpoint of normal morphol- 
ogy, with occasional elucidations from embryology, com- 
parative anatomy, and teratology. 

I regret that so many points remain undetermined and 
so many problems unsolved. These relate especially to 


the meninges and the olfactory region of the brain. 

§ 2. Order of Treatment.—\l. Introduction, §§ 1-18. 

II. General Constitution of the Brain, Segments, etc., 
§§ 14-69. 

Ill. The Metencephal (postoblongata), §§ 70-90. 

IV. The Epencephal (preoblongata, cerebellum, and 
pons), §§ 91-128. 


postcentral f. 
parietal f. 


paroccipital isthmus 
occipital f. 
paroccipital f. 


4 
exoccipital f. 


cerebellum 


myel 


The brain was medisected when fresh, and the hemicerebrum spread 


and flattened considerably while hardening. The specimen is really the right half, but for readier comparison with other specimens and 
figures a diagram was made (by Mrs. Gage) reversed so as to represent the left half. This figure is based upon a photograph of the diagram. 


The cerebellum is correct in outline, but no details are shown. 


Other aspects of the same specimen are shown in Figs. 702, 756, 774, 775. 


Just ventrad of the narrow isthmus, between the overlapping branches of the subfrontal and precentral fissures, is a white x; 1, 2, 3, 4, 5, 6, 
undetermined fissures; 7, an isthmus between 6 and the exoccipital which is nearly concealed by the adjoining gyres. See§4. - 


been used for medicinal purposes. An analysis by Dr. 
Jackson, of Boston, subsequently confirmed by Dr. Rich- 
ards, of Poughkeepsie, New York, showed the presence 
of the following ingredients: Sodium chloride, potassium 


136 


V. The Mesencephal (gemina and crura), §§ 129-141. 

VI. The Diencephal (thalami), §§ 142-157. 

VII. The Prosencephal, its cavities, parietes, com- 
missures, fissures, and gyres, §§ 158-356. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bradford Mineral 
Brain. (Springs, 


_—— ==> LL a aaa naan nnn nn nan en eee 


VIII. The Rhinencephal (olfactory bulbs, etc.), §§ 
357-372. 

IX. The Meninges (dura, arachnoid, pia), §§ 373-409. 

X. Bibliography. 

§ 3. Method.—The text consists largely of commen- 
taries upon the points illustrated by the figures. What 
seem to me the more important facts and fundamental 
ideas of encephalic morphology are embodied in concise 
propositions. Unless otherwise stated these propositions 
apply to the human brain, and may not always hold good 
for those of other vertebrates, or even other members of 
the mammalian class.* 

§ 4. Mig. 663 illustrates: A. The general aspect of a 
brain from the side; its continuity with the myel (spinal 
cord) through the oblongata; the existence of a smaller 
mass (the cerebellum) and a larger (the cerebrum); the 
overlapping of the former by the latter more extensive 
at birth, and in earlier than adult brains; the existence of 
other parts, the olfactory bulb, the pons, and the oliva 
(the elliptical elevation of the postoblongata upon which 
the line from that word ends); the fissures of the cere- 

‘brum; the subdivisions of the cerebellum (foliums) are 
not indicated. 

(The remaining points illustrated refer to the cerebral 
fissures, and may be considered more advantageously in 
connection with Part VII.) 

B. The simple, almost schematic, relations of the 
fissures demarcating the several operculums (compare 
Fig. 784); the preoperculum only is named. The sub- 
operculum is the region ventrad of the subsylvian fissure. 
The operculum is between the presylvian and Sylvian 
fissures; and the postoperculum is the overlapping margin 
of the temporal lobe, the region on which is the word 
Sylvian and ventrad of it. 

C. Theincomplete covering of the insula (see Fig. 788) 

D. The presence of a distinct medifrontal fissure, sub- 
dividing the medifrontal gyre. 

E. The independence of the postcentral, parietal, and 
paroccipital fissures. 

F. The presence of the exoccipital (the “ape fissure ” 
of some writers). 

G. The frequency of the zygal or H-shaped form of 
fissure—e.g., paroccipital, parietal, postcentral, sub- 
frontal, orbital, and fissure 2; see § 307. 

§ 5. The Facts.—Most of the statements are parts of 
common anatomical knowledge, and special references 
are seldom given in this connection; therefore the fol- 
lowing extract from the preface to Huxley’s “ Anatomy 
of Vertebrated Animals” may be appropriately added: 

“The reader, while he is justly entitled to hold me re- 
sponsible for any errors he may detect, will do well to 
give meno credit for what may seem original, unless his 
knowledge is sufficient to render him a competent judge 
on that head.” 

§ 6. The Ideas.—Unfortunately, the facts of anatomy 
are susceptible of various interpretations according to 
the relative weight assigned to them. In particular 
there are divergent views respecting the segmental con- 
stitution of the entire brain and the normal pattern of 
the cerebral fissures. 

§ 7. The Illustrations.—Of the one hundred and forty- 
five figures, one hundred represent preparations made 
by me for the museum of Cornell University; these 

reparations are designated by their catalogue numbers, 

he drawings have been executed, from the specimens 
and from photographs, by Prof. E. C. Cleaves (C.), 
Mrs. S. H. Gage (G. or 8. P. G.), and Mrs. Wilder. The 
twenty-five borrowed figures are credited to their 
sources. The remaining illustrations are original dia- 
grams or drawings, or direct reproductions of photo- 
graphs. 

§ 8. Terminology.—The general subject will be dis- 
cussed in the article Terminology, Anatomical, in another 
volume; meantime those interested are referred to the 
article under that title in Vol. VIII., of the first edi- 





* The uses of certain animal brains as aids in the study of the hu- 
man organ are set forth in the article, Brain: Methods, etc., and in 
my paper, 1896, g. 


tion, pp. 515-587; to “ Anatomical Technology ” (Wilder 
and Gage, 1882); to the Reports, during the last ten years, 
of Committees of the American Association for the Ad- 
vancement of Science, the American Neurological Asso- 
ciation, the Association of American Anatomists, and the 
Anatomische Gesellschaft; to the article, “Anatomical 
Nomenclature,” by F. H. Gerrish, in “ Progressive Medi- 
cine,” for 1899, pp. 327-346; to G. M. Gould’s “Sugges- 
tions to Medical Writers,” 1900, chap. iv.; and to my 


_address, “Some Misapprehensions as to the Simplified 


Nomenclature,” Assn. Amer. Anat., Proceedings, 1898, 
pp. 15-389, and Sezence, April 21st, 1899. The principal 
publications prior to 1896 are included in the bibliography 
of my “ Neural Terms, International and National,” Jour. 
Comp. Neurology, December, 1896, vol. vi. Here, there- 
fore, it is necessary only to comment briefly upon the 
two groups of terms employed in this article. 

§ 9. Terms of Position and Direction (Toponyms).—In 
place of the more or less ambiguous terms wpper, lower, 
anterior, posterior, inner, outer, etc., will be employed 
terms referring to the regions of the vertebrate body in 
whatever attitude it may be—viz., dorsal, ventral, cepha- 
lic, caudal, mesal, lateral, ental, ectal, etc., constituting 
an intrinsic toponymy. The adverbial forms are dorsad, 
mesad, ectad, etc. 

§ 10. Terms of Designation (Organonyms).—Each part 
is designated uniformly by one and the same name. 
Where two or more names are already in use, the simpler 
or shorter has been chosen. In some cases simple names 
have been formed by the omission of unessential words 
or by the combination of two, or by the coinage of words 
from the Latin or Greek. Where the English form (paro- 
nym) differs from the elassical the former is often pre- 
ferred. For examples, “ pneumogastric ” becomes vagus ,; 
“pons Varolii,” pons; “corpus callosum,” callosum ; 
“commissura anterior,” precommissure; “aqueeductus 
Sylvii” and “iter a tertio ad quartum ventriculum” 
give place to mesocelia (the cavity of the mesencephal), 
Eng. mesocele.* 

§ 11. Mig. 664 illustrates: A. The general form and 
appearance of the cerebrum of an educated and moral 
distinguished man, rapid in thought and movement. 

B. The general symmetry as to form and especially as 
to certain fissures, central, occipital, paroccipital, in- 
flected, associated with some decidedly asymmetric con- 
ditions—e.g., the relations of the postcentrals to the para- 
centrals. 

C. The bifurcation of the dorsal end of both central 
fissures and the bifurcation of the caudal branch on each 
side. 

D. The coexistence of the more common relation of 
the paracentral to the postcentral on the right with the 
inclusion, on the left, of both branches of the postcentral 
within the curve of the paracentral; see § 285 and Fig. 
769. 

E. The great depth of both occipital fissures; this is 
their real depth, and is not due to a superficial extension. 

F. The distinctness and simplicity of the paroccipital 
fissures, and the existence of the more usual combination 
—i.é., continuity with the parietal on the left and inde- 
pendence on the right: see Fig. 778, 

G. Nevertheless, the difficulty of deciding how this 
case should be entered upon a Table. On the right the 
isthmus between the parietal and the paroccipital is per- 
fectly distinct and visible in any direct view; yet it is 
below the level of the adjacent gyres and might perhaps 
be regarded as a vadum. On the left the vadum (at 
the point marked 13) is much more depressed, and hidden 
from easy view by the overlapping gyre just cephalad 
Ollie 

H. The unusual complexity of the fissures represent- 
ing the parietal and the postcentral. On each side there 
are recognizable three irregular fissures caudad of the 
central; the most dorsal of each group is triradiate and 





* Orthographic discrepancies between this article and my recent 
papers (e.g., in the retention of certain diphthongs and of the ultima 
of anatomical, morphological, etc.) are due to the necessity of con- 
forming to the plan of the entire work. 


137 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





perfectly distinct, and is marked postcentral ; on the 
right one of the rays (4) cuts the margin of the hemi- 
cerebrum deeply. The most ventral (2 and 9) joins the 







superfrontal (?) 
inflected (?) 
8 


central 


10 
postcentral 
paracentral 
parietal 


15 


paroccipital 
occipital 


Fic. 664.—Dorsum of the Cerebrum of James Edward Oliver, Professor of Mathematics in Cornell 





Il. GENERAL CONSTITUTION OF THE Brarn.—§ 14. 
Definition.—The brain (Gr., &yxépadoc; Lat., cerebrum ; 
late Lat., encephaton ; It., cervello, cerebro ; Sp., cérebro ; 
Fr., cerveau ; Ger., Gehirn; 
Eng., encephalon, encephal) is 
the enlarged, segmented, ce- 
phalic (“anterior”) portion of 
the neuron or cerebro-spinal 
axis. 

§ 15. The neuron* is that 
one of the great mesal (me- 
dian) organs which is nearest 
the dorsal surface of the body, 
and farthest from the heart 
(Fig. 665). The other two are 
the enteron (alimentary canal), 
and the axon (skeletal or body 
axis; notochord in early em- 
bryos, but in later stages and 
adults the series of centrums or 
bodies of the vertebree), Fig. 
670, odontoid process, etc. The 
enteron is in the ventral (he- 
mal) cavity; the neuron oc- 
cupies the dorsal (neural or 
cerebro-spinal) cavity; the ax- 
on forms a partition between 
the two. 

§ 16. Fug. 665 illustrates: A. 
The existence, in man as in 
other vertebrates, of two par- 
allel body cavities, a dorsal or 
neural, and a ventral or hemal, 
separated by the axon, the 
skeletal axis. 

B. The presence, in the ven- 


postcentral 


parietal 
paracentral 








occipital 


University ; aged sixty-six; 3,334. %.57. When removed the brain was firm in texture and 
weighed (with the piarachnoid but without the dura) 1,416 gm. (49.94 ounces), approximately 50 
ounces. It was transected at the mesencephal; the cerebrum was medisected and each half 
hardened while resting in a mixture of alcohol, formal, zine chloride and water, of specific gravity 
equal to that of the brain; later it was transferred to increasing strengths of alcohol. The cere- 
brum is believed to retain very nearly its natural form. The diacele (“third ventricle”) was 
unusually wide and the medicommissure wholly absent (see §152). There were no obvious signs 
of diseased conditions beyond a slight opacity of the piarachnoid about the dorsal ends of both 
central fissures. Professor Oliver was a man of the purest character and a philosophic thinker, 
in not only the higher mathematics, but other sciences and ethics. He was left-handed and 
absent-minded, but rapid in thought and action. For an account of his life and a list of his 
writings, see the memoir by G. W. Hill, read before the National Academy of Sciences, April, 1896; 
also Science, April, 1895, and the Ithaca Jowrnal, March 28th, 1895. 1 (right) and 8 (left), fissures 
parallel with the centrals and representing, perhaps, both precentrals and supercentrals; they 
unite with the longitudinal fissures (superfrontals 7); but a vadum exists on each side; 2 (right) 
and 9 (left), the most ventral of the postcentral groups; 3 and 10, the middle of each group (sub- 
central ?); 4, a ray of the postcentral cutting the margin of the precuneus; 5, the right paroc- 
cipital isthmus; 6, an incision; 7, a distinct diagonal fissure; 8, see 1; 9, see 2; 10, see 3; 12, a 
fissure cutting the margin of the precuneus deeply but connected with neither the paracentral 
nor the postcentral; 18, location of the paroccipital vadum. Inadvertently no guide lines indicate 
the parietal fissures, but they may be recognized from their relations to the paroccipitals. See § 11. 


tral cavity, of the heart, a hol- 
low muscular organ, rhythmi- 
cally contractile during life. 

C. The presence, in the ven- 
tral cavity, of a muscular 
tube, the enteron (alimentary 
canal). 

D. The presence, in the dor- 
sal cavity, of a subcylindrical 
rod, the neuron (cerebro-spinal 
axis), itself containing a cav- 
ity, the neurocele (“central 
canal” and “ ventricles ”). 

§ 17. Excepting at its first 
formation (when it is a rod 
with a dorsal furrow) the en- 
tire neuron is a tube, a sub- 


Sylvian fissure. The middle one (3 and 10) is continuous 
with the parietal on the right, but on the left a vadum 
may be recognized. 

I. The unusual location, depth, and symmetry of the 
inflected (7?) fissures. 

§ 12. References.—In the Bibliography at the close of 
this article the names of authors and editors are arranged 
alphabetically. The date after the name is the year of 
publication, and the following letter, if there is one, 
designates a particular paper or book out of two or more 
published within a single year. My own name is abbre- 
viated in the text to W. My papers on the structure and 
nomenclature of the brain prior to 1897 are enumerated 
in the Bibliography of “ Neural Terms,” 1896, 2, which is 
probably accessible to most anatomists either as a reprint 
or in the Journal of Comparative Neurology. 

§ 13. Acknowledgments.—For assistance in the making 
of preparations or photographs, for suggestions as to 
methods, for helpful criticism of the former edition, or 
for the loan of figures, Iam indebted to the following 
former students, of whom several are present colleagues: 
P. A. Fish, 8. H. Gage, Mrs. Gage, G. S. Hopkins, O. 
D. Humphrey, B. F. Kingsbury, W. C. Krauss, B. D. 
Myers, and B. B. Stroud. 


138 





cylindrical mass enclosing a 
cavity. This cavity is the newrocele, and the enclosing 
material constitutes the celian parietes. The existence of 
the neurocele may be demonstrated by the transection 





* Certain points relating to this word will be discussed in the article 
Terminology, Anatomical. The following brief statement is the ab- 
stract of my paper, 1899, d, as printed in Science, March 16th, 1900, 
420: “Is neuron available as a designation of the central nervous 
system? Newron (from ro vevpov) was proposed by me in this sense 
in 1884 (V. Y. Med. Journ., August 2d, p. 114), and employed in the 
same journal, March 28th, 1885, p. 356; in addresses before the Amer. 
Neurol. Assn. (Jowrn. Nerv. and Ment. Dis., July, 1885) ; Amer. 
Assn. Ady. Sci. Proceedings, 1885, and in the second edition of 
* Anatomical Technology,’ 1886. It has been employed by McClure, 
Minot, Waters, and others. The reasons for its abandonment in 1889 
for neuravis, as stated in the Proceedings of the Assn. Amer. Anat- 
omists for 1895, p. 44, and REF. HANDBOOK OF MED. SCI., ix., 100, 
now seem to me inadequate. Vewron is the basis of newral (as ap- 
plied to aspect, folds, furrow, and canal) and of newrenteric and 
other compounds. and it is the natural correlative of enteron (entire 
alimentary canal) and of axon (notochord or primitive skeletal axis). 
Not until 1891 did Waldeyer propose newron for the nerve cell and its 
processes; not until 1893 did Shafer apply it to the axis-cylinder 
process. As with tarsus and ciliwm, the context would commonly 
avert confusion between the macroscopic and microscopic significa- 
tions of the word ina given case. The compounds macroneuron and 
microneuron might be employed if necessary, or (as suggested by 
Barker, 1899, p. 40), the histologic element might be designated by 
neurdne, as if from vevpsv, The question is now further complicated 
by Van Gehuchten’s adoption of Neurdve as the title of a new jour- 
nal of neurology.” 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





of any part of the neuron in any other vertebrate, and 
in an immature human being; but with the adult, in 
certain regions, the olfactory bulbs (Fig. 672) and most 
of the myel (spinal cord, Fig. 670), the cavity is more 
or less completely obliterated. 

§ 18. Location.—The brain is contained mainly within 
the cranium, although part of the postoblongata or even, 


neuraxis 
esophagus | lieurocele 
2 


axon lung 





¥Fia. 665.—Caudal Aspect of a Thoracic Transection of a Fetus About 
3.9 em. from Nates to Bregma, and Estimated at Ten Weeks ; 2,189. 
x 4. 1, Thorax, part of the ventral or hemal cavity; 2, spinal 
canal, part of the dorsal or neural cavity ; 3, scapula. 
Defects.—The fetus was badly shrunken by immersion in too 
strong alcohol, and the parts here shown dried somewhat while 
photographing. Certain details as to the pleura, spinal nerves, and 
arachnoid are omitted, the object of the figure being mainly dia- 
grammatic. See § 16. 


as appears in Fig. 670, a little of the cerebellum, may ex- 
tend beyond the limits of the foramen magnum. Itis 
remarkably sheltered and clothed by the cranial bones 
and by the soft parts ectad and entad of them, the scalp 
and the meninges (dura, arachnoid, and pia) (Figs. 795, 
796, 798). 

§ 19. The Brain a Modified Tube.—In its simplest ex- 
pression the brain, like the remainder of the neuron, may 
be represented as a tube of nervous tissue lined by a non- 
vascular, ciliated* epithelium, the endyma(“ependyma”), 
and covered by a vascular membrane, the pia (“pia 
mater”). | 

20. In what may be regarded as an approximately 
typical condition, the parietes consist of three layers or 
strata, viz., an ental, mainly cellular, adjoining the 
endyma, the entocinerea (“central tubular gray”); an 
ectal, mainly cellular, adjoining the pia, the ectocinerea 
(cortex); an intermediate, fibrous, between the other two, 
the alba or medulla; see Fig. 666. In some regions, 
particularly the epicelian and paracelian roofs, the ento- 
‘cinerea is dislocated or crowded as it were from its nor- 
mal position next the endyma by albal or fibrous intru- 
sions, commissures, especially the callosum, Parts of 
the ectocinerea (e.g., claustrum and lenticula, Fig. 781) 
are also separated more or less completely from the rest. 

§ 21. Unequal Thickness of the Parietes.—In the earliest 





* There is considerable divergence of statement among authors as 
to the presence of cilia, especially in adults. P. A. Fish has described 
(1890, 256) the ciliated cells in the encephalic cavities of the cat, both 
oldand young. Heurges the importance of thorough preservation by 
the injection of the preservative into the cavities ; states that a magnifi- 
cation of not less than six hundred diameters must be employed, and 
intimates that the failure to recognize them in man may be due to de- 
fective methods of preparation or examination. See also the recent 

aper of Studnitka: ‘* Ueber das Ependym des Centralnervensystems 
Wirbeltiere.” Siteungsber. K. Bohm. Ges. Wiss., Math. Nat. Cl., 
1899, xlv., p. 7. 


stages the celian parietes are of approximately equal 
thickness throughout, although certain portions of the 
roof, ¢.g., of the metacele, are never so thick as portions 
of the floor. With some low or generalized vertebrates 
—e.g., Scymnus, a shark (T. J. Parker); Necturus, a sala- 
mander (W., 1884, a, Fig. 16); Ceratodus, a Dipnoan (W., 
1887, a)—this condition prevails throughout life, at least 
with certain regions. 

With man, until the fetus attains a length of at least 6 
cm., and an estimated age of twelve weeks (see Fig. 667), 
the cerebral parietes are almost uniformly thin; when 
24 cm. long, and about twenty weeks old, certain regions 
are considerably thicker than others, as seen in Fig. 716; 
in the adult brain of man, and indeed of mammals gen- 
erally (Figs. 686 and 735), the difference between even 
closely adjacent portions of the parietes is simply enor- 
mous; compare, e.g., the mesencephalic floor (crura) with 
the caudal part of its roof, valvula (Figs. 670 and 687); 
the two divisions of the epicelian roof, cerebellum and 
lingula (Figs. 670, 687, 702); the diacelian sides, thalami, 
with the floor, tuber or terma (Figs. 670 and 687); the thin 
or membranous parts (fimbria, tenia, pala, etc.) adjoin- 
ing the rima with the adjoining hippocamp and caudatum 
(Figs. 716 and 732). 

§ 22. Telas.—Where the proper nervous constituent of 
the parietes is wanting the endyma and the pia are in 
contact and constitute a membranous area or zone, a tela. 
Among vertebrates the most constant and extensive of 
these is the roof of the metacele, the caudal portion of 
the “fourth ventricle,” here called metatela (Figs. 675, 
680, 686). 

A similar portion of the roof of the “third ventricle ” 
is the diatela (Figs. 675, 681, 682); its cephalic continua- 
tion as the roof of the aula is the autatela; finally, in 
man and apes, a part of the floor of the paracele (“lat- 
eral ventricle”) is a membranous zone, the paratela (Figs. 
738, 735). 

§ 28. Hig. 667 illustrates: A.—The large size of the 
paracele, the thinness of the parietes and their nearly 
uniform thickness. 

B. The extent of the paraplexus, and its fulness as 
compared with that in the adult. Possibly when fresh it 


CAVITY, 


CELE, OR 


VENTRICLE 





Fic. 666.—Schematiec Transection of the Brain, representing the 
topographical relations of the two kinds of nervous substance, the 
white, which is fibrous and conducting, and the gray, which is cel- 
lular as well as fibrous, and dynamic in function. The entocinerea 
is primary, and alone exists in the myel; the ectocinerea is second- 
ary; it constitutes the mesencephalic cappa, and the cortex of the 
cerebrum and cerebellum. ‘The cilia are omitted. 


more nearly filled the paracele, but was contracted by 
the alcohol (compare Figs. 716 and 735). 

C. The similarity of the precornu and medicornu. 

D. The absence of distinct indication of the postcornu, 
indicating that this may be formed eventually not by a 
special protrusion caudad, but by the thickening of the 


139 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





parietes in such a way as to leave an occipital space of 
variable size. 

E. The commencing formation of the hippocamp as a 
corrugation of the mesal wall of the medicornu. 


paraplexus, 


Sylvian fossa 





2 hippocamp 


Fig. 667.—The Left Hemicerebrum of a Fetus (Measuring 6 cm. from 
Bregma to Heel, and Estimated at Twelve Weeks), Opened from the 
Lateral Aspect; 340. x 3. 1, A fissure; 2, tip of temporal lobe. 


F. The non-extension of the paraplexus and thus of 
the rima to the extremity of the medicornu. 

G. The presence of at least one distinct transitory fis- 
sure (1). 

H. The evidences of some mesal fissures as slight 
corrugations just cephalad of the plexus. 

I. The formation of the Sylvian fossa, with as yet no 
trace of the insula. 

§ 24. Pleruses.—As already stated the endyma is non- 
vascular; but provision is made for the practical intro- 
duction of blood-vessels into the encephalic cavities by 













= (Orn ix 


Y_. pia 


thalamus 
endyma 


portiplexus 






-porta 


r__thalamus 


-— porta 
~ portiplexus 


D 


Fic. 668.—Schematic Representations of Four Stages in the Formation 
of the Portiplexus, as a Type of Plexuses. At A. the porta is seen to 
have the following boundaries: cephalad, the fornix; caudad, the 
thalamus: ventrad, the junction of the two; dorsad, however, there 
is merely the endyma passing from fornix to thalamus, and the 
ectal pial fold, one of its laminz being fornical and the other thal- 
amic. The first step in the formation of any entocelian plexus is 
represented at B, where the pial fold (or vessels therefrom) pushes 
the endyma before it into the cavity. At C the process is carried a 
step farther, and at D the parts are represented as in the adult, with 
the plexus apparently inside the porta, and yet really excluded from 
the cavity by the unbroken covering of endyma. 


the formation of plexuses at various points. A plexus 
igs an apparent intrusion of a fold of pia, or of vessels 
from the pia, into one of the cavities; but the endyma is 
carried before the intruded portion, and covers it com- 
pletely so that, strictly speaking, neither the pia nor its 
vessels are in thecavity. The conditions are comparable 


140 


with the relations of the abdominal viscera to the peri- 
toneum. If one takes a closed sack of flexible material 
and pushes the fist against one side it may be carried so 
far as apparently to be within the sack; yet all the 
while it is covered by the material of the sack and strictly 
excluded from the true cavity. Simple examples of the 
plexus formation are presented by the epiplexus (Fig. 
695), and portiplexus (Fig. 668). The metaplexus is seen 
in Fig. 686; the diaplexus in Figs. 686 and 782; and the 
paraplexus in Figs. 718, 726, and 732. The dispropor- — 
tionate size of the paraplexus at early stages (Figs. 667 
and 747) indicates that it is intimately related to the 
growth of the cerebrum. The structure and diseases of 
the paraplexuses are discussed by Findlay, 1889. 

§ 25. Ripa.—Where the endyma leaves the nervous 
parietes either at the margin of a tela or for reflexion 
upon a plexus, there is a sort of shore line which I have 
calledripa. The name was originally given to the ragged 
edge left when a tela or plexus is torn from the nervous 
parietes (see Figs. 692, 699). 

§ 26. Fig. 669 tllustrates: A. The effect of the cranial 
flexure (§ 36), the two segments, mesencephal and epen- 
cephal, with their 
cavities, appear- 
ing upon the same 
section surface, 

B. The _ triplic- 
ity of the epicele, 
consisting as it 
does of a mesal 
portion and two 
lateral extensions, 
the lateral recesses 
(§ 60). In Fig. 695 
the lower part of 
the figure is still 
more enlarged, 
and commented 







mesocele ~_ 


epicele < 
lateral recess . * 
cerebellum __ 


preoblongata -—___\__. 


upon. 
9 ayjiy, FIG. 669.—Transection of the Brain of an Em. 
§ 27. Lhe Brain bryo Rabbit, Sixteen Days Old. X 9. (From 
as @ House.—  Kialiker.) 


Within certain 

limits the brain may be likened to an edifice, and the 
comparison has been carried out in some detail on p. 
413 of Wilder and Gage, 1882. Architectural terms, 
floor, roof, sides, may be employed appropriately to in- 
dicate the general locations of the parts relatively to each 
other and to the common cavity, and I have proposed 
two specific terms, aula (a hall) and porta (a doorway), 
for the designation of certain portions of the cavity. 

§ 28. Irregularities of Contour.—In the brain straight 
lines and plane surfaces are infrequent, and the spiral 
form is not uncommon; hence dissections are often more 
instructive than mechanical sections, and normalization, 
actual or ideal (§ 38), is sometimes desirable. 

§ 29. Commissures, ete.—Of the parts connecting lateral 
masses across the meson, whether cellular or fibrous, 
whether direct (true commissures) or oblique (decussa- 
tions), some are merely specializations of pre-existing 
floors or roofs; ¢ég., precommissure, postcommissure, 
supracommissure, pons; others, the callosum and com- 
missure of the fornix, are marked extensions of pre- 
existing lines or areas of conjunction (Fig. 741). The 
medicommissure, finally, as well remarked by Spitzka, 
is rather a fusion of contiguous surfaces than a com- 
missure in the usual sense of the word. 

§ 380. Atrophic Parts.—Certain parts (terma, hemi- 
septum, valvula, tuber) which are very thin and ap- 
parently functionless, nevertheless serve to contain the 
neurolymph (cerebrospinal liquid), and may have a 
morphological significance as representing parts more 
developed in other forms. ‘Two other parts, the epiphy- 
sis (“pineal body”) and the hypophysis (“pituitary 
body ”) are rather thick than thin, but are not known to 
have definite functions; their peculiarities will be con- 
sidered in connection with the diencephal (§§ 146, 154), 
of which they are appendages. 

§ 31. Riparian Parts.—Along the ripas, or lines of re- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ae ert 


Brain. 


a 


flection of the endyma upon telas or plexuses, the sub- | metacele (Fi 2); i i 

C I 2 oe 3 g. 702); the fimbria along the hippocampal 
stantial nervous parietes are commonly reduced in thick- margin of the rima, the tenia along ie aE At iepint 
ness, so as to resemble the terma, valvula, and tuber in | and the pala at its extremity (Figs. 730, 732, and 735). 
some degree. Such are the obex at the end of the § 32. The riparian condition may not be incompatible 


on ids OR EE tas 
coronal suture: ere Dae 


ei 






lambdoidal suture 






myelocele 





{ 
Teceae Nae ae PNIO Xana - 


Fig. 670.—Mesal Aspect of the Right Half of an Adult Head, the brain hardened in place by continuous alinjection; 811. X .7. (This was the 
head of William Menken, who was hanged for murder in July, 1885; the specimen was shown at the American Neurological Association in 
1886, and at the American Laryngological Association in 1888 [see article by Dr. Harrison Allen, in New York Medical Journal, February 
2, 1889] ; the mode of preparation is described in the article Brain : Methods, etc.). 1, The star upon the mouth of a vein opening into the 
longitudinal sinus indicates the location of the dorsal end of the central fissure ; 2, caudal part of the paracentral fissure ; 3, inflected fissure ; 
4, supercallosal fissure; 5, callosal margin of the falx, indicated by the interrupted line; 6, occipital fissure; 7, calcarine fissure: 8, in the 
longitudinal sinus just dorsad of the torcular; 9, tentorial sinus; 10, a sphenoidal sinus (not vascular, but a cavity in the sphenoid bone) ; 
11, a frontal sinus; 12, naso-palatine canal; 13, basioccipital bone; the basisphenoid has 10 upon it, but the two bones are continuous: 14, 
naso-pharynx ; 15, oro-pharynx; 16, soft palate. The heavy black line bounding the shaded mesal cavities is the endyma. 

Defects.—The planes of section of the brain and of the other parts are not absolutely identical, although perhaps nearly enough so for 
most purposes. Many of the boundary lines are too faintly indicated, e.g., that of the section of the chiasma. A continuous line represent- 
ing the pia should have surrounded all the cut surfaces in close contact therewith. Another line representing the arachnoid should follow 
the general contours, as stated more fully in connection with Fig. 801. The segmental name diencephal, hides most of the oval area indicat- 
ing the medicommissure; this last should have been named and should not be dotted. The heavy black line representing the endyma should 
extend farther into the stem (infundibulum) of the hypophysis, and into the epiphysis, as in Fig. 687. At the second e of the abbreviation 
MESEN the endymal line should not be interrupted. The interruption opposite the n of the abbreviation METEN represents the metapore 
(foramen of Magendie), and should have been so designated as in Fig. 687. Notwithstanding the minuteness of the myelocele (‘central 
canal of the cord” ) in the human adult its location should have been indicated by the continuation of the endymal line. The neck, scalp, 
features, and all the soft, vascular parts are swollen by the alinjection; the margins of the tongue are moulded upon the teeth; the soft 
palate and dorsal wall of the pharynx are obviously thickened, and the subturbinal projects beyond the true margin of the septum into the 
naso-pharynx, as is perhaps the case temporarily during the congestion attending a severe “cold in the head.” No attempt has been made 
to indicate the blood-vessels, the structure of the skin, the exact direction of the lingual muscles, or the details of the nuchal region. 


141 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





with distinct and even important functions. The supra- 
commissure and the habena (Fig. 707), for example, are, 
in one sense, parts of transition from substantial to mem- 
branous parietes; but they doubtless, like the fimbria, 
have some distinct use. 

§ 83. Marginal Cinerea.—The riparian parts mentioned 
in § 31 consist of alba; but with the cerebrum and cere- 
bellum the cortical margins have a special morphological 
interest, and are but little known. 

§ 84. Physiologically the intermediate portions of 
organs are commonly most important, as well as most 
easily recognized and examined; but morphologically 
the extremes have great significance, and present un- 
solved problems for future investigators. 

§ 35. Fig. 670 illustrates: A. The relative location and 
extent of the cranial and facial regions of the head so far 
as they appear at the meson. 

B. The continuity of the two portions of the neuron, 
the myel (“spinal cord”), and the brain (encephal), at or 
near the junction of the cranium with the spine. 

C. The obvious subdivision of the brain into several 
regions, represented, for example, by the cerebellum, the 
cerebrum, and the intervening narrower part, which is 
sometimes called isthmus cerebrt. 

D. The possibility of recognizing in the adult brain 
smaller divisions or definitive segments, corresponding 
with the divisions of more nearly equal 
size in certain other vertebrates. 

E. The difficulty of assigning exact lim- 
its to the brain and myel or to the regions 
of the brain, since they are continuous and 
do not present arthra (articulations or 
joints) as with the skeletal segments. 

F. The representation of each segment 
at or near the meson by some well-known 
part: the metencephal by the postoblon- 
gata; the epencephal by the cerebellum 
and pons; the mesencephal by the crura 
and geminal lobes; the diencephal by the 
thalami; the prosencephal by the cere- 
brum; and the rhinencephal by the olfac- 
tory bulbs. 

G. The existence of a mesal series of 
communicating cavities surrounded by 
the endyma. 

H. The insignificance of the aula, the 
mesal cavity of the prosencephal, as com- 
pared with not only the other cavities but 
the cerebrum itself. 

I. The presence of an orifice, the porta 
(“foramen of Monro”), evidently leading 
laterad from the mesal aula into a cavity 
within the right hemicerebrum. 

J. The relations of the masses to the cav- 
ities, as are related the floors, roofs, and 
side walls of an edifice to the apartments. 

K. The great difference in the thickness 
of the roofs and floors at different points. 

L. The continuity of the side walls, floors, and (ex- 
cepting at one point) of the roofs. 

M. The existence of certain fibrous masses, commis- 
sures, extending across the meson, and therefore divided 
in this preparation. 

N. The lodgment of a subspherical appendage of the 
base of the brain (the hypophysis) in a deep pit in the 
floor of the cranium (the “pituitary” or hypophysial 
fossa). 

O. The change in direction of the cranial floor at 
about this point, the remnant of the embryonic cranial 
flexure. 

P. The similar angle formed by the base of the 
brain. 

Q. The still more decided angle formed by the general 
outlines of the floors of the encephalic cavities at a point 
nearly corresponding with the cephalic orifice of the 
mesencephalic cavity. 

R. The liability of misapprehension from the employ- 
ment of the ordinary descriptive terms, vertical, hort- 


shown. 


142 


“isthmus ”’ 


metatela - 


EPENCEPHAL 


zontal, anterior, posterior, upper, and lower, since each of 
these words would have one meaning for the myel and 
postoblongata, and another for the diencephal. It is as 
if two adjoining houses faced, one to the east and the 
other to the south. The employment of eastern and south- 
ern as designating structural features common to the 
two would be likely to cause misapprehension. 

8. The convenience of regarding the entire floor as 
ventral, the entire roof as dorsal, any region of the brain 
nearer the myel as relatively caudal, and any region 
farther therefrom as relatively cephalic. 

T. The dorsal expansion of most of the segments. 
The wedge-like shape of the mesencephal is easily recog- 
nized; the thalami are not wholly exposed, but the region 
is more extended dorsally than ventrally; the cerebellum 
is much larger than the pons, while the disproportion of 
the cerebral hemispheres to their strictly basal, mesal 
part, the aula, is one of the many remarkable features 
of the adult human brain. 

U. The tendency of certain segments to overlap ad- 
joining parts, especially in the caudal direction. 

V. The lack of exact collocation between the en- 
cephalic regions and the cranial bones; the cerebellum 
corresponds to less than half of the superoccipital bone, 
and extends a little beyond its margin at the foramen 
magnum. 









ms epiphysis 


CEREBRUM 


optic nerve 
=5-r = OVO 





Fig. 671.—Right Side of the Brain of an Embryo 22 mm. Long and Estimated at 
Eight Weeks; 2,652. xX 7. 
flexure ; oS oe edge of the metatela; 3, pons flexure. The olfactory bulbs are not 

ee § 37. 


Prepared and drawn by B. B. Stroud (1899, a). 1, Cranial 


W. The collocation of the lambdoidal suture with the 
dorsal end of the occipital fissure. 

X. The location of the mesal craniometric points, 
nasion, bregma, lambda, and inion. 

§ 86. The Encephalic Flexures.—These are commonly 
described as three, the cranial, the pons, and the neck. 
The second and third are temporary in man, respectively 
indicating the junction of the myel with the postoblon- 
gata and of the latter with the preoblongata. The cranial 
or mesencephalic flexure is a permanent feature of the 
human brain, as seen in Figs. 670 and 687. There is, in 
addition, a flexure, likewise permanent, in the diencephal 
so that the prosencephal is dorsad instead of cephalad of 
it; this persists in man and other Mammals, and in Birds. 
and Reptiles, but with Amphibia and “fishes” the pro- 
socele and diacele are on approximately the same level; 
see my papers, 1887, b, and 1896, d. 

The relative positions of the several encephalic flexures, 
although not their relative sharpness or the length of the 
intervening parts of the brain, may be indicated to the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


eye approximately by a capital W, with an oblique line 
(half of a V) forthe myel. Inthe accompanying diagram 
the three _ flexures 
commonly named are Pr. 
indicated by the 

words cranial, pons, 

and neck; Pr. stands 

for the prosencephal- 

ic region, and D. for 

the diencephalic flex- 

ure. In this diagram, D. 
in accordance with 

my custom, the cephalic (“anterior”) end is at the left. 
Unfortunately, however, the two figures which illus- 


Cranial Neck 


Pons Myel 


f FRONTAL 





callosum (genu) -~-- -- 


terma -__ & 


precribrum ~~~... 7 
optic nerve —; 
y a 
if 
: Uf cs 
chiasma ~¥>> 
optic tract “7777 





lura ; 
tuber ¥ H ; 
albicans 7! ; \ \ $ 
posteribrum +4~4*$———4- 
rats | j 
pregeniculum +4—+4, Ee 
i 3 OCCIPITA 






Sy lateral lobe 





vallis 


Fig. 672.—Base (Ventral Aspect) of the Brain. From Henle, Edinger, and nature. 


the ventral and lateral column ; 3, ventrimesal fissure. 


Brain, 
Brain, 



















D. The presence of corrugations on both the mesen- 
cephal and the cerebrum. The former appear in many 
of our preparations; the latter may be artifacts. 

§ 88. Normalization.—This term is used to include all 
processes by which modified or morphologically ab- 
normal forms and relations may be reduced, either ac- 
tually or ideally, to their known primitive and presumed 
normal conditions. Rectification would have nearly the 
same significance; it denotes the reduction of complex 
structures to simple, of irregular to regular, of crooked 
to straight, and of rough to plain. Examples of this 
process are the representation of the segments as subequal 
in size and on the same plane (Figs. 674 and 675); the 
lateral extension of the various outgrowths of the mesal 





eee ae OM ACLOrY fs 
-——- olfactory bulb 


, ——- ~ Olfactory crus 
——-—-- presylvian f. 
__.- operculum 

_— insula 

— insular f. 


+ —— Sylvian f. 












peduncular sulcus, 


flocculus 
- pyramid 
-oliva 


x .7. 1, Ventral (‘‘anterior’’) column; 2, line between 


Preparation.—The cerebellum has been allowed to fall dorsad by its own weight; thereby the occipital lobes are divaricated somewhat, 


the encephalic curvature is reduced, and the crura are more fully exposed. 
tuber, and the pia removed, together with the cranial nerve roots, excepting the optic. 
On the left the operculums are divaricated somewhat, so as to expose the ventro-lateral aspect of the insula. 


attachment. 


The hypophysis and infundibulum have been severed from the 
The right olfactory crus has been divided near its 


Defects:—As may be seen from profile views of the brain (Figs. 670 and 687), in the normal condition of the organ the pons and the 
chiasma are naturally nearly in contact, and the intervening regions, crura, etc., are practically invisible ; the ventral surface of the met- 
epencephal also forms little more than a right angle with that of the prosodiencephal; consequently in a direct view of either region the 


other is greatly foreshortened, and even the equal division of the obliquity between them shows neither to advantage. 


The fresh or 


imperfectly preserved brain, when resting upon the dorsal aspect, will, however, straighten itself, as it is commonly represented. To 


include so large a surface within a figure of moderate size certain details must be inadequately presented or omitted altogether. 


The 


fissures in the present figure, substantially as given by Henle, need not be regarded as signifying anything more than the general aspect of 


the cerebrum. 


trate the flexures most perfectly (671 and 676) have the 
reversed position, so that comparison with the diagram 
is less readily made. 

§ 87. Fig. 671 illustrates: A. The general form of the 
brain at this stage, especially the sharpness of the several 
flexures. 

B. The size and prominence of the mesencephal and 
its extension over the adjoining regions. 

C. The distinctness of the constriction cephalad of the 
mesencephal as compared with that caudad, and the 
apparent absence of reason why the latter should be re- 
garded as a definitive segment any more than the former. 


The two crura should be equal in width. The pyramid decussation is inadequately indicated (see Fig. 689). 


See § 41. 


parts (Figs. 683 and 714); the straightening of the medi- 
cornu (Fig. 729); the schematic representation of the 
fissures (Figs. 757 and 758), and the designation of the 
human geniculums as pre and post rather than external 
and internal (§ 62, K). 

§ 89. The Brain a Segmented Organ.—A fundamental 
morphological idea * of the brain is that it consists of a, 
series of segments, comparable, although not, probably, 


* Like other symmetrical organs it consists of right and left halves, 
approximately identical. It is also regarded by some as divisible into. 
dorsal and ventral zones; but this has not, I think, been demonstrated 
for the entire brain. 


142 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





strictly equivalent. The development and comparative 
anatomy of the organ can hardly be treated upon any 
other basis; it is recognized in the discussion of en- 
cephalic physiology and of psychology, and the descrip- 
tive anatomy of the organ is most conveniently based 
thereon. 

§ 40. The segmental constitution of the human brain 
is invisible from the dorsal aspect (Fig. 664); hardly sug- 
gested when the cerebellum as well as the cerebrum is in 
view; more obvious from the lateral aspect (Fig. 663) ; 
still more so from the ventral side (Fig. 672); clearer still 
from the mesal aspect (Figs. 670, 687, and 756), and unmis- 
takable with early embryos (Figs. 671, 678, and 679), 
which therefore, but for practical difficulties as to procur- 
ing, preserving, and dissecting, would form a natural 
introduction to human encephalic morphology. 

§ 41. Fig. 672 illustrates: A. The enormous prepon- 
derance of the visible parts of the prosencephal and epen- 
cephal over the other segments, thereby occasioning the 
common and not unnatural though very unphilosophical 
division of the entire brain into cerebrum (cerebrum 
proper, olfactory bulbs, and thalami) and cerebellum 
(with pons and postoblongata), the intervening narrow 
region, the cruraand the quadrigeminum, being regarded 
as merely an isthmus.* From the morphological stand- 
point, however, the statement would be nearly reversed. 
The mesencephal is at one period the most prominent 
and distinct region (Figs. 671 and 676). The cerebellum 
may be characterized as an hypertrophied bridge over the 
“fourth ventricle,” and there are some grounds for re- 






garding the 

PROSENCEPHAL ; 
__...cerebrum DIENCEPHAL olfactory 
te thalami bulbs as 
MESENCEPHAL [concealed] p rima ry, 


----gemina 


4 EPENCEPHAL 
#..cerebellum 


METENCEPHAL 


and the cer- 
ebral hemispheres as 
their secondary  ap- 


postoblongata pendages (see my pa- 
«+. - MYEL per, 1887, a) 

RHINENCEPHAL B Tl 2 z . f 
olfactory bulb . Lhe extension o 


the cerebrum beyond 
all other parts of the brain, the 
occipital lobes overlapping the 
cerebellum even when the latter 
is allowed to displace the former. 
For the relations of these parts 
in the anthropoid apes, see my 
paper, 1884, g. 

C. The lapping of the temporal 
lobe over the optic tract, as shown 
by the two interrupted, curved 
lines on the right (left of the fig- 
ure). 

§ 42. Fig. 673 illustrates: A. 
The general form of the body and 
limbs at this period. 

B. The visibility of all the en- 
cephalic segments, excepting the 
diencephal; even this may be re- 
garded as represented by the op- 
tic nerve, dimly seen through the 
indentation at the ventral margin 
of the cerebrum. 

C. The marked preponderance 
of the cerebrum. 

D. The absence of the transi- 
tory fissures; compare, however, 
the right hemicerebrum, as shown 
in Fig. 746. 

E. The simplicity of the other regions, better shown 
in Fig. 746; the cerebellum is a narrow and undi- 
vided mass; the mesencephal presents a slight trans- 
verse depression between the pregeminum and post- 
geminum. 

§ 43. The recognition of the brain as a segmented 


Fic. 673.—Fetus Measur- 
ing 49 mm. from Nates 
to Bregma, and Esti- 
mated at Twelve Weeks; 
1828. 1. The speci- 
men was received in 
alcohol, still enclosed by 
the membranes. After 
removal it was pinned 
to loaded cork and kept 
under alcohol during 
the exposure of the 
brain. The attitude and 
expression are note- 
worthy, and have been 
faithfully reproduced 
by the photograph and 
drawing ; the right side 
of the brain is shown in 
Fig. 746, and the dorsal 
aspect was published in 
the New York Medi- 
cal Journal, February 
16th, 1884, p. 177. 


* This, the “isthmus cerebri’’ of some writers, must not be con- 
founded with the ‘isthmus rhombencephali’’ of others, which in- 
eludes a portion only of the mesencephalon (see Table I.). 


144 


organ is not dependent upon the determination of the 
exact number of segments, their equivalency, or their 
boundaries. The postoblongata represents several poten- 
tial segments or neuromeres, but practically it may be 
regarded as one. Some even regard the entire oblongata 
together with the cerebellum and pons as a single seg- 
ment. 

§ 44. Some idea of the diversity of opinion and usage 
among anatomists with respect to the number and desig- 
nations of the definitive 
segments may be gained 
from the table published in 
the first edition of this work 


terma 


(viii., 114), which is sub- eT inoct 
stantially the same as in 
my paper, 1885, 6, and in PROSENCEPHAL 
Wilder and Gage, 1882, 405.  , preerce 
The appended Table I. in- 3 
dicates he difference be- g eainchieal 
tween the verbal schemas 4 
adopted by the Anatom- g T nooesa 
ische Gesellschaft in 1895, § ee, 
and by the Association of epic: 
American Anatomists in 
1897; the second is follow- METENCEPHAL 
ed in the present article. metacele 

§ 45. Commentaries on the 
Schematic Medisected Brain, 
Fig. 675.—A. No two orig- 
inal workers in compara- 
tive neurology would be 
likely to construct schemas §& 
identical in all respects; the % (] rhombocsie 
one here presented is not | 


satisfactory to me and I can 
hardly expect it to suit 
others. But with all its de- 
fects I believe it may serve 
three useful ends—viz. : (a) 
indicate the relative posi- 
tion of certain parts in the 
floor or the roof of the gen- 
eral cavity ; (0) facilitate the 
recognition of the essential 
identity of the brains of all 
vertebrates with that of 
man; (c) stimulate efforts 
toward the construction of 
a more perfect schema. 

B. Only mesal parts are 
presented, 7.e., such as are ; 
divided in a medisection.* This excludes the cerebral 
hemispheres and olfactory bulbs, the lateral lobes of the 
cerebellum, and the elevations of the crura and quad- 
rigeminum at the side of the ventral and dorsal mesal 
furrows. 

C. The parietes present four degrees of thickness, viz.: 
(a) thin, ¢.g., the terma and the tuber in the floor, and in 
the roof the valvula and the lingula between the thick- 
ened quadrigeminum and cerebellum; (0) thick, e.g., 
the two just mentioned, the crura, and the oblongata 
caudad of the pons; (c) reinforced, e.g., the pons, chiasma, 
and precommissure; (7) membranous, consisting only of 
the endyma and the pia, constituting a tela, e.g., the 
roofs of the metacele (metatela), of the diacele (diatela), 
and of the prosocele. The plexuses (metaplexus, etc.) 
are special modifications of the telas (§ 24). The meta- 
pore is here represented as an interruption of the meta- 
tela. If, as now seems probable (§ 83), it is an evagina- 
tion, there still remains the difficulty of determining its 
extent, and the best mode of representing it. 

D. For the sake of comprehensiveness certain features 
are included which do not occur in all vertebrates—e.g. : 
the metapore (in man and a few others); the pons (mam- 
mals only); the medicommissure (mammals and some 


Fic. 674.—Schema of the Neuron 
(Cerebro-Spinal Axis), as if the 
cavity were exposed by the re- 
moval of the roof. The six en- 
cephalic segments are given a 
conventional spherical form, 
but without intending to imply 
that this is their actual shape or 
that all are separated by con- 
strictions. The main object of 
the diagram is to associate the 
encephalic segments with their 
names and the names of their 
cavities. 


* The callosum and fornix are omitted because their inclusion 
would have caused undesirable complications. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain. 





TABLE I.—COMPARATIVE VIEW OF THE SEGMENTAL 


THE ANATOMISCHE GESELLSCHAFT IN 1895. 
Partes ventrales. Partes dorsales. 


VI. TELENCEPHALON. 


hy po- ( Corpus striatum ; rhinenceph- 
alon ; pallium. 


Pars  optica 
thalami. 


VY. DIENCEPHALON. 
Pars mamillaris hypo-{Thalamus; metathalamus; 
thalami. epithalamus. 
IV. MESENCEPHALON. 
Pedunculi cerebri. 4 Corpora quadrigemina. 
III. Isramus RHOMBENCEPHALI. 


ie conjunctiva; velum 


Pedunculi cerebri. medullare anterius. 


II. MeETENCEPHALON. 
{ Cerebellum. 


I. MYELENCEPHALON. 
Medulla oblongata. 
Pars dorsalis. 


Pons. 


Pars ventralis. 


ScHeEMAS ADOPTED BY— 
THE ASSOCIATION OF AMERICAN ANATOMISTS IN 1897. 


I. RHINENCEPHALON. 
Bulbi olfactorii with their tracts, part of the aula and of 
the precommissure. 
II. PRosENCEPHALON,. 


Palliums, connected by part of the aula and part of the 
precommissure. 


III. DrzncEPHALON. 
Thalami, including the chiasma; genicula. 


IV. MESENCEPHALON. 
Crura and quadrigeminum. 


: VY. EPENCEPHALON. 
Cerebellum ; pons; preoblongata. 


VI. METENCEPHALON. 
Postoblongata. 





reptiles); the paraphysis (not found in mammals*); the 
chiasma (absent in teleosts). 

E. The dotted areas represent fibrous parts crossing 
the meson whether directly (precommissure) or oblique- 
ly (chiasma); the similar representation of the medicom- 
missure is not warranted by its cellular structure in 
mammals. 

F. Other differentiations of the substance of the 
parietes are not indicated, e.g., into the alba (white sub- 
stance) and the cinerea (gray). 

G. The hypophysis is notched and crossed by the 
broken line to indicate its twofold source, neural (7) and 


supracommissure 





epiphysis 


J. The two indentations of the cerebellum, ental and 
ectal, represent respectively the fastigium (§ 95) and the 
furcal sulcus (§ 117), but without implying their exact 
collocation. 

K. The crista has been observed in comparatively few 
vertebrates and its morphological significance is undeter- 
mined (§ 366). 

L. The Absence of Flexures.—Granted that no brain is 
perfectly straight and that many are strongly flexed in 
one or more places, how many flexures shall be repre- 
sented and what shall be their extent? The only impar- 
tial condition of the axis is straight (§ 38). 


postcommiussure peas 
Paraphysis. s.d. Vf Sapo cerepeuca ,metaplexus 
crista, ae VLaiaptexus J d.t, metapore 
DIENCEPHAL ae 
RHINENe | PROSENCEPHAL eae " MESENCEPHALSSEPENCEPHAL==METENCEPHAL==4 myelat rosscnel sulcus 
2 6 Primal zone 







precommissure 


termla . chiasma 


tuber ‘hypophysis 









albicans 
medicommissure 


‘endyma 
‘Pia 





oblongata 


Fig. 675.—Provisional and Imperfect Schema of the Brain as if Medisected; intended to approximate the “least common multiple” of the 


brains of vertebrates above the lancelet. 


Abbreviations :—In the floor, at the sides of the precommissure, p. 0. designates the olfactory division (pars olfactoria) and p. t. the 


cerebral or temporal division (pars temporalis) of that commissure. : 
enteron (prehypophysis), and . the strictly nervous portion (posthypophysis) ._ 
dorsalis), and d. t. the decussation of the trochlear nerves (decussatio trochlearis). 


beginning with the most cephalic (compare Fig. 680). 


enteric (e) § 146. The ectal line which elsewhere repre- 
sents the pia enveloping the brain should not be so inter- 
preted for the enteric portion. 

H. The indentation of the precommissure merely em- 
phasizes the relations of its two portions to the rhinen- 
cephal and the prosencephal respectively (§ 364). 

I. The indentation of the mesencephalic roof represents 
the transverse furrow which—in mammals only—de- 
marcates the quadrigeminum into a pregeminum and a 
postgeminum; the former, I believe, is always the larger, 
but the ratio is not known tome. No attempt is made 
to indicate the intergeminum (“interoptic lobes” of 
Spitzka). 


*See the turtle’s brain Fig. 680. The part is briefly discussed by 
Minot, 1892, 690, and by StudniCka, 1895. 


Vioteelie— 10) 





In the hypophysis, e, designates the portion derived from the 
In the roof, s.d. designates the dorsal sac (saccus 
The numerals indicate the six: definitive segments 


M. On the same principle the dorsal and ventral out- 
growths, paraphysis, dorsal sac (s.d), epiphysis, and 
hypophysis, are made to project nearly at right angles 
with the brain axis. In many vertebrates the hypoph- 
ysis tends caudad, but in man it tends rather in the 
opposite direction, and in the goose-fish (Zophius) it lies 
far cephalad of the rest of the brain. 

N. The Dorsal and Ventral Zones.—It is conceded that 
the myel is demarcated by an interzonal sulcus (“sudews 
limitans ventriculorum” of His) into a dorsal zone which 
is sensory and a ventral which is motor; also that the 
sulcus and zones are represented more or less distinctly 
in the caudal half of the brain. On the figure the sulcus 
is conventionally indicated by the segmental names, 
mesencephal, etc., and by the three lines connecting them, 
But I have as yet been unable to satisfy myself of the 


145 


Brain. 
Brain. 





continuance of these features in the cephalic half of the 
brain (see § 153).* 

O. Comparisons will be made naturally and justly 
with (a) representations of the primary neural segments 
or true neuromeres like, e.g., that of Charles Hill (1899, 
1900); (®) the schema of Prof. Wilhelm His (1898) which 
was adopted in 1895 by the Anatomische Gesellschaft 
(His, 1895); (c) that of Huxley (1871); (@) my own suc- 
cessive attempts, especially that in the first edition of 
this work, vol. viii., p. 114, which was substantially 
identical with that in the last four editions of Quain’s 
“Anatomy.” From all four it differs in the recognition 
of the olfactory region of the brain as a definitive seg- 
ment; from the first it differs also in regarding adult 
rather than early embryonic conditions—thus in recog- 
nizing the final, actual, or definitive segments rather than 
the primitive or potential neuromeres; from the second, 
in addition to minor points that may be mentioned later, 
it differs also in the greater regard for the conditions in 
the lower vertebrates; in the non-recognition of the 
“isthmus rhombencephali” as a definitive segment; in the 
method of numerating the segments and in the names of 
some. See also my papers, 1897, e, and 1899, c. 

P. The Number of Segments.—On this point the differ- 
ences of opinionand usage are wide and radical; my own 
views have changed more than once and may change 
again. Noone admits more fully the need of further 
information and of more logical interpretation. The 
practical question that now confronts us—investigators, 
teachers, and students alike—is this: In the present state 
of our knowledge, ignoring no known conditions of the 
brain, adult or developmental, and assigning at least 
equal weight to the lamprey and to the hag as to man, 
what number of transverse divisions shall be recognized, 
so as to facilitate the exposition and comprehension of 
the main features of a highly complex organ while not 
hindering the elucidation of the mysteries as yet unsolved? 
These divisions must be natural, not necessarily identical 
but at least comparable, and neither so few as to be use- 
less nor so many as to be inconvenient. The practical 
requirements are met by the numbers five and six. Five 
definitive segments were recognized in Quain and in the 
first edition of this work. Six are now recognized by 
both His and myself; but, as will be seen later, the first 
of mine (rhinencephal) is not admitted by him, while I 
am unable to see a definitive segment in the “isthmus 
rhombencephali.”+ 

Q. In regarding the olfactory bulbs, their tracts or 
crura, the pars olfactoria of the precommissure, and the 
corresponding portion of the aula, as constituting a 
definitive segment, the rhinencephal, I may be unduly 
influenced by the conditions in certain other vertebrates 
(Figs. 680, 790, 791, and 794) and by the considerations 
briefly outlined in 1897, e; but I feel that scant justice 
has been dealt hitherto to this probably primitive por- 
tion of the brain. 

R. The Developmental and Structural Disparity of 
the Segments.—Whatever number of definitive segments 
any anatomist admits, he will hardly claim that they 
are identical in either structure, mode of development, 
or relation to the primitive neuromeres. According to 
Charles Hill the mesencephal represents two neuromeres, 
and there certainly are several in the oblongata. 

8S. The Relative Size of the Segments.—This point is an- 


* Burckhardt has represented the zones and other features by an 
elaborate system of colors ; 1895. 

+ Should the ‘‘isthmus rhombencephali” be regarded as a definitive 
segment? In the early fetal brain of man, the cat, and perhaps some 
other mammals, there is a neck-like region just caudad of the mesen- 
cephal. Professor His names this region ‘*‘ isthmus rhombencephali,” 
and apparently regards it as co-ordinate with the other five segments 
recognized by him (1893, 173-174; 1895, Suppl. Bd., 157). But these 
same specimens, and indeed many of the figures of Professor His, 
present an equally distinct constriction cephalad. Even if the former 
represents the second of the two neuromeres which Charles Hill 
credits to the mesencephal, it is not easy to see why one of these 
regions, so insignificant in the later stages, should be reckoned as a 
definitive segment rather than the other. This point has been formu- 
lated independently by Dr. Stroud in the title of his paper, 1899, a, 
“If an Isthmus Rhombencephali, Why Not an Isthmus Prosen- 
cephali?”’ from which Fig. 671 is borrowed. 


146 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


alogous to that respecting the direction of the axis of the 
entire brain (L). Even were the preponderance of the 
cerebrum in man and other mammals to be indicated the 
precise ratio would not be easy to fix. But in some 
sharks the cerebellum is very large; in Teleosts the mes- 
encephalic lobes are most conspicuous; in Chimaera the 
diencephal is greatly prolonged (W., 1877, z); in the elec- 
tric ray the postoblongata (metencephal) equals in size the 
remainder of the brain. Finally, to offset the relative in- 
significance of the olfactory bulbs in the Primates and 
their total absence in certain Cetacea, they compare favor- 
ably with the other segments in many Reptiles and Am- 
phibia, in the hags (Fig. 790) they are as wide as the cere- 
brum, and in the lamprey (Fig. 789) they surpass it in 
bulk. There seems to be no escape from the conclusion 
exemplified in the schema, viz., that the definitive seg- 
ments are potentially equal in size. 

T. The Numerical Designation of the Segments.—In ac- 
cordance with the rule (to which there is, so far as I 
know, but a single exception *)—viz., that the members 
of any cephalo-caudal series of similar parts, ¢.g., ribs and 
vertebrie, should be numbered beginning with the one 
next the head—anatomists have hitherto generally desig- 
nated the segment next the myel as last and the one at 
the other extreme as first. That plan is adhered to in Fig. 
674, and throughout this article. The contrary enumera- 
tion was introduced by Professor His in 1893. It has been 
adopted by the Anatomische Gesellschaft, and there is 
likely to result confusion such as would attend the re- 
versal of the universal method of enumerating the cranial 
nerves. 

U. The Segmental Names.—As may be seen from the 
table of His reproduced in the latter part of the article 
Brain, Development of, and from the abstract of it in 
Table I., the most radical differences concern the two 
segments next the myel. The Association of American 
Anatomists follows Quain in designating the most caudal 
metencephaton and the next epencephalon. The Anatom- 
ische Gesellschaft follows Huxley in applying meten- 
cephalon to the penultimate segment and designating the 
ultimate by myelencephalon.+ 

§ 46. Fig. 676 illustrates: A. The. great relative bulk 
of the head, constituting about one-half of the entire 
body. 

B. The indications of encephalic segmentation by 
slight furrows, represented by the converging lines upon 
the side of the head. 

C. The prominence of the mesencephal at this period, 
forming the “top of the head.” 

D. The sharpness of the cranial flexure, whereby two 
of the segments appear in a dorsal view, and two in a 
ventral, while the fifth appears partly in both views, as 
shown by Figs. 677 and 678. 

E. The conditions of the eye and ear; the greater dif- 
ferentiation of the manus than of the pes; the presence 
of a short but distinct tail. 

§ 47. Fig. 677 illustrates: A. The distinctness of the 
myelocele (“central canal”) even to the root of the tail. 

B. The sudden and great expansion to constitute the © 
metepicele (“fourth ventricle ”). 

C. The marked constriction between the mesocele and 
the metepicele. . 

D. The existence, on the contrary, of the greatest 


*Dr. Gerrish informs me that in the famous work of Albinus, 
““Tabulze sceleti et musculorum corporis humani,’’ 1747, the vertebrze, 
lumbar, thoracic, and cervical, are numbered from the caudal to the 
cephalic end of each series; nevertheless, curiously enough, the ribs 
are enumerated in the more usual way. 

+ Undesirable results or concomitants of the application of myelen- 
cephalon to the last (most caudal) segment, and of metencephalon to 
the next (cerebellar) segment, are the following: (a) Disregard of 


‘the prior association of epencephalon with the cerebellar segment b 


Owen and Quain. (b) Disregard of Owen’s prior application of mye 
encephalon to the entire cerebro-spinal axis. (c) Inconsistency, 
since the myel of myelencephalon obviously refers to the ‘spinal 
cord” which, however, is termed medulla spinalis. (d) The appar- 
ent impossibility of having an appropriate or correlated convenient 
word term for the cavity of the last segment. Myelocelia (Eng. 
myelocele) was applied by me to the cavity of the myel (canalis 
centralis) ; myelencephalocelia would be cumbersome; likewise 
ventriculus myelencephalicus. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





width of the metepicele opposite the ventral transverse 
furrow which is regarded by me as demarcatin g the 
cephalic portion (epicele) from the caudal (metacele). 

E. The slightness of this transverse depression of the 
floor. Withsome human embryos of this and later stages 
(Fig. 671) there is a marked flexion (the pons flexure) of 
this entire region, at about the middle of its length, so 
that the two segments are easily distinguished. 

§ 48. Fig. 678 illustrates: A. The greater width of the 
mesocele than of the diacele, so that the latter might be 
described as merely a passage between the former and 
the prosocele. 

B. The absence of any distinct thickening of the dia- 
celian walls to indicate the formation of the thalami. 


MESENCEPHAL 





Fic. 676.—Right Side of a Human Embryo, 18 mm. long, and Esti- 
mated to be Four Weeks of Age; 274. x 6. 

Preparation.—The embryo was received in its membranes, and 
had apparently lost much of the neck curvature, so that the head is 
more nearly than usual in line with the body. The encephalic 
cavities were exposed by removing their roofs; the original outline 
is indicated by the broken line. 


C. The mesal depression in the diacelian floor, probably 
representing the infundibulum. 

D. The lateral extension of the paraceles, the cavities 
of the future hemicerebrums. 

E. The presence of an elevation of the paracelian floor, 
probably representing the caudatum. 

F. The continuity of the parietes at the junction of 
the prosencephal with the diencephal, and the absence of 
any indication of plexal intrusion at this period. 

§ 49. Commentaries upon Fig. 679.—A. This figureisa 
combination of parts of Figs. 677 and 678, as if the en- 
cephalic curvature were obliterated. This ideal straight- 
ening, a form of normalization (§ 88), may be illustrated 
as follows: Flex the index finger upon itself as faras pos- 
sible; let the nail represent the prosocele, the knuckle the 
metepicele, and the prominent middle joint the mesocele. 
From either the dorsal or palmar aspect only parts of 
the convex surfaces are visible; but if the finger is ex- 
tended all fall into one view. 

B. The main object of this figure is to facilitate a com- 
parison between the encephalic cavities of this early em- 








bryo and those of the adult cat as shown in Fig. 686. 
The differences are much greater in appearance than in 


oO 
is 
A 
oO 
oO 
-ejoul 


| 


° 
® 
— 
oO 
ig) 
<4 
® 
< 
is 
fo) 
io) 
fa) 
= 
oO 





Fig. 677.—Dorsal Aspect of the 
Embryo Shown in Fig. 676; 
274. 6. This and three of 
the following figures (678, 679, 
681) are too deeply shaded. 
See § 47. 


Fiqg. 678.—Ventral Aspect of the 
Embryo Shown in Figs. 676, 677, 


and 679; 274. x 6. The left 
rie: has been removed. See § 


reality, consisting mainly in the reduction of most of the 
cavities, the thickening of most of the parietes; the great 
and irregular ex- 
tension of the later- 
al masses, hemicer- 
ebrums, containing 
the paraceles (“lat- 
eral ventricles ”). 

C. The resem- 
blance of this fig- 
ure to the appear- 
ance presented by 
the brain of ec- 
turus (a salaman- 
der) after the re- 
moval of the roof is 
almost startling ; 
see my paper, 84, a. 

§ 50. The adult 
human brain pre- 
sents great and per- 
haps peculiar de- 
partures from the 
general type as on 
based upon embry- ‘ie 
ology and compara- 
tive anatomy, and 
while anatomically 
admirable and 
physiologically nearly perfect, it may fairly be char- 
acterized as a morphological monstrosity. Among 
other general features, the segmental constitution of the 
organ is more apparent in many lower or more general- 


es comas ee telI0g 
ee oe BLE, 
~... porta } P 


paracele 


Toso- 
cele 


ae es diacele 


mace aeale aihe epicele 





on~es.-2-.. Metacele 


os 


Fic. 679.—The Encephalic Cavities of the 
Embryo Shown in Figs. 677 and 678 Repre- 
sented upon One Plane. 


147 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ized vertebrates, e.g., the turtle (Fig. 680) and the hag 
(Fig. 782), and even in mammals where the cerebrum is 
less preponderant than in man. But with mammals the 
other segments are more easily recognized if the cere- 
brum and cerebellum are either tilted in opposite direc- 
tions as in the rabbit preparation (Fig. 681), or the former 
is also medisected as in the cat (Fig. 682), or both partly 
cut away as in the sheep (Fig. 794). 

§ 51. Fig. 680 illustrates: A. The availability of this 
reptilian brain for the exemplification of certain features 


epiphysis 
dorsal sack 
paraphysis 


supracommissure geminum 






porta 
olfactory nerves 


on 


optic nerve 
chiasma 


precommissure hypophysis 


Fig. 680.—Mesal Aspect of the Medisected Brain of the Green Turtle, Chelone midas. 1. From nature 
The letters R., P., D., M., E., and Mt., designate respec- 
tively the six segments, rhinencephal, prosencephal, diencephal, mesencephal, epencephal, and meten- 
‘The first and second are placed on the pial surfaces of the olfactory bulb and hemicerebrum ; 


and from the paper of O. D. Humphrey, 1894. 


cephal. 
the other four are within the cavities. 


of the organ; it is large as compared with that of am- 
phibia and most other reptiles; the cerebrum and cere- 
bellum do not overtop the other parts so as to obscure 
their serial relations; excepting the pons and callosum 
most of the commissures are represented; and the cranial 
flexure is slight (Fig. 671). 

B. The departure from the schematic brain in two re- 
spects: (a) the reduction of the mesal portion of the 
rhinocele and prosocele to a slight cavity, the aula, open- 
ing laterad by the porta; (6) the crowding of the cephalic 
segments caudad, occasioning the diencephalic flexure, 
and bringing the aula and porta dorsad of the diacele in- 
stead of cephalad of it. 

C. The elongation and close apposition of the three dor- 
sal outgrowths, paraphysis, dorsal sack, and epiphysis. 

D. The relatively large size of the olfactory bulb, and 
the duplicity of the olfactory nerve. 

§ 52. Fig. 681 illustrates: A. The greater obviousness 
of the segmental constitution than with the adult human 
brain from any point of view. 

B. The smaller relative size of the cerebrum than in 
man or the cat (Fig. 682). 

C. The much less extent of the callosum than in man 
or the cat, making it possible to uncover the diencephal 
without the medisection required in the cat (Fig. 682). 

D. The presence of a distinct roof of the diacele, the 
interthalamic space, notwithstanding the cerebrum has 
been tilted. 

BE. The relation of this roof, the diatela, to the habenas, 
the ridges demarcating the dorsal and ectocelian from the 
mesal or entocelian surfaces of the thalami. 

F. The non-adhesion of the thalamus to the hemicere- 
brum in any way such as to indicate that the former 
enters into the composition of the paracelian floor. 

G. The more nearly equal size of the lateral (pileums) 
and mesal (vermis) lobes of the cerebellum, and the con- 
comitant absence of the vallis which is so obvious on the 
caudal aspect of the adult human cerebellum (Figs. 672 
and 697). 

§ 58. Fig. 682 illustrates: A. The possibility, even 
with so high a mammal as the cat, of making a prepara- 
tion that, without disturbing the essential morphological 
features of the organ, may exhibit portions of all of 
the encephalic segments excepting the last, the meten- 
cephal. 


148 


postcommissure 


cerebellum 







medicommissure 











B. The tendency of three of the encephalic segments 
to overlap those caudad of them. The cerebellum, the 
epencephalic roof, partly conceals the postoblongata, 
metencephal, in its natural attitude; in the present figure 
it is tilted caudad. The mesencephal (gemina or optic 
lobes) is covered partly by the cerebellum and partly by 
the cerebrum, and also at the sides overlapped somewhat 
by the postgeniculums, elements of the diencephal; in 
the. figure these bodies are in deep shadow, crossed by 
the line 8 on the right, and on the left by the line lead- 
ing to the postgeminum. 
Finally, the cerebrum con- 
ceals the diencephal and 
mesencephal, part of the 
rhinencephal, and even 
the cephalic slope of the 
cerebellum in the cat, 
while in man it alone is 
visible when the brain is 
viewed from the dorsal 
aspect (Fig. 664). 

C. The relations of the 
callosum and fornix to 
the two hemicerebrums, 
as lines of secondary ad- 
hesion between the two, 
the one dorsal and the 
other ventral. 

D. That the triangular 
area, hemiseptum, is real- 
ly only a portion of the 
mesal wall of either hemi- 
cerebrum, which has been 
intercepted between the two lines of junction above 
named. 

E. That the interval, pseudocele (“fifth ventricle” 
between the two hemiseptums, has no connection with 
the true encephalic cavities. 

F. That the callosum and fornix are in no sense parts 
of the roof of the diacele (third ventricle): this is consti- 
tuted by (1) its proper endyma, (2) the pia covering this, 
as all other parts of the brain, (8) the pia pertaining to 
the fornix, which layer of pia, with the layer (2) and the 
intervening vessels, constitutes the velum. 

G. Incidentally it may be remarked that the cruciate 
fissure in cats and dogs constitutes, as it were, a gash 


{ trochlear 
decussation 


metatela 


myel 












» cerebrum 


» _ aulatela 


fimbria 


PROSEN- } 
CEPHAL 


~, thalamus 
- postgeniculum 
~~~ epiphysis 

~. pregeminum 


DIENCEPHAL .- 


MESENCEPHAL , _ 


EPENCEPHAL ,, 7 
—., 7 
~. postgeminum 


~>~~_ cerebellum 


FIG. 681.—Dorsal Aspect of the Brain of a Young Rabbit, the Cere- 
brum and Cerebellum Pushed in Opposite Directions. 
Preparation.—While fresh, the cerebellum was tilted caudad and 
the hemispheres cephalad, and the velum removed ; the brain was 
then placed in strong alcohol so as to retain the desired shape. The 
segmental names are at the left, the names of parts at the right. 
The specimen has been lost or destroyed. ‘ 


across the mesal margin near the cephalic end of the 
hemicerebrum; it appears, therefore, upon both the mesal 
and the dorso-lateral aspects. The well-known and easily 
experimented-upon motor areas of the limbs occupy the 
U-shaped gyre between the cruciate and coronal fissures. 
It does not follow, however, that the cruciate fissure and 
the human central fissure are homologous (§ 303). 

§ 54. Relative Size of the Segments in the Embryo and the 
Aduit.—In the embryo at one period the mesencephal is 
the most prominent region, and it remains the largest in 


: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





some fishes; in the adult human brain it is one of the 
least conspicuous. 

§ 55. Segmental Overlapping.—Although originally 
subequal in size, certain segments early manifest a ten- 
dency to extend beyond their neighbors in one or more 
directions. In man and the mammals generally this 
overlapping is in inverse ratio to the original size of the 
parts. The mesencephal, at one period most prominent, 
is encroached upon by the diencephal at the sides, by the 
pons ventrad, the cerebellum dorsad, and all are eventu- 
ally covered by the cerebrum, primarily a comparatively 
insignificant portion of the brain. 

§ 56. This segmental overlapping is, upon the whole, 
greater caudad than cephalad, most of the segments pre- 
senting something like the “rake” of the mast of a ship. 
The cerebellum, for example, not only extends both 
cephalad and caudad from its connections with the epen- 
cephalic floor, but is tilted distinctly caudad (Figs. 670, 
687, and 693). 

§ 57. Transections at any level caudad of the aula 
usually affect two or more segments. This is illustrated 
in the following diagrams (Fig. 683). 

§ 58. The Caudato-thalamic Fusion.—The relations of 
the prosencephal to the diencephal are further compli- 
cated by the intimate fusion of the sides of the latter 
(thalami) with the floors of the former (caudatums). <A1- 
though, therefore, in the early embryonic stages (Fig. 671) 
it is very easy to distinguish between the two segments, 
there is some difficulty in the adult. For convenience, 
in the present article, the capsula (“internal capsule ”) is 


Fic. 682.—The Brain of a Cat from the Dorsal Aspect, 
After the Callosum and Fornix had been Divided and 
the Hemicerebrums Divaricated; 474. xX 2. 1, Ar- 
tery (precerebral ?) ; 2, artery joining 1, perforating 
the callosum from the velum; 3, 4, lines of division 
of the arachnoid, between the cerebrum and cerebel- 
lum ; 5, line of division of the velum, which is partly 
removed on the left side so as to expose the thala- 
mus and gemina of that side. 

Preparation.—While fresh and supported by the 
basis cranii, the hemicere- 
brums were carefully separ- 
ated so as to expose the cal- 
losum ; this was divided, be- 
ginning with the splenium ; 
then the fornix until the in- 
cision reached the point of 
attachment of the velum. 
The cerebellum was tilted 
caudad and the arachnoid be- 
tween it and the postgeminum 
divided; the cerebellar edge Dig 
of the arachnoid is represent- 
ed by the line 4. The valvula 
is shown as if inflated with 
air. On the left side, along 
a line (5) extending obliquely 
caudo-mesad from under the 
margin of the fornix, the two 
layers of pia constituting the 
velum were divided, and the 
part at the left removed so as 
to expose more distinctly the 
postgeminum, pregeminum, 
and thalamus. The cerebral 
pia was removed. A similar 
preparation of the human 
brain is very desirable, but 
difficult to make, on account 
of the weight of the cere- 4 
brum. 

Defects.—The arteries 
should have been injected 
with a red mass, for the bet- 
ter exposition of the pia, the plexuses, and especially the mesal 
artery (2) which penetrates the callosum. No attempt has been 
made to show the lines of refiection of the arachnoid between the 
two hemicerebrums, along a line corresponding with the ventral 
margin of the falx and indicated approximately in the transection 
(Fig. 732). The fornix is represented too thick and should not be 
dotted. The trochlearis nerve (N. tr.) stops too sharply at the mar- 
gin of the valvula, from which it arises. The convexity of the val- 
vula is too sharply defined. 


cruciate f. 


splenial f. 


lateral f. 


thalamus 


pregeminum - 
postgeminum - 


nerve 
prepeduncle 


trochlearis t 


epiplexus 


adopted provisionally as the boundary, so far as regards 
the thalamus and the lenticula (part of the striatum). 
But the same medullary stratum intervenes between the 
lenticula and the caudatum, both prosencepalic parts, 
and the whole subject requires further elucidation. 


§ 59. The Segments Primitively Mesal and Single.—This 
view is generally accepted with regard to the diencephal 
and the parts caudad of it on account of the familiar 


A. 








FiG. 683.—Diagrams Illustrating the Lateral Overlapping of the Mesen- 
cephal by the Two Segments Cephalad of It. The transverse axes of 
the prosencephal, diencephal, and mesencephal are indicated by the 
lines 1, 2, 3, respectively; in A they are directed laterad, as in the 
early embryonic stages; at B they are inclined caudad, and tran- 
sections at a or b would cut two or three segments instead of one. 


conditions of early development. The prosencephal like- 
wise, although commonly described as a pair of lateral 
masses, is single in “fishes” (see the figures and state- 
ments in connection with that segment, §§ 158-162), 














olfactory bulb 


coronal f. 


genu 
- rostrum 
1 

- pseudocele 
2 


\ of callo- 
sum 


fornix 
vyelum 


splenium 


3 


valyula 


lateral 


pileum or 
lobe 


of the cerebellum 


vermis J 


The case of the rhinencephal is less readily disposed of, 
and will be stated in connection with that segment (§ 370). 

§ 60. Potential Triplicity of the Hncephalic Segments.— 
Although primarily mesal and simple, each segment 
presents at some period and in some vertebrates a dis- 


149 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








tinctly threefold condition, with one mesal and two 
lateral portions. The prosencephalic triplicity is ex- 
hibited in all air-breathing vertebrates and some aquatic 








precornu 


y 


porta 


cella Se 
medicornu é 
postcornu 


Fig. 684.—Cast of the Encephalic Cavities, Ventral Aspect ; approxi- 
mately correct. > 1(?) (From Weisker, modified.) The names at 
the right, doubly underlined, designate five divisions of the en- 
cephalocele, together with the slender myelocele (central canal of 
the spinal cord). The metacele and epicele together constitute the 
** fourth ventricle ”’ of the text-books ; the mesocele corresponds to 
the aqueduct or iter; the diacele equals the * third ventricle ”’ less 
the aula, which is the mesal part of the prosocele; prosocele in- 
cludes all not already specified, viz., the mesal aula, the lateral 
paraceles (‘‘ lateral ventricles ’’), and the two portas through which 
they are continuous. The names atthe left designate the parts 
of the paracele, viz., the cella, extending caudad from the porta ; 
the precornu, extending cephalad ; the medicornu, extending in 
a spiral direction laterad, ventrad, cephalad, and mesad, succes- 
sively ; and the postcornu projecting caudad from the cella. 2is 
placed near the tip of the right lateral recess of the epicele. The 
larger part of the figure is modified from a photograph of the 
wax model made by Weisker, of Freiburg. The metacele, my- 
elocele, and part of the epicele are from a cast of the cavities in 
achild. The ventral aspect was chosen in order to display to 
better advantage the uninterrupted series of mesal cavities, and 
the portas. 

Defects.—I doubt whether any part represents the correspond- 
ing’cavity accurately. The portas are too long (compare Fig. 718). 
The diacele presents neither the orifice for the medicommissure 
(the presumed location of which is indicated by the dotted circle 
(1) just caudad of the portas) nor the marked ventral extension 
toward the hypophysis. The medicornua are not sufficiently 
curved; in reality the extremity of each approaches the diacele 
within about 2.5 cm.; the postcornua are too short; the bound- 
aries of the epicele are vaguely and perhaps incorrectly indicated, 
and the lateral recesses (2) should be longer. 


paracele 


forms (Dipnoans, etc.); with birds and frogs the mesen- 
cephal is markedly tripartite (Fig. 682); with man and 
other mammals, and likewise with some other verte- 
brates, the epicele presents more or less extensive “lateral 
recesses” (Figs. 669, 684, 698). The embryonic dien- 


150 


~~~ prosocele 
+) ——=— $= 


diacele 


epicele 








., metacele 


myelocele 








cephal protrudes at either side an optic vesicle that be- 

comes the retina and optic nerve. 

§ 61. Mig. 684 illustrates: A. The continuity, general 
form, and relative size of the several divisions of 
the adult human encephalocele, as viewed obliquely 
from the ventro-dextral aspect. 

B. The obvious triplicity of the prosocele, and 
the existence of lateral extensions of the epicele. 

C. The slenderness of the mesocele as compared 
with its relative size in the embryo (Fig. 680) and 
in the adults of some other vertebrates (Fig. 685). 

D. The general modifications of the primitive 
and typical condition of the encephalic cavity which 
led the older anatomists, and still lead some of their 
modern successors, to regard the whole as compris- 
ing four “ventricles,” a first and second (lateral), 
a “third,” and a “fourth,” the aula being ignored 
and the mesocele considered merely as a “ passage 
from the third ventricle to the fourth.” 

§ 62. Hig. 686 dllustrates: A. An arrangement 
and circumscription of the encephalic cavities in 
the adult cat (an accessible mammal), essentially 
identical with that in the human adult (Fig. 735) 
and fetus (Fig. 716), and in vertebrates generally. 

B. The great differences in size and shape be- 
tween the various divisions of the encephalocele; 
the mesocele is little larger than the myelocele, and 
istubular; the diacele is narrow but high; the meta- 
cele wide but shallow; the epicele is very irregular; 
the myelocele is patent throughout, while in man it 

is nearly obliterated. The epicelian lateral recesses 
are not exposed, so the triple constitution of a 
typical segmental cavity is exhibited only by the 
prosocele, with its mesal, aula, and lateral paraceles. 

C. The different constitution of the celian pari- 
etes. The roofs of the aula, portas, and metacele 
are membranous telas, with plexuses on the ental 
surface. 

D. The reduced thickness of the parietes near the 
rima, constituting the fimbria, one of the riparian 
or marginal parts. 

E. The apparent interruption of the wall of the 
medicornu at the rima (“ great transverse fissure ”). 
On close examination, however, although the proper 
nervous parietes are absent, the intruded pial fold 
(paraplexus) is seen to be covered by the endyma 
reflected from the adjoining parts, so that the in- 
jected alcohol was completely confined. 

F. The not very obvious relation of the ectal furrow, 

hippocampal fissure, to the ental elevation or colliculus, 

hippocamp; on the right the line from postgeniculum 
crosses the end of the fissure, which is not otherwise 
indicated. 

G. The relations of the alba (medulla) to the ectocinerea 

(cortex) and the entocinerea (“central tubular gray ”); 


olfactory nerve 
olfactory bulb 
% cerebrum 
thalami 
geminum 
> cerebellum 
: postoblongata 

' 
1 


meee toe 


2 hypophysis 
optic nerve 





Fic. 685.—Left-hand figure: Brain of Frog Seen from the Left After 
Removal of Parts of the Left Side; 654. x 1.5. Right-hand fig- 
ure: Enlargement of the Geminum (Mesencephal), so as to show 
more distinctly the lateral cavity of the mesocele and the orifice 
(comparable with the porta) by which it communicates with the 
mesal cavity. 


the metepencephalic entocinerea has been removed in ex- 
posing the cavities, but it is distinct and abundant at the 
sides of the mesocele (aqueduct), of the diacele, consti- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain. 





tuting the thalamus, and of the prosencephalic precor- 
nu, constituting the caudatum and—unexpectedly—the 
hemiseptum and column of the fornix, all which were 
distinctly gray in the fresh preparation. 

H. The caudal extension of the cerebrum so as to 
reach the cerebellum, and thus conceal the lateral aspect 
of the intervening segments, diencephal and mesencephal. 

I. The fusion of the thalamus with the caudatum, of 
the diacelian side wall with the paracelian floor. The line 
of junction of the two 
segments may be regarded 
as indicated approximate- 
ly by the word dien. 

J. The absence or in- 


conspicuousness of the cinerea _ __ 


lenticula, claustrum, and Aiba aie ge 
insula (compare Fig. 782). : oye 

K. The less width of cent die aie reso 
the diencephal than in caudatum | _ 


man, so that the genicu- 
lums maintain their prop- fornix ~~ __ 
er morphological relation 
of cephalic (pre) and cau- 


dal (post), rather than of « severe si 
lateral, or “external,” and pregeniculum __ 
mesal, or “internal,” as in : 
man. rima _ 
L. The extension of the Paranieeaae 


paraceles, the proper cav- 
ities of the hemicere- 


medicornu _-/ 
brums, caudad from the F 


aula even farther than fimbria _ 
cephalad, thereby war- : : 
ranting the diagrammatic hippocamp --— 
representation of the par- __ postgeniculum - - -- 
aceles as lateral exten- nC ae 


sions, not cephalic only. 
M. The absence of a 1 eae a 






postcornu in the cat as in pileum .-——< 
most other mammals, the 

exceptions being man, 

monkeys, seals, porpoises, a 
and some dogs. apiplextss=——=—— 


N. The distinctness of 
the crista in the cat. It 
is not named on the fig- 
ure, but may be seen as a 
conical elevation at the 
cephalic side of the aula; 
the line from aula points 
at it. 


EPENCEPHAL 
COT a 


Fic. 686.—The Encephalic Cavities of a Cat, Exposed from the Ventral Side; 479, 


concomitant completeness of the celian circumscrip- 
tion. 

C. The non-communication of the pseudocele with the 
true cavities. (The meninges and blood-vessels are con- 
sidered under Fig. 801.) 

$§ 66. In tracing the continuity of the endyma at the 
meson it is best to begin with a region where a rupture 
could hardly occur in either floor, roof, or sides, and 
where also a transection is most readily effected when 

















— pseudocele 
_' precornu 
-” 


- 

Lae _- aula 
o- 

- 


ae. 


- _ 


_- porta 


- 
eter 
- 
Pa 


_- 7 paracele (cella) 


_--— diacele 


eas 


-- medicornu 


-— mesocele 


ae rea: a= epicele 





—= metacele 





4 


~ myelocele 


xX 2. 1, The valvula, 


§ 63. Celian Cirewm- 
scription.—The facts of 
development and compar- 
ative anatomy, and anal- 
ogy with other hollow 
organs warrant the pre- 
sumption that the ence- 
phalic cavities communi- 
cate only with one another 
and with the myelocele. 
Any communication with 
the ectal surface is pre- 
sumably artificial, except- 
ing, perhaps, at the meta- 


which is so thin in the cat that the cerebellar folia show dimly through it (the line is interrupted just 
above the L of EPENCEPHAL); 2, the narrow space between the lateral aspect of the mesencephal and 
the overlapping hemicerebrum ; in anthropotomy this is commonly reckoned as part of the ** great trans- 
verse fissure’; 3, obliquely cut surface, left by the removal of the caudatum and adjacent parts of 
the left hemicerebrum. 

Preparation.—The brain was exposed from the ventral side and left in the calva for better support. 
the cavities were alinjected so as to harden the parietes and keep them apart. Successive slices were 
removed until the portas and aqueduct (mesocele) and myelocele were exposed. With a narrow- 
bladed knife the walls of the diacele (including the medicommissure), epicele, and metacele were cut 
away obliquely; also on one side (the right of the preparation, but the figure is reversed so that it 
appears on the left) the caudatum, hippocamp, and part of the thalamus, so as to expose the continuity 
of the precornu and medicornu. The olfactory bulbs were removed with the ventral portion of the 
cerebrum. The boundaries of the cinerea (cortex, etc.) and alba (medulla) were ascertained by com- 
paring the similarly exposed surface of a fresh brain ; some of the differences between the two sides are 
due to a slight difference of the section-levels. 

Defects.—The brain should have been prepared in a chromic-acid solution, or injected with the red 
mixture, so as to differentiate the alba and cinerea. 


the entire brain is to be studied in two parts, a cerebral 


pore (“foramen of Magendie”) and the lateral recesses 
4§§ 78, 98). ; 

§ 64. Hndymal Continuity.—The endyma is the essen- 
tial and absolutely constant constituent of the celian 
parietes; hence in all figures purporting to illustrate 
celian circumscription the line representing the endyma 
should be distinct and uninterrupted, excepting where 
discontinuity has been demonstrated. 

§ 65. Fig. 687 illustrates: A. The sharpness of the 
cranial or mesencephalic flexure in man. Compare the 
sheep (Fig. 794) and the turtle (Fig. 680). 

B The continuity of the endyma lining the mesal 
series of cavities excepting at the metapore, and the 


and a cerebellar portion. This “place of election” is 
the mesocele (“aqueduct” or “7¢ter a tertio ad quartum 
ventriculum ”). 

A. Theendyma covering the floor of the mesocele may 
be traced caudad (actually almost directly ventrad) with 
slight depressions and elevations through the oblongata 
to the myel where it lines the slender myelocele, the 
“canal of the cord.” 

B. Recommencing at the same point in the mesocele, 
the floor endyma turns quite sharply ventrad over the 
cephalic curvature of the crus, passes the albicans, and 
reaches a region where the floor is thin and frequently 


151 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





torn in removing the brain. This is the tuber, commonly 
called’ “tuber cinerewm,” which is continuous with the 
infundibulum, and thus with the hypophysis. The 
cephalic part of the tuber is reinforced by the chiasma, 


pseudocele 
auliplexus 





fornix 
- supracom- 
missure 


dura SX 


gon 
/ 


i 
precerebral a. Ce 
copula / / 

ey, 


A ont 
aula / a, 
(bay) 
precommissure / 


\ 
\ 
! 
terma 
\ 


chiasma 
hypophysis 
albicans ! 


postcribrum 
crus 





1 \ 
myel'! : 


myelocele 


F1G. 687.—The Mesal Cavities of an Adult Brain Exposed from the Left, with Their Immedi- 
5. Fig. 801 represents the entire meson of the same specimen on a 


ate Parietes. X .65. 
smaller scale, and its mode of preparation is there described. 


Defects.—In addition to those specified under Fig. 801, the most serious are: (@) the 
non-representation of the postpontile recess, the mesal depression just caudad of the 
pons, shown in Fig. 702, 2; (b) the presence of the line curving dorso-caudad from the 
rostrum of the callosum; (c) the imperfect indication of the membranous parietes of 
the dorsal sac, the pouch lying upon the epiphysis; (d) the non-designation of the diacele. 


the ental margin of which presents a marked transverse 
ridge, sloping caudad into the tuber and cephalad into 
the optic recess. In Figs. 689 and 708, the chiasma and 
tuber are shown with the hypophysis attached; but in 
Fig. 672 it is detached, leaving an orifice, the lura. 

C. Directly dorsad from the chiasma, the cephalic wall 
of the diacele is the terma (lamina terminalis, or 1. cine- 
rea), So thin and delicate as not infrequently to be rup- 
tured during the removal or manipulation of the brain. 
The proper nervous material of the terma seems hardly 
more substantial than the lining endyma and the cover- 
ing pia, here represented by the ental and ectal lines. 
The ectal aspect of the terma is shown in Fig. 711. 

D. Suddenly there is a marked thickening of the 
cephalic wall, from the reinforcement, so to speak, of 
the terma by a fibrous cord, oval or elliptical in section. 
This, the precommissure, connects the olfactory bulbs and 
portions of the cerebrum upon opposite sides, and hence 
belongs to both the rhinencephal and prosencephal; the 
cavity just caudad and dorsad of it is the aula, the mesal 
portion of the rhinocele and prosocele; $$ 362-864. 

E. From the precommissure caudad to the roof of the 
mesocele the course of the endyma is extremely irregular, 
and the nature and shape of the roofs are very diverse. 
The immediate roof is largely membranous, and the con- 
dition is further complicated by blood-vessels large and 
small, and by plexuses. Finally, the parts lying directly 
upon the meson differ materially from those just laterad 
of it, and as the chances are altogether against a medi- 
section being exactly mesal in the whole of its course, 


152 









= valvula 


Mx metapore 


there is nearly a certainty that upon the first inspection 
one will miss anticipated features and see what one does 
not understand. 

F. The recognition and comprehension of the actual 
facts in a given preparation will be fa- 
cilitated by consulting the diagram 
(Fig. 725), and the representations of 
the brains of the cat and rabbit (Figs. 
681 and 682). The important point to 
bear in mind is that the complete cir- 
cumscription of the mesal encephalic 
cavities would be unaffected were the 
entire cerebrum removed, including 
the callosum, hemiseptum (the lateral 
wall of the pseudocele), and fornicom- 
missure (the mesal continuity of the 
fornix), down to the point where the 
heavy line representing the endyma 
leaves the narrow, white area repre- 
senting the fornicommissure to cross 
the convex surface of the fornicolumn 
and be reflected upon the auliplexus. 
The details of this, the aulic and portal 


region, are more clearly seen in the en- 
_-~ lingula larged figures of the porta (Figs. 721 
<7-- epicele and 719). 


G. From the auliplexus (at or very 
near the meson) or from the portiplexus. 
(if the section plane passes through the 
right or left porta instead of the mesal 
aula) the endyma may be traced caudad 
upon the ventral surface of a mem- 
branous fold, the velum. Strictly 
speaking, between the endyma and the 
velum, which is a fold of pia, inter- 
venes the remnant of the primitive 
nervous roof of the diacele. This may 
persist in some animals, but in the adult 
cat and in man, so far as I am aware, 
there is practically nothing between 
the pia constituting the velum and the 
endyma. At each side of the meson 
there depends a more or less distinct. 
vascular fringe, the diaplexus, continu- 
ous with the auliplexus, the portiplex- 
us, and thus with the paraplexus, 
these last three being successive mem- 
bers of the prosoplexus. 

H. The relations of the endyma to the velum and plex- 
uses are more clearly shown in Fig. 782, representing a 
transection of the diacele. There also are shown the re- 
lations of the habena. This is a low ridge following a 
curved line along the mesal aspect of the thalamus from 
the dorsal end of the porta to near the epiphysis; it is 
covered by endyma, but just dorsad of it, dimly seen in 
the figure, is a shallow furrow, the habenal sulcus, from 
which the endyma is reflected first dorsad, and then me- 
sad, upon the velum and the diaplexuses. The habena 
unites with its opposite (fellow of the other side) at the 
supracommissure. The endyma line is seen to leave the 
velum, and descend to the dorsal (really cephalic) surface 
of the epiphysis, whence it extends cephalad to and over 
the margin of the supracommissure, then into and out of 
the epiphyseal recess, and over the convex cephalic sur- 
face of the postcommissure; thence it enters the meso- 
cele, where the tracing of its continuity was begun, only 
it is now the lining of the roof, the geminal bodies, in- 
stead of the floor. 

I. Continuing caudad, there is but slight change in the 
direction of the roof of the mesocele; a great reduction in 
its thickness occurs in the transition from the postgem- 
inum to the valvula. The succeeding part, the lingula, 
is somewhat thicker and trends slightly dorsad, to become 
continuous with the cerebellum proper. The cavity 
here resembles a gable roof, with a sharp dorsal angle. 
The caudal slope is formed by the nodulus, a compara- 
tively massive mesal lobe; but from its margin, common- 
ly more rounded than appears in this figure, the endyma 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 


TABLE II.—PROVISIONAL GROUPING OF SomME NeEuRAL Parts ACCORDING TO THEIR SEGMENTS AND SOME 


2. Chief 








OTHER CHARACTERS. 


4, Membranous 6. Thin and 

















which it can be stated confi- 
dently what is normal, or how 
frequently certain peculiarities 
occur. 

§ 68. Classification of _ the 
Parts of the Brain.—The fore- 
going account.of the brain as 
a whole constitutes an intro- 
duction to the description of 
each of the six segments, be- 
ginning with that immediately 
succeeding the myel. 

§ 69. Commentaries wpon 
Table II.—A. It is substan- 
tially identical with Table 
VII. in my paper, 1896, h. 
Compare the tables in the first 
edition of this work (1889, @), 





* The subject is treated with un- 
usual fulness by Krause, 1889, 192-195. 















1. Segment. Raettnont 3. Cavity. portion. 5. Plexuses. riparian parts. 7 Hepes 8. Some other parts. 
I.| Rhinen - i - i i i i i i i 
ae - ceph pe olfac-| Rhinocoelia. ... on arate rciclolststarcitlcte sterai|iersiele ist e.cyorn evettarece ee ae : i = : ° aeehg tN limen, 
II.| Prosencepha-| Cerebrum....| Prosoccelia (in-| Prosotela (in-| Prosoplexus| Tenia, fimbria,) Preeeommissura Pallium insula, len- 
lon. cluding the} cluding the} (including the| pala, terma. (pars temporalis), ticula, caudatum 
mesalaulaand| mesal aulatela} mesal auliplex- callosum, fornix. paraphysis. : 
mea fay para- ae SF maak ena lateral 
III.| Diencepha-| Thalami..... Diacoelia ...... ateed tiene te Habena ....... Supracommissu ra,} Postcribum, tuber, hy- 
lon. medicommissura,| pophysis, : epiphysis, 
IV.| Mesencepha- | Quadrige mi-| Mesocoelia.....| Mesotela(in the}................ Valvula........ Pouteoaint elite Orn Sus erieth 
lon. num. lamprey). decussationes teg- crusta, lemniscu 3, 
V.| Epence pha-| Cerebellum. .| Epicoelia...... |.....+5..- seteniyets Epiplexus..... Lingula........ pan shen 3 senpGac Prepitoueuia anal 
VI. ae Posto blon-| Metaccelia Metatela Metaplexus Metapor' lig-| D Spoken ee gees 
pie sayy peer | MLCtAtCl aces see back Lp pele ig- eeatie pyrami- Syren oliva, trape- 
VII.| Myelon...... Myelon...... Myelococliaz <i) MYGIOLEIA® CIN occ.c cee cccvnre slave Mee A Commissura ventra- Conus, filum 
lumbar en- lis, c. dorsalis. t é 
largement of 
birds). 
is abruptly reflected, together 
with the pia which had cov- if 
ered its caudal surface; these Taga ae 
two membranes, closely united, RHINENCEPHAL 
and with apparently little or no --~ --—- olfactory tract 
trace of the primitive nervous 
roof, constitute the metatela. Lhe" a tesa pat 
This is interrupted or modified 4——— ~- caput of caudatum 
at the orifice here called meta- intercerebral fissure -- 1 2 
pore, but commonly known as 4 P D 
yea of Magendie dh oa Fe SMM hs eee “PHAL 
the present figure it is at the porta —fies3------ zeus 
point where an artery appears. aula - ot 
Later observations indicate ees -- cauda of caudatum 
that the above accounts of the bia —— habena 
metatela and metapore do not se — - ~— medicommissure 
apply to all specimens; see diacele .---- pe OR SIRS US 4 ~ - -- — thalamus 
Re 7483. P : dorsal sack --—-- wees \ NAIR BAL ND) ih a pregeniculum RIENCE HAL 
§ 67. Encephalic Variations. deat a os postgeniculum 
—Excepting as to the fissures Os ed ee. D eeebe es so~ CpIbi yas 
and gyres, and the pyramidal ft Nea ary pregeminum 
decussation, treatises upon an- : bscssescnouax 
atomy seldom refer to varia- _ trochlearis nerve --~- ‘cabal tes bs hehe 
tions or anomalies of the sur- See Se pons 
faces or ental structures of the === focculos EPENCEPHAL 
brain,* yet they are frequent, ——__ cerebellum 
and sometimes significant, mor- 
phologically if not physiologi- 
cally. So far as I can deter- 
mine from my own materials, e etntols : ==3 
@i@earou feuresand descrip- oo =~ a ~~ --—-~~-~ ~ postoblongata | METENCEPHAL 
tions, there is hardly a feature 
of the human brain respecting ate 


F1q. 688.—Brain of the Sheep, dissected so as to exemplify the segmental constitution of the organ in 


mammals. From “ Physiology Practicums.” 1, Cephalic slope of the cut surface of the cerebrum ; 
2, mesal wall of the paracele—at a higher level this would be one of the hemiseptums ; 3, horizontal 
cut surface of cerebrum ; 4, the mesal, vertical portion of the paracele ; 5, indicates the location of 
the ripa between the thalamus and caudatum, but it is overhung by the latter so as not to appear in 
this view ; 6, mesal furrow of the pregeminum. 

From the cerebellum have been cut both caudal and dorsal parts. On the cut dorsal surface are 
seen the central alba and the peripheral cinerea, but the outline of the latter is diagrammatic only. 
At the sides are the tiers of foliums constituting the flocculus. 

From the cephalic end of the cerebrum haye been cut the parts projecting over the olfactory 
tracts, but part of the cephalic slope is here marked 1. With the dorsal portion were removed the 
entire callosum and the fornix excepting the cephalic vertical part. This and the mesal walls of 
the paracele are really cut at a lower level than the larger cut surface on the left. On the right the 
insula has been exposed by pushing up and breaking off the overhanging parts. The ectal sur- 
faces, covered by pia, are indicated by irregular lines representing the blood-vessels. 

The ental surfaces, covered by endyma, are those of the caudatums in the paraceles, the habenas, 
medicommissure, and dorsal pouch ; and the fioor of the aula and portas. 

The irregular line laterad of the habena and extending around the endymal area on the epiphysis 
represents a ripa (shore line). It consists of the cut or torn edges of the pia from the dorsum of the 
thalamus and of the endyma from the habena which united to form a membranous roof of the dia- 
cele, the diatela, which has been removed. 

Similarly the pial, dorsal surface of the thalamus is demarcated from the endymal surface of the 
caudatum by a ripa which meets the other at the porta. 

The epiphysis, although a constituent of the diencephal, is tilted caudad so as to rest upon the 
pregeminum, and the mesal part is covered by the dorsal sack. 


153 


Brain. 
Brain, 








and in Wilder and Gage, 1882, 409. From the tables 
of Schwalbe (1881, 397) and His (1893 and 1895) it differs 
especially in the absence of any attempt to indicate the 
relative “values” of the several segments upon embryo- 
logic or other grounds. 

B. Its purpose is twofold: (a) To indicate, according 
to my present information and belief, the number and 
constitution of the definitive encephalic segments. (0) 
To illustrate, the verbal correlations between the names 
of the segments themselves (column 1), and those of (8) 
their major cavities, (4) their membranous parietes, and 
(5) their vascular plexuses. 

©. The Latin form of the names is employed (see § 10). 

Ill. MerencerHau.—§ 70. Synonyms: Metencepha- 
lon, after-brain, myelencephalon, macromyelon. 

§ 71. Tabular Arrangement of Parts.—Chief part: post- 
oblongata (caudal portion of “ medulla oblongata”). 
Cavity: metacele (caudal portion of “fourth ventricle ”). 
Floor: postoblongata. Sides: restes (“restiform bodies ”) 
and ligula. Roof: metatelaand obex. Plexuses: meta- 





AND 
RHINENCEPHAL 





PROSENCEPHAL 
MESENCEPHAL DIENCEPHAL 


EPENCEPHAL 





METENCEPHAL 


MYEL 


Fic. 689.—Ventral Aspect of the Entire Brain Stem. Xi. (From 
Quain.) Compare Fig. 672. The Roman numerals I.-XII. designate 
the twelve pairs of cranial nerves; di, the optic tract, more com- 
pletely exposed than in Figs. 672 and 728; a, albicans; c, insula; 
ea, ventral column; ¢ 1, first cervical, or suboccipital nerve; ce, 
cerebellum ; cl, lateral column; d, ventral fissure of the myel, just 
cephalad of which is seen the decussation of the pyramids; e, pre- 
geniculum; f, lemniscus; jl, flocculus; h, hypophysis; 7, postge- 
niculum ; 0, oliva; P, crus; pa, pyramid; PV, pons; 7, “ lateral 
tract of oblongata,” direct cerebellar tract; Sy, at the ventral mar- 
gin of the insula, indicates where the basisylvian fissure begins ; tc, 
tuber (‘‘ tuber cinereuwm’’), between which and the hypophysis is 
the infundibulum; Th, thalamus, cut surface; X*, postcribrum 
(‘posterior perforated space’’) ; X X, precribrum (“anterior per- 
forated space’’) ; ++, motor root of trifacial nerve. 

Preparation.—The entire left hemicerebrum has been removed 
by an incision described as passing (in the capsula?) between it 
and the thalamus; on the right side are left the insula, the adjacent 
part of the frontal lobe, the olfactory tract, and the precribrum. 

Defects.—Several parts, notably the albicantia (a) and the floc- 
culus (fl), are represented in a somewhat conventional way, and 
the cimbia (“ tractus peduncularis transversus’’) is omitted. The 
crura, especially the left, are shaded so as to appear twisted. 


154 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


plexuses. Orifice or evagination: metapore (“foramen 
of Magendie”). Decussation: Dec. of the pyramids. 
Other ectocelian parts and features: Ventral sulcus; ven- 
tral column; pyramid; oliva; arciform fibres; lateral 
column; funiculus of Rolando; tubercie of Rolando; 
cuneate funiculus; funiculus gracilis; clava; ligula; 
obex. Other entocelian parts and features: Mesal sul- 
cus; ala cinerea ; postfovea; eminentia cinerea. 

§ 72. The postoblongata (Figs. 670, 688, 689, etc.) is so 
obviously a continuation of the myel that if there were 
no parts cephalad of it, and if it were wholly contained 
within the spinal canal, it would probably be regarded as 
merely a somewhat modified region of the myel, compar- 
able with the lumbar enlargement near its other extrem- 
ity, which also in birds contains a distinct and thin-roofed 
dilatation, the rhombocele.* There is, therefore, ample 
etymological warrant for the name macromyelon (large 
myel region), applied by Owen, and for myelencephalon 
(myel-like brain region), employed by Huxley, His, and 
others. On account, however, of its equally obvious 
continuity with the preoblongata (especially in animals 
lacking the pons, e.g., the turtle, Fig. 680); its location, 
mostly within the cranium; and the number, peculiarity, 
and vital importance of the nerves connected with it, the 
postoblongata is conveniently regarded as a definitive 
segment} of the brain under the title, metencephal. 

§ 73. Nevertheless both the macroscopic and the mi- 
croscopic structure of the postoblongata are much better 
understood in connection with those of the myel. For 
more details the reader is referred to the articles Spinal 
Cord and Brain, Histology of the. 

§ 74. Hg. 689 illustrates: A. The ectal origins of the 
cranial nerves. 

B. The ventral aspect of the adult insula (comp. Figs. 
672 and 781). 

C. The continuity of the optic tract with both genicu- 
lums. 

D. The decussation of the pyramids (see under Fig. 

72). 

E. The representation of all six segments upon the 
ventral aspect of such a preparation, including the parts 
of what is commonly called the “brain stem.” 

§ 75. The postoblongata differs from a corresponding 
length of the myel in size, shape, amount of alba, 
amount and arrangement of cinerea, the extent and form 
of the cavity, and the nature of its roof. 

§ 76. In the myel the two halves dorsad of the com- 
missures are in contact; this is the case also with the 
caudal extremity of the postoblongata; but for most of 
its length the originally mesal surfaces are separated by 
a rapidly widening interval, so that what was mesal be- 
comes successively dorsal, and finally lateral, while what 
was lateral becomes approximately ventral. These 
changes materially increase the width of the segment. 

§ 77. Metacele.—The cavity, a tube in the myel and 
caudal part of the postoblongata, is expanded into an 
irregular triangular fossa, the metacele or caudal part of 
the “fourth ventricle.” The roof of this cavity consists 
of only the lining endyma and the covering pia, consti- 
tuting the metatela. 

§ 78. Metapore (foramen-of Magendie).—In 1826-27 Ma- 
gendie described (1827, i-29) an orifice in the roof of the 
“fourth ventricle” by which that cavity communicates 
with the subarachnoid space. Magendie designated the 
orifice as entrée des cavités du cerveau or entrée des ventri- 
cules cérébraux. In 1855 Luschka published a description 
and figure of the orifice, which he renamed foramen Ma- 
gendit. In the present article these and various other 
polyonyms are replaced by the mononym metapore, Lat- 
in metaporus, signifying an orifice in the metatela, the 
membranous roof of the metacele, the cavity of the me- 
tencephal. 





* This dilatation of the myelocele has also been called sinus rhom- 
boidalis ; and this name has likewise unfortunately been applied to 
the *‘ fourth ventricle,” the continuous cavity of the metencephal and 
epencephal; furthermore, there have come into use derivatives like 
‘**rhomboidal lip” and *‘ secondary rhomboidal lip.” 

+ As stated in § 43, this region represents several potential segments 
or neuromeres. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





§ 79. Most later anatomical writers have admitted the 
existence of the metapore, but the descriptions are com- 
monly brief and the figures unsatisfactory. That by 
Key and Retzius is suspiciously symmetrical, although 


—uvula 
i tonsilla 


metatela 

i metaplexus 
flocculus 
metapore 
pons 


oliva 


obex 





Fic. 690.—The Metapore (Foramen of Magendie) as Exposed by the 
Divarication of the Cerebellum and Cblongata; 318. x 1. 
Preparation.—The brain of an adult Swedish carpenter was re- 
moved with great care, by dividing the calva sagittally at the left of 
the meson, so as to avoid tearing membranous adhesions. The 
brain was supported on a bed of cotton ; the arteries and the arach- 
noid extending from the cerebellum to the oblongata were cut away 
and the two parts held asunder witb fingers so as to expose the re- 
gion of the metapore. A photograph was then taken, upon which 
the drawing is based. After hardening, however, most of the cere- 
bellum was cut away and another photograph taken of the reduced 
mass. The specimen and both photographs were shown at the 
ae of the Association of American Anatomists, December 28th, 


Defects.—The right side of the cerebellum was displaced more 
than the left, giving rise to the marked obliquity. The metapore 
itself should be shown on a larger scale. The postcerebellar arteries 
are omitted ; they do not appear distinctly in the first photograph, 
and no record was made of their locations. This is unfortunate, 
since in all the cases in which they are preserved their relations to 
the metapore are close. Had more of the caudal aspect of the cere- 
bellum been included, there might have been shown the line of at- 
tachment of the arachnoid at the boundaries of the postcisterna. 
The wavy lines on the dorsum of the oblongata hardly do justice to 
the vascularity of the pia covering that region. 


it is copied by Schwalbe; Henle’s (Fig. 691) 4s more nat- 
ural. The best figures and the fullest description are 
those of Carl Hess, 1885, but few figures have the ap- 
pearance of having been based upon photographs. 

§ 80. My own earlier scepticism was based partly 
upon the absence of any such orifice in the cat and sheep, 
and upon the presumption in favor of endymal continuity 
and celian circumscription. The steps of my conversion 
to the more common view are stated in the first edition 
of the REFERENCE HANDBOOK and in the papers there 
referred to. The examination of specimens carefully 
prepared for the purpose showed that: 

(1) The metapore is a normal and nearly constant fea- 
ture of the human brain at and after birth. 

(2) It exists also in apes and some monkeys. 

(3) There are two human types, viz.: (@) definite, as 
shown in Fig. 690; (0) indefinite, Fig. 691. The latter is 
the more common. 


Brain, 
Brain, 


§ 81. Hig. 690 illustrates: A. The existence of a natural 
orifice in the membranous roof of the “ fourth ventricle.” 

Bb. The simplicity of the form and relations of the met- 
ay in this specimen. It is mesal, symmetrical, and 
oval. 

C. The appearance of the metaplexuses just within the 
cephalic margin of the metapore with no such extension 
upon the cerebellum as is shown in Fig. 691. 

§ 82. Hig. 691 illustrates: A. The admission of the nor- 
mal existence of the metapore in the adult by so expert 
an anatomist as Henle. 

B. The attachment of an extension of the metatela from 
the cephalic border of the metapore upon the uvula and 
pyramis of the cerebellum. 

C. The extension of the metaplexuses upon the thus 
everted ental aspect of the metatela, whereas in the speci- 
men represented in Fig. 690 they barely appeared at the 
margin. 

D. The topographical relation of the contorted post- 
cerebellar arteries to the metapore. 

E. The relation of the flocculus to the lateral recess 
(Fig. 698). 

$88. The Metapore the Outlet of an Evagination.—In 
accordance with the general morphological relations of 
the germ layers Minot published (1892, 676) this passage: 

“Several writers have thought that the membrane [en- 
dyma] was broken through at certain points, but it prob- 


_-_---- yallicula 










—— i arachnoid 


— — pyramis 
— tonsilla 
-\— metaplexus 


= metapore 
=~ obex 


iti 
— — postcerebel- 
lar artery 
en eer VOLLOOLAL 
v4! tr ¢ artery 
7X 


Fic. 691.—The Metapore (Foramen of Magendie) and Adjacent Parts 
Nearly as Represented by Henle ( *‘Anatomie,”’ iii., Fig. 232). 

Preparation.—In the absence of statement by the author, it may 
be said that the brain was probably removed in the usual way, and 
the cerebellum tilted cephalad so as to expose its caudal aspect and 
the dorsum of the oblongata. The left tonsilla was then cut out, ex- 
posing on that side the parts marked I, IX, anda continuation of the 
posteerebellar artery. 

I, metatela (velwm medullare posterius), its lateral portion ; II, 
lateral recess of the metepicele (fourth ventricle) opened by the re- 
moyal of part of the metatela ; III, fiocculus; IV, epiplexus (pleaus 
choroideus lateralis). 

Changes.—The boundary line of the tonsilla has been made more 
distinct than in the original. In the upper part has been introduced 
a line to represent approximately the line of attachment of the 
arachnoid, constituting the dorsal boundary of the postcisterna 
(see Fig. 806). 

Defects.—The margins of the metapore are too sharply defined ; 
this is, perhaps, unavoidable when the parts are upon so small a 
scale ; it cannot be said to bear either way upon the question of the 
naturalness of the orifice, for the effect of tearing a tough mem- 
brane like the metatela would be to leave ragged edges. The rela- 
tions of the plexuses and accompanying strip of metatela are inade- 
quately indicated, and the writer regrets his present inability to 
elucidate them. The postcerebellar arteries are represented as if 
distributed only between the oblongata and cerebellum, and between 
the lobes of the latter (compare Fig. 806). 


ably is really continuous throughout life. The fourth 
ventricle is to be regarded, then, as an expansion of the 
central canal permanently bounded by the original med- 
ullary walls.” 

In the following year, in a letter which he authorized 


155 


Brain. 
Brain. 


me to publish in my paper (1893, d), Minot made the im- 
portant suggestion that the metapore represented the 
mouth (proximal orifice) of an evagination of the endy- 
ma. Mrs. Gage found (18938) an evagination in Ama, and 
in Diemyctylus a distal orifice. Recently J. A. Blake 
has gone over the whole subject and shown (1898, 1900) 
by an admirable series of sections that in cats and dogs 
and other mammals there is a caudal protrusion of the 
metatela in the form of a closed sac, but that in man 
and apes, and (with modifications) in other primates, the 
larger part of the sac disappears so as to leave a free 
communication between the “fourth ventricle” and the 
postcisterna, a subarachnoid space. Blake’s paper is ac- 
cessible to American anatomists, and the bibliography is 
very complete; much, however, remains to be done. 

§ 84. The increased cinerea of the postoblongata con- 
sists of (1) the continuous expanded masses of the ven- 
tral and dorsal cornua, especially the latter, which, with 
the modified ventral commissures, constitute the metace- 
lian floor; (2) special masses of cinerea, more or less 
completely separate, the nidi of Spitzka, the niduli of 
Herrick, the “nuclei” of most writers, constituting the 
ental or deep origin of certain cranial nerves, and pre- 
sumably representing detachments of the cornua; (8) the 
dentatum olive, or olivary nucleus, a capsule of cinerea 
within the oliva, resembling the cerebellar dentatum. 

§ 85. Fig. 692 illustrates: A. The insensible transition 
from the myel to the postoblongata, and thus from the 
myel as a whole to the brain as a whole. 

B. The apparently sharp demarcation between the 
epencephal, represented here mainly by the pons, and the 


prepeduncle medipeduncle 


lingula 


postpeduncle 


restis 
clava 12 


prepeduncular fossa 
prepeduncle 







2 ripa 


crus 1 postpeduncle pyramid oliva 
Fia. 692.—Left Side of the Metepencephal (After the Removal of the 
Cerebellum) ; 2,136. > 1.5. 1, Emergence area of the trifacial 
nerve, the larger the sensory root, the smaller the motor; 2, the 
fibre arciforme partly encircling the oliva; 3, line of emergence 
of the accessorius and of the dorsal roots of the spinal nerves; 4, 
continuation of the lateral column of the myel; 5, line of emergence 
of the ventral roots of the spinal nerves ; 6, ventral column ; 7, ven- 
tral (mesal) fissure: 8, myelocele: 9, dorsal (mesal) fissure; 10, 
funiculus gracilis, the oblongatal continuation of the myelic dorso- 
mesal (*‘ posterior median’) column, enlarging cephalad into the 
claya; the clava and funiculus together are sometimes called ** pos- 
terior pyramid’’; 11, ‘‘ posterior median fissure”; 12, funiculus 
cuneatus ; 13, the shaded band represents the mesal portion of the 
metacele (caudal part of the ‘‘ fourth ventricle ’’) between the restes 
(“‘restiform bodies’’) of the two sides; 14, acoustic tubercle, over 
which run the acoustic strize, which are not shown; 15, tubercle of 
Rolando, the continuation of the unspecified funiculus of Rolando, 
interpolated between the funiculus cuneatus and the emergence 
line of the dorsal roots. ; ; 
Defects.—Although good in general form and showing the oliva 
and its arciform fibres (2) with unusual distinctness, the specimen 
does not exhibit the several columns very clearly, and the lines of 
demarcation, excepting the ‘* posterior median fissure,”’ are taken 
from other preparations and from figures; this applies also to the 
lines upon the pons indicating the passage of the caudal fasciculi 
entad of the cephalic. The dotted lines demarcating the sectional 
areas of the peduncles are only approximately accurate. The facial 
ae acoustic nerves are not shown, or the acoustic strize (see Fig. 
393). 


adjoining segment. In reality, however, not only do the 
cephalic and caudal margins overhang the adjoining sur- 
faces to a certain extent (see Fig. 702, 1 and 2), but it is 
by no means certain that the pons covers no more and no 
less than the epencephalic portion of the oblongata. In 


156 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the sheep and cat, for example, the trapezium, here in- 
visible, is exposed (Fig. 794), while with many lower 
vertebrates the pons is rudimentary or absent altogether, 
and the boundaries between metencephal and epencephal 
must be otherwise determined; e.g., the turtle, Fig. 
680. 

C. The lapping of the cephalic portion of the pons 
over the caudal, giving the appearance of a twist or rota- 
tiou of the medipeduncle upon its own axis to the extent 
of the fourth of a circle. 

D. The relation to the oliva of the arciform fibres (2), 
which appear to be derived from the pyramid and to pass 
around the caudal end of the oliva to enter into the com- 
position of the restis and postpeduncle. 

E. The projection of the right clava beyond the left, 
a marked lack of symmetry in this specimen. 

F. The ripa, or line of demarcation between the gen- 
eral, pial surface of the myel and oblongata, and the en- 
dymal, metacelian surface. The ripa consists of the pia 
and endyma with, in some specimens (Fig. 702), a thin 
intervening lamina of nervous substance. 

G. The prepeduncular fossa, a shallow depression on 
the dorso-lateral surface of the prepeduncle, near the 
medipeduncle. 

§ 86. The visible longitudinal divisions of the postob- 
longata do not correspond altogether with the myelic 
columns. The ventrai column (Fig. 672, 7, Fig. 689, ca, 
Fig. 692, 6) continues cephalad partly in the pyramid of 
the same side, as would naturally be expected, but mostly 
dips entad of the pyramid and oliva and forms longitu- 
dinal fasciculi near the meson farther dorsad. 

§ 87. Of the lateral column (Fig. 689, e/, and Fig. 692, 
I) a large part crosses at the decussation (shown in Fig. 
689, but not always visible) to constitute mainly the 
pyramid of the opposite side. Some of the fibres join the 
restis of the same side, constituting the “direct lateral 
cerebellar tract.” The rest of the lateral column dips en- 
tad of the oliva and “forms the longitudinal fibres of the 
substantia reticularis grisea.” 

§ 88. The dorsal column of the larger portion of the 
myel is displaced in the cervical region by the dorso- 
mesal (“posterior median”) column (Fig. 692, 10); this, 
in the postoblongata, is called funieulus gracilis. Near 
the apex of the metacele it presents a distinct enlarge- 
ment, the clava (Fig. 692), cephalad of which the funicu- 
lus is no longer distinct. Between the funiculus gracilis 
and the lateral column (Fig. 692, 4) there intervene, in the 
postoblongata, two funiculi, of which the more lateral 
(15) is regarded as the direct continuation of the dorsal 
column of the myel, but is commonly called funicuius of 
Rolando, sometimes “lateral cuneate”; between it and 
the dorso-mesal column (funiculus gracilis) intervenes 
another interpolated funiculus, the cuneate (12); this and 
the funiculus of Rolando appear to enter into the com- 
position of the restis (“restiform body ”) which is con- 
tinued as the postpeduncle into the cerebellum; but, ac- 
cording to Quain, this relation is rather apparent than 
real, the components of the restisand postpeduncle being 
(a) the arciform fibres (Fig. 692, 2) from the ventral 
column, and (0) the “ direct cerebellar tract ” of the lateral 
column. : : 

§ 89. The increased bulk of the postoblongata is due 
also in part to the entrance (or exit) of the roots of the 
accessory, hypoglossal, vagus, and glosso-pharyngeal 
nerves, which are more numerous than the spinal nerve 
roots upon a similar length of the myel (see Figs. 672 
and 689). 

§ 90. Fig. 693 illustrates: A. The general topographic 
relation of the cerebellum to the segments just cephalad 
and caudad, and to the ventral portion of its own seg- 
ment, through the three pairs of peduncles, prepeduncle 
(5), postpeduncle (8), and medipeduncle (the cut area 
crossed by line 5 on the right and by lines 3, 4, and 5 on 
the left). 

B. The tendency of anatomical writers to ignore the 
existence or traces or morphological significance of the 
thin or membranous portions of the encephalic parietes 
(see my paper, 1891, 5). 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





IV. EPENCEPHAL.—§ 91. Synonyms.—Epencephalon; 
metencephalon; cerebellar segment; hindbrain. 

§ 92. Principal Parts.—Floor: preoblongata and pons. 
Roof: cerebellum and lingula. Sides: peduncles. 


“Cavity: epicele with lateral recesses. Ectocinerea: 


cortex. Entocinerea: dentatum, fastigatum, embolus, 
globulus. Chief cerebellar divisions: (mesal) vermis: 
(lateral) pileums (“hemispheres”). Flocculus and para- 
flocculus. 

§ 98. Boundaries.—The epencephal may be defined as 
including as much of the brain tube as intervenes. be- 


~ 
VAL 


fi 
Nees 





Fig. 693.—Dissection of the Peduncles. 0.5. (From Quain, after Sap- 
pey, and Hirschfeld and Leviellé.) 1, Mesal sulcus; the line crosses 
the middle of the wide cut surface of the medipeduncle; 2, mesal 
sulcus at the place of emergence of the acoustic strive; 3, postpe- 
duncle, continuous with the restis; the cut end of the postpeduncle 
is crossed by the line, 2; 4, the clava, the swollen portion of the fu- 
niculus gracilis; 5, prepeduncle; 6, lemniscus; 7, lateral sulcus of 
the crus; 8, pregeminum, the postgeminum just caudad. 

Preparation.—On the left, the three peduncles are cut short; the 
right half of the cerebellum is cut obliquely, and tilted laterad, so as 
to show the connections of the prepeduncle and postpeduncle. 

Defects.—There is no evidence of the lines of division, ripas, of the 
endyma in exposing the metepicele (‘‘ fourth ventricle ’’), or of the 
existence of the valvula and lingula between the prepeduncles. 


tween the membranous portion of the roof (metatela) and 
the decussation of the trochlearis nerve, together with 
the corresponding regions of the floor and sides and the 
encompassed cavity, the epicele. 

§ 94. Fig. 694 illustrates: A. The general aspect of the 
adult cerebellum from the side. 

‘B. The location of three main sulci, furcal, cacuminal, 
and peduncular. 

§ 95. Epicele-—The epencephalic cavity includes the 
cephalic (“anterior”) portion of the “fourth ventricle ” 
together with its dorsal extension (fastigium) into the 
cerebellum, more or less triangular in form. According 
to Blake (1898-1900, 89-90) the cavity of the cerebellum 
has at first a greater dorso-ventral extension which is 
reduced by the fusion of the opposed walls. 

§ 96. Lateral Recesses.—By this name are commonly 
known the pair of extensions of the “fourth ventricle ” 
laterad and ventrad (Figs. 684, 695, and 698). Their walls 
are partly membranous (metatela) and partly substantial 
(sides of oblongata, peduncles of flocculus, and certain 
nerve roots). They might with equal appropriateness, 
perhaps, be described under the metencephal, and the 
difficulty in determining the segmental assignment is 
very naturally included by Blake (1898, 104) among the 
reasons for the non-recognition of two segments in this 
region. 

§ 97. Fig. 695 illustrates : A. The embryonic continuity 
of the endyma and more substantial elements of the 
parietes around the lateral recesses at this stage (see § 98). 

B. The corrugation of the thin portion of the par- 
epicelian parietes preparatory to the formation of the 
epiplexus. 

§ 98. Outlets of the Lateral Recesses.—Although closed 
in the embryo (Fig. 695) the ventral ends of the recesses 





are commonly described as open, constituting communi- 
cations with the subarachnoid space even when the meta- 
pore does not exist. I have been disposed to regard these 


peduncular sulcus 


flocculus 





Fig. 694.—Left Side of the Cerebellum of an Aged White Man ; 3,434. 
<1. (From Stroud, 1897, a.) The outlines were drawn with the 
camera lucida. 


orifices as artifacts from the readiness with which the 
membranous adhesions of that region are torn during the 
removal and examination of the brain according to cus- 
tomary methods. But the histological and embryological 
researches of Blake seem to show that in man and in mam- 





| 
| 
| 
parietes 


4 


Fig. 695.—Transection of the Brain of an Embryo Rabbit, Sixteen 
Days Old. (From KOlliker.) 65; enlargement of part of Fig. 669. 


mals generally the ends of the recesses are opened by the 
more or less extensive disappearance of the membranous 
parietes. 

§ 99. Fig. 696 illustrates, in addition to points also shown 
in Fig. 694: A. The great depth of the furcal sulcus. 

B. The absence of the lingular foliums (§ 119). 

§ 100. Preoblongata.—The floor of the epicele is the 
preoblongata, continuous with the postoblongata and 
with the crura. In the turtle (Fig. 680) and other non- 
mammals there is no obvious line of demarcation. 


157 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





> 


markedly reinforced by a transverse fibrous mass, the 
pons, that it is easily recognized; but the width of the 


fureal s. 
‘ 








postramus. 


metapore 


FIG. 696.— Mesal Aspect of the Cerebellum of an Adult Male Negro; 3,118. 
x 1. Traced from a photograph. (From Stroud, 1897, a.) : 


pons varies so greatly that its margins can hardly be ac- 
cepted as the boundaries of the entire segment. Compare 
the turtle (Fig. 680) with the sheep (Fig. 794) and man 


(Figs. 672 and 689). 


§ 101. Pons.—In mammals the preoblongata is so 


peduncular sulcus 
' 


cacuminal s. 


bellum, the pollex the short and sharply curved post- 
peduncle, the index the longer and less curved prepe- 
duncle, and the other three fingers the intermediate and 
thickest medipeduncle, continuous with its oppo- 
site through the pons. 
§ 105. Hig. 697 tllustrates: A. The lapping of the 
tonsillze over the uvula. 
wy Pr B. The location of the flocculus and the com- 
mencement of the peduncular sulcus. 

C. The relative position and size of the three pe- 
duncles. 

§ 106. Flocculus and Parafloceulus.—Attached to 
the medipeduncle by short peduncles of their own 
are small foliated masses, the flocculus (in two 
lobes) and the paraflocculus (in one) (Figs. 698 and 
701). Contrary to the implication of the names, the 
paraflocculus is really attached mesad of the floceu- 
lus; in Fig. 698 they are twisted so that the reverse 
appears to be the case. The peduncle of the floc- 
culus forms part of the wall of the “lateral recess ” 
(Fig. 698). Little is known of the functions of 
these parts or of their homologues in other animals. 
According to Stroud (p. 96) the paraflocculus is 
much larger in the cat and capable of division into: 
a supraflocculus and mediflocculus. 

§ 107. Fig. 698 tllustrates: A. The location and 
form of the flocculus, with its two divisions and. 
rounded folia, and of the smaller paraflocculus, 
presenting but slight traces of foliation. All are 
attached to the medipeduncle, and the flocculus is. 
sometimes called the peduncular lobe. 

B. The general location of the lateral recess. 
(2), or parepicele, between the peduncles cephalad, 
the restis and other parts of the postoblongata mesad, 
and the flocculus stem laterad; its peculiar relations. 
with the glosso-pharyngeal and vagus nerves are in- 
adequately shown and need special preparation and 


§ 102. Peduneles.—At and near the meson the connec- | study. 


tions of the cerebellum with the adjoining segments are 
thin; the lingula is relatively atrophied (Fig. 702) and the 
metatela wholly membranous (Figs. 670 and 687); but 


laterally the cerebellum has massive 
continuations, constituting three pairs 
of peduncles: a cephalic (prepedun- 
cles) to the mesencephal; a caudal 
(postpeduncles) to the metencephal 
and myel, and an intermediate (medi- 
peduncles) to the pons, part of the 
same segment. 

§ 108. The peduncles constitute a 
continuous mass of alba at either side, 
but their relative positions and extent 
are pretty well determined by various 
methods, anatomical, microscopical, 
and experimental. The medipeduncle 
is the largest and most lateral; it is 
mainly continued from the lateral lobe 
of the cerebellum to the pons, where 
the fibres cross the meson, interdigi- 
tating with their opposites, and form- 
ing a relation with the cinerea. The 
postpeduncle mainly connects the ver- 
mis with the restis, while the prepe- 
duncle connects chiefly the dentatum 
with the mesencephal and parts far- 
ther cephalad. The dorso-lateral as- 
pect of the prepeduncle presents a 
distinct shallow depression, the prepe- 
duncular fossa (Fig. 692). 

§ 104. The relative location and di- 
rection of the three peduncles on the 
right side may be illustrated by the 
digits of the right hand. Hold the 
hand with the fingers down, the thumb 
pointing backward, the index forward, 
and the other three fingers, slightly 
overlapping, outward between them. 
The palm may then represent the cere- 


158 





C. The twisting of the peduncles of the flocculus and 
paraflocculus whereby their real attachments are appar- 
ently reversed. The paraflocculus, although its name. 


pyramis ~— 


¢ cuneiform lobe 


peduncular sulcus prepeduncle nodulus flocculus 
medipeduncle lingula epicele 
postpeduncle 


Fic. 697.—Caudal (** Lower’”’ or ‘‘ Posterior ’’) Aspect of the Adult Cerebellum. A little less: 


than natural size. (From Edinger, inverted and slightly modified.) 1, Part of the right 
quadrangular lobe. The cut ends of the peduncles are dotted ; the large medipeduncles 
extend latero-dorsad into the lateral lobes; the flocculi are attached to the medi- 
peduncles. The continuity of the vermian divisions with those of the lateral lobes is. 
not apparent upon this aspect. 

Defects.—In addition to the general remark made under Fig. 700 the following 
special deficiencies are to be noted: (1), There is no line to represent the divided endyma 
of the metatela along the caudal (here upper) side of the cavity (epicele) ; all this region 
requires elucidation in respect to celian circumscription ; (2), the omission of the plex- 
uses and nerve roots; (3), the postvermis should be more deeply shaded to indicate its 
depth below the level of the tonsillae, which also are really almost in contact; (4), on 
coop hs ee Fig. 700, the vermis should present a line indicating the reflexion of the 
arachnoid. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


suggests a lateral position, really is attached mesad of 
the flocculus; see Fig. 701. 

§ 108. The cerebellum is essentially an arch over the 
epicele (cephalic part of the “fourth ventricle”) (Fig. 


y floceulus 
medipeduncle | _ paraflocculus 


It metacele 





leet 243 
pontiraphe 


Fic. 698.—Caudal Aspect of the Right Flocculus and Adjacent Parts ; 
2,238. > 2. 1, Endymaat the left side of the epicele; 2, right lateral 
recess, laid open; 3, oliva; 4, pyramid; 5, trifacial nerve; 6, ab- 
ducens; 7, facial; 8, acoustic; 9, glosso-pharyngeal; 10, recess 
latero-dorsad of oliva. 

Preparation.—The cerebellum was removed by division of the 
peduncles to near the floor of the epicele, and the postoblongata by 
a transection just caudad of the pons; the lateral recess (2) had 
already been torn open, as usual, in removing the brain, and its en- 
tire extent and exact form are not determinable from this prepara- 
tion (see Fig. 684). 


699). This condition exists in the embryo, and per- 
sists in many of the lower vertebrates. The adult 
human organ, however, is a foliated mass of complex 
fibrous and cellular structure, 
well meriting the adjective 
hypertrophied, applied to it by 
E. C. Spitzka. 

§ 109. Fig. 699 illustrates : 
A. The large size of the epi- 
cele at this period, as compared 
with the 
thickness of 
the parietes. 

B. The ex- 
tensions _lat- 
ero - ventrad 
constituting 
the parepi- 
celes or “ lat- 
eral recesses” (compare Figs. 384 and 
895). 

C. The non-appearance of the mesal 
lobe, vermis, at this period and the 
absence of sulci upon the lateral 
masses, pileums. 

D. The continuity of the riparian 
part, a, the kilos (“ posterior velum ”), 
along the line of junction of the ectal 
pia and ental endyma, they not being 
represented distinctly; if their torn 
edges were distinct they would con- 
stitute the cestus. The cestus and 
kilos indicate the line of attachment of 
the metatela. 

§ 110. Aspects of the Cerebellum.—In 
the natural condition of the adult brain 
the rounded margin of the cerebellum 
demarcates two surfaces looking re- 
spectively “upward” and “down- 
ward.” But in accordance with the 
general principle of normalization 
(§ 38) and by analogy with the simpler 
case of the epiphysis (§ 154) the cere- 





Fic. 699. — Caudal Aspect of 
the Cerebellum and Oblon- 
gata of a Fetus. (Size and 
age and magnification un- 
certain, specimen and notes 
having been lost; it proba- 
_bly resembled quite nearly 
the specimen shown in Fig. 
373.) a, The kilos. 





postsemilunar lobe 


peduncular sulcus 





quadran 


Fig. 700. — Cephalic (‘‘ Upper” or *‘ Anterior’’) Aspect of the Adult Cerebellum. 
inger, inverted and slightly modified ; a little less than natural size. 
portion of the central lobe. 

Defects.—The original figure is obviously diagrammatic; it was selected as more clear 
than usual, and as representing the general interpretation of the foliar arrangement on 
this aspect of the cerebellum ; I am not, however, satisfied in all respects, and regret that 
I cannot determine certain points upon my own preparations, so as to base the figures upon 
them entirely. These remarks apply equally to Fig. 697. 


Braib, 
Brain. 





bellum is here regarded as if projecting dorsad at 
right angles with its supporting portion of the brain- 
axis, the oblongata (Fig. 702). The two main surfaces 
become therefore cephalic and caudal, but they are not 
sharply delimited. 

§ 111. Pileums and Vermis.—The adult cerebellum 
comprises a mesal lobe, the vermis, and two lateral 
masses, the pileums, commonly called “hemispheres.” 
On the cephalic aspect, the vermis (prevermis) is promi- 
nent (Fig. 700); but on the caudal the lateral lobes project 
decidedly beyond the postvermis, the surface of which 
is thus at the bottom of a deep mesal crevice, the vallis 
(“vallecula”) (Fig. 697). 

§ 112. Foliwms, Sulei, and Lobes.—The entire surface 
of the adult cerebellum presents numerous lines, for the 
most part parallel and having a generally transverse 
direction. These lines represent crevices of greater or 
less depth, the sulci, and the intervening thin plates are 
the folia. Certain of the interfoliar crevices are so con- 
stant, deep, or distinct as to warrant the recognition of 
the intervening groups of folia as lobes. 

The commonly received division of the two regions of 
the cerebellum into lobes is indicated upon the figures. 
I am free to admit, however, that I am by no means fully 
satisfied therewith. 

§ 113. Fig. 700 illustrates: A. The natural tilt caudad 
of the cerebellum, so that its normally cephalic surface 
looks dorso-cephalad, even when the oblongata is held in 
the cephalo-caudal plane. 

B. The extension of the cerebellum, so as to overhang 
the postoblongata. 

C. The enormous preponderance of the pileums (lateral 
lobes) over the vermis (mesal lobe) in the adult; compare 
however, Fig. 699. 

D. The slight demarcation between the vermis and 
pileums on this aspect. 

E. The appearance of part of the postsemilunar lobes, 
and of the peduncular sulcus, both these appearing 
partly also upon the caudal surface. 

F. The connection of the two cacuminal (presemi- 
lunar) lobes by means of a single folium, the cacumen. 

§ 114. Cortex (ectocinerea).—Each folium consists of a 
central lamina of alba and a covering of cinerea having 
a peculiar cellular structure; see the article Histology of 
the Brain. 






vant 


gular lobe 





central lobe 
lingula 


valvula prepeduncle 


From Ed- 
1, The ala or lateral 


159 


Brain. 
Brain. 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





§ 115. Peduncular Suleus (“great horizontal fissure”). 
—When the flocculus and paraflocculus are removed, or 
the overlapping foliums of the cerebellum are separated 
from them and from one another by the removal of the 
pia, the non-foliated lateral surface of the medipeduncle 
is easily seen to continue laterad and dorsad for about 1 
cm. between the tiers of foliums on the cephalic and the 
caudal aspects. This interval is the beginning or stem 
of what iscommonly called the “ great horizontal fissure,” 
but which, from its obvious relation to the medipeduncle, 
I have called peduncular. By most writers it is repre- 
sented as continuing along the dorsal (“ posterior”) mar- 
gin of the cerebellum and as demarcating the cephalic 
and caudal aspects of the entire organ. In particular it 
is regarded as meeting its opposite at the meson just 
caudad of the cacumen, a single thin folium which, at 
either side of the meson, enlarges and becomes a subdi- 
vided cacuminal (“ presemilunar ”) lobe. 

§ 116. The Peduncular Sulcus Incomplete as a Land- 
mark.—But, while it is perfectly possible, with most 










pregeminum. - - 
postgeminumr ~ 


prepedunele. ..- 
medipeduncle - } 


culminal lobe. 


B. B. Stroud, del, 


Fic. 701.—Diagram Showing the Divisions of the Human Cerebellum as If Extended in One 
The line between the cacuminal lobe and the tu- 
beral lobe should be designated peduncular sulcus C* horizontalis magnus’’). 


Plane. (From Stroud, 1897, b, 108. ) 


specimens, to recognize a deep sulcus of the pileum which 
passes caudad of the cacumen and trends laterad in the 
direction of the medipeduncle, an inspection of the depths 
arouses doubts of its essential continuity and morpho- 
logical significance. 

§ 117. Furcal Suleus.—On various grounds, especially 
comparative anatomy and development, Stroud has con- 


160 


cluded (1897, a, 6) that the primary and most constant 
sulcus, and the one which should be held to demarcate 
the two main regions of the cerebellum, is one which 
leaves the stem of the peduncular sulcus opposite the at- 
tachment of the paraflocculus and passes at right angles 
across the cephalic surface, dipping between the ad- 
jacent foliums so deeply as to more nearly reach the 
cavity than any other of the sulci. As seen in Table III. 
the furcal is the preclival sulcus of Schifer. 

§ 118. The region. cephalad of the furcal sulcus is 
divided by the culminal sulcus (postcentral of Schiifer) 
into the culminal lobe and the central lobe. 

§ 119. Lingula.—When the central lobe is lifted or 
removed there will be exposed the valvula, the thin 
zone of the mesocelian roof, and caudad of it, completely 
overhung and concealed by the adjacent parts of the 
cerebellum, a series of three, four, or five transverse di- 
minutive foliums; see the medisection (Fig. 702). At 
birth the lingular folia are rounded and distinct, but in 
the adult they are relatively smaller, often flattened as if 

by pressure of the overhanging cere- 

bellum, and sometimes (at least in cer- 

tain negro and insane brains) nearly or 

completely absent.* The cephalic foli- 

um is narrowest and has a rounded 

outline (Fig. 700): the pia adheres 

quite firmly to these folia, so that they 
- are liable to be torn off. 

§ 120. Mig. 702 tllustrates: A. The 
mesal topography of the cerebellum 
and adjacent parts when brought into 
nearly their “normal position,” 7.e., 
when the metepencephalic floor is 
nearly horizontal (cephalo-caudal) and 
when the longer axis of the cerebellum 
is nearly dorso-ventral; this is nearly 
their condition in a body lying prone, 
with the axon and longer portion of 
the neuron (myel) approximately hor- 
izontal, as with most quadrupeds and 
the majority of walking and swim- 
ming vertebrates (see § 9, and the arti- 
cle on Terminology, Anatomicaly. For 
comparison with Figs. 670, 687, and 
756, this or they must be regarded as 
turned about one-fourth of a circle. 

B. The exact number and form of 
the cerebellar folia and subfolia at 
birth, so far as they appear upon an 
approximate medisection. 

C. The combination of the folia to 
form lobes, more or less well defined. 

D. The arboriform arrangement, 
whence the name arbor vite (herein 
mononymized to arbor). 

E. The topographical relations of 
the mesal lobe (vermis) to the lateral 
lobes; caudad, dorsad, and at the ven- 
tro-cephalic region the lateral lobes 
project beyond the vermis, but the 
latter is the more prominent with the 
culmen at the cephalic side and with 
the nodulus at the caudo - ventral 
angle. The interval between the lat- 
eral lobes on the caudal aspect consti- 
tutes the vallis. 

F. The enormous size of the cere- 
bellum as compared with its cavity, 
even had the dorsal part of the latter 
been maintained at its natural size by 
alinjection. 

G. The projection of the cerebellum beyond its attach- 
ments and proper cavity. Cephalad, it overhangs not 
only the valvula, but the postgeminum, these being parts 
of the mesencephal; caudad, whatever exact limit be as- 


* The lingula has not been recognized in the apes, but Stroud is in- 
clined to regard as its homologue what he described (1897, b, 120) as a 
‘cephalic’ lobe in apes and in certain human brains, ¢é.g., Fig. 698. 


signed to the epicele, 
the vermis covers the 
entire “fourth ventri- 
cle.” 

H. The distinctness 
of the four lingular 
folia, constituting the 
transition from the 
massive cerebellum to 
the atrophic (?) val- 
vula. 

I. The prominence 
of the cephalic and 
caudal margins of the 
pons, and the concomi- 
tant depth of the pre- 
pontile and postpontile 
recesses. 

J. The merging of 
the dorsal commissure 
of the myel and post- 
oblongata into the 
obex, and of this into 
the ligula; in the adult 
this latter seems to be 
hardly more than the 
combined pia and en- 
dyma (see Fig. 692), 
but in the child’s brain 
from which this fea- 
ture was derived, al- 
though the meninges 
had been removed, 
there was, neverthe- 
less, a distinct lamina 
of nervous substance. 

§ 121. The divisions 
of the caudal region 
of the cerebellum can- 
not be seen complete- 
ly unless the _ post- 
oblongata is forcibly 
bent ventrad or cut 
away; indeed the en- 
tire oblongata and pons 
may advantageously 
be removed by tran- 
section of the pedun- 
cles ventrad of the floc- 
culi as in Fig. 697. 

§ 122. When the pil- 
eums are divaricated 
the postvermis caudad 
of the cacumen is seen 
to be at first narrow, 
then wider, and then 
decidedly compressed. 
The wide portion is 
the pyramis; the short 


region between it and the cacumen, the tuber; the longer 
portion of the remainder is the uvula crowded between 
subglobular divisions of the pileums, the tonsils. Fi- 
nally, and seen with some difficulty, is the nodulus, a 
group of three or four foliums, connected at either side 
by the kilos with the flocculus. The relations of these 
parts to one another and to the lateral masses and to the Vermis. 
sulci are indicated upon Table IV. 


"TABLE III.—SYNONYMS OF THE PRINCIPAL SULCI OF THE CERE- 
BELLUM; STROUD, 1897, a. 


Preferred. 


1. Central sulcus. 

2. Culminal sulcus. 
3. Furcal sulcus. 

4. Cacuminal sulcus. 
5. Peduncular sulcus. 


‘6. Pyramidal sulcus. 
7. Uvular sulcus. 


8. Nodular sulcus. 
Vou. II.—11 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


furcal sulcus -——= 


furcal sulcus w= V(t an 





Brain, 
Brain, 





ug evan sulcus 
















pyramidal sulcus 


~=-— pyramis 


oe 


——— pyramis 


=) 9 ih. = 


=="pyramis 


tonsilla 
uvula 








7. clava 
5 
ligula 





Re 


! cae 
valvula f a } 
H ) lingula 7 


/ 


r obex 


i nodulus 


' 
} 
mesocele ; ee ss. Myelocele 


; / 
epicele metacele 
EPENCEPHAL METENCEPHAL 


Fic. 702.—The Metepencephal (Cerebellum, Oblongata, and Pons) of a Child at Term, Showing the Approxi- 


mately Mesal Aspect of the Right Half; 478. x3. Traced from an enlarged photograph. (This is the 
same specimen that is shown in Fig. 756, where, however, no attempt was made to represent details, and 
the cerebellum is more nearly in its * ‘natural attitude.” 1, Prepontile recess; 2, postpontile recess (fora- 
men ccecum) ; 3, presumed caudal end of the pyramid; between 3 and 4 there might be—but were not 
seen—indications of the pyramid decussation (Figs. 672 and 689) ; 5, slight elevation of the metacelian floor ; 
the triangular darker area just ventro-cephalad represents the postfovea ; 6, the dorsal extension of the epi- 
cele into the cerebellum ; 25, metatela (diagrammatic). 

Defects.—The plane of section passed slightly sinistrad of the meson; hence certain features are not 
exactly what would have appeared upon a precise medisection. On the cut (unshaded) surfaces the alba 
and cinerea are not distinguished, the latter having been bleached by the alcohol. The pons section does 
not show the fibres of the raphé. The cavities were not alinjected and hence are unnaturally small. The 
meninges were removed; so there is no indication of the dorsal attachment of the arachnoid to limit the 
subarachnoid space, and the obex, ligula, and metatela are supplied from other specimens, but the extent of 
the metapore (foramen of Magendie) is not shown. 

When the drawing was made, the significance of the furcal sulcus had not been recognized. Dr. Stroud 
has kindly revised the identifications. He would limit the prevermis to so much as is cephalad of the fur- 
cal sulcus ; but for the present 1 retain the original designations of the two regions of the vermis. The sul- 
cus just cephalad of the cacumen is the cacuminal ; that just caudad is the peduncular, deep in the pileum 
eo but shallow at the meson. The tuber is the part between the peduncular and tuberal sulci. 

ee 


TABLE IV.—SYNONYMS OF THE LOBES OF THE CEREBELLUM; FROM 
STROUD, 1897, a. SLIGHTLY MODIFIED. 








; VARIOUS 
TERMS PREFERRED. SCHAFER. eae 
Vermis Worm and hemi- : . 

and pileum. sphere. Hemisphere. 














Lobus lingulz....../Frenulum ling- 
ule. 
= : 1. (Lingu-|1. Lingular lobe..|1. Lobus centralis..|Ala lobuli cen- 
Schafer. la?), Ceph- tralis. 
1. Sulcus precentralis. alic lo be, : 
2. Sulcus postcentralis. variable 
3. Sulcus preclivalis. 2. Centrall2. Central lobe...|2. Not recognized 
4. Sulcus postclivalis. lobe. as a distinct 
5. Sulcus horizontalis magnus. lobe. 
c Sulcus postgracilis. 3. Culmen..|3. Culminal lobe .|3. Lobus culminis .. ola lunatus an- 
. Sulcus intragracilis. erior. 
6. Sulcus pregracilis. } Lara sul- 
s. postpyramidalis. eras 
7. Sulcus prepyramidalis. 4, Clivus ...|4. Clival lobe..... 4. Lobus clivi,..... Lobus lunatus 
8. Sulcus postnodularis. 4 posterior. 


161 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





TABLE IV.—SYNONYMS OF THE LOBES OF THE CEREBELLUM; FROM 
STROUD, 1897, a, SLIGHTLY MODIFIED.—Continued. 








TERMS PREFERRED. SCHAFER. peaveens 
i Vermis Worm and hemi- ; 
Vermnis. and pileum. sphere. Hemisphere. 
5. Cacumen |5. Cacuminal lobe|5. Lobus cacuminis.|Lobus postero-su- 
perior. 
Presemilunar 
lobe. 
6. Tuber .../6. Tuberal lobe.../6. Lobus tuberis....|Post paid ce ha 18 
lobe. 
Lobus postero-in- 
ferior. 
a. pretuberall..... Raeisjelelv'e sealateiviel Che hie SEMI NaTIS 
lobe. inferior. 
b. medituberal |........... oeeeeeeee (0. Slender lobe. 
lobe. 
L. gracilis pos- 
terior. 
C. POSTLUID OG lh iecrciee Ceireenisianices c. L. gracilis ante- 
lobe. rior. 4 
7. Pyramis..|7. Pyramidal lobe.|7. Lobus pyramidis.|Cuneiform lobe. 
L. biventralis. 
8. Uvula....|/8. Uvularlobe....|8. Lobus uvule..../Tonsilla. 
Amygdala. 
9. Nodulus ./9. The -nodulus/9. Lobus noduli.....|Flocculus. 
does not ex- 
tend laterad 





into the -pil- 
eum. 

The flocculus is 
a separate di- 
vision. It is 
not a part of 
the pileum (or 
hemisphere). 








§ 123. Fig. 703 illustrates: A. The constitution of the 
dentatum asa corrugated capsule of cinerea, open cephalo- 
ventrad. 

B. The entrance of the fibres of the prepeduncle 
through the hilum of the dentatum to connect with its 
cells. 

§ 124. Hntocinerea.—Upon a medisection of the organ 
there would appear to be only alba and ectocinerea, the 





Fic. 703.—The Dentatums and Prepeduncles. 


direction of the prepeduncles as shown in Figs. 692 and 693. 


Defects.—By an inexcusable oversight the prepeduncles are not indicated by a line 
and the name ; but they are readily recognized as the fibrous tracts at the sides of the epi- 
There is no representation of 
the “ fleece,” the layer of fibres radiating from the ectal surface of the dentatum. 


cele, converging from the dentatums to the geminum. 


former branching in a tree-like manner, whence the name 
arbor (vite). But in the central part of the cerebellum, 
near the apex of the epicele, are four pairs of masses of 
cinerea sometimes called roof-nuclei or tectal nidi. There 
are reasons for thinking that the primitive cerebellar ento- 


162 


. cinerea of the dentatum 


fibres of the dentatum 
rimula 


(From Stilling, somewhat modified.) 
Preparation.—The plane of section was oblique, so as to coincide with the general 


cinerea has been displaced, and is represented by these 
masses enumerated in their order from the meson laterad: 
Fastigatum; globulus; embolus; dentatum. 

§ 125. The Dentatum.—This is the largest and most. 
easily recognized of the four masses; (see Figs. 703 and 
704). It has the form of a corrugated capsule, open 





dentatum 


Fig. 704.—The Dentatum and Other Masses of Cinerea in the Centra} 
Part of the Cerebellum. From Stilling, somewhat modified. * 2—. 
Preparationv=—This is commonly designated as a “horizontal” 
' section. Really, the plane cannot be indicated in such simple terms. 
The central part of the figure, including the cinereal masses, is 
through the fastigium, the roof of the apex of the epicele. 
Defects.—No attempt has been made to represent the fibrous con- 
stitution beyond the purely diagrammatic indication of the cephalic 
(anterior) decussating commissure. 


meso-ventro-cephalad, for the reception of the fibres of 
the prepeduncle (Fig. 703). In any cerebellum, whether 
fresh, or hardened in chromic acid compounds, or even 
alcohol, it is readily recognized upon transections or 
upon sagittal sections begun about 1 cm. either side of 
the meson and continued laterad for 2 or 8 cm. The 
dentatum has received the following additional names, 
of which the last only is used with any frequency: 
Nucleus dentatus ; corpus denticulatum, s. fimbriatum, s. 
lenticulatum, s. ciliare ; Eng., ciliary body. 

§ 126. The Fastigatum.—This, more often called 
“fastigial nucleus,” is close to the meson, directly in the 
roof (fastigium) of the epicele; Fig. 
703. It is rounded cephalad, but the 
caudal end presents two or three 
projections. 

§ 127. The Embolus and Globulus. 
—These smaller masses of cinerea lie 
between the dentatum and the fas- 
tigium, and somewhat dorsad of the 
latter. Their forms are indicated by 
their names, and are well shown in 
Stilling’s figure as reproduced in 
Fig. 704. More common (and cum- 
bersome) titles are nucleus globosus or 
globuliformis, and nucleus emboli- 


— postpeduncle fo rms: 
OF § 128. Hig. 704 illustrates: A. The 
Globull existence, near the apex of the epi- 


cele, of four pair of cinereal masses, 
representing, perhaps, dislocated por- 
tions of. the cerebellar entocinerea. 

B. The lack of precise symmetry 
in the forms of these masses; of the 
globuli there are three on the left and 
two on the right, the more cephalic 
probably representing two. 

V. MESENCEPHAL. —§ 129. Syn- 
onyms: Mesencephalon; midbrain. 
Tabular arrangement of parts: Chief 
parts: quadrigeminum and crura. 
Cavity: mesocele (aqueduct or iter.) 
Floor: crura. Sides: gemina: Roof: 
gemina and valvula. Ectocinerea: cappa. Entocinerea 
(“central tubular gray”). Commissures: postcommis- 
sure, trochlear decussation. 

§ 130. In early embryonic stages the mesencephal is 
the most conspicuous region of the entire brain, but con~ 


Pee 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





sists of a single, thin-walled vesicle, with a relatively 
large cavity (Figs. 671 and 677). As the parietes thicken, 
two furrows appear upon the dorsal aspect; a mesal, 
demarcating the left elevation from the right, and a 
transverse, subdividing each of these into a cephalic and 
a caudal portion (Fig. 678); there results, in the adult 
mammalian brain, the formation of four approximately 
similar elevations, whence the names, corpus quadri- 
geminum, corpora quadrigemina, optic lobes, etc. In the 
present article they are called gemina (twin bodies), pre- 
geminum and postgeminum (Figs. 693 and 707). They 
constitute.the larger part of the mesocelian roof. 

§ 181. Valoula.—A caudal portion of the mesocelian 
roof retains nearly its primitive tenuity as a transparent 
lamina, the valvula, between the gemina and the lingula 
(Fig. 702). Its cephalic part presents some slight corru- 
gations, either a mesal furrow anda pair of lateral ridges, 
the frenulums (Fig. 706), or a mesal ridge in addition. 

§ 132. The fibres of the trochlearis nerve decussate in 
the valvula. It is practically convenient, although not 
perhaps quite correct, to regard the trochlear decussa- 
‘tion as the boundary between the mesocelian valvula 
and the epicelian lingula (see Fig. 675). 

§ 133. Mesocele.—In all mammals what Tiedemann 
picturesquely described as a “ vast and spacious cavity ” 
becomes relatively an insignificant tubular passage, 
which has been called “aqueduct” and 7ter a tertio ad 
quartum ventriculum. As may be seen from Figs. 670, 687 
and 756, it is expanded or trumpet-shaped at the cephalic 
end, and irregular in form at the caudal; the intermedi- 
ate, longer part varies considerably in different indi- 
viduals, being sometimes nearly cylindrical, but usually 
a transection presents points in two, three, or four direc- 
tions, lateral, ventral, dorsal; the departures from the 
cylindrical shape are more frequent and distinct in the 
postgeminal and valvular portion (see Figs. 687, 706, and 
708), and may be regarded as vestiges or suggestions of 
the potentially tripartite condition which is actually pres- 
ent with birds and frogs (Fig. 685). 

§ 134. Lemniscus and Brachia.—The lateral slope of 
the mesencephal presents three megascopic features, the 
lemniscus, postbrachium, and prebrachium, shown in 
Fig. 706; in the former the fibres run approximately 
cephalo-dorsad, in the latter obliquely 
dorso-ventrad; their course and con- 
nections are considered in the article 
Brain, Histology of the, as is also the 
extent of the ectocinereal lamina called 
cappa. The lemniscus and its connec- 
tions have been discussed at consider- 
able length by E. C. Spitzka, 1884, e. 

§ 185. Hntocinerea.—This is the least 
modified of all portions of the ence- 
phalic “central tubular gray ”; it forms 
a layer 2 to 3 mm. thick surrounding 
the mesocele. 

§ 186. The Crura (crura or peduncult 
cerebri).—Excepting the parts already 
named, the mesencephal consists mainly 
of a pair of fibrous masses (Figs. 672 
and 689) containing the compacted mo- 
tor and sensory conductors between 
the regions caudad, whose relations are 
mainly with the body, and the regions 
cephalad, which are the organs of the 
mind. Each crus consists of two re- 
gions, a ventral, the crusta, and a dor- 
sal, the tegmentum (Figs. 706 and 708). 

§ 137. Intercalatum (substantia ni- 
gra, locus niger).—A transection 
through the crus at almost any level 
reveals a dark mass (Figs. 706 and 
708) of crescentic outline, approximately dividing the 
section into a ventral third and a dorsal two-thirds. Its 
lateral and mesal borders correspond to the furrows 
called sulcus lateralis and s. oculomotorius. The name 
commonly employed refers to the distinctly dark color 
(due to pigment in the cells) of the mass in man and 


caudatum. 












postgeniculum 


lemniscus * 
optic tract 


postecribrum 


Brain, 
Brain, 


some apes; but the absence of color in other mammals has 
led E. C. Spitzka to propose a name referring to its more 
constant character of intercalation between the ventral 
crusta and the dorsal tegmentum; the locative mononym 
be eye by the Association of American Anatomists 
in ; 

§ 188. Postcommissure.—The cephalic margin of the 
mesocelian roof is of moderate thickness, and curved 


- epiphysis 
> supracommissure: 
- epiphyseal recess 







- postcommissure 
+-— mesocele 


tegmentum 
-=-~—7- intercalatum 


ay a | 





crus 


Fig. 705.—The Postcommissure and Adjacent Parts; 2,239. 1.5. 
Preparation.—The diencephal was transected just cephalad of 
the postcommissure ; the diatela was torn away to admit more light ; 
the space just above the epiphysis was occupied by the dorsal sack. 
The figure should be compared with the medisections (Figs. 670 and 

687), and with the dorsal aspect of the region (Figs. 707 and 708). 


dorsad so sharply as to present a cephalic convexity 
(Fig. 705) and a caudal concavity (Fig. 687). Osborn has 
suggested that it is intersegmental like the trochlear de- 
cussation (Fig. 675). 

§ 139. Mig. 705 tllustrates: A. The appearance of this 
aspect of the postcommissure as a cylinder. 

B. The considerable size of the epiphyseal recess; al- 
though a mere diverticulum within an apparently func- 
tionless organ, it is larger than the cephalic orifice of 
the mesocele in this specimen. 

C. The distinctness of the supracommissure (commis- 
sura habenarum). 


frenulum 
valvula 
| aqueduct 


prebrachium 


a regeminum 
postbrachium | 


postgeminum 


\ 










tegmentum 


Fig. 706.—Caudal Aspect of the Mesencephal and Part of the Diencephal ; 2,360. X 1.5. 1, 
Tenial sulcus; 2, right postgeniculum ; 3, right pregeniculum. 

Preparation.—A well-hardened, alcoholic, adult brain was transected just cephalad of 
the pons, at a level indicated nearly by the line from crus in Fig. 707. A block containing 
the thalami and adjacent parts was then cut out by incisions in various directions, the 
fornix peeled off, and the velum and other parts of the pia removed ; the ink lines near 
the sides marked ripa indicate the lines along which the lateral margins of the velum, 
the paraplexuses, were torn away. 

Defects.—More should have been left at the sides and ventrad. On the left, the 
roughly indicated curved line just laterad of the tenia was due to inadvertence, and may 
be disregarded. See § 140. 


D. The location of the dorsal sac upon (morphologi- 
cally, cephalad of) the epiphysis; see Fig. 687. 

E. The modified relative position of these parts. Ina 
less modified condition of things, the two commissures 
and the epiphysis should all lie nearly in one plane; but 
the pressure of the superincumbent cerebrum has made 


163 


Brain, 
Brain. 





the long axis of the epiphysis cephalo-caudal instead of 
dorso-ventral, and left the two commissures and the two 
orifices in a dorso-ventral series instead of a cephalo- 
caudal. 

§ 140. Fig. 706 illustrates: A. Segmental overlapping. 
The thalami and geniculums project caudad beyond the 
intersegmental line, and the caudatum is here directly 
laterad of the thalamus instead of cephalad; consequently 
a transection through the pregeminum would divide not 
only the mesencephal, but also both the diencephal and 
the prosencephal. 

B. The caudal extension of the thalamus as a rounded 
eminence, the pulvinar, on which, at the right, the word 
thalamus is placed. 

C. The existence of two other eminences on this aspect 
of the diencephal, the postgeniculum, mesad and more 
distinct, and the pregeniculum, laterad and less distinct. 
With lower mammals the general mass of the thalamus 
is less developed than in man, and the pregeniculum is not 
only still less prominent, but also decidedly cephalad, so 
that the prefixes pre and post are much more appro- 
priate. 

D. The continuity of the optic tract with both the 
geniculums, more obviously with the pregeniculum. 

E. The nearly complete concealment of the pregemi- 
num, in this view of the parts, by the postgeminum; the 
former is seen at the left to project slightly. 

F. The location and forms of the postbrachium and 
prebrachium; the former is between the two geminums, 
the latter just cephalad of the pregeminum; as they pass 
ventrad they embrace, as it were, the postgeniculum. 

G. The location of the lemniscus, just caudad of the 
postbrachium. 

H. The T-shape of the mesocele in this specimen. 

I. The thinness of the mesocelian roof, here constituted 
by the valvula, with a mesal furrow and lateral ridges, 
the frenulums. 

J. The relatively extreme thickness of the mesocelian 
floor, constituted by the crura. 

K. The division of each crus into a ventral crusta and 
a dorsal tegmentum, the boundary between these two 
regions being defined partly by the lateral furrow, op- 
posite the word erus, on the left, and partly by a pig- 
mented tract, the intercalatum, not here seen, but shown 
in Figs. 705 and 708. 

L. The deep ventral depression between the crura, 
constituting an intercrural area. 

M. The presence, at the cephalic end of this area, of 
several rather large foramina for the transmission of 
arterial branches, whence this part is called postcribrum 
(“posterior perforated space”). 

N. The trefoil outline of the mesencephalic transection 
due to the mesal and the two lateral depressions. 

O. The obviously and unquestionably pial and ecto- 
celian character of all the natural mesocelian surfaces. 

P. The equally unquestionable continuity of these sur- 
faces over the geniculums to the pulvinar. 

Q. The absence of anything like a ripa on the visible 
surface of the thalamus until we reach the sharp and 
irregular line so marked at the left. 

R. The endymal and entocelian character of the slender 
natural surface of the caudatum. 

8. The continuation of this endymal surface upon the 
visible length of the tenia. 

T. The significance of the ripa as not only a boundary 
between contiguous pial and endymal surfaces, but as 
indicating where the margin of the paraplexus or some 
membranous continuation of it has been torn away. 

§ 141. Mig. 707 illustrates: A. The segmental overlap- 
ping of the diencephal at the side of the mesencephal 
and of the prosencephal at the side of that (see § 55). 

B. The division of the caudatum (the entocelian por- 
tion of the striatum) into a cephalic, enlarged caput and 
a caudal, slender cauda. 

C. The unlike topographical relations of these two 
parts, in that the caput is uncomplicated, while the 
cauda has a slender, marginal (riparian) band at its mesal 
side, the tenia, having peculiar relations with other parts. 


164 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








D. The location of the diacele between the two thalam\ 
and its continuity with the aula. 

E. The presence of the medicommissure (seen somewhat 
better in Fig. 709). 

F. The relation of the callosal genu to the intercerebral 
fissure and the pseudocele; but for the callosum the 











intercerebral f. 
‘cortex 
medulla 


postcommissure 
supracommissure 


pregeminum 
postgeminum 


prepedunde 


Fig. 707.—Dorsal Surfaces of the Caudatum, Thalamus, and Gemina. 
(From Henle, reduced and slightly modified.) 1, Tenial sulcus; 2, 
fimbrial sulcus; 3, habenal sulcus; 4, trigonum; 5, “anterior tu- 
bercle”’ of the thalamus. 

Preparation.—The dorsal portion of the cerebrum has been re- 
moved, including the callosum, fornix, velum, paraplexuses, and 
diatela; also the pia covering the epiphysis’ and mesencephal. 

Defects.—The shading is too deep and does not indicate the dis- 
tinction between the pial and the endymal surfaces. The caudal 
parts of the thalami are crowded mesad, and the gemina are not 
Well shaped. 


fissure and thegpseudocele would be continuous, as 
would also the hemiseptum with the general mesal wall 
of the precornu. 

G. The demarcation of the mesal, entocelian surface 
of the thalamus from the dorsal, entocelian surface by a 
rough edge just dorsad of the habena; here it is repre- 
sented by the narrow, white line between the two black 
ones, and designated as the habena; it is really a ripa 
along the dorsal side of the habena (see also Figs. 687 
and 739). 

H. The presence of three shallow furrows on the dor- 
sal surface of the thalamus; a dorso-mesal, just dorsad 
of the habena, the habenal sulcus; a lateral, correspond- 
ing nearly with the mesal edge of the tenia, the tenial 
sulcus; an intermediate and oblique, corresponding with 
the lateral margin of the fimbria (removed), the fimbrial 
sulcus. 

I. The demarcation of the dorsal surface of the thala- 
mus, which is pial and ectocelian, from the adjoining 
surface of the caudatum and tenia, which is endymal and 
entocelian, by a sharp, irregular line at the mesal edge 
of the tenia, constituting a ripa. This line was intro- 
duced into the figure; it is absent in the original, as in 
all similar figures known to the writer, excepting Fig. 
16, in Meynert’s “ Psychiatry,” where it is called “linea 
aspera,” without, however, any reference to its morpho- 
logical significance. 

J. The vague and unsatisfactory representation of the 
parts at the porta. This region has yet to be cleared up 
in respect to the relation of the pial and endymal surfaces; 
it was my inability to show these relations clearly upon 
original preparations that led me to employ the present 
figure provisionally. 

K. Incidentally it may be remarked that both this and 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





the previous figure exemplify the advantages of that 
feature of the simplified nomenclature which consists in 
the designation of members of natural or artificial groups 
of parts by words compounded of the generic terms and 
prefixes indicating relative position; e.g., pregeminum 
and postgeminum; pregeniculum and postgeniculum; 
precommissure, medicommissure, postcommissure, and 
supracommissure. 

V. DrencepuaL.—§ 142.—Synonyms: Diencephalon, 
deutencephalon, thalamencephalon, interbrain, *tween- 


brain. ‘Tabular arrangement of parts: Chief parts: 
thalami. Cavity: diacele. Floor: tuber, chiasma, and 
diaterma. Sides: thalami. Roof: diatela (practically 


the velum). Plexuses: diaplexuses. Commissures and 
decussations: medicommissure, supracommissure, chi- 
asma. KEctal elevations: albicantia, pregeniculums, and 
postgeniculums. Perforated areas: precribrums and 
posteribrum. Ental elevations: habena. Ectal de- 
pressions: trigonum, habenal, tenial, and fimbrial sulci. 
Ental depression: aulix (“sulcus of Monro”), Append- 
ages: hypophysis, epiphysis, and dorsal sac. 

With the adult of man and all other mammals the 
primitively thin sides of the diencephal are greatly thick- 
ened and become the thalami, with the geniculums (pre- 
and post-) as latero-caudal elevations. The relations of 
the diencephal to the entire brain are well indicated in 
the young rabbit (Fig. 681). 

§ 143. The pregeniculum and postgeniculum are repre- 
sented in Figs. 706 and 707, and described in connection 
therewith; the optic tract and the chiasma are shown in 
Figs. 689 and 711, and considered in connection with the 
optic nerves in the article, Cranial Nerves. 

§ 144. Mig. 708 illustrates: A. The form, direction, 


Se eer prehypophysis 
optic n. 
















infundibulum 


1 


optic tract 
2 


tuber 
albicans 


crus 
posteribrum 


ocuRmotor nerve 


erusta 


intercalatum ; crus 


4. tegmentum J 


mesocele 


postgeminum 


Fia. 708.—The Tuber (tuber cinereuwm) and Adjoining Parts; 706. 
x 1.5. (The same region is shown in Figs. 672 and 689, upon a 
smaller scale.) 1, Expanded proximal end of the infundibulum, 
covering the lura, which is exposed in Fig. 672; 2, a slight elevation 
between the tuber and the optic tract. The irregular line across 
the tuber and optic tracts represents the cut or torn edge of the pia, 
which adheres quite firmly to the chiasma. The black spots repre- 
sent the foramina in the postcribrum and elsewhere through which 
vessels passed; the triangular region laterad of the chiasma is a 
part of the precribrum (‘‘ anterior perforated space’). 

Preparation.—The brain was removed with great care, the hy- 
pophysis being extricated from its fossa by dividing the dural folds 
in several cirections with the sharp point of a scalpel, and then in- 
troducing the blunt-pointed syringotome. 

Defects.—The natural surfaces of the crura should have presented 
amore fibrous appearance (somewhat as in Fig. 689), and another 
preservative than alcohol would have differentiated the cinerea on 
the cut surface. The albicantia have perhaps the appearance of 
overhanging the postcribrum too far, but this is more nearly correct 
than the usual representation, as, for example, in Figs. 672 and 689. 
The left intercalatum should be shown more nearly like the right. 


and complete separation of the albicantia; they are usu- 
ally represented (as in Figs. 672 and 689) as hemispherical 
elevations; here they are seen to be elliptical in outline, 
their longer axes converging caudad, and the caudal ends 
overhanging the postcribrum; in the sheep (Fig. 794) and 
in mammals generally the albicantial sulcus is a shallow 
depression or wholly absent. 

B. That the hypophysis is wider than long, and con- 
sists of two parts, conveniently called prehypophysis and 
posthypophysis ; the latter is the smaller and partly as it 
were let into an emargination of the former. 

C. The expanded base of the infundibulum (1). 

D. The raised, unnamed area (2) at either side of the 
tuber. 

EK. The demarcation of the crusta from the tegmentum 
by the intercalatum. 

F. The slight, angular extensions of the mesocele, 
which sometimes is almost circular in outline. 

§ 145. The diacelian floor is various in direction and 
composition. Beginning with the mesencephalic floor, 
the crura (Fig. 687), there is a marked decrease in thick- 
ness in the region of the postcribrum (which may really 
be common to the two segments), as well as a deflection of 
the floor ventrad; the albicantia (Figs. 672, 689, and 708) 
constitute lateral thickenings, and then the floor is re- 
duced to an atrophied lamina comparable with the val- 
vula; this, with the shorter, thin part just cephalad of 
the intervening and dependent hypophysis, constitutes 
the tuber (tuber cinerewm) and infundibulum. The 
fusion of the stems of the primitive optic vesicles to 
form the chiasma, and the fusion of this with the other- 
wise thin diacelian floor, confers upon the latter in this 
region considerable thickness and firmness, but this part 
is again succeeded by the atrophied terma (Figs. 687 and 
711), strictly the diaterma, in distinction from the proso- 
terma dorsad of the precommissure. Although the dia- 
terma has a nearly dorso-ventral direction, it should 
properly be regarded as part of the floor, since the aula, 
the mesal division of the prosocele, is constructively ceph- 
alad of the diacele, although actually more nearly dorsad. 

§ 146. Hypophysis (pituitary body or gland, Figs. 670, 
687, and 708).—This has a twofold origin, viz., from the 
neuron (posthypophysis) and from the enteron (prehy- 
pophysis); see the article Brain, Development of. Herd- 
man thinks it may have been an ancestral sense organ 
(American Naturalist, 1888, p. 1127). At present, not- 
withstanding its constancy throughout the vertebrates, 
its function is still in doubt, but the not infrequent co- 
existence of acromegaly with lesion of the hypophysis 
merits careful consideration.* 

§ 147. In marked contrast with the massive sides the 
diacelian roof is, for the most part, very thin, consisting 
apparently of the endyma only, closely attached to the 
ventral or diencephalic layer of the velum, from which 
are developed the parallel diaplexuses (Figs. 716 and 782) 
dependent at either side. Cephalad, the diatela is con- 
tinuous with the aulatela, or perhaps directly with the 
fornix dorsad of the aula and portas; caudad, it extends 
for some distance beyond the proper diencephalic bound- 
ary, is reflected ventrad upon the dorsal (properly 
cephalic) aspect of the epiphysis to constitute the dorsal 
sac, and is then continuous with the supracommissure, 
and the epiphysis itself (Fig. 687). 

§ 148. Mig. 709 illustrates: A. The size, form, and 
connections of the medicommissure; it is relatively 
smaller than in other mammals (Fig. 688), and slightly 
constricted about its middle; if isolated it would have the 
form of a pulley-wheel with a shallow groove. 

B. The relations of the mesal aula to the portas and to 
the diacele (see § 163). 

C. The thinness of the lamina uniting the two halves 
(columns) of the fornix. This lamina must be regarded 
as the primitive prosocelian terma as high as the dorsal 
limits of the porta, and may, therefore, be called the 
prosoterma. 


* On this subject articles have been published by Woods Hutchinson 
in the New York Medical Journal for July, 1900. 


165 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





§ 149. Habena (habenula); (Fig. 687).—At the dorsal 
margin of the mesal surface is the habena, a slight ridge, 
with a dorsal convexity, extending from the porta to 
the supracommissure, which unites it with its opposite. 






pseudocele 


hemiseptum precorme caudatum 


endyma 
fornix 


—medicommissure 
thalamus 


-diacele 


Fic. 709.—The Medicommissure and Adjacent Parts; 20382. 1.3. 
(Compare Fig. 707, where some of the same parts are shown on a 
smaller scale.) 

Preparation.—The brain was removed with care so as not to 
tear the medicommissure, and alcohol was injected per luram so as 
to harden the parietes and keep them apart. ‘The prefrontal lobes 
were then removed, thus opening the precornua and exposing the 
caudatums; with these as guides the block containing the medicom- 
missure was safely isolated; the thalami are cut away almost to the 
level of the commissure. See § 148. 


Along the dorsal side of the habena is the habenal sul- 
cus, and the two represent nearly the line of reflection of 
the endyma from the mesal surface of the thalamus upon 
the roof: of the diacele (see Figs. 681, 687, 707, and 732). 

§ 150. Fig. 710 illustrates : “A. The overlapping of the 
cerebrum upon the diencephal, so that the transection of 
one includes the other. 

B. The folding of the pia covering the now apposed 
dorsal surface of the thalami and the ventral surface of 









Ahm pia velum 


LWA i Be 
{ 1a \ 
\ PROSENCEPHAL 


.cerebrum 


Tostrum 


callosum™ 


? ¢ 
fornix 


DIENCEPHAL 
thalamus 


Fic. 710.—Diagrams Illustrating the Relations of the Callosum, For- 
nix, and the Pseudocele, the Constitution of the Velum, and the Su- 
perposition of the Prosencephal. The upper figure represents the 
mesal aspect of the right half of the schematic brain; the lower, a 
transection of both right aud left halves at the level indicated by the 
line A in the upper. In the lower figure the thickening of the black 
line representing the fornix may indicate the hippocamp, but 
strictly it should be corrugated, presenting an ectal furrow—the 
hippocampal fissure. The relations of the fornix to the rest of 
the parietes would also be more completely shown had the black 
line been interrupted a little laterad of the hippocamps. 

Defects.—The aula, the mesal part of the prosocele, is shown of 
equal size with the diacele, and on the same level; this is not the 
case, so far as the writer is aware, with any vertebrate in which the 
callosum and fornix attain dimensions such as are indicated in the 
figure (see Fig. 725) ; but so far as concerns the special objects of 
this figure, the above inconsistency may be ignored. Unlike most 
of the figures, the substantial nervous parietes are represented by 
the heavy black line, the pia and endyma by lighter ones. 


the cerebrum so as to constitute the velum (see Fig. 732); 
but since this figure does not represent the lapping of 


the prosencephal upon the diencephal at the s¢des, or the. 


166 





formation of the rima and paraplexus, the pia of the two 
segments is continued independently around each. 

C. The theoretical constitution of the diacelian roof 
by (1) the possible, though not always actual, continua- 
tion of the thicker nervous material at the sides, (2) the 
lining endyma, (3) the covering pia, one or both layers 
according to the closeness of their adhesion. 

D. The relations of the callosum, fornix, and pseudo- 
cele; the two former represent two lines of extended 
junction between the apposed mesal surfaces of the 
hemicerebrums; they are continuous at the splenium 
and likewise in man at the cephalic end; the space thus 
circumscribed like the hollow of a partition is the pseu- 
docele or “fifth ventricle”; it is really narrower, but the 
relations are as indicated. : 

E. The general constitution of the fornix is more fully 
described in § 197. 

§ 151. Medicommissure (commissura media, s. grisea, 
s. cinerea, s. mollis, s. thalamic fusion).—Primarily sepa- 
rate, the apposed, mesal surfaces of the thalami unite (at 
about the fifth month of gestation according to Mihalko- 
vics), giving rise to what is commonly called the “ middle 
commissure ” (Figs. 670, 687, 707, and 709). It is in a di- 
rect line between the porta and the aqueduct, consider- 
ably nearer the former, and just dorsad of the aulix. The 
shorter, dorso-ventral, diameter, is 4-5 mm., the longer, 
cephalo-caudal, 6-7. It is relatively larger in all other 
mammals (¢.g., sheep, Fig. 688); it is present in turtles 
(Fig. 680) but absent in birds and other immammalia. 
Its functions are experimentally unknown, but in a man 
and a cat lacking the callosum, it was larger than usual. 

§ 152. Anomalies of the Medicommissure.—lt is said to 
be sometimes double. Among sixty-six brains Wenzel 
found it absent inten. It is wanting in at least half a 
dozen of the (about two hundred) brains prepared or ex- 
amined by me with reference to it, amongst others in No. 
8,334, Professor Oliver.* 

§ 158. Azliz (sulcus of Monro; part of the interzonal 
sulcus?).—Most well-preserved brains present a move or 
less distinct furrow just ventrad of the medicommissure 
terminating cephalad at the porta (“foramen of Monro ”) 
and caudad near the postcommissure, sometimes in the 
mesocele and sometimes in the epiphyseal recess. It was 
figured and described by Reichert under the title “sul- 
cus Monroi,” for which I proposed (1884, e) the ee 
aulizx, a furrow (Figs. 675, 687).+ 

§ 154. Epiphysis (conarium, pineal body or gland ; Figs. 
675, 687, 707).—Excepting the lancelet (Branchiostoma) 
every vertebrate likewise has this apparently useless or 
vestigial diverticulum of the diacelian roof. Max Flesch 
believes that it is associated with the temperature ap- 
paratus, but the number of forms in which has been 
traced a connection between it and a rudimentary mesal 
eye is so great as apparently to warrant the view that it 
is the remnant of a primitive mesal organ of vision; see 
the papers of Béraneck (1892,) Heckscher, Ritter (1891), 
and Studniéka (1899); Ritter also describes the relation 
of the epiphysis to a blood sinus in Phrynosoma. 

§ 155. Acerous (acervulus cerebr’).—The adult epiphy- 
sis frequently has embedded in follicular cavities calcare- 
ous particles known by the above names, and as “ brain- 
sand”; in the brain shown in Fig. 687, it was so abundant 
as to leave a considerable cavity when removed, but this 
unusual feature is not represented. 


* [venture to suggest that some of the reported cases may have 
been based upon inadequate evidence. Unless the brain is medi- 
sected while fresh, or prepared by the injection of a preservative into 
the arteries or the cavities, or both, the medicommissure commonly 
fails to be reached; its peculiar softness causes it to break easily; and 
the imperfect preservation of the adjacent thalamic surfaces might 
lead to the non-recognition of the slight elevation indicating its exist- 
ence. If the specimen is allowed to dry slightly, and is then held so 
that the light is reflected from the smooth endymal surface of the thal- 
amus, then the presence of the remnant of the commissure will be in- 
dicated by the absence of such reflection from an area corresponding 
with its usual location. There are few other parts of the brain where 
errors of observation are more likely to occur. 

+ His and others have applied the name “sulcus Monroi”’ to an al- 
leged sulcus extending from the mesocele to or toward the optic 
recess, and have interpreted it asa portion of the interzonal sulcus 
(sulcus limitans ventriculorum) ; the grounds for dissent from this 
interpretation are stated in my papers 1896, d, and 1897, a. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





§ 156. Peculiar Topographic Relations of the Epiphysis. 
—One of the striking results of the segmental overlapping 
and crowding is the embedding, as it were, of the epiph- 
ysis amongst four segments. Although directly con- 
nected with the thalami, the epiphysis leans caudad so 
as to rest upon the pregeminum; the cephalic aspect of 
the cerebellum rests upon the postgeminum and abuts 
against the epiphysis; finally the callosum, a cerebral 
commissure, has its splenial curvature upon the epiphy- 
sis. Between all these parts, of course, there are mem- 


EF 


KJ 


paracele 












pseudocele 
i hemiseptum 


+ rostrum 


optic tract 
chiasma 


4 : ‘ = optic nerve 


Fic. 711.—-Cephalic Aspect of the Terma (‘‘lamina terminalis”) and 
Adjacent Parts of a Young Child; 218. 1.5. 1, Torn margin of 
the pia on the chiasma; it has been removed from the adjacent sur- 
face; 2, gyrus subcallosus, continuous dorsad with the * peduncle 
of callosum.”’ 

Preparation.—The brain was exposed by removing the skull 
with nippers and scissors so as to avoid tearing the terma; the optic 
nerves were divided close to their foramina of exit. After harden- 
ing in alcohol, the parts adjacent to the terma were carved away ; 
the surface at either side is concave, following the general direction 
of the terma. The block was strengthened by a long (shawl) pin 
passed from side to side, and a common pin was pushed into the 
striatum at either side so as to project beyond the optic nerves and 
keep the latter from striking the sides of the vial. The removal of 
the pia from the terma was the most difficult part of the prepara- 
tion, and the utmost care did not prevent the tearing of a small slit 

- in the left side, which is ignored in the figure. 


branes and vessels, but if they are disregarded the epiph- 
ysis, a part of one segment, the diencephal, may be 
described as encompassed by three others, the mesen- 
cephal, the epencephal, and the prosencephal. With a 
brain hardened in its natural shape, a disc 2 cm. in di- 
ameter (e.g., a “nickel”) will cover parts of all four en- 
cephalic segments; see particularly specimens 385 and 
2,268; in drawings, for the sake of clearness, the parts are 
sometimes represented as if less crowded; e.g., Figs. 672 
and 687. 

§ 157. Fig. 711 tllustrates: A The existence and com- 
pleteness of the terma (lamina terminalis or 1. cinerea), 
constituting the cephalic boundary of the mesal enceph- 
alic cavities; in the embryo it is actually the most ceph- 
alic part of the brain, but is later concealed by the pro- 
jecting hemicerebrums. 

B. The continuity of the terma with the chiasma, 
leading to the rupture of the former during the removal 
of the brain unless the optic nerves are early divided. 

C. The extreme thinness and delicacy of the terma 
which cannot be represented adequately in such a view, 
and is not always indicated in the medisections; Fig. 687. 

D. The existence of a somewhat thicker extension of 
the terma at each side, forming the cephalic boundary 
of the optic recess. 

E. The pair of slightly raised bands, commonly called 
the “ peduncles of the corpus callosum,” continuous ven- 
trad with the gyri subcallosi. 

F. The convexity of the entocelian surface of the 
caudatum (see also Fig. 707). 

G. The relation of the callosal rostrum to the hemi- 
septums, the lateral halves of the septum lucidum. 

H. The somewhat unusual thickness of the hemisep- 
tums in this specimen. 

VII. ProsencepHaL. —§ 158. Synonyms: Prosen- 


cephalon; telencephalon; forebrain; secondary forebrain; 
cerebrum; * pallium. The prosencephal is here regarded 
as composed of the cerebrum (cerebral hemispheres) less 
the olfactory bulbs and tracts, and the parts and cavities 
connecting them across the meson. See Table IL., p. 153. 

§ 159. Peculiarities of the .Prosencephal.—From the 
other segments the prosencephal is distinguished by (a) 
the extraordinary range of variation among vertebrates, 
as seen in, ¢e.g., the hag (Fig. 791), the lamprey (Fig. 790), 
the salamander (Fig. 717), the frog (Fig. 685); the rabbit 
(Fig. 681); and cat (Fig. 682); (>) its preponderance in the 
human adult as contrasted with its primary insignificance 
(Fig. 676); (c) its (generally conceded) function as the 
organ of the “ mind.” 

§ 160. Prosocele.—The prosencephalic cavity is pri- 
marily single and mesal, as indicated in the diagram, Fig. 
674; it may remain so in cyclopean monsters (Fig. 712), 
and a nearly undivided adult cerebrum has been de- 
scribed by Turner (Fig. 7138). 

§ 161. Mg. 712 illustrates: A. The increase of the pro- 
sencephalic vesicle in size and in the thickness of its 
parietes. As shown in Fig. 2 of the original paper, the 
floor and cephalic wall of the mesal region are 7 to 11 
mm, thick, supposing the parts to be of natural size. 

B. The subordination of the lateral extensions to the 
mesal portion of the prosencephal; they do not, as in the 
normal brain, extend cephalad of the mesal boundary, 
but merely laterad, caudad, and to a certain extent ven- 
trad, so as partly to overlap the mesal portion. 

C. The partial formation of fissures, one of which may 
represent the Sylvian. 

D. As stated in the text, the prosencephalic cavity is 
single, z.e., not divided by constricted orifices (portas or 





Fic. 712.—Ventral Aspect of the Brain of a Cyclops, at Term. (From 
Cleland, Journal of Anatomy and Physiology, xii., Pl. xvii., Fig. 
1.) The size of the specimen is not stated. The arachnoid has been 
removed from the mesal region, and from the left. The original 
paper contains a flgure of a medisection of the entire mass, a de- 
scription of some animal cyclopians, and a brief discussion of the 
nature of the malformation. 


“foramina of Monro”) into a mesal aulaand lateral para- 
celes. In this respect the cyclopean brain may be com- 
pared to the normal brain of “fishes” (Ganoids and 
Teleosts). 

E. The morphological instructiveness of many mal- 
formations. Goethe well said, “In her mistakes Nature 
often reveals her secrets”; indeed it is scarcely possible 
to imagine any encephalic malformation that may not 


* Cerebrum is sometimes employed loosely as embracing not only 
the olfactory region, but the thalami, quadrigeminum, and crura. 


167 


Brain. 
Brain, 





suggest, illustrate, or apparently contravene some mor- 
pnological idea.* 

§ 162. ig. 713 illustrates: A. The possibility that an 
individual should reach maturity with a cerebrum so 



















> yA \ a az 


are 


p: a 
| i i) ay 


il 


a) 
| % , >i Sung z ~ o 


Ww = 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


§ 163. “ Third Ventricle.”.—The cavity commonly so- 
called really represents the mesal portions of the cavities 
of three segments; so much as lies between the thalami 
is the diacele; but the portion cephalad as far as the 
terma and fornix, although relatively small, 
pertains to the prosencephal and rhinence- 
phal; in some lower vertebrates (e.g., Chi- 
maera, my paper, 1877, a) it is much more 
extensive. 

§ 164. Wig. 715 illustrates: A. The fun- 
damental morphological relation of each 
hemicerebrum as a lateral outgrowth, proc- 
ess, diverticulum, or “wing” of the mesal 
portion of the prosencephal. 

B. The non-formation or obliteration of 







rhinocele x 


‘ 2 


paracele 


mesocele 


Fig. 714.—Diagram of the Prosocele and Adjoining 
Cavities. 


all the fissural corrugations and inequal- 
ities, excepting the Sylvian, which is a mere 
shallow depression extending obliquely 
dorso-caudad along the lateral aspect of 
each hemicerebrum. 

C. The enormous size of the porta, yet 





F1G. 713.—Dorsal Aspect of an Imperfectly Divided Cerebrum. X .7. (From Turn- 
er, Journal of Anatomy and Physiology, xii., January, 1878, pp. 241-253.) af, 
Precentral gyre; ap, postcentral gyre; if, subfrontal gyre; mf, medifrontal 
gyre; O, occipital lobe; pe, “‘ convolution of parietal eminence ’’; PO, occipital 
fissure ; pp, ‘ postero-parietal convolution ’’; Ry central fissure ; sf, superfrontal 
gyre; I, II, mesal transverse gyres, nearly at the level of the adjoining hemicere- 
brum ; III, sloping cortical surface ; IV, mesal gyres at a lower level than I and II. 

Preparation.—The brain was taken from an epileptic imbecile, male, forty- 
eight years of age, 146.7 em. (four feet ten inches) high, and weighing 55.7 kgm. 
(123 pounds). The entire brain w eighed 1,111.7 gm. (39.25 ounces), of which the 
cerebrum constituted 978 gm. (34.5 ounces). Most unfortunately this rare, if not 
actually unique, specimen was simply placed in alcohol, which was not changed ; 
hence the base was ill-preserved, and the ental features, although described in 
some detail by Turner, cannot be fully understood. A transection disclosed a 
single mesal, cerebral cavity, about 5 cm. wide, the floor of which is said to have 
been “‘ formed of the upper surfaces of the corpora striata and optic thalami, which 
bodies were related to each other and to the tenia semicireularis as in anormal 
brain ’’; yet ‘the third ventricle opened freely into the cerebral cavity along the 
middle of the floor.”” It is to be hoped that figures and more detailed descriptions 
may be published respecting the structure of this remarkable specimen. A good 
abstract of the original paper is given in Brain, i., 183-134, April, 1878. 


the maintenance of its complete circum- 
scription. 

D. The tenuity of most of the parietes; in 
the occipital region they are no thicker than 
a sheet of ordinary paper, and are really 
exaggerated by the two ink lines and inter- 
vening space. 

E. The extraordinary distinctness of the 
mass named caudatum, of which another 
view is given in Fig. 722. 

F. The peculiar form and relations of the 
rounded mass intervening between the cau- 
datum and the lateral wall, and which may 
represent the lenticula. 

G. The non-appearance of the thalamus 
in the floor of the paracele. 

H. Upon the whole, the retention, sub- 


nearly undivided. Substantially, the prosencephalic 
vesicle has not only increased in size and in parietal 
thickness, with but slight differentiation into a mesal 
and lateral mass, but the entire mass has developed 
fissures and gyres after the usual pattern, in general, ex- 
cepting that certain gyres cross the meson; @ prvort, in- 
deed, it is not clear why such a brain should not be effi- 
cient for mental as well as bodily manifestations. 





* On this account it is to be the more regretted that so few such 
specimens are adequately preserved, examined, figured, described, 
and explained; indeed, no case is known to me in which the best 
possible use has been made of the opportunity ; it is particularly de- 
sirable that, when malformation is suspected, the brain be thoroughly 
hardened by alinjection (injection of alcohol) of both the arteries and 
the cavities. 


168 





stantially, of a condition of the cerebrum 

comparable with the normal state at a much 
earlier period of development; it is, as it were, an ex- 
pansion of such a cerebrum as exists at twelve weeks 
(see Fig. 667). 

§ 165. Paraceles (“lateral ventricles ”).—But the lateral 
extensions speedily become so considerable as to warrant 
the specification of a mesal portion, awla, a pair of para- 
celes (“lateral ventricles”), and constricted communica- 
tions, the portas (“foramina of Monro”) (see Figs. 678, 
684, 690, 723).* 

§ 166. Cornua.—EKach paracele is primarily sub- 
spherical and simple as in Figs. 667 and 678; in hydro- 





* If the rhinencephal is regarded as a segment, the aula and portas 
must be regarded as pertaining in part to it. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cephalus this condition may be maintained approxi- 
mately till birth (Fig. 715). But normally, by the unequal 
thickening of the parietes, by their encroachment upon 
the cavity, and perhaps by the further extension of the 
latter, there are somewhat vaguely demarcated a central 
cella, continuous through the porta with the aula, and 






hippocamp (?) 
paraplexus 


| 
) 
1 
' 
! 
! 
"4 
VBA 





Brain, 
Brain, 


three “horns,” a ventral medicornu, a cephalic precornu, 
and a caudal postcornu. The last exists only in Primates 
(man, apes, monkeys, and lemurs) and a few other mam- 
mals, mostly members of the seal family. The cornua 
appear in Figs. 684, 720, 726, 785, and 736. 

§ 167. Fig. 716 illustrates: A. The great extent of the 
paraceles at this period, relatively to the entire cere- 
brum, and to the mesal part of the prosocele, the aula. 

B. The less difference in the thickness of the parietes 
than in the adult. 

C. The distinct collocation of the hippocamp with the 
hippocampal fissure. 

D. The topographical relation of the Sylvian fossa, the 
first stage of the Sylvian fissure, to the caudatum. 

E. The extension of the postcornu farther caudad of 
the aula than the precornu extends cephalad. 

F. The absence of the insula at this period. 

G. The outgrowing margin of the operculum. 

H. The depth and peculiar shape of the lambdoidal 
fissure (see Fig. 750). 

§ 168. The porta, in a little modified condition, may be 
seen in the large salamander, Oryptobranchus. When the 
lateral wall of the alinjected hemicerebrum is removed 
(Fig. 717), the paracele is seen to communicate with a 
mesal space (aula) and thereby with its opposite and with 
the diacele, through a considerable orifice, the porta. Its 
caudal end is narrower than the cephalic, but it is seen 
to be completely circumscribed by ordinary nervous walls. 

§ 169. Hig. 717 tllustrates: A. The simple condition 
of the prosencephal in this amphibian; each hemicere- 
brum is an elliptical, thin-walled sac, the cavity of 
which, the paracele, communicates through a porta with 
the aula and so with the diacele. 

B. The large size of the porta, its length equalling 


caudatum 
Sylvian fossa 1  :. precornu 
. caudatum 5 > genu 


precornu 

Fig. 715.—The Left Paracele (Lateral Ventricle) of a - pseudocele 
Female New-Born, (7 Months?) Hydrocephalus. E 
No. 2,131. X 1. 1, One of several slight undulations - hemiseptum 
of the ental surface in the frontal region; 2, slight 
pit, probably artificial ; 3, cephalic margin of a break, 
apparently natural, in the mesal parietes; the ven- - fornix 
tral margin of this break is indicated by 7, and the 
corresponding caudal margin projects slightly mesad 
just caudad of the line ; it may be supposed that this 
interruption of the mesal wall represents the loca- orta 
tion of the callosum that might have been formed; 4, Pp 
5, slight elevations as yet undetermined; 6, dis- - aula 
tinct though rounded ridge corresponding to the 4 
shallow Sylvian fissure, the only recognizable fis- tenia 
sure; 7 (see 3); 8, occipital end of the hemicere- ambri 
brum, projecting slightly beyond the cut surface ; Se 
9, membranous portion of the parietes (perhaps an dentate gyre 
attenuated tenia) through which the thalamus e 
shows. . 

Preparation.—The child was supposed by the hippocamp 

physician and parents to be seven months advanced ; 
it breathed a few times; the weight was 1,618 gm. diacele 
The neck and scalp were swollen, but the head was 
not unusually large. Normal salt solution was :n- , 
jected into the umbilical vein and escaped, with supracommissure 
blood, from the jugular. Then half a litre of 
ninety-per-cent. alcohol was injected, the jugular postcornu 
being closed. The scalp, calva, and dura were re- 
moved, and the head supported in brine while the ~ Jambdoidal f 
brain was extracted; in spite of care there was Bi ‘ ; : 
some separation of the hemicerebrums at the me- medicornu : 2 thalamus : _ y G 
son. The contained liquid was allowed to escape, paraplexus epiphysis 


the brain placed in ninety-per-cent. alcohol, and 
the hemicerebrums inflated to their natural size; 
they were then covered with a thin layer of absor- 
bent cotton to keep them submerged. The alcohol 
was changed twice at intervals of two days, and on 
the fifth the various sections were made under al- 
cohol. The mass supposed to represent the caudatum 
was extremely dense. The pia was firm, and in 
parts more substantial than the attenuated parietes. 
The condition of the diencephal was not fully de- 
terminable;: the mesocele seemed to be wholly oc- 
cluded, which would account for the condition of the 
cerebrum. Th? entire specimen needs further study 
and comparison with similar cases. 


plexus. 


Fic. 716.—Ventral Exposure of the Prosocele of a Fetus about 24 cm. Long, and Esti- 
mated to be Twenty Weeks Old; 499. X 1.5. ( 
and the caudatum; 2, thin extension of the paraplexus into the postcornu; soon 
after the preparation was made this became detached and was lest ; another speci- 
men must be depended upon to show whether or not such extension exists, and in 
what way it is disposed of in case it be deciduous; 3, hippocampal fissure ; 4, dia- 


1, Line of continuity of the thalamus 


Preparation.—The brain was hardened in place by arterial alinjection; the 
scalp and calva were removed piecemeal, and the dorsal part of the cerebrum re- 
moved by one sweep of the knife under alcohol. ) 
side as indicated by the heavy line (endyma) enclosing the lighter area. The left 
caudatum was removed so as to expose the paracele more completely on that side 
and make the figure comparable with that of the cat (Fig. 686). 


The parapiexus was cut at each 


169 


Brain, 
Brain, 








supraplexus diencephal 


© 
E 
o 
=| 

Ee 
= 
1S) 
x 
= 
° 
| 


: 2 porta 
Fig. 717.—Prosencephal of Cryptobranchus (a Salamander), the Left Paracele Exposed; 291. X 6. 
Preparation.—The fresh brain, while supported by the skull, was alinjected by lifting the 
metatela (membranous roof of the “fourth ventricle ’’) and pointing the cannula at the broad 
epicele ; the entire brain at once swelled somewhat, and the thinness of the walls caused it to 
harden almost immediately ; the lateral wall of the left hemicerebrum was then sliced off, and 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





§ 171. The exact conditions 
and relations of the rima, para- 
plexus, tenia, fimbria, and thal- 
amus near the porta have not 
been as yet clearly made out. 
Preparations should be made 
with special reference to their 
elucidation, and figures upon a 
very large scale. Excepting the 
metapore (“foramen of Magen- 
die”) no part of the brain in- 
volves so many and so important 
morphological questions; see the 
difficulties and doubts admitted 
under Fig. 719. 

§ 172. Mg. 719 tllustrates: A. 
The size, form, and direction 
of the porta from the mesal as- 
pect. 

B. The complete circumscrip- 
tion of the porta, dorsad, by the 
reflection of the endyma upon 
the intruded plexus (Fig, 668). 

C. The greater length of that 
part of the prosoplexus which 
hangs in the porta (portiplexus) 
than of that which hangs in the 


the paraplexus cut off where it projected from the aula through the porta into the paracele. 


about one-third that of the entire cerebrum; its cephalo- 
caudal direction as compared with that of mammals, 
birds, and reptiles, where—especially in mammals—it is 


dorso-ventral. 


C. The absence of a rima; the prosoplexus enters the 
aula from the supraplexus and sends a prolongation 


through either porta into the 
paracele, where it hangs freely. 

§ 170. The porta is com- 
pletely circumscribed, so that 
a cast has a definite outline, 
viz., that of an elongated el- 
lipse, its longer diameter, 4-6 
mm., its shorter 1-8 (see Figs. 
718, 724). The portal bound- 
aries are as follows: caudal, 
the thalamus (perhaps the te- 






—~ paracele 


---- right porta 


i diacele 


Fig. 718.—Cast of Aula, Portas, and 
Part of Diacele. X 1.5. The main 
object of the figure is to demonstrate 
the complete circumscription of the 
porta, and its independence of the 
rima($ 177). The material used was 
a mixture of wax and gutta percha. 
The mesal ridge which represents 
the aulic recess is just dorsad of the 
precommissure (Fig. 724). The fig- 
ure should have been so placed as 
to make this ridge nearly vertical. 


nia); cephalic, the column of 
the fornix; ventral, the junc- 
tion of the thalamus and col- 
umn; dorsal, the endyma re- 
flected from the thalamus and 
column upon the intruded por- 
tiplexus (Fig. 668). So long 
as this endyma retains its ad- 
hesions, so long the circum- 
scription of the porta is com- 
plete. 


170 


precommissure = 


precerebral a. 


aula (auliplexus). 

D. The constitution of the ve- 
lum as a fold of pia, with blood-vessels intervening; one 
lamina of the fold belongs to the fornix, and the other to 
the thalamus, or rather to the diatela or primitive dia- 
celian roof (Fig. 710). 

E. The relation of the ventral end of the porta to the 
aulix (“sulcus of Monro”). 











pia 
fornix (a) 
endyma 


habena 


velum 


pia 


termatic a. 


diaterma - 


Fic. 719.—The Right Porta and Adjacent Parts, Seen Obliquely from the Caudal Side; 385. x 4. The 


lateral aspect of the left porta of the same brain is shown in Fig. 720, under which the mode of 
preparation is described. 1, Dotted line from the ventral end of the porta to the ventral margin of 
the precommissure, and assumed to demarcate the diacele from the aula; 2, part of the mesal sur- 
face of the hemiseptum, unusual and not fully understood (see § 172, H). 

Defects.—The area marked 2 is not a cut surface as its plainness would indicate ; it was shaded 
lightly in the drawing, but became blank in the engraving. The extent of the pseudocele and the 
length of the copula are so unusual as to be anomalous; these peculiarities, however, do not 
materially affect the porta, which is the important feature of the figure. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





F. The thinness of the commissure of the fornix, a. 

G. The unusual length of the copula connecting the 
callosal rostrum with the prosoterma. 

H. The unusual extension of the pseudocele and of its 
lateral parietes, the hemiseptums; it is uncertain how far 
this existed naturally, or was produced by the pressure 
of alinjection. 

§ 173. Fig. 720 illustrates: A. The location and general 
form of the paracele; unfortunately, however, the post- 


“J [eayuao 


bo] 
=) 
a 
E 
3 
<i 
7 © 
~ 
‘So 
mn 
3 
9S 
wz 
os 
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Ss 
=I 
5 
5 
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precornu porta 


Fic. 720.—The Left Paracele (** Lateral Ventricle *’), Viewed Obliquely 
from the Latero-Cephalic Aspect; 385. ™X about .5. (This figure 
was published in the New York Med. Jour. for March 21, 1895, and 
is here reproduced by permission.) 

Preparation.—The arteries and cavities were alinjected. When 
the brain was thoroughly hardened the medicornu was first exposed 
by removing successive slices of the temporal lobe till it was reached ; 
contiguous parts were then removed till the entire paracele was 
brought to view ; this involved the formation of five cut surfaces, all 
oblique excepting the most: dorsal, which was about 1.5 cm. from 
the meson. The dura was retained until the preparation was com- 
plete and the drawing made; it has since been medisected, so that 
the left porta may be looked through. 


cornu is unusually short, and foreshortened by the way 
in which the preparation is viewed; but the sharp curve 
of the medicornu is well seen, and the projection of the 
precornu cephalad from the porta. 

B. The absence of any indication of a rhinocele, which 
exists in the sheep (Fig. 792), and in mammals generally. 

OOD he tnd is- 
tinctness of the col- 
liculi, calear, collat- 
eral eminence, and 
“ . occipital eminence; 
“-§ whether this was 

® due to hydrocepha- 
lus or to the press- 
ure of the injected 
alcohol it is impos- 
sible to say. 

D. The location 

and size of the por- 
ta, which is shown 
on a larger scale in 
Fig. 721. 
Cc. E. The location 
of the paraplexus 
and of the rima 
through which it 
enters, covered, 
however, by the en- 
dyma (Fig. 759). 

§ 1%4. Hig. 722 
illustrates: A. The 


ey10d snxe[d 
-1j10d 





721.—The Left Porta and Adjoining 
Parts of the Alinjected Brain Shown in 


FIG. 


Fig. 720; 385. X 38. The form of the lat- 
eral or paracelian orifice of the porta ap- 
pears more distinctly, and the endyma is 
seen clearly to be reflected upon the porti- 
plexus from the adjoining surfaces. Just 
dorsad of the line from rima are a few 
(presumably) artificial rents in the en- 
dyma. 


Brain, 
Brain, 





great size of the porta in this hydrencephal; its ventral 
half is concealed by the caudatum, but the total length 
(dorso-ventral dimension) is 19 mm. (three-fourths of an 
inch) and its width 8-9 mm. 

B. The complete circumscription of the porta, not- 






portiplexus 
i— porta 
paratela 

6 

. caudatum 

4 

lenticula (?) 


5 
— Sylvian fossa 


FiG. 722.—Lateral Aspect of the Right Caudatum and Porta (Foramen 
of Monro) of a New-Born (seven months ?) Hydrocephalus. 2131. 
x1. 1, Angle between two cut edges of the thin mesal wall; 2, 
cephalic end of the natural (although presumably abnormal) hiatus 
in the mesal wall, corresponding with 3in Fig. 715; 3, ental surface 
of mesal wall; 4, depression between caudatum and adjoining pa- 
rietes ; 5, triangular depression near tip of medicornu ; 6, membra- 
nous part of parietes ; see § 3, C. 

Preparation.—See Fig. 715; the paraplexus on this side was 
trimmed closely. 


withstanding the delicacy of the parts and the pressure 
that may have caused its enlargement. 

C. The great extension of the paraplexus and adjoin- 
ing portions of the parietes; the parts marked 6 and 7 









ntercerebral f 


callosal f. 


‘hemiseptum 
paraplexus 


Fig. 723.—The Two Portas, from the Precornua; 2,345. x 1.5. 1. 
Part of the intercerebral fissure, between the rostrum dorsad and 
the chiasma ventrad ; 2, precornu ; 3, tenial vein ; 4, undetermined 
band on the cephalic slope of the thalamus; 5, dorsal part of right 
paracele ; 6, the short diverging lines point to the locations of veins 
(septal ?) at the angle of junction of the hemiseptums with the cal- 
losum; dorsad of the junction of the hemiseptums with the ros- 
trum is a small (septal ?) vein at either side. 

Preparation.—See under Fig. 724. The slice including the portas 
is 12 mm. thick ; the caudal (aulic) aspect is shown in Fig. 724, the 
cephalic (precornual) in this. 

Defects.—The shading does not indicate with sufficient distinct- 
ness that the entire surface, and plexus at either side dorsad of the 
porta, slope dorso-caudad beneath the callosum, and are not continu- 
ous with it. Asin Figs. 724 and 739, the lines representing the cal- 
losal fibres are diagrammatic. Other preparations and figures upon 
a still larger scale are needed, in order to exhibit the somewhat in- 
tricate relations of the parts about the porta. The morphological 
importance of the entire aulic region can hardly be overestimated. 


are membranous; the zone just caudad of 7, and forming 
part of the upper margin of the figure, may be the 
fimbria; and the thicker zone just caudad of it may be 
the hippocamp. 

§ 175. Fig. 723 illustrates: A. The existence of the 
two portas, and their obviously natural condition. This 
point, already shown in several previous figures, is here 


171 


Brain, 
Brain. 


reiterated because this aspect of these orifices is seldom 
presented, and because a distinguished anatomist has de- 
clared (Progrés Médical, Nos. 25 and 26, 1879) that when 
one finds a communication between the middle and lat- 
eral ventricles in an adult human brain it results from 
an artificial perforation; see my papers, 1884, a and 
1884, f. 

B. The transection of the callosum in two places, viz., 
dorsad near the genu and ventrad through the rostrum; 
the part of the septum or pseudocele here shown was 
therefore embraced by the genual curve of the callosum 
(see Figs. 687 and 756). 

C. The continuity of the hemiseptum with the corre- 
sponding column of the fornix; so far as the porta is 
concerned, the former may be compared to a thin parti- 
tion, and the latter to a door-post; see also Figs. 707 and 
709. 

§ 176. Fig. 724 illustrates: A. The existence, form, 
size, and complete circumscription of the two portas 
(“foramina of Monro”). 

B. The extent of the aula, the mesal division of the 
prosocele, and the cephalic or prosocelian constituent of 
the “third ventricle.” It includes the interval between 
the portas, extending ventrad so as to include the pre- 
commissure, only part of which appears in the figure. 

C. The existence of the aulic recess, a subtriangular 
depression between the precommissure and the two col- 
umns of the fornix; the line from the word aula ends in 
this recess; on the cast shown in Fig. 718, it is a ridge. 

D. The peculiar curvature of the columns of the fornix. 
They converge dorsad, curving at the same time caudad, 













= intercerebral f. 
-- Callosal f. 


= callosum 
endyma 


roof of paracele 
hemiseptum 


pseudocele 

+. paraplexus 
Tipa 

fornix 

< velum 

auliplexus 

+ porta 

L aula 

1. column 

precommissure 

4. tuber 

i optic tract 


chiasma 


1. optic nerve 


Fie. 724.—The Two Portas, as Seen from the Aula, Looking Obliquely | 


Dorso-Cephalad ; 2345. * 1.5. (Compare with Figs. 723 and 739.) 
1, Tenial vein; 2, velar vein; the number rests upon the thalamus. 

Preparation.—From a brain, the arteries of which had been in- 
jected with the red glue mixture, and the cavities with alcohol, a 
transection was removed, 12 mm. thick, so as to include the chiasma ; 


for security of handling it was trimmed down so as to include little | 


more than the parts represented. The optic nerves were divided 
obliquely, to show their cut ends more fully. 

Defects.—The alba and cinerea are not distinguished, and the 
figure is not upon a scale large enough to show certain details as to 
the connections of the velum and plexuses. The divided ventral 
ends of the columns of the fornix were inadvertently omitted, but 
may be seen in Fig. 739. 


so as to appear as cut ends in this transection; ventrad 
they diverge, are twisted somewhat, and again curve 
caudad, so that their cut ends should appear again just 
dorsad of the optic tracts, as shown in Fig. 739. 

E. The relation of the precommissure to the columns, 
which pass just caudad of it. Ina figure including a 
greater width of this region, the cut ends of the precom- 
missure would appear at the side, as in Fig. 739. 


172 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





F. The reflection of the endyma upon the plexuses 
from the fornix and thalami, at two points upon each 
side; such lines of reflection constitute a ripa. 

G. The continuity of the hemiseptums with the cal- 
losum dorsad and the fornix ventrad. 

§ 177. Rima.—The porta is primary, and constant 
among all vertebrates where the prosocele presents a 
tripartite condition (§ 60). In reptiles, birds, and mam- 









ea" 


_————-~= epiphysis 


porta~ 
olfactory Cxey endyma 
bulb ; ; Pee | 
precommis- — parietes 
sure pia 


terma. ; mye 
chiasma hypophysis 


Fig. 725.—Schematic Medisection of the Prosencephal and Two Ad- 
joining Segments; approximately the right half of Fig. 714, seen 
from the mesal aspect. (See § 178.) 


mals (perhaps also among some lower forms) at the dorsal 
end of the porta there begins a line of greater or less 
length along which the proper nervous parietes of the 
paracele are abrogated for the intrusion of a pial exten- 
sion, the paraplexus; this line of intrusion is the rima 
(chief part of the so-called “great transverse fissure ”) 
shown in Figs. 720, 725 (diagram), 780, and 735. It is to 
be noted that (1) the paraplexus fills the space, and (2) 
the endyma is carried before it, so that there is no true 
solution of continuity. The only way in which the 
porta and the rima can become continuous is by the arti- 
ficial rupture of the membranous attachment, but this is 
by no means infrequent with brains removed and handled 
in the usual way. 

§ 178. Fig. 725 illustrates: A. The communication of 
the paracele (lateral ventricle) with the mesal series of 
encephalic cavities solely through the porta (“foramen 
of Monro”). 

B. The reduction in size of the aula, the mesal divi- 
sion of the prosocele, relatively to the diacele, and to the 
prosocelian lateral extensions, the paraceles. 

C. The location, in man and other mammals, of the 
aula at the dorso-cephalic side of the diacele, instead of 
directly cephalad as in Amphibia. 

D. The concomitant change in the direction of the dia- 
celian and prosocelian floors; instead of cephalo-caudal, 
their direction is more or less nearly dorso-ventral. 

E. The crowding of the epiphysis caudad by the over- 
lying cerebrum; the epiphysis and hypophysis are re- 
tained in the figure, however, mainly as landmarks. 

F. The relation of the rima (essential part of the 
“ great transverse fissure”) to the porta. The line along 
the meso-ventral aspect of the hemicerebrum represents 
a narrow tract where the paracelian parietes are reduced 
to the lining endyma and the covering pia, and where 
the latter, or its vessels, intrudes into the paracele, still 
covered, however, by the endyma. The rima always 
begins at the margin of the porta, and extends, in man, 
to near the tip of the medicornu (see § 183 and Figs. 728 
and 734). 

G. The secondary and morphologically unessential 
nature of the caudato-thalamic extension, the enormous 
thickening of the thalamus, the lateral wall of the 
diacele, and of the caudatum, the wall and floor of the 
paracele. This feature of the mammalian brain, which 
is very confusing and not altogether easy to describe, 
may be ignored in a diagram like the above, where the 
parietes are represented of nearly uniform thickness, as 
in the embryo and in adult amphibians. 

§ 179. Fig. 726 illustrates: A. The close contact and 
even interdigitation of the mesal aspects of the frontal 
ae of the sheep concomitantly with the absence of a 
alx. 


paraplexus 


hippocamp 


Fig. 726.—Sheep’s Brain, the Paraceles (‘‘ Lateral Ventricles”’) Exposed. 2. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 

















at tas ea waneetont as een aoe OLTACLOTYs OULD 
transected 


—— 


2 
« 


_...genu 


~~ hemiseptum 
\ -- PSEUDOCELE 


—caudatum 


PARAPLEXUS 


2 we ee ee ee we of - 09 ]]08UM 


~.HIPPOCAMP 
-- splenium 


Se ae es 


FIMBRIA 


(From my “ Physiol- 
ogy Practicums.”’) 

Preparation.—By the removal of successive slices the paraceles have been opened ; the left has 
then been more completely exposed by oblique sections, and the paraplexus trimmed off so as 
to expose the wide fimbria and the furrow between it and the hippocamp. The plane of section 
did not coincide exactly with the callosum; the caudal three-fifths of this is represented by the 
transverse lines; also the cephalic end, the genu; but an intermediate portion is wholly re- 
pore, exposing the narrow pseudocele (*‘ fifth ventricle’’) and its thin lateral walls, hemisep- 
ums. 

Defects.—The cerebral cortex is not represented. The caudal half of the cerebellum is omitted. 

1, Intercerebral fissure; 2, callosal fissure; 3, vessel; 4, interrupted lines indicating the con- 
tinuation of the paracele into the rhinocele (Fig. 792) ; 5, precornu; 6, caput of the caudatum ; 
7, Sylvian fissure crossed by arachnoid; 8, vessel at bottom of fissure; 9, cauda of caudatum ; 


Srain, - 
Brain, 





allow the plexal intrusion; at 
this age, therefore, the human 
thalamus is as perfectly ex- 
cluded from the paracele as it 
is in mammals generally. 

§ 182. Paratela.—But with 
all human adults (perhaps also 
with the new-born, and possi- 
bly with fetuses during the 
later months) the tenia and 
fimbria, for most of their 
length, are separated by an in- 
terval, 2-7 mm. in width, nar- 
rowing at the porta and in the 
medicornu. This interval is 
filled by (1) the paraplexus, 
which retains its attachment 
to the fimbria rather than to 
the tenia; (2) an extension of 
the endyma from the margin 
of the tenia with or without 
the adhesion of the subjacent 
pia. This zone of endyma, or 
endyma and pia, extending 
from the porta to near the end 
of the rima is the paratela 
(Figs. 732, 7385). 

§ 183. Fig. 728 tllustrates: A. 
The existence of substantial 
walls of nervous substance 
about the medicornu at the 
distance of at least 1 cm. from 
the tip of the temporal lobe. 

B. The concomitant non-ex- 
tension of the rima (“great 
transverse fissure”) to the ex- 
tremity of the medicornu. 

C. The existence of digita- 
tions at the ventral end of the 
hippocamp (pes hippocampt). 

D. The non-extension of the 
hippocamp to the extremity 
of the medicornu. 

E. The dilatation of the 
medicornu in hydrocephalus. 


10, part of caudal wall of paracele. 


B. The width of the fimbria and hippocamp, and 


thence of the entire fornix, as compared with the 
C. The apparent absence of the tenia. 


D. The total exclusion of the thalamus, even in ap- 


pearance, from the paracelian floor. 


§ 180. Fig. 727 illustrates: A. That, at this age, the 


paraceles extend much farther dorsad than in 
the adult, far beyond the level of the callosum. 

B. That the paraplexus is relatively more ex- 
tensive. 

C. That the caudatum is relatively larger. 

D. That the margin of the fimbria reaches the 
groove between the caudatum and the thalamus, 
which probably represents the tenial sulcus of 
the adult. 

E. That the thalamus is therefore absolutely 
excluded from the paracelian floor, without even 
the appearance of representation which exists in 
the adult. 

§ 181. With all mammals other than man, the 
apes and certain members of the seal family, the 
margins of the rima are, throughout their whole 
extent, separated only so far as to permit the in- 
trusion of the paraplexus, e.g., the sheep (Fig. 
726); nor does this adhesion yield at all in cases 
of hydrocephalus, observed by me in dogs and 
cats. With the human fetus, also, up to the esti- 
mated age of four months (Figs. 727 and 734), at 
least, the tenia and the fimbria are closely ap- 
posed—as closely, that is, as they can be and yet 


F. The efficacy of alinjec- 
tion in maintaining the size of 
an encephalic cavity and pre- 
serving the contour of its parietes. 

G. The nearly typical zy gal, or H-shape, of the orbital 
fissure (see Fig. 778, III.). 

§ 184. The Rima Not Coextensive with the Medicornu.— 
The rima extends from the porta to near the extremity 
of the medicornu, but for about 1 cm. from its extremity 


human. 


callosum fornix 


medicom- 
missure 
,thalamus 


- diacele 





Fic. 727.Transection of the Brain of a Fetus, About 16 cm. from Nates to 
Bregma, and Estimated at Four Months; 1816. 1.3. 

Preparation.—The fetus was received in alcohol, not very well preserved. 
The calva was cut away with scissors, and the dura and pia removed. The 
entire brain was then transected at the level of the medicommissure, but only 
the dorsal half of the divided surface is included in the figure; it is the ceph- 
alic aspect of the caudal part. The two lines crossing the right hemicerebrum 
indicate the plane of the section shown in Fig. 761. 


173 


* Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





the parietes are substantial (Fig. 728). The transition to 
the rima is constituted by the riparian part, pala, which 









connects the two rimal margins, fimbria and tenia. This 
ca 
& 
= 
2 
rama ead 
°o 
ce 
bm 
i 
13 
wy S. 
at Gs os 
2d g 
oO =m = 
i NES Db 
= = a 
o ¢ s 
ee = 35 
© &s 
a ach 
tery 5 
eh 
rs 
a 
a: 
Bee 
O28 
Se 
_ 
RATS a a 
SS} 
~_™uneus 
hippocampal f. 
—medicornu 
—hippocamp 
G 


Fig. 728.—Ventral (Orbital) Aspect of the Right Fronto-Temporal Re- 
gion of the Hydrencephal Shown in Fig. 743, after removal of the 
tip of the temporal lobe; 747. 1. 1, Zygon of the orbital fis- 
sure (see Fig. 778) ; 2, 3, 4, undetermined fissures ; 5, undetermined 
fissure, zygal in form, perhaps the orbito-frontal ; 6, meditemporal 
(?) fissure ; 7, subtemporal (7) fissure ; 8, collateral fissure. 

Preparation.—See Fig. 748. 


thin portion has, in man, a shape like the blade of a turf- 
cutter; it is not distinctly shown in any of the figures in 
this article, but in Fig. 730 it would constitute the thin 








pala tela :Tipa 
; oe 
9 O-: 
. parietes 
A B C D endyma 


Fig. 729.—Schematic Transections of the Medicornu at Four Different 
Levels. For simplicity the cornu is represented as tubular and 
straight, normalized, so to speak (§ 88), and the parietes merely as 
substantial tissue covered by pia and lined by endyma. For some 
distance from its extremity (1-2 cm. in man) the medicornual pari- 
etes are typical, as at A; this condition of the parts appears in Fig. 
728. The proper nervous parietes suddenly become very thin and 
transparent, so as to resemble the terma and yvalvula, as at B. At€ 
the proper nervous parietes have entirely disappeared, leaving only 
the two membranes; this is the normal constitution of a tela, and 
sometimes exists near the tip of the medicornu, though relatively for 
a much less distance than on the diagram. Finally, whether or not 
a plexus is intruded into the cavity, as is the case with the medi- 
cornu, the tearing away of the tela leaves a ragged edge which is a 
ripa at either side of the rima. 


lamella at the ventral end of the fimbria. In the diagram, 
Fig. 729, the pala is seen in transection at B. 

§ 185. Hig. 730 illustrates: A. The early and distinct 
formation of the caudatum (see also Fig. 715). 


174 





B. The continuity of the two margins of the rima, the 
fimbria and tenia, near the tip of the temporal lobe, the 
place of their union, at and after birth, being somewhat 
distinct, the pala. ; 

§ 186. Hig. 731 dllustrates: A. The thinness of the 
fornix at the meson (§ 202). 

B. The considerable extent of the pseudocele; since 
this is not connected with the true encephalic cavities, it 
cannot be exaggerated by the hydrocephalous condition. 

C. The completeness of the paracelian floor after the 
removal of the thalamus; the interval, rima, between the 
substantial tenia and the lateral margin of the fornix 
(fimbria) is completely filled by the paraplexus and the 
paratela. 

D. The greater width of the rima in the cella than near 
the end of the medicornu. 

E. The extension of the calcarine fissure (stem of 
united occipital and calcarine) across the hippocampal 
gyre; it does not, however, reach the hippocampal fissure. 

§ 187. Fig. 732 wlustrates: A. The main point is the 
continuity of the floor of the paracele (“lateral ventricle”) 
irrespective of the dorsal surface of the thalamus, and 
the concomitant exclusion of this diencephalic mass from 


caudatum 


paracele 








tenia 
‘ 4 


. < 


4A 
" { hippocam- 


a pal f, 
‘~-- fimbria 


temporal lobe 


Fic. 7380.—Mesal Aspect of a Right Fetal Hemicerebrum, Partly Dis- 
sected ; 3,000. X 2.5. 1, Transection surface between the caudatum 
and thalamus; 2, part of cut surface left by removing a section of 
the mesal wall (including the rudimentary fornix and callosum) in 
order to expose the caudatum ; the paraplexus was also torn from 
its attachments, leaving the rima open; its margins, the tenia and 
fimbria, are separated more than is natural; in a fetus of this age 
they should be closely apposed (see § 181 and Fig. 727) ; 3, 4, transi- 
tory fissures in the places of the future occipital and calcarine. 


this portion of the prosencephalic cavity; but so many 
other points are shown incidentally that the figure will 
be described in detail. 

Beginning at the dorsal side of the figure, the inter- 
cerebral fissure is seen to separate the apposed mesal sur- 
faces of the hemicerebrums. The arachnoid dips into 
this fissure to a certain depth, so as to pass around the 
ventral margin of the falx (not shown in the figure); 
since this has (as seen in Fig. 801) a curved margin, and 
becomes narrower (dorso-ventrally) cephalad, the extent 
of the arachnoidal fold varies at different levels; in the 
specimen here figured, for example, which is about 1 cm. 
thick at the level of the callosum, the arachnoid crosses 
5mm. dorsad of the callosum on the caudal aspect and 8 
mm. on the cephalic. The pia, however, follows the ap- 
posed hemicerebral surfaces to and into the callosal fissure 
at either side and is continuous upon the dorsal surface 
of the callosum. Of the vessels the figure includes only 
the two parallel precerebral arteries (4). The callosum 
itself presents a slight mesal elevation, which is more dis- 
tinctat the cephalic side of the section and of a somewhat 
different color (§ 217). The callosum extends laterad and 
likewise dorsad to form the roof of the paracele, and it is 
to be noted that the lateral portion of this cavity would 
be opened by a horizontal section at the level of the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





dorsal surface of the callosum; hence the appearance 
commonly described and figured under the name of 
“centrum ovale majus” seldom if ever exists. For the 
condition of things in fetal brains, see Fig. 727, § 180. 

Ventrad of the callosum is the fornix, connected there- 
with by a thin lamina, the hemiseptum, at either side of 
amesal cavity, the pseudocele. The lateral 
margin of the fornix is formed by the fimbria 
(corpus fimbriatum). 

At the extreme left of the figure the lateral 
wall of the paracele is seen to be formed by 
a cinereal mass, the caudatum. By reference 
to Figs. 707 and 735, it will be seen that this 
narrows rapidly from the cephalic end (caput) 
as a slender prolongation (cauda); but this 
cauda is really folded somewhat upon its 
longitudinal axis so as to constitute, in at 
least part of its course, not only the side but 
a part of both the roof and floor of the para- 
cele; in the figures just mentioned the roof 
portion and part of the lateral is removed, 
leaving only the floor portion. Along the 
mesal border of the cauda there passes a vein 
(8), the tenial vein, which may be regarded as 
indicating the boundary between the cauda- 
tum and the thalamus. 

Projecting mesad of the vein is seen a 
lamina, consisting evidently of the paracelian 
endyma, and also, at least near the caudatum, 
of some nervous substance; this is, or in- 
cludes, the white band named tena in this 
article, but commonly called tenia semicireu- 
laris or stria corned. 

Allthe parts so far described are unques- 
tionably constituents of the prosencephal; the 
remaining portions shown in Fig. 732 belong 
to the diencephal. The walls of the diacele 
are the thalami, of which the figure includes 
only the portions dorsad of the level of the 
medi- and postcommissures (sce Fig. 687). 

The mesal surface is covered by endyma, 
which is continued over the low ridge called 
habena (“habenula”) seen from the mesal as- 
pect in Fig. 687, and from the dorsal in Fig. 
707. Just dorsad of the habena is a slight 
furrow, the habenal sulcus; here the endyma 


Sylvian 
fissure 


ee 





insula 


(interpositum), which belongs equally to the dience- 
phal and to the superposed prosencephal. Were it 
possible in separating the two segments, the dorsal 
layer should accompany the cerebrum, and the ven- 
tral remain attached to the thalami; the continuity of 
the two is seen at the aula and the two portas, as well 


y, endyma 


‘ 





s 


tenial vein 











/ 

if teni 
Hoe a 
é 


4 
paraplexus attached 
se to the paratela 


sparaccle 
cae 


J_-callosum 
1 
~pseudocele 






@ ~—~hemiseptum 






~ 


">~dentate gyre 
~ ~ealcarine fissure 
~>+~_fimbria 
“~~ hippocamp 
Sa . 
~~ _medicornu 


~~ collateral fissure 
~~-  subtemporal fissure 


Fig. 731.—Transection of the Right Hemicerebrum of an Adult Hydrocephalus ; 747. 
1, Ventral curvature of splenium ; 2. groove at cephalic margin of splenium ; 
38, mesal furrow of fornix (the line does not quite reach it). 
the lines from hippocampal fissure and dentate gyre is the continuation of the 
callosal fissure, separated from the hippocampal by a fiattened area of cortex. 
deep fissure opposite the word insula is the central. 

Preparation.—This represents the cephalic aspect of the caudal part of the 
hemicerebrum, the mesal aspect of which is shown in Fig. 743. 
was along the oblique line d-v on that figure. 


The furrow between 


The 


The transection 
So much of the thalamus as was 


meets the pia covering the dorsal aspect of 
the thalamus, and is reflected with it dorsad 
and then mesad toward the opposite side. 


included was cut away, together with some of the adjoining prosencephalic mass, 
capsula, lenticula, and perhaps claustrum, leaving little more than the cortex of 
the insula at that Qoint. ’ 

Defects.—The shading does not discriminate sufficiently between the natural 
and artificial surfaces, but the former are curved while the latter are straight and 


Instead of passing horizontally across the in- 
terval between the thalami, however, the en- 
dyma is deflected over the two vascular plex- 
uses (folds of pia or vessels therefrom) which 
hang in the diacele. The habena and its sulcus, more 
accurately, perhaps, the latter, constitute the boundary 
line between the mesal, entocelian, endymal surface of 
the thalamus, and the dorsal, ectocelian, and pial surface, 
which extends dorso-laterad. 

Between the dorsal surface of the thalamus and the 
ventral surface of the fornix (including, of course, the 
fimbria), the pia is freely separable, and appears to con- 
sist of butasingle layer; but laterad it is traceable to the 
paraplexus, and it is almost inconceivable that a plexus 
should be formed of a single layer of pia as a free edge 
covered by endyma. When, however, this fornico-thal- 
amic pia is traced mesad, it is found to separate into two 
layers, a dorsal, belonging to the fornix, a ventral, con- 
stituting part of the diacelian roof (diatela) with a pair 
of arteries, a pair of veins, and numerous smaller vessels 
in the intervening space. The ventral layer is not 
separable (in man) from the diacelian endyma, but the 
dorsal not only may be detached from the fornix in an 
alcoholic specimen, as may the pia from most of the sur- 
faces which it covers, but here, excepting at the margins, 
the disjunction was almost spontaneous, and there is a 
distinct space (8) between it and the commissure, bounded 
at the sides by the thicker (hippocampal) constituents of 
the fornix. This double curtain of pia is the velum 


bounded by sharp lines. 
hemiseptum is added by dotted lines. 





The alba and cinerea are not distinguished. The left 


as along the entire margin of the paraplexus (see Figs. 
710 and 737). 

Corresponding with the margin of the fimbria, the dorsal 
surface of the thalamus presents a shallow groove, the fim- 
brial sulcus (“sulcus choroideus,” Fig. 707); laterad from 
this the surface is nearly regular, and overlaid partly by 
the paraplexus and a membrane apparently endyma only, 
and partly by the thin but more substantial lamina (tenia ?) 
already described as an extension of the caudatum. 

The entire dorso-mesal surface of the thalamus, instead 
of being homogeneous, as it has been sometimes figured 
and described, may be divided, first and most sharply 
into a mesal, or entocelian, and a dorsal, or ectocelian, 
portion, the boundary between the two being the habena 
and its sulcus. The dorsal surface itself presents a two- 
fold division into a subfornical (B) and a parafornical (C 
and D), separated by the fimbrial or choroid sulcus. 
Finally, the parafornical area is covered partly by the 
paratela and plexus and partly by the tenia, and may 
thus be distinguished as subparatelar (C) and subtenial 
(D), there being occasionally a furrow, the tenial sulcus, 
between them. The desirability of discriminating be- 
tween these areas will appear in connection.with Fig. 
7338, where certain different, and perhaps anomalous, con- 
ditions are described. 


175 


Brain. 
Brain, 





So far as this preparation is concerned, there is abso- 
lutely no adhesion of endyma to any part of the thalamus 
dorso-laterad of the habenal sulcus; on the contrary, the 
endyma is traceable in uninterrupted continuity about 


caudatum 





pia 


habena 


A 


medicommissure 


em 


Fic. 732.—Transection, Partly Schematic, of the Fornix and Adjacent Parts at a Level Cor- 


wt intercerebral f. 







arachnoid 









4 
i 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


There are, however, differences between these and 
other preparations which are not easy to explain, except- 
ing upon the general supposition that a region in which 
the conditions are nearly peculiar to the human brain 
might naturally be expected to present 
individual peculiarities and even anom- 
alies. 

§ 190. There seems to be considerable 
variation in the details of the parts in- 
volved in the apparent representation of 
the thalamus within the paracele; this 

is perhaps to be expected, 


BEE 










allosal £, since the conditions that 
have made the usual state- 
endyma ments possible constitute a 
great and perhaps peculiar 
paracele modification of the primitive 
and typical relations—indeed, 
tenia almost a malformation. 
paraplexus It is hoped that the fore- 
fimbria going descriptions and fig- 
pseudocele ures may at least serve to 
hemiseptum induce anatomists to investi- 
gate the subject in all its 
commissure bearings. 


§ 191. In What Sense does 
the Thalamus Form Part of the Floor of 
the Paracele (Lateral Ventricle)?—So 
widespread and so deeply rooted seems 


diatels to be the notion that the thalamus con- 
‘dinplexta stitutes a part of the paracelian floor in 

the same sense as do the caudatum and 
Aine the hippocamp, that, much as I would 


prefer to avoid the critical attitude, I 

am induced to comment upon the cur- 

rent representations of this region. 
Admitting, for the sake of occupying 


responding with the Interval between the Medicommissure and the Postcommissure ; 
1,824. % 2.5. 1, Fimbrial sulcus (*‘suleus choroideus”’) ; 2, tenial sulcus (in some 
specimens) ; 3, tenial vein; 4, precerebral arteries; 5, velar veins; 6, velar arteries; 
7, habenal sulcus; 8, interval (natural ?) between the velum and the commissure of the 
fornix; 9, lateral part of the fornix (hemifornix) ; A, mesal, endymal surface of thala- 
mus; B, ©, D, zones of its dorsal surface; B, subfornical; C, subendymal; D, subte- 
nial. Between the left paraplexus and the tenia the membranous floor of the paracele 
is the paratela. 

The figure represents the caudal surface of the transection ; the observer is look- 
ing cephalad, and his right coincides with the right of the specimen and the figure; 
the two sides are substantially identical, but less is shown upon the right; the meson 
of the figure, the anatomical middle of the various parts and cavities represented, is 
dextrad of the middle of the area covered by the figure. Throughout the figure the 
cavities are shaded and the blank areas represent transected surfaces. The arachnoid 
is represented by a narrow, straight line, the pia by a corrugated line, and the endyma 
by a heavy line; the endyma is made to adhere closely to the entocelian surfaces, but 
the pia and arachnoid are separated slightly from the parts which they cover. 

Preparation.—See Fig. 744, representing another transection of the same brain. 
The celian parietes were thoroughly hardened before the brain was removed from the 
skull, and the membranes and plexuses have retained their connections notwithstand- 
ing much handling and considerable transportation. There is some distortion and 
dislocation of the loosely connected parts about the fornix, but it has been possible to 
clear up most of the doubtful points by comparison of the two sides and with adjoin- 
ing sections. So far as respects the exclusion of the dorsal surface of the thalamus 
from the paracele, the preparation affords unequivocal evidence. 

Defects.—As in several other figures representing transections of plexuses, it has 
been assumed that a plexus consists of a fold of pia covered by endyma; for present 
purposes it matters not whether there is a complete fold of the pia, or merely an ex- 
tension of vascular loops. The ventral lamina of the velum is made too low. The 
medicommissure, the dorsal margin of which is included at the ventral side of the fig- 
ure, did not actually appear in this section, which was just caudad of it, but is intro- 
duced as a readily recognized landmark. The indusium is not shown (§ 217). 


common ground, that a certain area of 
the dorsal surface of the human thala- 
mus is covered by endyma; that it is 
continuous with the caudatum, and that 
therefore, like that body, it enters into 
the composition of the paracelian floor; 
none will deny that an adjoining area 
of this same dorsal surface is as dis- 
tinctly covered by pia; that it is con- 
tinuous with the optic lobes (gemina), 
and Jike them wholly excluded from the 
encephalic cavity. 

To represent the entire dorsal aspect 
of the thalamus as a smooth, unbroken 
surface is practically to affirm one of 
two things: either the whole is pial or 
ectocelian, which would be in contra- 
vention of the obvious facts; or else the 
whole is endymal or entocelian, which 
would involve not only the gemina but 
the cerebellum and oblongata, a mani- 
fest reductio ad absurdum.* 

§ 192. The Collicult.—This: collective 
term is applied to the rounded emi- 
nences and ridges which project into the 
paraceles (“lateral ventricles”) from 


each paracele, over, in turn, the ventral surface of the 
callosum, the caudatum, the tenia, the paraplexus, the 
fimbria, the thicker portion of the fornix, and the hemi- 
septum, back again to the callosum. 

§ 188. With some specimens the interval between the 
paraplexus and the caudatum seems to be occupied by a 
somewhat substantial lamina, separable from the thala- 
mus, continuous with the caudatum, and perhaps merely 
a special development of the tenia, but requiring further 
investigation (Fig. 7383). 

§ 189. The point illustrated upon Fig. 733 is the con- 
tinuity of the paracelian floor from hippocamp to cau- 
datum without the intrusion of the thalamus. This 
figure is to be studied in connection with the transection 
(Fig. 732), and the dorsal view of the floor in Fig. 735. 


176 


their parietes. They are the caudatum (caput and cau- 
da), hippocamp (“hippocampus major”), calear (“hippo- 
campus minor”), collateral eminence, and occipital emi- 
nence. Excepting perhaps the first, each of these 


* For a fuller discussion of the relations of the thalamus to the para- 
cele, and for commentaries on the misrepresentations in standard 
works, see the first edition of the REFERENCE HANDBOOK, viii., 144- 
147, and ix., 107, and my papers, 1888, a, and 1889, d. The delicacy of 
the membranes, the readiness with which they are detached along a 
ripa, the rough handling to which brains are commonly subjected 
during the ordinary processes of removal and examination, the slight 
degree in which preservatives can reach the parts in question when 
the entire organ is merely immersed as usual, and, finally, the fact 
that some agents, excellent for microscopic purposes, do not well pre- 
serve the endymal attachments—all these conditions conspire to bring 
it about that the endyma across the wide rima should be torn, and the 
dorsal surface of the thalamus protrude through the rent. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





represents a corrugation of the entire thickness of the 
parietes, the ental elevation (colliculus) being collocated 
with an ectal depression (fissure); this collocation is in- 
dicated in the list of total fissures, § 258. 

§ 193. The Callosal Hminence.—Besides the colliculi 
named in § 192, all of which are more or less distinct in 
at least some adult brains, there is one which is perfectly 
obvious in some fetuses (Fig. 734, 1), and which, from its 
apparent collocation with the callosal fissure (Fig. 742), 
may be called, provisionally, the callosal eminence. It, 
the hippocamp, and the occipital eminence form an ir- 
regular triradiation. Its commencement and disappear- 
ance require further observation, but its unbroken con- 
tinuity with the hippocamp confirms the idea that the 
callosal and hippocampal fissures are essentially parts of 
one, merely deflected by the splenium of the adult. 

§ 194. The relative size of the colliculi is not the same 
in the adult asin the fetus. This is clear from the com- 
parison of Fig. 734 with Figs. 744 and 761. The callosal 
eminence may disappear wholly; the occipital is seldom 
recognized (Fig. 744); the collateral is certainly less 
prominent in the adult than in the fetus (Fig. 734). 

§ 195. Hig. 734 tllustrates: A. The contiguity of the 
margins of the fimbria and the tenia (the edge of the 
caudatum) with just room for the entrance of the para- 
plexus, and the concomitant complete exclusion of the 
thalamus from the paracelian floor (compare Figs. 732 
and 788). 

B. The existence of an ental ridge (1) at this period, 
continuous and corresponding with the hippocampal and 
callosal fissures; whether it extends still farther cepha- 
lad, as in Fig. 742, cannot be ascertained from this speci- 
men. 

C. The branching off of a ridge corresponding ap- 
‘parently to the occipital fissure, and representing the 


adult occipital eminence. : 







fmbria—__N& 
paraplexus, 
tenia 
thalamus 
caudatum 
paraplexus 
velum 
fimbria: 
hippocamp, 


medicornu. 


t ieee 





D. The existence of two intermediate ridges, perhaps 
prefiguring the calcar and collateral eminence. 


fossa Sylviana paraplexus 
caudatum i fimbria 


\ 














_- occipital eminence 
_-occipital Te 


_calcar 


~=COllateral eminence 


j~—-~— collateral f. 


~>s.~hippocamp 


~s...medicornu 


Fia. 734.—Left Hemicerebrum, Laid Open, of a Fetus Weighing 88 
gm. (3 ounces), Measuring 15 cm. from Heel to Bregma, and Esti- 
mated at Fourteen Weeks; 2,083. 1.5. 

Preparation.—The fetus was received fresh; the head was cut 
off and pinned by the neck to a cork loaded with sheet lead; a 
shaw] pin was inserted as a handle at one side of the head. A slit 
was made through the scalp at the lateral angle of the prefontanel, 
and the guarded cannula adjusted so that ninety-five-per-cent. alco- 
hol should enter the paracele gently, with opportunity for egress at 
the side of the cannula. After six hours the alinjection was discon- 
tinued, but the specimen remained in alcohol for two days, when 
the scalp was removed and the specimen placed in ten-per-cent. 
nitric acid. After five hours the calva was so far decalcified that it 
could be cut away with the scalpel and scissors without jarring the 
very delicate brain. The left hemicerebrum was then exposed as 
indicated, and the nape of the neck removed to expose the collateral 
fissure. Upon a larger scale some of, the, points would have ap- 
peared more clearly. 3 


intercerebral f. 


callosal f. 


paraplexus 


fimbria 
hippocamp 
5 

epiphysis 

6 


mesocele 
—.tegmentum 


-—crusta 


Fic. 733.—Dissection, Partly Schematic, of the Floor of the Left Paracele (‘* Lateral Ventricle’’), Caudal Aspect; 2,345 and 2,347, 1.5. Com- 
pare in part with Fig. 706. 4, Lateral sulcus of the mesencephal; 3, oculomotor nerve; 5, line of somewhat sudden deflection of the splenial 
fibres caudad into the occipital lobe ; 6, large vein; 7, fimbrial sulcus; 8, angle between the fimbria and the hippocamp ; 9, hippocampal fissure. 


Preparation.—The arteries were injected with the red glue mixture, and the cavities with alcohol. When hardened, a thick slice was 
taken by one transection at about the middle of the length of the callosum and another at the splenium, just shaving off the tip of the 
epiphysis. The original transection of the brain stem between the mesencephal and epencephal was modified by carrying two sections 
cephalo-mesad, meeting at the level of the valvula. On the right of the cerebrum the parts were left undisturbed, excepting that the 
paraplexus was raised so as to expose the floor of the cavity. On the left, a thin slice of the hemicerebrum is left attached to its opposite by 
the pia. In order to expose the paracelian floor as completely as possible from this point of view, the sections had to be made in many 
directions. The paraplexus was trimmed down for a certain distance; then a wedge-shaped piece was cut from the thick caudal wall, 
hippocamp, etc., including part of the thinner floor, fimbria: this exposed the velum, the double fold of pia between the dorsal surface of 
the mes- and diencephal and the ventral surface of the fornix. Very cautiously then the two parallel incisions were carried across the 
floor to and into the caudatum constituting the lateral wall; the strip so enclosed was then lifted; it included (1) a piece of the fimbria; 
(2) the disconnected part of the paraplexus; (3) a strip of the thin lamina intervening between the plexus and the caudatum; in 2,347 all 
these were found separable from the dorsal surface of the thalamus, substantially as in the transection, Fig. 732; in 2,345 there were com- 
plications which should form the subject of monographic consideration. See § 189. 

Defects.—The defects of the figure are due mainly to the attempt to combine the appearances presented by two different preparations. 


Vou. Il.—12 
WT 


Breil REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 





intercerebral f. 


GENU of the CALLOSUM 


ARACHNOID 


CAPUT of the CAUDATUM 


—— PSEUDOCELE 
—~HEMISEPTUM 


CAUDA Of CAUDATUM fy 


—FIMBRIA 


Sylvian f.- 
supertemporal f. 


ote 
POSTCORNU : 
e 





Fig. 735.—The Paraceles (‘‘ Lateral Ventricles’’) of an Adult Male, Exposed from the Dorsal Side; 2,867. 1.2. 

Preparation.—The entire body (an emaciated consumptive, weighing only 37.71 kgm., 83.25 pounds) was alinjected through the fem- 
oral artery. Eight and one-half litres were introduced on the first day, and some escaped from the mouth. On the second day, and again 
on the fourth, another litre was injected. On the fifth day there was injected a litre of Pansch-Gage starch mixture (see article Brain : 
Methods, etc.). When the brain was removed, on the eighth day, the only odor was of the alcohol. The substance had already hardened 
somewhat and the arteries were well filled, notwithstanding some of the mass had extravasated into the thorax. The brain was tran- 
sected through the mesencephal (see Brain: Methods), and the paraceles exposed by removing the dorsal portion of the cerebrum in 
thick slices down to the level of the callosum ; then in thinner slices and wedge-shaped pieces till the desired condition was reached. On 
the left the medicornu was exposed into the part extending cephalad ; the terminal portion extending also mesad could not be shown with- 
out cutting away an undesirably large mass. On the left also the occipital lobe was cut to a slightly lower level than on the right; hence, 
on the right appears the dorsal slope of the calear, while on the left the plane of section coincides with the line of its greatest elevation, and 
the width of the postcornu is correspondingly reduced. To lessen the width of the figure a part of the lateral convexity was removed by 
dorso-ventral incisions between 3 and 4, and 4 and 5, so the line representing the pia ceases at 3and 5. Finally, the left paraplexus was 
trimmed off quite closely. (For the rest of this explanation, see at bottom of page 179.) 


178 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


§ 196. Fig. 735 illustrates: A. The general relation of 
the paraceles (lateral ventricles) to the cerebrum; al- 
though relatively much smaller than in the fetus, they 
are absolutely extensive; here their natural extent has 
been maintained by the injection of alcohol; when ex- 
amined in a fresh brain or in one hardened in the usual 
way their walls are often found nearly in contact.* 

Bb. The termina] dilatation and squareness of the post- 
cornu, as contrasted with the pointed form which usually 
exists in brains not prepared by filling the cavities; 
sometimes, indeed, there has been doubt as to the extent 
of the postcornu, as admitted by Huxley, Zoél. Soc. 
Proceedings, 1861, p. 250; in Krause’s “ Handbuch” 
(1880), Fig. 479, the postcornua are merely linear. 

C. The great thickness of most of the parietes as com- 
pared with their thinness in the fetus, Fig. 667. 

D. The retention of the fetal tenuity of a portion of 
the mesal wall, viz., the hemiseptum (halves of the 
septum lucidum). 

E. The considerable length and width of the human 
pseudocele (fifth ventricle); so far as I have observed it 
is wider than in any other animal; in Fig. 726 (of the 
sheep) it is unnaturally wide. 

F. The relation of the cortex (cerebral ectocinerea) to 
the medulla (alba), as an ectal layer following the fissural 
indentations. 

G. The relation of the insula to the Sylvian fissure; 
the former is a typical subgyre, the latter is a typical 
superfissure. 

H. The relation of the claustrum to the insular cortex 
ectad and the lenticula entad (see also Fig. 782). 

I. The constitution of the caudatum by two regions, 
a larger cephalic, the caput, and the cauda, narrow, and 
following the curve of the medicornu. 

J. The junction of the occipital and calcarine fissures 
so as to constitute as it were a single bifurcate fissure. 

K. The size and distinctness of the collateral eminence, 
an ental elevation or colliculus, corresponding to the col- 
lateral fissure upon the ventro-mesal aspect of the cere- 
brum. 

L. The existence, on the left, of an elevation, the oc- 
cipital eminence, corresponding with the occipital fissure. 
This colliculus is distinct in the fetus (Figs. 734 and 761), 
and in some adults (Fig. 744) is better marked than in 
this specimen. 

M. The location of the portas (foramina of Monro), 
and their visibility in a direct dorsal view of the para- 
celes; by reference to Figs. 720 and 724, it will be seen 
that each porta opens into the corresponding paracele 
obliquely, looking laterad, cephalad, and also dorsad; 
hence it is visible from three different directions at right 
angles with one another. 

N. The distance between the two portas. Deducting 
the slight length of the passages themselves, this dis- 
tance represents the width of the aula, the mesal division 
of the prosocele, which is commonly reckoned as merely 
the cephalic part of the “third ventricle.” 

O. The continuity of the hemiseptum, a part of the 
-mesal wall of the paracele,.with the fimbria,.a part of. its 
floor; indeed, their topographical relations may be illus- 
trated by bending a sheet of paper or metal, and holding 





*The paper of E. A. Spitzka (1900) will contain an account of the 
topographic relations of the paraceles to the cerebral surfaces. 





Brain, 
Brain, 








it so that one portion is vertical and the other nearly 
horizontal; the former will represent the hemiseptum, 
the latter the fimbria. 

P. The narrowness of the human fornix as measured 
by the distance between the lateral margins of the two 
fimbrias in their horizontal portions: compare the sheep, 
Fig. 726. It is true the word fornix does not occur on the 
figure; but, as discussed in § 197, the fornix is constituted 
by the two hippocamps, with their fimbrias, united at the 
meson by the commissure (Fig. 732); in this dissection 
the commissure is invisible, being upon a lower plane, 
so the fornix, as a whole, cannot be indicated. 

Q. The smallness of the paraplexus as compared with 
its fetal condition, Figs. 667 and 747. 

R. The formation of the free margin of the paraplexus 
by the medicornual vein, considerable in size and more 
or less contorted, by which the blood of the plexus is re- 
turned to the velar vein. 

8. The considerable width of the attached portion of 
the paraplexus. This appears on the left side where the 
plexus has been trimmed quite closely. The rima is the 
line of apparent interruption of the parietes for the in- 
trusion of the paraplexus, and is unusually wide in this 
specimen. 

T. The completeness of endymal continuity and celian 
circumscription. These terms have been discussed in 
$$ 63-66, as exemplified upon the mesal aspect of the 
brain, Fig. 687. There only the mesal cavities are visible. 
In the present figure (aside from the pseudocele, which 
is not a true member of the series) there appear only the 
great lateral cavities of the prosencephal. The continu- 
ity of the endyma is represented by the uninterrupted 
heavy line surrounding either paracele. Likewise is the 
endyma a continuous sheet upon the sides and floor of 
this cavity. At the margins of therima it may be traced 
as a smooth surface upon the intruded paraplexus, and 
its cut edges are represented on the left in this figure. I 
am aware that several authors claim or admit the exist- 
ence of orifices along the medicornu whereby the neuro- 
lymph may escape therefrom into the adjacent subarach- 
noid space; but I am compelled, at present, to regard 
these as artifacts, like the half-dozen ruptures of the 
Se near the porta in the preparation shown in Fig. 

21. 

U. The apparent entrance of the thalamus into the 
composition of the floor of the paracele. This condition 
is presented on the left side; on the right it is hidden by 
the overlapping paraplexus. : 

§ 197. Fornix is a collective noun, a comprehensive 
name applied to a congeries of parts, each of which has 
its own name, and all of which, with a single exception, 
may exist in lower vertebrates and in man or other mam- 
mals, in certain anomalies, without the formation of the 
fornix as a whole. 

§ 198. Columns of the Forniz.—In each hemicerebrum 
there is a bundle of fibres ascending from the albicans 
and thalamus, passing just caudad of the precommissure, 
forming the cephalic boundary of the porta, diverging 
presently from its opposite, pursuing a curved direction 
along the floor of the medicornu and ending in the tem- 
poral lobe; in the aulic region, where it is most compact 
and exposed, this is commonly called an “anterior pillar 
of the fornix”; see Fig. 739. 

§ 199. Hippocamp (“hippocampus major”).—In each 





(Fig. 735.)—1, Cut surface, extending meso-ventro-cephalad ; 2, cut surface of the genu, the cephalic curvature of the callosum ; part of its nat- 
ural, pial surface lies just cephalad ; the transverse lines on the areas 2 and 9 are introduced merely to indicate the direction of the callosal 
fibres, not as representations of microscopic structure ; 3, point of disappearance of the pia as a result of cutting away part of the lateral 
convexity of the cerebrum ; 4, meeting-place of the two oblique cut surfaces caused by the exposure of the medicornu ; 5, point of reap- 
pearance of the pia, which was interrupted at 3; 6, is an area just caudad of the left calcarine fissure ; 7, the occipital fissure ; 8, the occip- 
ital eminence (see under Defects) ; 9, oblique cut surface of the splenium, of which a part of the natural surface is shown just caudad ; 10, 
the cut edge of the paratela covering the thalamus; from 10 a line should pass mesad to the narrow area between the two lines. | 

Defects.—The alcohol had so bleached the cinerea as to render the recognition of its outlines somewhat difficult, so the width of the 


cortical zone is only approximately accurate. 


The absence of shading upon the larger part of the surface would imply that it is all upon one level; really, however, the highest part 
corresponds nearly with the length of the exposed portion of the right caudatum, and from that level there are gentle slopes cephalad, cau- 


dad, and laterad. The cut edges of the hemiseptums are also at a lower level than the adjacent lateral parietes. 


Not all of the arteries are 


represented. The occipital eminence (8) is indistinct upon the right and made too small upon the left. The cut edge of the paratela (10) 


is made too thick and the relations of parts are indistinct (see § 191). 


On the left, near the word fimbria, is a defective patch of shading du to a blemish in the paper. ; 
The arachnoid is represented distinct from the pia at only two places, viz., on the right, near the cephalic end, where the former crosses 
the wide mouth of a fissure, while the latter dips into it as a fold, and at the collosal fissures, just caudad of the splenium. 


179 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





hemicerebrum there is a corrugation of the entire thick- 
ness of the parietes, resulting in the formation of a total 
fissure, the hippocampal (§ 259, C), and an ental eleva- 
tion, or colliculus, the hippocamp, along the medicornu; 
the hippocamp is 
thickened also, and in- 
timately associated 
with the fibres of the 
column already men- 
tioned. 

§ 200. Fimbria.—In 
each hemicerebrum be- 
tween the hippocamp, 
with its corresponding 
cortex, and the rima, 
or line of intrusion of 
the paraplexus, there 
is a zone consisting of 
alba alone, and form- 
ing, as it were, a mar- 
gin for the hippocamp 
(Figs. 733, 735, and 
759). This is the fim- 
bria (corpus fimbriatum, 
tenia hippocampt). 

§ 201. The column 
and its caudal, curved 
extension, the hippo- 
camp and the fimbria, 





Fia. 736.—The Left Hippocamp and Ad- 
joining Parts. xX 5. (From Quain, 
altered from Hirschfeld and Leveillé.) 
1, Apex of the temporal lobe; 1’, un- 
cus; 2, cut surface of the cerebral me- 
dulla surrounded by the cortex ; 3, at 
the apex of the postcornu ; 3’, collat- 
eral eminence; 4, part of the spleni- 
um, nearly medisected; 4’, points to 
the calcar; 5, cut end of the lateral 
portion of the fornix which is contin- 
ued at the hippocamp (5’) and the 
fimbria (6); 6, the fimbria; 6’, the 
terminal expansion of the hippocamp, 
ealled pes hippocampi; 7, dentate 
gyre (“fascia dentata”’). 

Preparation.— The left occipito- 
temporal region of the cerebrum was 
separated from the rest, together with 
a part of the splenium and fornix, and 
the dorsal and lateral parietes of. the 
postcornu and medicornu sliced away 
so as to expose nearly the entire ex- 
tent of the cavities. 

Defects.—The specimen had not 
been alinjected, and the figure looks 
somewhat diagrammatic, especially as 
to the dentate gyre (7) ; the actual ex- 
tremity of the medicornu does not ap- 
pear (see Fig. 728). There is no indi- 
cation, along the free margin of the 
fimbria, that one surface of this lamina 
was covered by pia and the other by en- 
dyma, and that they were continued in 
and upon the removed paraplexus. 


are simply portions of 
the prosocelian pari- 
etes, mainly of the par- 
acelian floor; they are 
continuous with the 
mesal wall, hemisep- 
tum (Fig. 782), and 
thus indirectly with 
the roof (callosum); 
excepting at the ven- 
tral end, in the tip of 
the temporal lobe, how- 
ever, their substantial 
continuity with the 
caudatum and _ tenia 
and other portions of 
the paracelian parietes 
is interrupted by the 
rima. It would be 
perfectly legitimate, 
therefore, to designate 
the irregular, elongat- 
ed portion of either 
paracelian floor, com- 
posed of hippocamp, 
fimbria, and fornicol- 
umn, by a special 
name, ¢@.g., hemiforniz. 


& 202. Commissure of the Forniz.—The parts compos- 
ing either hemifornix pertain each to its own hemicere- 
brum, and in brains in which the callosum is undeveloped, 
these have no connection across the meson dorsad of the 
aula and portas, representing the primitive mesal cavity 
of the prosencephal. So far as I know, the fornicommis- 
sure is thinner in man than in any other mammal; Fig. 
731. 

§ 203. The fornix is monographed by Honegger in the 
Recueil Suisse (zodlogie), 1890, v., 311-484. The hippo- 
camp has been treated by Alex. Hill, in a paper of which 
an abstract is published in the Royal Society Proceedings, 
vol. iii., p. 5. Variations in the form of the hippocamp 
and the collateral eminence are described by Howden in 
Journ. Anat. and Physiol., xxiii., p. 283, January, 1888. 
J. G. MacCarthy has described an interesting feature of 
the hippocampal structure in Journ. Anat. and Physiol., 
xxxili., p. 76, 1898. In the same journal are several re- 
cent papers by G. Elliott Smith discussing instructively 
the fornix and the commissures generally. 

§ 204. Lyra.—When the fornix is transected through 


180 


the columns (Fig. 737) and turned caudad the exposed 
ventral surface, including the splenium, is seen to pre- 
sent lines which have been rather fancifully compared to 
the strings of a harp; the lyra is not a part, but merely 
a surface. 

§ 205. Fig. 737 illustrates: A. The general form of 
the velum, a double fold of pia between the thalami and 
the superposed cerebrum, one of the layers belonging to 
each of the two segments (Fig. 710); the great veins are 
between the two, and others enter them from adjoining 
organs. The free lateral margins of the velum project 
into the paraceles as the paraplexuses (Fig. 720), and 
its rounded apex hangs in the aula and the two portas as 
the auliplexuses and portiplexuses (Figs. 721 and 724). 

B. The triangular form of the fornix; the cephalic, or 
“ascending ” part, consisting of the two parallel columns, 
constituting the so-called “anterior pillar”; it expands 
caudad, the sides being incurved instead of nearly 
straight, as with the cat, and at the splenium is quite 
wide. Each lateral half here is practically composed of 


| 


ii 
a 
ix 


‘NR 









































i 


















































i 
ili 
il 



































































































































































































































Fig. 737.—The Velum and Lyra. X 1.5. (From Quain, after Sappey 
and Vicq d’Azyr.) 1, The narrower cephalic part of the velum; 2, 
left paraplexus, the margin of the velum which enters the paracele 
as the paraplexus ; 3, left velar vein, partly covered by the right; 4, 
columns, with small veins said to come from th2 callosum and se 
tum, the precornual veins; 5, tenial vein; 6, medicornual vein; 7, 
thalamic vein ; 8, vein from left medicornu ; 9, postcornual vein ; 11, 
body of fornix, transected and refiected ; 12, lyra; 18, on the lateral 
part of the fornix; 14, splenium. (The names here employed for 
the veins are those adopted in the article Brain, Circulation of, in 
this volume.) 

Preparation.—With a preparation such as is represented in Fig. 
735, if the fornix were transected at its middle (f ), the caudal half 
turned caudad, and the cephalic half, with the attached hemisep- 
tums, removed down to the middle of the height of the portas, the 
appearances would be nearly as in the present figure. 

Defects.—The relation of the parts shown to the rest of the brain 
would be clearer if there were included at least an outline of one 
side or of the adjoining region. The tenias are omitted, between 
which and the fornical margins, fimbrias, the paraplexuses enter ; 
at the mesal side of each paraplexus should be a line, a ripa, indi- 
cating where the endyma covering the plexus was torn or cut in the 
separation of the fimbria. The whole, especially the lyra, is some- 
what idealized. * 


the corresponding hippocamp and fimbria, which, as they 
continue along the medicornu, are sometimes called the 
“posterior pillar.” 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





C. The nature of the lyra (§ 204). The line from 12 
ends at the meson, the location of the fornicommissure or 
thin part connecting the thicker lateral portions. 

D. The double relation of the splenium to the callosum 
and the fornix. The larger part, body, of the callosum 
consists of fibres which pass laterad, dorsad of the para- 
celes, constituting their roof; at the splenium some fibres 
pass dorsad, some caudad, some ventrad, and others in 
intermediate directions; now all the constituents of the 
fornix form parts of the floors rather than the roofs of 
the paraceles, and at the splenium fornix and callosum 
become continuous. 

§ 206. Modifications of the Prosocelian Parietes.—Pri- 
marily the cerebrum is a pair of lateral extensions of a 
small mesal rudiment, the first (cephalic or “anterior ”) 
encephalic vesicle; this forms their only bond of union 
with one another and with the other segments; their 
walls are thin and vary little in thickness or composition. 
Secondarily, the two hemicerebrums are closely conjoined 
by the callosum and other commissures; between the 
cerebrum and the crura (and thus the oblongata, the 
myel, and indirectly the entire body) are developed ex- 
tensive fibrous communications, the capsulas or “internal 
capsules”; the parietes are, for the most part, extraordi- 
narily thickened, the most notable, and physiologically 
the most important of these increments constituting what 
are commonly called the “corpora striata,” from the ap- 
pearance presented on sections of alternating strips of 
alba and cinerea. Each striatum, however, is now recog- 
nized as composed of an entocelian (“intraventricular ”) 
portion, the caudatum, and an ectocelian (“ extraventricu- 
lar”) portion, the lenticula (“lenticular” or “lentiform 
nucleus”), separated by the capsula already mentioned 
(Figs. 739 and 782). 

§ 207. The Caudatum and Lenticula.—With all Rep- 
tiles, Birds, and Mammals, and at a very early period, the 
lateral wall and floor of the paracele present a more or 
less distinct elevation; in man, and some other mammals, 
the form is such as to suggest the application of caput to 
the cephalic (precornual) portion, and cauda to the taper- 
ing continuation along the medicornu, thus of caudatum 
to the entire mass (Fig. 735). 

Between the caudatum and the cortex the greatly 
thickened hemicerebral wall presents (a) the medullary 
lamina called capsula (§ 208); (0) next the cortex, a sub- 
circular disc of cinerea, the claustrum (Figs. 739 and 
782); and (c) the lenticula, consisting of three zones, all 
more or less striated, the ental the smallest, and the ectal, 
also called putamen, the largest. The lenticula, like the 
claustrum, may be a dismemberment of the cortex. This 
entire region, from caudatum to operculums, is of great 
morphological as wellas physiological interest and should 
be studied in the other mammals. 

§ 208. Capsula and Corona.—As already stated (§ 206) 
the capsula or “internal capsule” is the thick layer of 
fibres between the caudatum and thalamus mesad and the 
lenticula laterad; it is continuous with the crura caudad, 
and expands in the substance of the cerebral alba in such 
a way as to be called there corona (radiata). The histolog- 
ical and physiological aspects of the capsula and corona 
are considered in other articles; here an attempt will be 
made to indicate only their topographical relations by 
explanations of the accompanying figures (738 and 739). 

§ 209. Mig. 738 illustrates: A. The general relations 
of the alba (medulla) to the ectocinerea (cortex). 

B. The locations of the two great masses of entocinerea 
(central tubular gray), the caudatum and the thalamus. 

C. The intermediate position of the lenticula, asa blunt 
wedge-shaped mass between the caudatum and thalamus. 

D. The position of the capsula (“internal capsule ”) as a 
stratum of alba between the lateral lenticula and the other 
two masses, and constituting a fibrous path for motor 
and sensory conduction between the cortex and the crura. 

E. The existence of two zones in the lenticula, the 
more lateral being distinguished as putamen ; a third 
would have appeared at a level farther ventrad (Fig. 739). 

F. The existence of a thin, cinereal lamina ectad of the 
lenticula, between it and the cortex; this is the claus- 


trum; it and the cortical corrugations of this region are 
shown upon a larger scale in Fig. 782. 

§ 210. Fig. 739 illustrates: A. The existence and rela- 
tive positions of four important masses of connecting 
fibres, the callosum, columns of the fornix, precommissure, 


FRONTAL LOBE 






recornu 
P S 


caudatum 


fornicolumn ™ 
lenticula 2 


thalamus 


OCCIPITAL LOBE 
Fic. 738.—Longisection of the Right Hemicerebrum at the Level of 


the Aula. Xx .05. (From nature [2,397] and from Gray.) 
Preparation.—The mesal outlines of the removed frontal and 
occipital regions were adapted from Gray. The plane of section 
corresponds nearly with the direction of the dotted line from aula 
on Fig. 739. The line A, B,C should have been dotted. This line 
and the one parallel with it mesad by the ‘‘internal capsule ’’ were 
introduced with reference to another figure which is not given here. 


and chiasma, differing from one another in either their 
direction or their appearance upon this section. The 
most ventral, the chiasma, is mainly a decussation, as. 
described in the article Cranial Nerves. The next, pre- 
commissure, isa true commissure, connecting correspond- 
ing regions of the temporal (and frontal?) lobes; at the: 
meson it is seen as a raised transverse band, but laterad, 
on account of its deflection caudad, it is divided ob- 
liquely, and appears as an eiliptical dottedarea. The 
two columns have at this level a nearly dorso-ventral 
direction, appearing as raised bands just dorsad of the 
precommissure (the line from the word aula ends upon 
the right), but they are curved in such a way as to be 
divided obliquely in two places—one at the level of the 
precommissure, and the other about 1 cm. (on this scale) 
dorsad. Finally the callosum, a true commissure, unit- 
ing corresponding regions of the cerebrum, is divided in 
the direction of its fibres. 

B. The general relation of parts and cavities at this 
important level. Two segments are represented—the 
diencephal (thalami, chiasma, and diaterma) and prosen- 
cephal (the remaining and much the larger part). Of the 
cavities, the mesal space between the chiasma and pre- 
commissure is the cephalic part of the diacele, the dark- 
est portion being the optic recess. The prosocele is rep- 
resented by the aula, the mesal space dorsad of and 
including the precommissure; by the considerable 
lateral cavities, paraceles ; and by the intervening portas. 
All these are true encephalic cavities, but the dark 
triangular area still farther dorsad is the pseudocele.. 


181 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Three kinds of surfaces are included, viz.: entocelian, 
lined by endyma; ectocelian, covered by pia; and pseu- 
docelian, with no distinct membrane. There is ecto- 
cinerea (cortex), entocinerea (caudatum and thalami), and 


culums (see Fig. 782). 













pia 
intercerebral f, 
supercallosal f. 
1 

| Fa 2 

fe "=~ callosal f. 


callosum 
roof of paracele 





H. The relations of the insula to the parts just named, 
and to the overlapping gyres which constitute the oper- 


I. The relation of the cinereal mass called amygdala to 


a fissure opposite 
the m of postoper- 
culum, which has 
thence been called 
the amygdaline fis- 
sure; Dwt, ates 
doubtless homolo- 
gous with the post- 
rhinal of quadru- 
peds. (§ 872, Fig. 









a3 chiasma 
\ claustrum 
N 
insula 
operculum 
postoperculum 





¥ic. 739.—Transection at the Chiasma and Precommissure, Caudal Aspect. 
1, Asubgyre (covered gyre) at the bottom of the su- 
percallosal fissure ; 2, margin of the cortex dorsad of the callosal fissure ; 


one-sixth and modified (compare Figs. 724, 738, and 782). 


the thalamus, faintly outlined on the other side; 5, capsula. 


Defects.—The dots representing cut fibrous areas are too heavy. The lines representing the callosal fibres 
are diagrammatic; one of them is interrupted. The pseudocele is not specified. The area cf the thalamus is 


too vaguely indicated. See § 210. 


what may, for the sake of a general term, be called medi- 
cinerea, the lenticula, and the claustrum, probably dis- 
memberments of the ectocinerea. 

C. The extension of the hemicerebrum nearly equally 
in three directions from the place of its morphological 
centre, the porta; were this brain not somewhat depressed 
by its own weight, the width and height would be nearly 
the same. 

D. The thickness of most of the parietes as compared 
with the earlier fetal conditions shown in Figs. 667 and 
716; the hemiseptums and the terma, however, have re- 
tained their tenuity in great degree. 

E. The absence of the crista which was seen in a 
young brain (Fig. 793), and is constant in the cat (Fig. 
686); whether it is absorbed or merely obscured in the 
human adult is not known (§ 366). 

F. The overlapping of the prosencephal at the sides of 
the diencephal, of the cerebrum upon the thalami. 

G. The relations of the several layers of alba and 
cinerea between the thalamus and the lateral surface of 
the cerebrum. The capsula (5) has an oblique direction, 
dorso-laterad, between the thalamus and caudatum and 
the lenticula (see Fig. 738). The lenticula itself com- 
prises three more or less distinct segments, each extend- 
ing farther dorsad than the one mesad of it; all present 
the alternating lines of white and gray which led to the 
application of stréatum to the united lenticula and cau- 
datum. The thin lamina of cinerea between the putamen, 
the most lateral division of the lenticula, and the insular 
cortex is the claustrum, and the alba between it and the 
lenticula is commonly, but inappropriately, called the 
“external capsule. ” 


182 

















765.) 

§ 211. Besides 
the precommissure, 
a medisection dis- 
plays two extensive 
lines of cut surface 
(Figs. 670, 682, 687, 
and 765), indicating 
that there was a 
continuity of the 
apposed, mesal sur- 
faces of the two 
hemicerebrums. Of 
these the dorsal, 
more extensive and 
more substantial, 
is the callosum 
(Figs. 724, 737, 739, 
and 740); the ven- 
tral is the commis- 
sure of the fornix 
(Figs. 782 and 748). 

§ 212. Callosum. 
—When the fresh 
hemicerebrums are 
divaricated, as in 
Fig. 740, the bot- 
tom of the intercer- 
ebral fissure is seen 
to be formed by a 
white mass which 
unites them for 
more than the middle third of their length; upon 
hardened brains this, the callosum (corpus callosum, 
trabs cerebri, etc.), is easily determined to be fibrous, 
and somewhat firm in consistency, and to extend into 
the hemicerebral masses. At about the middle of its 
cephalo-caudal extent, the trend of the callosal fibres is 
almost directly laterad, but at the cephalic and caudal 
ends, especially the latter, the direction is oblique, giv- 
ing rise to the conditions known as preforceps and post- 
forceps (Figs. 785 and 740). The rounded cephalic 
region of the callosum is the genu, and the caudal, the 
splenium. As seen in medisections (Figs. 670, 687, and 
743) the genu appears likea folding of the callosum upon 
itself, the ventral continuation being the rostrum, which, 
in man and other primates, is connected with the terma 
by the thin copula. The gentle curve of the.genu gives 
to the cephalic part of the pseudocele a rounded outline. 

§ 2138. Mg. 742 illustrates: A. The primary continuity 
of the hippocampal and callosal fissures, and of the 
frontal extension marked 1. 

B. The existence of several early fissures, some of 
which are probably transitory. 

C. The continuity of the callosum, fornix, and terma. 

D. The degree of separation of the callosum and the 
fornix at this period, and the concomitant form and ex- 
tent of the pseudocele. 

§ 214. Splenium.—This region of the callosum i is much 
less easy to understand than the genu from the study of 
normal adult brains, but most of the difficulties are re- 
moved or diminished by the study of fetal and hydro- 
cephalous specimens (Figs 742 and 743). From these it 
is clear that, like the genu, the splenium represents a 


paracele 
caudatum 
3 





precommissure (1) 


amygdala 
‘~X fornicolumn (y) 


_ \ precommissure (m) 
~~ diacele 

temporal lobe 

(From Dalton, by permission.) Reduced 


3, tenial vein; 4, the cephalic part of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain. 
Brain, 





flexion of the callosal sheet upon itself so that there is a 
dorsal lamina, a ventral lamina, and a caudal connecting 
portion ; commonly the dorsal and ventral portions are 


um are parts of the mesal wall of the precornu and 
postcornua respectively, while those which compose the 


(iP) 


¢ 


? 


A yy WY 


z H mn ‘\ 4 \ b : “ei : at 






















































































































































































































































































































































































































































































We i's w) 

mi nN vil 1 
a ul 

SA 




































































¥ia. 740.—The Dorsal Aspect of the Callosum, Exposed by Divaricating 
the Hemicerebrums. (From Quain, after Sappey and Foville.) x 
0.5. 1, Dorsal surface of the body of the callosum ; 2, mesal ridge 
or raphé ; 3, lateral ridges, bounding furrows in which, sometimes 
at least, are lodged the precerebral arteries; 4, lateral ridge, said 
to be formed by the arching of the callosum over the paracele; 5, 
cephalic curved margin, genu; 6, caudal curved margin, splenium ; 


ventral lamina and the splenium are parts of the para- 


splenium fornix 
me 
a callosum 
‘ 






pseudocele 
genu 






F, bmp. /“* 


G. dnt. “fimbria 


Fic. 742.—Mesal Aspect of the Left Hemicerebrum of a Fetus, Measur- 
ing 16.8 em. from Heel to Bregma, and Estimated at}/Eighteen Weeks; 
2,084. 1.5. 1, Cephalic extension of the primitive callosal fissure ; 
2, 3, 4,5, short but distinct radial fissures, some of them probably 
transitory ; 6, point of refiection of the endyma from the fornix at 
the dorsal end of the porta; 7, point of reflection of the endyma at 
the tip of the rima upon its other margin, the tenia, which has been 
removed ; 8, region which would haye become the uncus; 9, tip of 
the temporal lobe; F'’. hmp., the hippocampal fissure; G. dnt., the 
dentate gyre (fasciola or fascia dentata) ; L. ol., olfactory bulb. 

Preparation.—The fetus was ill preserved and the head dis- 
torted; the entire head was medisected with a scalpel; the brain 
was so tender that the caudatum and plexus broke loose. 

Defects.—_The terma is shown too thick; the tenderness of the 
specimen did not permit determining the location and form of 
the chiasma and precommissure. 


7, preforceps, callosal fibres passing 
cephalad into the frontal lobes; 8, post- 
forceps, fibres entering the occipital 
lobes; 10, cephalic portion of the cal- 
losal gyre, the line crossing the cepha- 
lic end of the supercallosal fissure ; 11, 
eallosal fissure; 12, caudal part of the 
callosal gyre, the line crossing the para- 
central gyre ; 13, cephalic surface of the 
cerebellum, the number being just cau- 
dad of the occipital fissure. 

Preparation.—While fresh the dor- 
‘sal portions of the hemicerebrums were 
separated widely ; the curved margin 
of the callosal gyre (“gyrus fornica- 
tus’) has been detached and pushed lat- 
erad so as to expose more completely 
the extension of the callosal fibres into 
the hemicerebrum; caudad this gyre 
has been divided. See § 212. 


‘in close contact, but in hydrence- 
phals (Fig. 743), as in the fetus at 
a certain stage, they are separated 
by a considerable interval; in 
these cases the pseudocele has a 
greater extent and a somewhat 
rounded caudal end. For the 
most part the callosum extends 
-dorsad of the paraceles, thus con- 
stituting their actual (though ndt 
primary) roof; but the fibres ex- 
tending obliquely cephalad and 
ccaudad from the genu and spleni- 





* This neuter noun is employed to des- 
ignate the primitive, undifferentiated mass 
or rudiment of a part, thus in the sense 
-of Anlage of the German embryologists 
(as adopted by Minot and others), and of 
fundament, as proposed by Mark (‘* Com- 
parative Embryology”). It avoids cer- 
‘tain obvious objections to those terms as 
English words, is shorter than primordi- 
um (proposed. by Willey), and is in har- 
mony with the following phrases from 
Aristotle, kindly quoted by President B. 
As Wheeler : TO MpOTOV;  TPWTH VAN; 7H 
TpaTn aitia, 





callosum 
genu splenium 
rostrum 
copula pseudocele 
prosoterma fornix 
precommissure 

diaterma 

chiasma haben 









Fig. 741.—Six Diagrams of the Devel- 
opment of the Human Callosum ; to 
be viewed from below upward. The 
chiasma and tuber are introduced 
merely to facilitate orientation by 
comparison with Figs. 670 and 687. 
In A the primitive end wall of the 
mesal series of cavities is undiffer- 
entiated but reinforced by the chi- 
asma which demarcates the tuber 
below and the terma above. In B 
the terma is reinforced by the pre- 
commissure, and its dorsal end 
(margin really, but seen as an end 
in medisection) is enlarged, consti- 
tuting the proton * or rudiment of 
the callosum and fornix. In C the 
elongation of the whole terma ren- 
ders more obvious its demarcation 
into the diencephalic portion (dia- 
terma) and the prosencephalic (pro- 
soterma) ; the calloso-fornical pro- 
ton presents a slight cavity or 
vacuole, the proton of the pseudo- 
cele. In D the callosum, fornix, 
and pseudocele are enlarged espe- 
cially caudad. In Eand F the proc- 
ess continues and all the adult 
structures are seen. The lateral 


septum, and it (the pseudocele) is 
never in communication with either 
the ental or the ectal surfaces. 


wall of the pseudocele is the hemi- 


celian floors, continuous with the 
fornix (Figs. 738 and 744). 

§ 215. Mig. 743 illustrates: A. 
The complete separation of the 
fornix and callosum as far as the 
splenium, which is thus a com- 
mon bond between them, although 
usually, and perhaps properly, 
reckoned as a constituent of the 
callosum only. 

B. The concomitant extension 
of the pseudocele and of the hemi- 
septum. 

C. The large size of the porta. 

D. The wasted appearance of 
the visible gyres, in contrast with 
those of Chauncey Wright (Fig. 
788). 

§ 216. Mig. 744 tllustrates: A. 
The continuity of the splenium 
with both the floor, roof, and 
caudo-mesal wall of the paracele; 
some of the fibres pass dorsad, 
some ventrad into the hippocamp, 
while others, constituting the post- 
forceps, extend caudad into the 
calear, dorso-caudad into the occip- 
ital eminence, and ventro-caudad 
into the collateral eminence. 

B. The unusual distinctness of 
the occipital eminence, this being, 
in fact, the preparation in which 
it first attracted my attention 
(comp. Fig. 761). 

C. The prominence of the cal- 
car, here seen, of course, greatly 
foreshortened; of the left hippo- 
camp only a segment of the caudal 
convexity appears in this prepara- 


183 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





tion, with the collateral eminence just beyond (compare 
Fig. 735). 

§ 217. Indusium.—This term (coupled with the adjec- 
tive grisewm) was given by Obersteiner (1892, p. 82) to 


supercallosal fissure 


callosum fornix 


porta pseudocele d 










Fic. 743.—Mesal Aspect of Part of the Right Hemicerebrum of an Adult 
Hydrocephalus; 747. % .7. The dorso-ventral line, d v, indicates 
the transection plane represented in Fig. 731. 1, Splenium ; 2, ven- 
tral surface of fornix ; 3, subsplenial gyres; 4, 5, ?; 6, collateral fis- 
sure; 7, uncus; 8, hippocampal fissure. The tip of the temporal 
lobe, included by the interrupted line just cephalad of v, indicates 
what was removed to expose the parts shown in Fig. 728. 


the thin layer of cinerea upon the dorsal surface of the 
callosum. It has been discussed by Giacomini, Blumenau, 
and more recently by Fish, 1893, a.* 

§ 218. In several (perhaps half a dozen) brains in the 
Cornell museum the callosum presents a de- 
cided thinning at about the junction of the 
middle with the splenial third; most if not 
all of the individuals were mentally defect- 
ive in some degree. 

§ 219. Incallosal Brains.—In addition to 
about fifteen cases of shortness or thinness of 
the callosum, there have now been reported 
at least a dozen instances of its complete ab- 
sence, together with the mesal part of the 
fornix. Commonly this deficiency was ac- 
companied with mental and physical weak- 
ness, amounting often to idiocy; but Malin- 
verni reported (Giornale del R. Acad. Torino, 
1874; Gazette médicale de Paris, January 16th, 
1875; Gazetta delle Cliniche, 1874, No. 15; 
London Medical Record, 1874, No. 73) the case 
of a soldier, forty years of age, who had been 
noted merely for melancholy, taciturnity, and 
lack of neatness. A case of total absence of 
the callosum and fornix is described and 
figured with unusual fulness by Alex. Bruce, 
in Brain, xiii., 171-190. There are included 
abstracts of previous cases and reduced copies 
of the illustrations of some. 

§ 220. Fig. 745 tllustrates: A. The absence 
of the callosum and of the commissure (mesal 
part of fornix). 

B. The development of the columns as far 
dorsad as a point corresponding apparently 
to the dorsal limit of the aula and porta 
(which is not distinctly indicated). 

©. The roofing in of the aula and diacele 
by a thin (membranous?) tela, the remnant 
of the primitive roof of the cavities. 

D. The absence of the medicommissure and 
small size of the precommissure, in contrast 
with the same parts in the incallosal cat 
(§ 221). 

E. The independence of the occipital fis- 


*T have to record with some chagrin that, upon a 
series of transections of an adult brain (1,824), sections 
of which are shown in Figs. 732 and 744, hardened in a 
mixture of ammonium dichromate and alcohol, the con- 
tinuity of the cinerea upon the callosum was recognized 
in October, 1880; notwithstanding its significance, fur- 
ther examination and publication were deferred. 


184 


sure, and the apparent junction of the calcarine with the 
hippocampal. 

F. The radial disposition of the mesal fissures; some 
of them probably represent the transitory fissures men- 
tioned in § 227. 

§ 221. Among other mammals than man the total ab- 
sence of the callosum has been observed, so far as known 
to me, only in three cats examined in the anatomical 
laboratory of Cornell University; one of these (No. 381) 
has been described in my paper (1883, c), and was repre- 
sented in the first edition of the REFERENCE HANDBOOK, 
Fig. 4,835. At the Boston meeting of the Association of 
American Anatomists, December 29th, 1890, I showed the 
brain of a sheep (No. 2,844) in which the callosum is rep- 
resented, if at all, by a short thin lamina; but this speci- 
men, fortunately unmutilated and thoroughly hardened, 
has not yet been figured or described. 

§ 222. Pseudocele (“fifth ventricle,” “ventriculus septi 
pellucidi”).—This compressed, subtriangular mesal cav- 
ity has no connection with the true encephalic cavities. 
either in the adult or at any stage of development. Its 
anatomical relations are shown in Figs. 687, 782, 785, and 
others; but they are more clearly understood from the 
series of diagrams in Fig. 741 based upon my own speci- 
mens and the account of Marchand (“Ueber die Ent- 
wickelung des Balkens im menschlichen Gehirn,” Archiv 
Siir mikr. Anat., Xxxvii., pp. 298-334). 

§ 223. In the-cat (Fig. 682) and mammals generally, 
both the anatomical and developmental conditions are 
different. The fornix commissure and the callosum con- 
stitute portions of two lines of secondary junction of the 
two hemicerebrums and are continuous at the splenium 


supercallo~ 
“~ ) sal fissure 


=....callosal f. 
4-...-..callosum 


sen sense 


; occipital 
eminence 


BL. ip oieie,« era COLCRES 


2 § collateral 
eminence 


.- hippocainp» 


Fig. 744.—Transection of an Adult Brain through the Splenium; 1,824. x1. 1, 
Postcornu ; 2, section of a subsplenial gyre. 

Preparation.—The brain was that of a Pole, male, and was received in the 
head through the kindness of Dr. F. Cary, a former student. 
object of furnishing reliable preparations for the elucidation of the celian pari- 
etes (see Fig. 732), the sides of the head were sawn off so as to expose the medi- 
cornu, and into this was injected a mixture of alcohol (95°) and water, each 2 
litres, ammonium dichromate, 10 gm.; the same was injected into the arteries. 
When the brain was completely hardened it was removed and transected at in- 
tervals of about 1 cm. 
pe Cate ee lines representing the callosal fibres should be continued across 

e meson. 


With the special 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. wld 


Brain, 





as in man; but cephalad the callosum ends as a point so 


that the triangular area is not completely circumscribed ; 


’ 


commonly, also, the interval corresponding to the pseu- 


gations of the wall (Fig. 747). They do not branch. 
Their general direction is radial. By the end of the 
fourth month they disappear from the lateral surface 


docele is narrower than in man. (Fig. 748) and partly at least from the mesal, although 
§ 224. In three apes (orang, gorilla, and chimpanzee*) | there is reason to believe that two of them may be prac- 

lam. term. r “Sule. call. marg. 
} ! 








Any sule. centr. 
T 


R. gyn. fornic \ preecun, 





sulec. occ. trans. 


f/ _fiss. cle. 
mm / 






Ne ; sule. occ. temp. inf. 
i : ¢ Xe g. hipp. 
col. ant.forn. sp.lue. / 4 \ x puly. thal, 
* com. ant. i } schn 
1. perf. ant. tr. opt. \ 


gyr. une. 


Fic. 745.—Mesal Aspect of the Right Hemicerebrum of an Incallosal, Microcephalic, Adult Brain. X .93. (From Onufrowicz.) -Abn., abnor- 


mal radiating fissures; Col. ant. forn., fornicolumn; Com. ant., precommissure; Cun., cuneus; Fiss. cle., calearine fissure; Fiss. par. 
occ., occipital fissure; G. hipp., hippocampal gyre; G. unc., uncus; L. perf. ant., precribrum; Lam. term., terma [aulatela and dia- 
tela]; ling., subcollateral gyre; precun., precuneus; Pulv. Thal., pulvinar (of the thalamus); R. gyr. fornic., margin of the callosal 
gyre (gyrus fornicatus) ; Schn., cut surface between the diencephal (thalami, etc.) and mesencephal (gemina) ; Sp. luc., hemiseptum [?] ; 
Sule. call. marg., supercallosal fissure [7]; Sule. centr., central fissure; Sulc. occ. temp. inf., collateral fissure; Sule. oce. tr., “* trans- 


verse occipital fissure’ [?]; Tr. op., optic tract. 

Preparation.—This was the brain of a male idiot, thirty-seven years of age, who had never learned even to feed himself; it seems to 
have been obtained fresh early and well preserved; the paper (‘‘ Das balkenlose Mikrocephalengehirn Hofman,” Archiv fiir Psychiatrie, 
1887, xviii., pp. 1-24) from which the figure is taken is by Onufrowicz, but this and most of the other figures are by Forel. There are sey- 
eral transections, but the laek of distinct indication of endymal continuity renders them less instructive than they might haye been. The 
weight of the entire brain is not stated. See § 220. 


and in all the monkeys examined by me the conditions 
are aS in man; the mode of development is not known 


to me. 


§ 225. To English-speaking anatomists interested in 


Om4 8 2 1 





ee 


Fia. 746.—Right Side of the Brain 
of a Fetus Measuring 49 mm. 
from Nates to Bregma, and Esti- 
mated at Twelve Weeks; 1,828. 
* 1.4. (The left side of the same 
is shown in Fig. 673, where the 
mode of preparation is described.) 


the morphology of the 
cerebral fissures and com- 
missures are particularly 
commended the _ recent 
writings of TD. J. Cun- 
ningham, and G. Elliot 
Smith in the Journal of 
Anatomy and Physiology. 

§ 226. Mig. 746 tllus- 
trates: A. The condition 
and relative size of the 
encephalic segments at 
this period. 

Bo The presence of 
transitory fissures which 
are absent from the other 
hemicerebrum (Fig. 673). 

C. The indication, so 
far as these transitory fis- 
sures are concerned, that 
in this individual the right 
hemicerebrum was more 
advanced than the left. 

§ 227. Transitory Fis- 
sures.—During the third 
and fourth months both 
the lateral and mesal sur- 


faces of the cerebrum present linear depressions corre- 
sponding with ental ridges and thus representing corru- 


* A gibbon brain has not yet been available. 


~ 


tically perpetuated by the formation of the permanent 
calcarine and occipital fissures along the same lines (Fig. 
730). 

§ 228. Mig. 747 illustrates: A. The great size of the 
paraceles and paraplexuses at tlris stage; compare 
Fig. 667. 


a lateral fissure 


paraplexus 


a mesal colliculus 


a lateral colliculus 
a lateral gyrus 
a mesal fissure 


1 


part of falx 





Fic. 747.—Transitory Fissures of a Fetus Measuring 5-6 cm. from Ver- 
tex to Nates, and Estimated at Fourteen Weeks; 2,770. X 2.2. 
Preparation.—After the exposure of the brain the frontal end of 
the cerebrum was sliced off so as just to clear the large paraplexuses. 
Of the falx all was removed excepting the fragment shown. The 
head was tilted so that the face is much foreshortened. 


185 


Brain. 
Brain, 





B. The slight and nearly uniform thickness of the 
parietcs. 

C. Suggestion of a wrinkling or corrugation of the 
parietes as if from growth within a confined space. 


transitory fissure 


® quadrigeminum 
cerebellum 


oblongata 
myel 


i Sylvian fossa 





Fia. 748.—Fetus Measuring 7 cm. from Nates to Vertex, and Estimated 
at Fourteen Weeks; 2,761. X .9. Neg. 1,090. Received in weak 
alcohol and injected through the umbilical vein with alcohol and 
zine chlonide. 


D. The approximately symmetrical distribution of 
these corrugations. 

E. The length of the fissure on either side, reaching 
from the Sylvian fossa nearly to the meson. 

F. The absence of any indication of branching. 


§ 229. Fig. 748 tllustrates: A. The large number of - 


transitory fissures at this stage. 

B. Their general arrangement 
as radiating from the Sylvian 
fossa; compare, however, Fig. 
TAT. 

C. The considerable difference 
in their length; one of the longest 
is indicated by the line from 
“transitory fissure”; one of the 
shortest is just below it. postoperculum 

§ 230. Transitory Fisswres Prob- falx 
ably Mechanical in their Origin.— 
The simplest explanation seems to 
be that their formation is due to 
the growth of the cerebral walls 
at a rate more rapid than that of 
the cranium; and that their dis- 
appearance results from the yield- 
ing or more rapid growth of the 
cranium. 

§ 231. Fig. 749 illustrates: A. 
The disappearance of the trans- 
itory fissures, at least upon the 
lateral aspect. 

B. The concomitant 
increase in the length of 
the cerebrum, apparent- 
ly from the development 
of the occipital region; 
compare Figs. 667 and 
673. 

C. The non - appear- 
ance of the lambdoidal 
fissure (Fig. 750). 

D. The commence- 


Sylvian fossa 































Fic. 749.—Fetus Measuring 8.8 cm. from Vertex to Nates, and Esti- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


culum as a fold of the temporal lobe projecting over 
the Sylvian fossa. 

E. The non-appearance at this stage of the other oper- 
culums or of any elevation indicating the future insula. 

§ 232. Abnormal Persistence of Transitory Fissures.— 
In several brains lacking the callosum (e.g., the one 
shown in Fig. 745), the mesal permanent fissures present 
the radial arrangement characterizing the transitory 
fissures. This condition likewise exists upon the lateral 
aspect in the case described by Hans Virchow and shown 
by Cunningham (1892, Fig. 7). 

§ 288. Are Transitory lissures Peculiar to the Human 
Brain ?—Hitherto, as remarked by Cunningham, they 





Fig. 750.—Dorso-Caudal Region of the Cerebrum of a Fetus Measuring 
about 30 cm. from Heel to Bregma, and Estimated at Six Months; 
1,817. x 1. 1, Sagittal suture; 2, lambdoidal suture; 3, right 
lambdoidal fissure ; 4, left lambdoidal fissure. 5 

Preparation.—The entire fetus had been preserved in: alcohol. 
From the left side the calva and dura were removed, excepting a 
narrow strip along the meson ; on the right there was left a trape- 
zoidal area, 12 to 25 mm. wide, including most of the sagittal and 
lambdoidal sutures. 


have been observed only in man. Before, however, con- 
cluding that they constitute a real human peculiarity 
they should be looked for in the other primates, where I 
believe they will be found at corresponding periods of 
development; the examination of the fetal gorilla de- 
scribed by Duckworth will be interesting in this respect. 
Cunningham has considered the transitory fissures quite 
fully, but the subject re- 
quires further investiga- 
tion. 

§ 234. Lambdoidal Fis- 
sure.—In several fetuses 
estimated at from three 
to seven months I have 
observed a fissure direct- 
ly underlying the lamb- 
doidal suture (see Figs. 
750 and 761, and my pa- 
per 1886, a). It is ap- 
parently identical with 
what are called by Cun- 
ningham “external cal- 
carine” and “external 
perpendicular ” (1892, a, 
Plates I. and II.); but I 
am unable to concur in 
his disposition of the 
matter or to decide 
whether the fissure dis- 
appears or persists (see 
Fig. 777). 

§ 285. Fig. 750 tllus- 
trates: A. The distinct 
collocation of a fissure 
and suture at this period. 

B. The early appear- 
ance (or late disappear- 
ance?) of this, the 
lambdoidal fissure; ex- 
cepting, perhaps, the 
dorsal end of the occipi- 


ment of the postoper- 


186 


mated at Four Months; 2,644.  .9. It is not very well preserved 
and the cerebrum is evidently shrunken. 


tal, the rest of this re- 
gion is smooth. 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 








C. The peculiar sharpness of outline, reminding one of 
the transitory fissures (Figs. 746 and 747; § 227). 

§ 236. Intercerebral Fissure.—The interval between 
the apposed, mesal surfaces of the two hemicerebrums is 
the intercerebral fissure (“interhemispheral,” “sagittal,” 


presylvian f. operculum. 


Sylvian f. 
| insula | 
' i 


central f. | 
; iy 








= Oh a ee 


olfactory bulb 2 3 4 


Fic. 751.—Left Fetal Hemicerebrum ; 1,820. x1. 1, Orbital region, 
unfissured ; 2, temporal lobe, unfissured ; 3, slight furrow, the pre- 
occipital fovea; 4, circular depression, unidentified (see § 241). 

Preparation.—The fresh hemicerebrum was placed in a mixture 
of alcohol and glycerin, equal parts; after two days half the mix- 
ture was replaced by alcohol; after two days more alcohol alone 
was used, and renewed on the following day. The original mix- 
ture seemed to prevent the usual distortion of fetal brains, and to 
facilitate the removal of the pia. Unfortunately the age and size of 
the fetus were not recorded. 


or “great longitudinal”) (Figs. 682, 707, and 739). It 
differs from ordinary fissures in the following respects: 
1, It is mesal or azygous, while all others are lateral or 
in pairs; 2, although its sides are formed by cinerea, its 
bottom, the callosum, is apparently alba, with a com- 
paratively thin layer of cinerea, the indusium, § 217; 3, 
although the pia has the usual relation, the arachnoid, 
instead of passing directly across, dips into it to a greater 
or less depth on account of the falx (Figs. 687 and 732); 
4, it is, in one sense, a Superfissure (§ 328) since in its 
depths are concealed the callosal fissures. 

§ 237. Poles and Lobes of the Cerebrum.—The two ends 
of either hemicerebrum are distinguished as the frontal 
and occipital poles respectively, and the tip 
of the temporal lobe as the temporal pole. 
For topographical convenience, and not be- 
cause they represent perfectly natural di- 
visions, either anatomical, histological, or 
physiological, each hemicerebrum may be 
regarded as forming five lobes, the insula 
and the frontal, parietal, occipital and tem- 
poral lobes (Figs. 757 and 758). In a gen- 
eral way, but by no means accurately, the 
last four lobes coincide with the cranial 
bones for which they are named. 

§ 238. The insula (lobus opertus, “cen- 
tral lobe ”) is nearly or quite covered in the 
adult brain by folds (operculums) from the 
adjoining lobes (Figs. 762 and 767); except- 
ing at part of the ventral side the insula 
is surrounded by an irregular furrow, the 
circuminsular fissure (Figs. 781 and 782). 

§ 239. The other four lobes have more or 
less complete natural boundaries on either 





gupercentral f= 
superfrontal f.__ _ — 
subfrontal f...- 


presylvian f..._ ' 


subsylvian f.. .- 


olfactory bulb..-~~ 


and an occipito-temporal portion, and the latter again 
into a temporal and an occipital lobe by artificial lines 
drawn from the preoccipital fovea, the indentation of the 
ventral margin corresponding with the petrous portion 
of the temporal bone (represented by the emargination 
opposite the word collateral in Fig. 757) to the splenium 
on the mesal aspect and on the lateral to the extremity 
of the Sylvian fissure. 

§ 241. Hig. 751 illustrates: A. The early appearance 
of the Sylvian, presylvian, and central fisures, and of a 
depression which perhaps represents the beginning of the 
paroccipital. See the ventral surface of this specimen 
(Fig. 789). 

B. The nearly uncovered and slightly fissured condi- 
tion of the insula at this period; the faint dorso-ventral 
line just caudad of the end of the line from insula rep- 
resents the just commencing transinsular fissure. 

§ 242. Permanent Fissures.—The surface of the adult 
cerebrum presents alternating depressions, fissures, and 
elevations, gyres (or “convolutions”). The fissures vary 
in depth from 1 mm. to 30, and in length from 1 cm. to 
10. The intervals between the fissures (and thus the 
width of the gyres) vary greatly, but an adult brain 
seldom presents an unfissured surface more than 20 mm. 
in width. Notwithstanding considerable variations in 
different brains, and in different parts of the same brain, 
one can hardly fail to be impressed with the approximate 
uniformity of the interfissural spaces (when viewed 
squarely, as suggested under Fig. 763), as if the fissures 
were produced mechanically by the extension of the sur- 
face within a confined space. 

§ 248. Hig. 752 illustrates; A. The condition of the 
insula and operculums at this stage. The former is dis- 
tinctly elevated, but as yet perfectly smooth, while in 
the otherwise less advanced brain shown in Fig. 751 it 
has a slight transinsular furrow. The subsylvian fissure 
is just forming as the ventral boundary of the preoper- 
culum. 

B. The demarcation of the subfrontal gyre by the sub- 
frontal fissure. 

C. The non-continuity of the parietal and paroccipital 
fissures. 

D. The non-appearance of the precentral and post- 
central fissures. 

E. The peculiar triangular depression which seems 
















.-..central f, 


<a> av WA Awa ee yy, 


nw om swee ove eee.. Parietal f. 


Postwncse wees OV 1 VIAL te 


pee) 
...paroccipital f. 
-Supertemporal f, 


insula 


flocculus - ~ 
oliva_ __ ¥ 


GP 


_..- postoblongata 


the lateral or mesal surface, but not on 
both. The primary division is by the line 
of the central fissure (Fig. 751) into a frontal 
region and an occipito-temporo-parietal re- 
gion. The former, although commonly ac- 


FG. 752.—Lateral Aspect of the Left Half of the Brain of a Fetus, Size and Age Un- 
known; 2,278.. < 1.. 1-8, Fissures not identified with certainty. On the temporal 
lobe, just dorsad of the pons, the apparent fissure is an artificial crack. ; 

Preparation.—The brain was medisected while fresh and this half placed in al- 
cohol upon its mesal aspect ; it has become thinner and wider than natural, but ex- 
hibits the fissures more perfectly on this account. 


cepted as a single lobe, is so extensive as to 
be conveniently subdivided by a line continued dorso- 
cephalad from the presylvian fissure into a postfrontal 
and prefrontal lobe, the latter including the orbital sur- 
faces. 

§ 240. The region caudo-ventrad of the central fissure 
line is divided first by the occipital fissure into a parietal 


to represent the commencement of the supertemporal 
fissure. 

F. The presence of three fissures or series of fissures 
caudad of the supertemporal, the middle of which may 
represent the exoccipital (§ 344). 

G. The interruption of the central fissure near its dorsal 


187 


Brain. 
Brain. 





end; so much as appears in the figure is continuous, but 
near the mesal margin of the hemicerebrum is a slight 
depression separated from the longer lateral portion by 
an isthmus (comp. Fig. 772). 

H. The small size of the cerebellum, the distinctness 
of the flocculus, and the prominence of the oliva. 


callosum fornix 


ie 


pseudocele ..... 4 3 h 








ia 
Ye gees 
supercallosal f. { \ 










olfactory bulb...._._.- 


,. occipital f. 


_.calearine f. 


.collateral f. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tinuous with the fissure only superficially; the cephalic 
branch isapparently my adoccipital; the caudal, although 
doubtless the dorsal part of the occipital, presents an 
unusual curve and is invisible from the lateral aspect. 

F. The extent of the precuneal fissure. 

G. The considerable extension of the central upon the 
mesal aspect. 

H. The presence of a subcalcarine fissure. 

§ 247. Each of the forty or more fissures 
demands monographic treatment; but the 
limits of this article will permit the detailed 
consideration of only two, the central (§§ 
269-308) and the paroccipital (§§ 309-825), 
as exemplifying different phases of fissural 
study. 

§ 248. Mig. 755 illustrates: A. An early 
stage in the formation of the Sylvian fissure, 
the presylvian fissure being represented by 
a mere notch. 

B. The incomplete separation of the calcar 
and the occipital eminence. 

C. The size of the postcornu relatively to 
that of the entire hemicerebrum. 


callosal f. 


Fic. 753.—Mesal Aspect of the Left (Reversed) Hemicerebrum of a Fetus, Size and 
Age Unknown; 2,278. 1. The lateral aspect of the left half of the same brain 
is shown in Fig. 752. 1, 2, Rostral fissures ; 3, tip of temporal lobe; 4, ventral end 
of hippocampal fissure; 5, uncus; 6 (should have been extended a little farther 
so as to reach the light band), fimbria; 7, dentate gyre (fascia dentata) ; 8, un- 


D. The corrugation constituting the collo- 
cated calcar and calcarine fissure. 

E. The equally distinct collocation of the 
occipital fissure at this period with the ad- 


determined fissure. 


§ 244. A cerebral fissure is a narrow space vacant of 
brain tissue and containing only a fold of pia with blood- 
vessels; yet it has many and sometimes important reia- 
tions, a complete account of which would embrace about 
fifty distinct topics. There are also about one hundred 
problems of a more or less general nature applying to 
several or all of the fissures. 

§ 245. Mig. 753 illustrates : 
A. The existence of three in- 
dependent furrows between 
the callosum and the margin 
of the hemicerebrum along 
the line of what is common- 
ly called the calloso-marginal 
fissure. 

B. The distinctness at this 
period of the four total or 
collicular fissures, occipital, 
calcarine, collateral, and hip- 
pocampal. 

C. The independence of the 


central f. 


paracentral g. 


paracentral f. 


callosal g. __ 


callosal f 


anne ‘ callosum — 
occipital and calcarine. 
D. The extension of the 
calcarine alone nearly or quite ; 
splenium - 


as far as the point reached 
in some other brains by the 6 
occipital alone or by the stem fasciola 
of the two. Sometimes the 
occipital is the longer in the 
fetus and occasionally, as in 
Fig. 754, union fails to occur. 

§ 246. Mig. 754 illustrates : 
A. The complete separation 
of the calcarine fissure from 
the occipital by a calcarine 
isthmus. On the other side 
the two are connected as 
usual. 

B. The bifurcation of the 
calearine at each end, consti- 
tuting a long zygal fissure 
(§ 307). 

C. The extension of the 
occipital fissure so as to fepresent what is usually the 
common stem of it and the calcarine. 

D. The presence of a “spur” extending caudad from 
the occipital toward the calcarine upon the isthmus. 

E. The appearance of trifurcation of the dorsal end of 
the occipital. The middle extension, however, is con- 


occipital f. - 
hippocampal g. __ 


collateral f. -- 


subcollateral g. 
{fareee 


188 


joining colliculus, occipital eminence, some- 
times called “bulb of the posterior cornu.” 

§ 249. Collocation of Permanent Fissures with Cranial 
Sutures.—In the adult the dorsal end of the occipital 
fissure has a notably constant position at the mesal angle 
of the lambdoidal suture, as seen in Fig. 670. With 
fetuses of between three and seven months this suture is 
decidedly caudad of the occipital fissure, but is distinctly 

















paneer antes =--~—-—---—~--precuneal f. 


ed as oa aa =e PreCuneus 


ee t occipital f. 
_—-— cuneus. 
___ calearine isthmus 
2 


- calearine f. 
subcalearine g. 


- Subcalcarine f. 


- postealcarine f. 
. collateral f. 


Fig. 754.—Caudal Half of the Mesal Surface of the Right Hemicerebrum of an Adult Female Paretic. 
No. 2,358 in the Museum of Cornell University. 1. 


collocated with the lambdoidal fissure (Fig. 750); this 
collocation does not persist after the seventh month, and 
it is not yet known whether the fissure disappears or 
changes its position. The approximate collocations of 
the central and other fissures with sutures are considered 
in the article Brain, Surgery of the. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


—_— 


Brain, 
Brain, 





§ 250. Fissures should be studied before gyres, because: 
1, They are simpler, being represented by lines instead 
of planes; 2, they are more commonly entirely independ- 
ent of other fissures; 3, they are comparable with the 
rivers of a region which are employed as boundaries of 







operculum - 
presylvian f. . 


Fic. 755.—Left Hemicerebrum of a Fetus, Size and Age Unknown. Opened from the 
lateral aspect; 1,819. x 1. 1, Obliquely cut surface; the unshaded area repre- 
sents a surface cut parallel with the meson. The line from paraplexus ends 
somewhat vaguely; it should reach the narrow zone between the hlppocamp and 


the cut surface marked 1. See § 248. 


the subdivisions; 4, themselves structureless, they really 
represent the locations of a greater amount of cinerea 
than lines of equal width and extent on the gyres, and 
have thus a greater, presumptive, physiological sig- 
nificance, although there seems to be a difference of opin- 
ion as to the functions of the intrafissural cinerea, 

§ 251. With children born at term the main fissures 


are always well defined, and in 
some cases there seems to be lit- 
tle difference between infant and 
adult cerebrums in respect to 
fissural complexity, although 
the insula is always less devel- 
oped and less completely cov- 
ered by the operculums (see Fig. 
663). Such brains are often more 
readily obtained and removed 
than those of adults, and if well 
preserved and carefully handled 
may materially aid both teach- 
ing and research. 

§ 252. For the elucidation of 
the intricacies of adult fissures, 
fetal brains are much more ser- 
viceable than those of monkeys. 
This, in contravention of the 
view and practice of Meynert, 
has been insisted upon by me 
(1886, g). Some of the pecu- 
liarities and complexities of the 
monkey brain are represented 
in Fig. 787. 

§ 258. Adult cerebrums com- 
monly present individual pecu- 
liarities which prevent their serv- 
ing as types or standards. I 
have found such in every brain 
examined; not merely, for ex- 
ample, in that of the philoso- 
pher, Chauncey Wright (Figs. 
768, 770, 788) but also in that of 
a mulatto; simple in several re- 
spects, it has peculiarities and 
complexities not as yet fully 
understood (see Figs. 762-766). 

§ 254. Fig. 756 illustrates: A. 
In connection with Figs. 663 and 
702, the perfection and beauty of 
form of the human brain at birth. 

B. The relatively small size of 
the cerebellum at birth. 

C. The distinctness and prom- 
inence of the pons. 









a 
olfactory bulb 31” — 





D. The lateral extent of the pseudocele; at the genu 
(cephalic curvature) of the callosum it is 1 mm. deep, 
representing about one-half of its entire lateral extent. 

E. The distinctness and depth of the principal fissures 
and the large number of minor ones. 

F. The peculiar ventral curve of the cau- 
dal half of the calcarine fissure, and the con- 
comitant expansion of the cuneus. 

ol G. The length of the fissure in the sub- 
calcarine gyre. 

H. The appearance of the cephalic stipe 
of the paroccipital fissure (18) upon the 
meson (see Figs. 774 and 775). 

§ 255. The study of fissures upon actual 
brains is facilitated by reference to diagrams 
such as have been published by C. L. Dana, 
Eberstaller, Ecker, Jensen, Pansch, ‘Schiifer 
(in “Quain”), and others. My present 
views are embodied in Figs. 757 and 758. 

§ 256. Comments upon the Fissural Dia- 
grams (Figs. 757 and 758).—A. They repre- 
sent my views at this time, but are not 
identical with those previously published 
(1886, g, and first edition of the REFERENCE 
HANDBOOK), and are subject to further modi- 
fications with increasing knowledge of the facts. For 
example, the small fissures caudad of the occipital are but 
little understood, and the orbito-frontal of Giacomini may 
prove to be more nearly constant than now supposed. 

B. An attempt has been made to indicate the relative 
depth and constancy of the fissures by lines of three de- 
grees of width; this grouping, however, is provisional. 


_- Sylvian f. 


-occipital f. 
posteornu 


. calcar 

~~ collateral em, 
___>>+hippocamp 
~~=. paraplexus 
~7—=—~=<- collateral f. 












callosum fornix _paracentral g. 
\ peeuttoeclo } diatela ‘central f. 
’ 7 ,paracentral f. 


callosal f. x 16 


19 
20 











calearine f. 


7 o - 
optic n. q 







medicommissure 6 / 
albicans 
pons 


f 





SY 231 25 
\ thalamus 


Fig. 756.—Mesal Aspect of the Right Hemicerebrum of a Male Child, at Term; 478. X .84. Other 


aspects of the same specimen are shown in Figs. 663, 774, and 775. 1, Postoblongata ; 2, preob- 
longata ; 3, postgeminum ; 4, pregeminum:; 5, thalamus, its mesal surface, forming the lateral 
wall of the diacele ; the dorsal, pial surface is designated by the line from the word thalamus ; 
these are parts of one and the same organ, separated by the membranous diatela ; but the trian- 
gular area dorso-cephalad of them marked pseudocele and apparently separated only by the nar- 
row white area marked fornix, is the hemiseptum, part of the mesal surface of the cerebrum ; 6, 
9, 16, 17, 21, 23, 24, 25, 26, 31, unidentified fissures; 7, postrhinal; 8, olfactory; 10, 11, rostral 
fissures; 12, supercallosal fissure, continuous with the paracentral; 15, intraparacentral fis- 
sure; 14, inflected fissure ; 18, cephalic stipe of paroccipital fissure ; 19, a ventral branch of the 
occipital fissure ; 20, 21, intracuneal fissures; 22, dorsal branch of the calcarine fissure; with 
the more caudal of the two ventral branches perhaps it represents the forked fissure sometimes 
called postcalearine ; 27, precuneus; 28, precuneal fissure; 29, dorsal end of the occipital 
fissure ; 30, the common stem of the diverging occipital and calcarine. 

Defects.—The specimen spread while hardening under its own weight, and is therefore 
wider and thinner than natural; this is, however, an advantage for the study of the fissures. 
The naturally considerable cranial flexure became still more marked as the brain rested upon 
the lateral aspect while photographing, and this, for convenience, is preserved in the draw- 
ing. The thalamus is unnaturally, though very instructively, uncovered by the callosum so 
that its caudal prominence, the pulvinar, is visible. The habena is not distinctly seen. The 
cerebellum is not represented accurately as to details, but is enlarged in Fig. 702. The hypophy- 
sis is lacking, and the aulic region is not shown in detail. 


189 


Brain, 
Brain. 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





©. Each separate line represents what I now regard as 
a fissural integer so far as the human brain is concerned. 
The following are also regarded as integers, although 
continuous with others: occipital, calcarine, postcalca- 


tnflected J. 
entral f, 


nections are (1) of 


/ 






PARACENTRAL G. 


‘calcarine f. 
SUBCALCARINE G. 


BAO TIVLIdIO00- 


Fic. 757.—Diagram of the Fissures upon the Mesal Aspect. The outline and certain fissures are 
from the mulatto brain (322), which was hardened within the cranium. 
1, Postrhinal (amygdaline) fissure ; 2 and 3, rostral fissures. 


rine, postrhinal. The presylvian, subsylvian, and basi- 
sylvian are really branches or continuations of the Syl- 
vian, but are separately named for convenience. 

D. The fissure lines are nearly straight and simple, 


SUBPARIETAL G. me 





HO. "TwLIdIN00 







olfactory f. 
basisyluian f. 


Fig. 758.—Diagram of the Fissures upon the Lateral Aspect. The outline and certain fissures 
are from the mulatto brain (322), which was hardened within the cranium. M, the **mar- 
ginal’ gyre; A, the “angular” gyre; Preop., the preoperculum; Subop., the subopercu- 
lum ; Subsy. f., the subsylvian fissure. The interrogation points on the lateral aspect of the 
occipital lobe indicate my doubts as to the existence of certain fissures, or as to the names 
that a ee be applied to them if they do exist. The subtemporal fissure is not shown (see 
Fig. 765). 


writers of what seem 
to be the best fissural 
names of a single 
word each—eg., 
from Huxley, collat- 
eral; from Owen, 
callosal, hippocampal, 
medifrontal, subfron- 


excepting where branching is a practically constant 
feature, as, ¢.g., with the paroccipital, paracentral, pre- 
cuneal, and postcalcarine. 

E. The connections are of two distinct kinds: primary, 
invariable, and inevitable from the mode of formation of 
the parts; secondary, and more or less common, but not 
necessary. 

F. Jnvariable and apparently inevitable fissural con- 


190 





the Sylvian with the basisylvian, 


presylvian, and subsylvian, all which might be re- 
garded as its continuations or branches; (2) of the cal- 
losal with the hippocampal. 


G. Usual connections are of the 
occipital with the calcarine, and of 
the supercallosal with the paracen- 
tral, but there are occasional excep- 
tions. 

H. Common connections are of the 
superfrontal and supercentral; the 
precentral and subfrontal; the pre- 
central and supercentral; the post- 
central and subcentral and parietal; 
the parietal and paroccipital. 

I. Occasional connections are of 
the precentral with the Sylvian, and 
of the central with the Sylvian over 
the margin of the operculum; in 
these cases, so far as known to me, 
the junction is seldom very deep. 

§ 257. From the deservedly pop- 
ular fissural diagrams of Ecker, the 
publication of which has so materi- 
ally advanced the general knowl- 
edge of the subject, these differ» 
mainly in the following respects: 

A. The omission of branches and 
contortions. 

B. The inclusion of the callosal, 
inflected, adoccipital, postrhinal, 
postcalcarine, medifrontal, precu- 
neal, and postcentral fissures. 


C. The disjunction of the supercallosal from the para- 
central; of the precentral from the subfrontal and super- 
central; of the postcentral from the subcentral; and of 
the subcentral from the parietal. 


D. The recognition of the adoc- 
cipital fissure and the cuneolus, 

E. The introduction of the ex- 
occipital as probably representing 
the true “ape-fissure ” of Wernicke. 

F. The combination of the “ trans- 
verse occipital” of Ecker with the 
caudal portion of his “interparietal” 
as a distinct fissural integer, the 
paroccipital. 

G. The adoption from various. 


_ postcornu 
- Calear 
A : _calcarine f. 
pia 
’ endyma 


operculum 





hippocampal f. 


Fig. 759.—Schematic Transections of 
the Three Paracelian Cornua in the 
Order of their Complexity. See § 259. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





tal, supercallosal ; from Wernicke, fronto-marginal ; from 
Jensen, tntermedial ; from Pansch, oce7pital and parietal ; 
from Schwalbe, precentral and postcentral ; from Mey- 
nert, preoccipital ; from Lussana and Lemoigne, inflected 
(Ital., ¢nflesso). 

H. The substitution of several mononyms for polyo- 
nyms, viz.: of presylvian for ascending branch of the 
Sylvian ; subsylvian tor anterior branch ; basisylvian for 
the part ventrad of the presylvian; and the restriction of 
Sylvian to the “ posterior branch.” 

I. The replacement of lingual lobule and fusiform lobule 





Fig. 760.—Transection of the Left Occipital Lobe of a Fetus, Size and 
Age Unknown; 2,278. 1.5. This figure is almost diagrammatic 
in its simplicity ; it shows very clearly the relation of the calearine 
fissure to the calcar as represented in Fig. 759, A. 


(not at all easy to apply correctly), by subcalearine gyre 
and subcollateral gyre, names at once associated with the fis- 
sures which respectively constitute the dorsal boundaries. 

J. The use of one and the same word, fissure, for all 
the cerebral depressions excepting the two foveas. 


inflected f. 





superfrontal f. 


orbital f. 


presylvian f. 
basisylvian f. 


INSULA 


Fig. 762.—Lateral Aspect of the Left Hemicerebrum of a Mulatto ; 322. 


K. The use of one and the same word, gyre, for all 
subdivisions of the lobes, excepting the cuneus and pre- 









a ae - caudatum 
hippocamp 
oceipital eminence __ 3 
occipital fissure ___ y ~~~ ~--7- Paraplexus 
calear, .—- cane ae fe postcornt: 


calcarine fissure __ 


lambdoidal f. 


FiG. 761.—The Caudal Part of the Right Hemicerebrum of a Fetus, 
Measuring 14 cm. from Nates to Bregma, and Estimated at Four 
Months; 1,816. 1.5. (See § 261.) 

Preparation.—This is part of the specimen shown in Fig. 727, 
where the mode of preparation is described ; the postcornu was ex- 
posed by removing the paracelian roof along the lines in that figure. 


aoe plexus was partly cut away, although not so represented in this 
gure. 


cuneus, already well distinguished by mononyms, and 
the cuneolus. 

§ 258. Total and Partial Fissures.—Of the permanent 
fissures most affect merely the cortex and the adjacent 
alba and are therefore sometimes called partial fissures ; 
the central, for example, though constant and deep, is 
only a partial fissure. But others represent corrugations 
of the entire parietes, so that the ectal depression, fis- 
sure, is opposite and obviously correlated with, an ental 





precentral f. supercentral f. 
subfrontal f. | 


supertemporal f. 


elevation or colliculus; the fissures commonly enumer- 


central f. 
postcentral f. 





subtemporal f. 
meditemporal f. 


x .8. 1, Cephalic part of the operculum demarcated from the rest by 


a fissure that does not extend through its entire thickness; 2, preoperculum ; 3, postoperculum ; the subsylvian fissure is probably repre- 
sented by a short indentation, visible only when the postoperculum (8) is removed; 4, what is commonly called the “ supramarginal 
gyre”; 5, may represent part of what is called the “angular gyre’’; 6, a supergyre overlapping the concealed, caudal part of the angu- 
lar ; 7, unidentified occipital gyre ; 8, 9, portions of the unidentified supergyre that overlaps the lateral part of the paroccipital gyre ; 10, 
gyre at the caudal (apparently dorsal) side of the dorsal, deflected end of the supertemporal fissure ; 11, opposite the dorsal end of the oceip- 
ital fissure (this is, however, invisible, and the straight fissure that extends laterad from 11 between 8 and 9, and curves ventrad at 6, 
may possibly be the exoccipital or Wernicke’s fissure, one of the so-called ** ape-fissures”’; it has apparent, though not real, connections 
with the occipital and supertemporal fissures) ; 12, curved fissure in the same supergyre, superficially connected with the supertemporal ; 
18, cephalic stipe of the paroccipital fissure ; 14, dorsal fork of the postcentral fissure ; the subcentral is not indicated by a separate num- 
ber and is continuous with the postcentral; 15, caudal extremity of the calcarine fissure, really simple and independent ; 16, cephalic 
radius of the triradiate supercentral fissure (see Fig. 765) ; 18, 19, 20, unidentified occipito-temporal fissures ; 21, just ventrad of the strait 
between the central and supercentral fissures (see Fig. 764) ; 22, the most cephalic of three distinct fissures crossing the medifrontal gyre. 


191 


Brain. 
Brain. 





ated as total are the hippocampal (Fig. 755), calcarine 
(Fig. 760), and collateral (Fig. 755); the Sylvian may 








Fic. 763.—Diagram Illustrating the Effect of the Convexity of the 

Cerebral Surfaces upon the Apparent Width of the Gyres. Upon a 
cylinder were drawn parallel lines at the uniform distance of 1 
em.: one side of the cylinder was then photographed, and the fig- 
ure is a reproduction of the photograph, reduced one-half. The 
reduction of the intervals according to the distance of the lines 
from the part nearest the eye illustrates the fact, not always dis- 
tinctly recognized, that the fissures near the periphery of a cerebral 
convexity always appear to be nearer together than they really 
are; the intervening gyres consequently appear of less than their 
actual width; see, for example, the superfrontal gyre in Figs. 762 
and 764. 


possibly be correlated with the caudatum (Fig. 716); the 
callosal and occipital are total fissures in the fetus (Figs. 






superfrontal f. 


precentral f. (?) 


supercentral f. 
inflected f. 


.- precuneal f. 


Fic. 764.—Dorso-Cephalic Aspect of the Left Hemicerebrum of a Mu- 
latto; 322. »%.8. 1. Caudal radius of the triradiate supercentral 
fissure; 2, strait between the central and supercentral fissures; 
3, caudal end of paracentral fissure (see Fig. 766) ; 4, cephalic end 
of the same (?); 5, Sylvian fissure; 6, postcentral fissure. See § 264. 


192 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





734 and 761), and the ental correlative of the latter is 
sometimes recognizable in the adult (Fig. 744). 

§ 259. Fig. 759 illustrates: A. The mesal wall of the 
postcornu presents a ridge, the calcar, and the mesal sur- 
face of the occipital lobe a furrow, the calcarine fissure; as 
seen in Figs. 760 and 761, the ectal depression and the 
ental elevation are obviously correlated. 

B. The precornu presents an ental elevation, the cau- 
datum, and a depression nearly opposite, the Sylvian 
fissure. But the correlation of the two is not quite clear 
and the conditions are complicated by the formation of 
the intrafissural (or intergyral) elevation called ¢nsula. 

C. Here, as in the postcornu, there is no doubt respect- 
ing the correlation of the ental elevation or colliculus, the 











gououtmoid 
[ey1q410 


n 
(+) 
orbital f. 3 
Ifactory f. . | ¢ 
olfactory f. ..L: Ee 
olfactory tract . - Es 
rr 
optic nerve , - y! 
chiasma - 
optic tract .- - : 3 
— 
postrhinal. bs B 
SS 
z 
collateral f. =, 
® 
B 
b=) 
6 
splenium 3 
ad 


ealearinef, -. 


Fig. 765.—Ventral Aspect of the Left Hemicerebrum of an Adult Male 
Mulatto; 322. X.8. 1, Ridge ventrad of the splenium, represent- 
ing, perhaps, one of the gyres described by A. Retzius, British As- 
sociation Proccedings, 1885; 2, stem of the occipital and calcarine 
fissures. See § 265. 


Preparation.—See Fig. 757. The olfactory bulb has been re- 
moved. 


hippocamp, and the ectal furrow, the hippocampal 
fissure; in addition, the proper nervous parietes are 
abrogated along a line, the rima, and the paraplexus is 
formed by the intrusion of the pial process covered by 
the endyma; the margins of the rima are specialized and 
become the fimbria and tenia; on the figure the tenia is 
not indicated as separate from the caudatum (Fig. 730). 
§ 260. Classification of the Permanent Fisswres.—The 
following grouping of the fissures is approximately nat- 
ural and has been found convenient by me; at the best, 
however, any such arrangements are provisional : * 





* Whatever may be desirable in theory, or eventually practicable, at 
present nothing seems to be gained by attempting to classify cerebral 
depressions as fissures and sulci, and in this article all are designated 
as fissures. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





A. Total fissures, representing a corrugation of the 
entire paracelian parietes; ¢.g., calcarine. 

B. Partial fissures with some structural correlative; 
é.g., olfactory. 

C. Partial fissures, nearly or quite constant, and de- 
marcating recognized gyres; e.g., subfrontal. 

D. Inconstant, intragyral fissures; e.g., medifrontal. 

§ 261. Mg. 761, inaddition to A and B, specified under 
Fig. 727, illustrates: A. The contiguity of the two 
margins ‘of the rima, excepting for the intruded para- 
plexus. 

B. The concomitant, absolute exclusion of the thalamus 
from the paracelian floor. 

C. The depth and peculiar form of the lambdoidal 
fissure (Fig. 750). 

§ 262. Hig. 762 illustrates: A. The form of this adult, 
mulatto, left hemicerebrum, unaltered save from alco- 
holic shrinkage. 

B. The general aspect of the gyres, comparable with 
the appearance in the cerebrum of the philosopher, 
Chauncey Wright (Fig. 788). 

C. Asimple, almost typical condition of certain fissures, 
é.g.. central and Sylvian, in a large part of their course, 
combined with great and unusual peculiarities of the 
same or other fissures. 

D. The visibility of the insula (see Figs. 767 and 788). 

E. The presence of a vertical branch of the presylvian 
fissure, which, however, does not extend through the 
thickness of the operculum. 

F. The union of the subfrontal with the precentral and 
with two of the fissures crossing the medifrontal gyre. 

G. The apparent narrowness of the superfrontal gyre, 
which nevertheless, as seen from the dorsal aspect, is of 
considerable width; in fact the narrowest portion of the 
superfrontal is just as wide as is the subfrontal measured 
in line with the stem of the presylvian fissure; this is 
a forcible exemplification of what is explained under 
Figs. 763 and 764. 

H. The great length of the supertemporal fissure, and 
its apparent dorsal branching in four directions; its true 
and deep continuation is cephalad between 5 and 10. 

I. The continuation of the calcarine fissure around the 
margin of the hemicerebrum so as to appear upon the 
caudo-lateral aspect as an undivided end (15); the calcar- 
ine is believed to be continuous commonly with a bifur- 
cated postcalcarine, and the condition in this brain seems 
to be unusual; see also Fig. 785. 

J. The superficial connection of the central and pre- 
central fissures. 

K. The partial appearance of the subtemporal fissure 
on the lateral aspect; see, however, Fig. 765. 

L. The forking of the Sylvian into an episylvian 
fissure, near 4, and a hyposylvian near 5. 

§ 263. The apparent width of gyres upon convex sur- 
faces of the cerebrum is affected by the point of view. 
Compare, e¢.g., the superfrontal gyre of the mulatto as 
shown in Figs. 762and 764. The conditions are schemat- 
ically illustrated in Fig. 763. 

§ 264. Mig. 764 tllustrates: A. The length and inde- 
pendence of the superfrontal fissure, and its close paral- 
lelism with the hemicerebral margin. 

B. The width of the supercentral gyre when viewed 
directly as compared with the oblique view shown in 
Fig. 762 (see § 262, G). 

C. The triradiate form of the supercentral and its rela- 
tion to the inflected. 

D. The continuity of the supercentral with the pre- 
central and central; in each case, however, there is a 
vadum or shallow. 

§ 265. Fig. 765 illustrates: A. The presence of a dis- 
tinct though rounded orbital prominence between the 
frontal and the lateral portions of the outlines, but the 
absence of any such boundary between the lateral out- 
line and the occipital. 

B. The narrowness of the olfactory gyre, between the 
olfactory fissure and the mesal margin of the frontal 
lobe. 

C. The distinctly zy gal form of the orbital fissure. 


Vou. IL—i3 


D. The length and distinctness of the subtemporal 
fissure. 

E. The extension of the calcarine fissure upon the oc- 
cipital end of the hemicerebrum. 

F. The presence of a fissure (orbito-frontal?) on the 
orbital surface cephalad of the orbital fissure. 


§ 266. List or ParriaL FissurEs, CONSTANT OR 
NEARLY S0, AND DEMARCATING GYRES. 








Fissures. Aspect. Gyres separated by them. 
1. Basisylvian....| Ventral ‘Ventral } Tonporal, 
a. Central... <6 Lateral ; Sareea al 
8. Circuminsular .| Lateral i Alois 
4, Inflected.......| Lateral {| Puperfrontal. 
De insular... ana. Lateral Insular. 
6. Olfactory......| Ventral ee 
is Orbital vance Ventral ae 
8. Orbito-frontal..| Lateral i Ae akon 
9. Paracentral....| Mesal ere ne 
10. Parietal... 22... Lateral i Aeeetal 
11. Paroccipital ...| Lateral i tant ei 
12. Postcentral....| Lateral ee ae 
13. Postrhinal..... Mesal | Tee 
14. Precentral..... Lateral Eien 
15. Presylvian ....| Lateral Dee ate 
16. Subcentral ....| Lateral ape as 
17. Subfrontal ....} Lateral i Sa tenet 
18. Subsylvian....} Lateral EA te 
19. Supercallosal..| Mesal ; Pai aarrea 
20. Supercentral...| Lateral ; cee pie medifrontal. 
21. Superfrontal. ..)| Lateral ; eae 
22. Supertemporal.| Lateral eS 
23. Transinsular...| Lateral Ae 





§ 267.—Lisr oF INconsTanr  Fissures, 
GYRES IN Wuicu Tury Occur. 


WITH THE 


Fissures. Gyres. 

(EA COCCIDILal ere aimee Precuneus. 

Dap Lu DIS Vil Vilar rae ercrererereye Subparietal. 

ae XOCCID ITA neeretrert estore Occipital (?). 

4, Fronto-marginal ......... Fronto-marginal. 

Da -Hy posyaw latin mas ert eas Supertemporal. 

Gx Intermedial *i;, 208 Keane Subparietal. 

7%. Intraparacentral ......... Paracentral. 

Si Medifrontelaenniteeeics Medifrontal. 

OP AROStGd CANO Nee tere ce cists Occipital (?). 
TO Postcuned erecta sce tele « Occipital (?). 
11. Postoccipital fovea....... Occipital (?). 
12. Postparoccipital ......... Paroccipital. 
L337 Precuneai noosa. oh; wants Precuneus. 


193 


Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 




















Brain. 
14. Preoccipital fovea........ Subtemporal. 
Lb Preparocelpital creates Paroccipital. 
LOS Rostralis seeks wales Callosal. 
Ae SUVOCCIPI Lalit sie ... Occipital (?). 
18; Subtemporal......0...... Medi- and subtemporal. 
10° Transtem poral aaeceen aate Meditemporal. 
paracentral f. (?) 
inflected f. ‘central f. 
fronto-marginal f.,. 99558 SN occipital f. 
supercallosal f. 6% p Dara-  Y, 
as mcentral gh < 
callosal f. eB “~— £ 








esi. er : ) Ny 
CALLOSAL G. ff ' PRECUNEUS nN 


Qe ~ 


olfactory f. 
postrhinal f. calearine f. 
collateral f. 


subcollateral g. 


oa hippo- 
hippocampal f. campal g. 


Fic. 766.—Mesal Aspect of the Left (Reversed So as to Appear the 
Right) Hemicerebrum of an Adult Male Mulatto ; 322. xX .5. 1, The 
common stem of the occipital and calcarine; 2, uncus; 3, optic tract, 
divided obliquely ; 4, fornix; 5, retreating ventral surface of the 
fornix ; 6, paracentral fissure. There can be no doubt that 6 is the 
caudal or main portion of the paracentral, but the cephalic portion 
so named is thought by E. A. Spitzka to represent the intraparacen- 
tral, the true cephalic limb being absent. Mr. Spitzka concludes 
(1900) that the inflected, like the central, typically indents the mar- 
gin of the paracentral gyre. Unfortunately, at this time, I cannot 
determine the point by re-examination of the specimen; but the 
need of doing so exemplifies the remark in § 253. 

Preparation.—See Fig. 757. 
Defects.—Most of the fissure lines are too faint ; the emargination 
of the ventral outline just cephalad of the optic nerve is too decided. 


§ 268. Mig. 766 illustrates: A. The existence and un- 
usual extent of the fronto-marginal fissure. 

B. The complexity of the precuneal fissure. 

C. The length of the collateral fissure. 


inflected f. 


supercentral f. ___ 
precentral f. -_...——-, 
superfrontal f. ,~—— 


subfrontal f.—— 


f 


presylvian f.- 


2 
3 
presylvian f. 


Posse so See 














Taking all things into account, the central fissure de- 
mands first and fullest consideration; there is, indeed, no 
fact concerning it that is not worth recording or that 
may not prove significant morphologically or practically 
valuable. The order in which the following topics are 
presented is far from perfect, but it may serve to indicate 
the many-sidedness of these cerebral features. To save 
space the pronoun 7¢ will commonly designate the cen- 
tral fissure. * 

§ 270. The Name.—It has been called, to use the Latin. 
forms, fissura, scissura, and sulcus, with the qualifying 
adjectives centralis, Rolandica, and postero-partetalis, all 
these having, of course, appropriate equivalents in the 
various modern languages. My doubts as to the utility 
of discriminating, at present, between fissures and sulci 
have been expressed in § 260, note. My reasons for pre- 
ferring central to Rolandic have been stated upon several 
occasions since 1882; but as the former name has now 
been adopted by the Association of American Anatomists 
and the Anatomische Gesellschaft it will probably super- 
sede the latter with anatomists of other nations. 

§ 271. General Location and Direction.—On the dorso- 
lateral aspect of the cerebrum, at about the middle of its. 
length; from a point at or near the dorsi-mesal margin, it 
extends latero-cephalad at an angle of about 70 degrees 
with the meson, or about 140 degrees with its opposite. 

§ 272. Dimensions.—Among adult hemicerebrums in 
the museum of Cornell University the length of the 
fissure, measured in a straight line between the two ends, 
varies from 8 to 10.5 cm., the usual length being about 
9.5 em., or about one-fourth of the entire circumference 
of a cerebrum as measured in a dorso-ventral plane inter- 
secting the fissure at about the middle of its length. If 
measured along the sinuosities, as if the fissure were 
straightened out, the length may be one-seventh greater: 
than if measured across the curves. The greatest depth 
varies from 10 to 15 mm. 

§ 273. Relation to Ental Elevations.—There is no evi- 
dence of any special collocation between it and any ental 
elevation, in man or any other mammal; hence, though: 
so deep, it is not a total but a partial fissure (§ 258, A). 

§ 274. Constancy.—The only case of absence of the 
central fissure known to me is that described by Sir Wil- 
liam Turner (Jour. Anat. and Physiol., XXv., 327-848). 


ne a a baa ie = 

22 = postcentral f. 
_u—=<=--" parietal f. 

==—— subcentral f. 

er Seld 












—— ae 


—- supertemporal f. 


paroccipital f. 


ee 8 


-——-—— — a =e ee en 


Fia. 767.—Lateral Aspect of the Left Hemicerebrum of an Adult Swedish Carpenter, Presenting an Unusual Degree of Fissuration ; 318. < .6—. 
Pre paration.—The hemicerebrum was hardened resting upon the mesal surface, and apparently with little change in form. The right 
was likewise numerously fissured. Of the unidentified fissures the only ones that seem to call for comment here are 9 and 10, which are 


transtemporal fissures, and 16, a well-marked hyposylvian. See § 275. 


D. The distinctness of the postrhinal fissure. 

E. An apparent peculiarity of the paracentral fissure 
as stated briefly in the description; the subject is dis- 
cussed by E. A. Spitzka, 1900. 

§ 269. Pre-Eminent Importance of the Central Fissure. — 


194 


The subject was an epileptic, twenty-six years old, and 
the entire (alcoholic) brain weighed 1,107 gm. (393 ounces) ; 





a The pas fissure is quite fully discussed by Cunningham (1892, 
chap. iii.). 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





the left hemicerebrum 530 gm., the right 437. The left 
fissures are stated to have had a normal development and 
arrangement, but on the right the Sylvian fissure was 


superfrontal f. precentral f. supercentral f. 


medifrontal f. 









subfrontalf. —_ presylvian f. 


central f.—V 


Sylvian f. 


Fie. 768.—The Left Hemicerebrum of a Philosopher (Chauncey Wright), from the Dorso-Lateral Aspect. 


termediate caudal convexity. In most adults it is cer- 
tainly more or less serpentine or tortuous, and the regular 
curves are sometimes distinct; but three cephalic con- 


central f.—D postcentral f. parietal f. 


paroccipital f. 


occipital f 


supertemporal f. 
xX 2%. 


Preparation.—See Fig. 788. The figure is based upon a photograph taken as nearly as possible at an angle of 45° with the meson, so 


as to present the dorso-lateral aspect. 


The line connecting the superfrontal and medifrontal fissures was made inadvertently. 


The numerals | to 22 are at the same points as in Fig. 788; on that figure 23 designated the central isthmus, which here has the word 


printed upon it; 33 is just at the end of the short inflected fissure. 


wide open so as to expose the insula largely; the central 
Jissure was wholly absent, together with the precentral and 
postcentral; the lateral surface presented three arched 
fissures, demarcating four arched gyres about the Sylvian 
fissure, a condition analogous to that in the dog and 
many other carnivora. The interest and importance at- 
taching to this case would have warranted a larger num- 
ber of better figures, and a representation of the left 
hemicerebrum. 

§ 275. Fig. 767 tllustrates: A. The unusual number 
of minor fissures, especially of the slight depressions 
which I have called fossule. 

B. The three cephalic curves of the central fissure, and 
their decided character. 

C. The extent of the supertemporal fissure. 

D. The continuity of the postcentral, parietal, and 
paroccipital fissures. 

E. The length of the dorsal branch of the presylvian. 

F. The two dorsal branches of the Sylvian, and the 
distinct hyposylvian branch (16). 

G. The crossing of the temporal lobe ventrad of the 
supertemporal fissure by two transtemporal fissures. 

H. The non-union of the subfrontal with the precen- 
tral; this last is not named but is the ventral continuation 
of the supercentral, beginning about opposite the sub- 
frontal. 

I. The continuity of the postcentral, subcentral, pa- 
rietal, and paroccipital, constituting what has been called 
the “intraparietal complex”; § 306. 

§ 276. Topographical Importance.—This is well indi- 
cated in the following vigorous declarations of Wagner 
and Ecker: “ Man muss sie immer zuerst aufsuchen, wm 
sich von da in dem scheinbaren Chaos der Hirnwindungen. 
.. .”. “ Bildet sie die den sichersten Ausgangspunkt fiir 
die Aufsuchung der Windungen. . . .” 

§ 277. Form, or Course in Detail.—According to Broca 
it normally presents two cephalic convexities with an in- 


a 





vexities have been observed in sufficient number to show 
the need of careful observation and tabulation. 

§ 278. Branches.—Offshoots from the central are usu- 
ally rather short and straight, starting at the summits of 
the curves; but in the brain presenting the most decided 
curvatures (Fig. 767) there is scarcely any branching. 

§ 279. Mig. 768 illustrates: A. The unfamiliar appear- 
ance of a hemicerebrum when viewed from this oblique 
aspect. 

B. The distinctness of the angles between the cephalic 
and the dorsal and ventral outlines; -this was commented 
upon by the first describer of this brain, Prof. Thomas 
Dwight, and appears in Fig. 788, though less markedly. 

C. The completeness and width of the isthmus between 
the dorsal and ventral portions of the central fissure; in 
Fig. 788 this is marked 28, but is so much foreshortened 
as to be hardly visible. 

D. The simple, curved form of the dorsal part of the 
central fissure, with no bifurcation such as exists at both 
ends of the ventral portion. 

E. The independence of the supercentral fissure. 

F. The presence of a medifrontal fissure subdividing 
the large area between the subfrontal and superfrontal 
fissures. 

G. The junction of the subcentral fissure with the 
parietal, and the continuity of the parietal with the par- 
occipital; whether this junction occurs at 1 or at 2 can- 
not be determined at present. 

H. The great length of the supertemporal fissure and 
the complexity of its dorsal end. 

I. The presence of a long and curved fissure, 6-7, on 
the lateral aspect of the occipital lobe. 

J. The presence of an unusual crescentic fissure (14) 
ventrad of the subcentral (15). 

§ 280. Junctions.—So far as 1am aware, connections 
between the central and other fissures (excepting the in- 
tercerebral, § 236) are rare, and incomplete or shallow 


195 


Brain, 
Brain. 





when they occur; ¢.g., in Fig. 762, where the concealed 
vadum between the central branch and the supercentral 
nearly reaches the surface, and in Fig. 767, where there 
is also a nearly invisible vadum just at the apparent union 
of the supercentral with the central. 
The occasional confluence of the cen- 
tral with the Sylvian over the margin 
of the operculum is commonly shallow, 
but sometimes quite deep, as in the 
right hemicerebrum of James Burk, 
figured by Mills (Journal of Nervous 
and Mental Disease, vol. xiii., Septem- 
ber, 1886). The depth of such straits 
should always be stated. 

§ 281. Bifurcation.—Terminal divis- 
ion of the central fissure at either end 
is rare; among the few cases known 
to me the ventral end is bifurcated on 
the right in a supposed insane person 
(885) and the ventral on the left of 
Chauncey Wright (Fig. 768); the dor- 
sal end is bifurcated on both sides in 
Professor Oliver (Fig. 664). 

§ 282. Relation to the Mesal Aspect.— 
Cunningham found (1892, 162) that the 
fissure indented the dorsal margin so 
as to appear on the mesal aspect (as in 
Fig. 757) in sixty per cent. of the hemi- 
spheres examined. My own observa- 
tions would make the proportion some- 
what larger. For the final determi- 
nation of the ratio there should be 
employed only adult specimens retain- 
ing their natural form. 

§ 283. Special Location.—About mid- 
way between a line coinciding with the 
precentral and supercentral fissures 
cephalad, and a line coinciding with 
the postcentral and subcentral caudad. 

§ 284. How to Distinguish from Ad- 
joining Fisswres.*—When the precentral is separate from 
the supercentral, and the postcentral from the subcen- 
tral, the central is notably longer than either. When 
these two pairs of fissures unite, however, it is the mid- 





was cut from the dorso-mesal region of the hemicerebrum by an incision at about 
45° with the meson; the pieces rest upon the oblique cut surfaces and the dorso- 
mesal margins correspond approximately to lines between the two Ds and the two 
Ms. 1, Dorsal outcrop of the cephalic end of the paracentral, which is also continu- 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tion. The following characters should be noted in case 
of doubt: its greater depth and length; its location 
relatively to the entire length of the cerebrum, and 
the angle it forms with the margin; its more complete 


superfrontal 
supercentral 


precentral 
central (d.) 


central (y.) 
postcentral 


paracentral 


parietal 


isthmus paroe. 


incision 
EN paroccipital 


occipital 


Fig. 770.—Dorsum of the Cerebrum of Chauncey Wright, a Philosophie Writer, Critic, and 
Mathematician (see description of Fig. 788). 
was inadvertently tilted a little to the left. 
bers correspond to those on Figs. 768, 779, and 788. 


x .8. When photographed the cerebrum 
I, Central isthmus on either side; the num- 


independence; the usual absence of terminal forks; par- 
ticularly its extension to or across the dorsal margin 
just cephalad of the paracentral, thus indenting the 
paracentral gyre (Fig. 769). 

§ 285. Alleged Duplication.—Calori and 
Giacomini have each described (1884) a 
brain which they interpreted as having 
two central fissures nearly parallel and 
separated by an “intercentral” gyre. The 
conditions in an educated suicide (8129) 
were similarly interpreted by me (1894, a); 
but a later comparison with a larger num- 
ber of brains leads me to conclude rather 
(1900, a) that the supposed second or cau- 
dal central is really an unusually long 
resultant of the union of the postcentral 
and subcentral, caudad of which is the 
parietal. The bifurcated dorsal end of 
the postcentral has the usual relation with 
the paracentral as it crosses the meson 
(see Fig. 769).* 

§ 286. Hig. 769 illustrates : A. The more 
usual relation of the central fissure to the 
dorsal margin, crossing it so as to appear 
on the mesal aspect. 

B. The constant relation of the central 


supercentral 


precentral 


central 


postcentral 


~ 


paracentral 


ous with the supercallosal; 2, a crescentic fissure which, in the foreshortened posi- 
tion of the parts, appears to join the paracentral, but is really separated from it by a 


vadum barely below the surface; 3, a similar fissure on the right, separated by a 
complete isthmus from the paracentral, which latter has no dorsal outcrop, but is 
continuous with the supercallosal; in the light of E. A. Spitzka’s observations 2 and 


3 may be the inflected fissures. 


dle of the group of three fissures at about the middle of 
the hemicerebrum having a general dorso-ventral direc- 





* The macroscopic methods here enumerated might require confir- 
mation from the histology of the region in question, as indicated in 
the discussion of my paper, 1900, a, by Donaldson, Spiller, and Mayer 
(Jour. Nery. and Mental Disease, October, 1900, 540). 


196 


* After the above paragraph was in type the 
kindness of Dr. D. 8. Lamb enabled me to ob- 
tain a transcript of the ‘‘Nota preventiva’’ of 
C. Leggiardi-Laura (Archiv di Psich. Sci. Penol. 
ed Antrop. Crimin., Torino, 1899, p. 421), ** Du- 
plicita della scissura di Rolando nei criminali.” 
It is there claimed that among thirty-seven female brains cen- 
tral reduplication occurred once, on the left, and among thirty males, 
twice on the left, once on the right, and once on both sides. In the 
absence of figures, especially photographs, and detailed descriptions, 
I must refer these to the same category as my Own; see also the 
remark of Dr. C. K. Mills upon my paper (1900, a) in Jour. Nery. 
and Mental Disease, October, 1900, pp. 537-541, and my later note on 
the subject, 1900, x. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





fissure to the paracentral, the former directed at the 
concavity of the latter. 

C. The usual relations of the paracentral and postcen- 
tral fissures, the former directed at the reentrant angle 
formed by the bifurcation of the latter. 

D. The not unusual bifurcation of the supercentral 
(upper precentral) fissures. 

E. The asymmetry of the paracentral in respect to a 
dorsal outcrop of the cephalic end. 

F. The danger of depending upon appearances in re- 
spect to the independent fissures 2 and 3. 

§ 287. Interruption.—As shown in Figs. 770 and 771, 
the central fissure is completely interrupted on both sides 
of the brain of Chauncey Wright, the isthmus* being 
fully on a level with the adjacent gyres. The brain of 
Dr. Fuchs, figured by Wagner, exhibited a like pecu- 
liarity, and the complete interruption has now been re- 
corded for perhaps fifteen hemicerebrums, a very small 
proportion of the enormous number examined. The left 
central is completely interrupted in the educated suicide 
(3,129) referred to in § 285; but the right is continuous. 

§ 288. Fig. 770 illustrates: A. The unusual square- 
ness of the frontal outline. 

B. The unusual length of the region caudad of the 
central fissures, and concomitantly that of the parietal 
fissure. 

C. The width and simplicity of most of the gyrts, 
especially as compared with those of Professor Oliver 
(Fig. 664). 

D. The complete interruption of both central fissures 
by an isthmus, (Fig. 771). 

E. The lack of symmetry of the central fissures in re- 
spect to (a) distance of the isthmus from the meson, (0) 
difference in form of the dorsal portions; (¢) unlike dorsal 
terminations of the ventral portions. 

F. The unusual depth of both paracentral fissures and 
their non-oppositeness. 

G. The unusually caudal location of the right para- 
central so as to embrace the dorsal end of the postcentral 
as if the latter were the central. 

H. The asymmetric condition of many other fissures. 

I. The unequal depths of the occipitals; the right ex- 
tends barely beyond the ‘rounded cerebral margin; the 
left is at least three times as deep; this fact has been as- 
certained since the publication of the diagram of the 
paroccipital region in the Proceedings of the Ass’n Amer. 
Anatomists, 1895. 

J. The details of the paroccipital region are considered 
under Fig. 779. In certain respects this brain is unique 
and merits extended monographic treatment; but this 
also will be easier and more instructive when a normal 
standard has been more nearly obtained.+ 

§ 289. Partial Interruption. — Several writers have 
called attention to the not infrequent presence of a vadum 





Fic. 771.—Central Region of the Dorsum of the Cerebrum of Chaun- 
cey Wright (Fig. 770), showing only the interrupted central fissures 
and the isthmuses; on the left the two portions of the fissure are 
designated by V and D respectively. 5. 


or shallow in the depths of the central fissure, commonly 
nearer the dorsal end; among 1,087 hemicerebrums ex- 





* This term is equivalent to pli de passage, annectent convolution, 
and bridging convolution ; the latter is misleading, for the interrup- 
tion of a fissure has no analogy with a bridge, but rather with a dam, 
dike, or isthmus, absolute size being of no moment. 

+The need of an improved standard for the study of fissures is 
clearly recognized by Mickle, 1895, opening paragraph. 


Brain, 
Brain, 


amined, Heschl found in 152 (about fourteen per cent.) 
an elevation (vadum) rising from one-sixth to five-sixths of 
the entire depth of the fissure, and suggests that the rare 


central central (y.) 


postcentral vadum 


parietal central (d.) 


postcentral 


occipital 





Fig. 772.—Dorsum of the Cerebrum of a Fetus Supposed to be Six 
Months Advanced; 2,972. 1. One of twins, both males, stillborn. 


cases of complete interruption result from the greater 
development of this feature. In view of these observa- 
tions the vadum should always be looked for.* 

§ 290. Mode of Tormation.—In at least three specimens 
in the Cornell hiuseum, viz., 827 (Fig. 773), 2,278 (Fig. 





Fic. 773.—Diagrams of the Right and Left Central Fissure Regions of 
a Fetus, 56 cm. Long and Estimated at Twenty Weeks; 827. X 2. 


752) and 2,972 (Fig. 772) there are evidences that the cen- 
tral begins in at least two portions, a dorsal and a ventral. 
Cunningham’s views are summarized thus in 1897, a, 598: 

“1. The typical mode of development is in two more 
or less distinct pieces. 2. Judging from the specimens 
in my possession this would likewise appear to be the 
more usual mode.” + The cases of partial (by vadums) or 
total (by isthmuses) interruption in the adult may be re- 
garded as retentions of the (usual or not infrequent) fetal 
condition. 

§ 291. Mig. 772 tllustrates: A. The unsymmetrical de- 
velopment of the central, postcentral, and parietal fis- 
sures. 

B. The representation of the right central fissure by a 
longer ventral portion; a dorsal portion which is merely 
a dimple, but perfectly distinct; and an intervening 
vadum. 

§ 292. Mig. 773 tllustrates: A. The interrupted con- 
dition cf both central fissures at their first formation. 

B. The lack of symmetry; on the right are two parts, 
the right ventral (V) being 2 mm. deep at its middle and 
the dorsal (D) 2.5 mm.; on the left are three distinct 
divisions—the dorsal parallel with the meson, the lateral 
at right angles with it, and the ventral oblique. 

§ 2938. Time of First Appearance.—Nearly all writers 


* The morphological and zoological significance of vadums is forci- 
bly stated by Cunningham (1897, a, 593): ‘A close study of the me- 
moir of Retzius (1897) has left on my mind the impression that he 
somewhat understates their morphological value. With Eberstaller I 
hold that they constitute one of the great and distinctive characters of 
the human brain.” 

+ The distinction between “ typical” and ‘‘ usual” in a case like 
this is not apparent. 


197 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





state that the central fissure is formed about the end of 
the fifth month, the twentieth week. The following ob- 
servations show that there is probably some variation in 
this respect, or—as is perhaps equally probable—that 
the length of the fetus varies considerably at the same 
stage of fissural development. In fetuses 827 and 1,817, 
respectively 56 and 65 cm. long, the fissure is vague or 
absent; in 1,820, 61 cm. long, it is distinct and deep; in 
2,278, 67 cm. long, it is well developed, and several 
other lateral fissures are visible. 

§ 294. Relative Order of Appearance.—Excluding the 
transitory fissures (Fig. 748) and the lambdoidal (which 
may be transitory, Fig. 750), the central is apparently the 
first of the lateral fissures to be developed after the Syl- 
vian (Fig. 751). But some of my preparations indicate 
that this order may not be invariable; in 2,081 the parietal 
and supertemporal are more advanced than the central ; 
in 1,817 there is no trace of acentral, although both super- 
frontals are distinct. Numerous and careful observations 
are needed on this point. 

§ 295. Form in the Fetus.— When first distinctly 
formed, the fissure line is nearly straight, with a slight 
cepbene convexity (Fig. 751). 

§ 296. Provimate Cause.—There is no evidence that it 
depends upon the pressure of a blood-vessel. The causa- 
tion of fissures and of encephalic corrugations in general 
has been discussed by Jelgersma, Cunningham (1892), 
and A. J. Parker (1896), and briefly by Schiifer (1893, 162). 

§ 297. Relation to Primitive Fisswres.—There is no 
good reason for regarding either of the three radiating, 
presumably transitory, fissures shown in Fig. 746, as the 
direct precursor of the central. 

§ 298. Integrality.—For the definition of fisswral in- 
teger see § 305. The occasional complete interruption 
(§ 287), the not infrequent existence of a vadum (§ 289), 
and the mode of appearance in several cases (§ 290), sug- 
gest the possibility that the central consists really of two 
fissural integers, commonly connected, and comparable, 
perhaps, with the parietal and paroccipital (§ 306). For 
the present, however, it seems justifiable and certainly 
more convenient to regard the conditions above named 
as anomalous, and to treat the central as a single fissure. 

§ 299. Lateral Variation. —Clevenger states that it is 
usually located farther caudad on the left side than on 
the right; its relations to motor areas would lead one to 
expect considerable lateral variation in position, direc- 
tion, and shape. 

§ 800. Physiological and Surgical Relations.—Itis com- 
pletely surrounded by important motor areas, and its 
exact relations to the cranium and surface of the scalp 
are of great pathological and surgical importance, these 
matters are considered in the articles Brain, Surgery of 
the, and Brain: Functions of Cerebral Cortex. 

§ 801. Psychological Relations.—Clevenger has a sug- 
gestive paper (Journal of Nervous and Mental Disease, 
April, 1880) on the ratio between the location of this 
fissure and the intelligence of the individual or species; 
although unable to admit his identification with the cru- 
ciate fissure of Carnivora, or to accept all his conclusions, 
IT regard the determination of the relative bulk of the 
precentral (frontal) region of the cerebrum and the post- 
central (occipito-parieto-temporal) region as of great im- 
portance in connection with the comparison between in- 
dividuals and species in respect to intellectual power and 
voluntary inhibition or self-control. 

§ 802. Condition in Other Primates.—In the apes and 
in all the ordinary monkeys the fissure is readily recog- 
nized; e.g., in the Macacus, Fig. 787. 

§ 303. Carnivoral Representative. —By various authors 
it has been homologized with the following fissures of 
the cat and dog: superorbital, ansata, coronal, and cru- 
ciate. Notwithstanding the similar relations of the cen- 
tral and cruciate fissures to motor areas, the question of 
their homology (morphological identity) must be held as 
yet undetermined. A clue may be furnished by the ob- 
servations of P. A. Fish (1899, 37) as to the collocation, in 
the seal (Phoca), of what seems to be the calear with the 
ventral portion of the splenial fissure. 


198 








§ 804. Mig. 774 illustrates: A. The form of a perfect 
and typical Some rehal fissure, very symmetrical, and 
completely independent of the parietal, although its 
cephalic ramus and what seems to be an extension of the 
parietal overlap and approach very closely. 

B. The peculiar appearance of the entire hemicerebrum 
and of the central fissure from this point of view. Other 
points are commented upon under Fig. 775. 

§ 805, Missural Integer.—This term was proposed by 
me (1886, ¢) to designate a fissure which is independent in 


inflected f..... 
Central i.e. ness 


paracentral f, .—... 


postcentral f...— 


parietal f... 


: . cephalic ramus 
cephalic stipe... __ 3 






occipital £57 .scas- = 


..paroccipital f. 
(zygon) 
paroccipital g..,___ 


caudal stipe ... —.. 
..-caudal ramus 


a 


calcarine f..... 


Fic. 774.—Dorso-Caudal Aspect of the Right Hemicerebrum of a Child 
at Birth; 478. 1. This figure was published in the Jowrnal of 
Nervous and Mental Disease, June, 1886. Other aspects of the 
same brain are shown in Figs. 663, 756, and 775. 


some species or individuals, and deepest at or about the 
middle of its length, corresponding nearly with the place 
of its first appearance. Any marked and frequent shal- 
lowing of a supposed fissural integer is reason for ques- 
tioning its integrality, and for seeking, in other individu- 
als and in allied species, evidence that it really consists 
of two. 

§ 806. The“ intraparietal* fissure” of Turner probably 
represents two fissural integers, the parietal and the paroc- 
cipital, because (1) in nearly half the cases examined by 
me there are two fissures separated by an isthmus of 
greater or less width; (2) when the two are continuous 
there is often a vadum at the point corresponding to the 
isthmus; (8) each of the two portions, whether separate 
or continuous, is usually deepest at or near its middle; 
(4) at their first appearance in the fetus they are always 
completely independent. 

§ 307. The typical paroccipital fissure consists of (a) the 
zygon or bar, the first part to be formed; (0) cephalic 
and caudal stipes continuing the curve of the zygon 
about the dorsal outcrop of the occipital; (c) cephalic and 
caudal rami, imparting to each end the characteristic 
form seen in Fig. 774. The paroccipital is a typical 
zy gal fissure. 

§ 308. Fig. 775 tllustrates, in addition to points seen 
equally well in Figs. 756, 668, and 775), the greater depth 
of the paroccipital zygon at the middle of its length, a 
fact hardly compatible with the supposition that it is 
only a caudal extension of the parietal, or that the caudal 
stipe and ramus constitute an independent fissure, the 
“transverse occipital” of Ecker. 

§ 309. What Is the So-Called “ Transverse Occipital 
Fissure” ?—Most writers seem disposed to adopt the view 


* Often, but incorrectly, written interparietal. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of Ecker that the caudal stipe and ramus of the paroc- 
cipital represent a “sulcus occipitalis transversus ” which 
unites with the longitudinal bar or zygon. None of the 
paroccipital g. central f. 
parietal f. 


occipital f. 








paroccipital f. 


IS HOP WMH 


supertemporal f. 
Sylvian f. 


8 


preinsula 


Fia. 775.—Dorso-Caudo-Lateral Aspect of the Right Hemicerebrum of a 
Child at Birth, Partly Dissected ; 478. 1. See the lateral and dor- 
sal aspects (Figs. 663 and 774). 1, Lateral surface of the zygal part 
of the paroccipital gyre ; this is, of course, pial, but the point of the 
V-shaped incision reaches a slightly lower level than the bottom of 
the fissure, occasioning the triangular cut area at the bottom ; 2, line 
representing the junction of the zygon with its caudal stipe ; 3, ectal 
line of the caudal ramus; 4, ental line of the same; 5, should have 
crossed the cut surface to the outcrop of the fissure marked 7 in Fig. 
663 ; 6, the exoccipital fissure (?) ; 7, unidentified fissure; 8, presyl- 
vian fissure ; 9, postcentral fissure ; 10, gyre between the postcentral 
and the parietal fissures; 11, cephalic slope of the cut surface ; 12, 
cephalic ramus. 

Preparation.—By reference to the lateral aspect, Fig. 663, the 
paroccipital fissure will be seen to be indicated by the name itself, 
connected with the middle of the zygon. For the present figure a 
wedge-shaped piece was 
removed by two incisions, 
starting respectively at the 
tip of the rami and meet- 
ing at an obtuse angle at 
the exoccipital. The re- 
moval of this piece ex- 
posed the lateral aspect 
of the paroccipital gyre 
and of the gyres adjoining 
it cephalad and caudad; 
also the depth of the zygon 
and the two rami. 


specimens examined by 
me seems to confirm 
this interpretation, and 
I am compelled to re- 
gard the very interest- 24 
ing condition shown by 133 
Cunningham (1892, 147 
Fig. 51) as simply an- 
omalous. Much. how- 
ever, remains to be 1 
done in this region. 

§ 310. Mig. 776 il- 
lustrates: A. The de- VW 
gree of fissuration at 
this period. 

B. The early condi- 
tion of the paroccipital 
fissure as a_ upsiloid 
(U-shaped), depressed 19 


inflected f. 















Brain, 
Brain, 








E. The distinctness of the inflected fissures at this 
period. 

F. The difficulties of identifying fetal fissures in the 
condition of those upon the frontal and parietal regions 
of this specimen. 

§ 311. Hig. 777 dlustrates: A. An almost schematic 
condition of the paroccipital fissure, simple in form and 


central f. 


postcentral f. 


paracentral f. 


3 


parietal f. 


paroccipital f. 


occipital f. 


lambdoidal f. (?) 





Fig. 777.—Dorso-Caudal Aspect of the Occipital Region of the Right 
Hemicerebrum of an Irishwomar., Thirty-Five Years Old, Exhibit- 
ing an Unusually Simple 
Condition of the Paroccip- 
ital Fissure; 38. x .8. 
Other aspects of this brain 
are shown in Figs 720 and 
721. 1, Subcentral fissure, 
continuous with the pari- 
etal, but separated from 
the postcentral by a con- 
siderable isthmus; 2, the 
branch of the postcentral 
just aah (caudad of) the 
isthmus does not really 
precentral f. enter the parietal, al- 
though the shadow upon 
purer ventred f the slightly depressed nar- 
6 row portion of the isthmus 
gives that appearance; 3, 
an independent fissure 
parallel with the postcen- 
tral; 4, cephalic ramus of 
the paroccipital ; 5, cepha- 
lic stipe of the same; 6, 7, 
caudal stipe and ramus; 
8, supertemporal; 9, the 
triradiate termination of 
a fissure superficially con- 
tinuous with the super- 
temporal. The name 
lambdoidal is applied 
with considerable hesita- 
tion. 


postcentral i 
Sylvian f. 


parietal f. 


- ‘supertemporal f. 


¢/__ paroccipital f. 
—— paroccipital g. 


wholly independent of 
the parietal, although 
the isthmus (opposite 
the end of the line 


line with lateral 
branches, rami. 

C. The independence 
of the paroccipital fis- 
sures at this period. 

D. The absence of 
any fissure closely re- 
sembling the “trans- 
-verse occipital.” 


Fig. 776.—Dorso-Caudal Aspect of the Brain of a Fetus Measuring 41 cm. from 
Heel to Bregma, and Estimated at Eight Months; 734. x 1. 11, Left in- 
flected fissure; 12, 13, separate portions of the left postcentral- 14, left 
parietal (?) ; 16, left paroccipital; 17, left supertemporal; 19, left occipital 
fissure. The remaining numbers indicate fissures of doubtful identity. 

Preparation.—The arteries were injected with starch mixture ; extravasa- 
tion took place at several points, especially the two following: (1) into the 
dorsal part of the right occipital fissure, converting it into a kind of fossa, 
at the bottom of which is seen the unaffected part of the fissure; (2) into 
the left paroccipital fissure, separating its walls to some extent. The essen- 
tial relations of parts are not affected. 


from paroccipital) is 
slightly depressed. 

B. An, unusual di- 
vergence of the caudal 
stipe (6) and ramus (7) 
of the paroccipital; the 
former again bifurcates 
just over the margin 
on the mesal aspect. 


199 


Brain, 
Brain, 





C. The presence of an oblique independent fissure 
caudad of the paroccipital suggesting the persistence of 
the lambdoidal of the fetus (§ 234 and Fig. 750). 

D. The separation of the postcentral from the subcen- 
tral by an isthmus, 2. 

E. The depth, simplicity, and cephalic trend of the 
occipital. 

§ 312. Continuity of the Paroccipital with the Parietal 
Occurs More Frequently on the Left.—This has been noted 
by Ecker, Cunningham, and myself. In a recent paper 
(1900, a) I reported the results of the tabulation of 200 
mated hemicerebrums, 7.é., from 100 individuals; all but 
5 were adults, the 5 infants ranging from term to three 

ears, 
y (a) Of the 100 left, 77 present continuity of the paroc- 
cipital with the parietal; in 23 the two fissures are sepa- 
rated. Of the 100 right there is continuity in only 39 
and separation in 61. 

(0) Of the 116 cases of continuity, 77 (66 per cent.) 
occur on left hemicerebrums, and only 39 (84 per cent.) 
on the right. Of the 84 cases of separation, 28 (28 per 
cent.) occur on the Jeft and 61 (72 per cent.) on the right.* 

§ 818. Have the Combinations Any Significance with Re- 
spect to Age, Sex, Race, Character, or Mental Condition ? 
—For the purpose of testing this, the 100 individuals 
were grouped as in the appended Table; but the group- 
ing is obviously unsatisfactory. 


§ 314. TABLE V.—PROVISIONAL AND UNSATISFACTORY 
GROUPING OF ONE HUNDRED INDIVIDUALS WHOSE 
PAROCCIPITAL FISSURES ARE KNOWN ON BoTH SIDEs. 























Group. | Characterization. Number. 
A Educated and orderly...:..0..,5..5- 10 
B Ignorant or UBknO WN 250 gen cays spss x 5 50 
C Insane—various degrees............. 25 
D Murderers i.3.65 srk eines aso 6 5 
E A TrICANS | VALIOUS SOTA ers eye see eit 5 
F Infants under three years............ 5 








§ 315. In Table V. the ten members of Group A are 
as follows: Chauncey Wright; Prof. James Edward 
Oliver (8,334); a lawyer (2,870) and his wife (8,065); 
a teacher of mathematics (8,091); an educated farmer 
(8,350); a physician (8,581); a woman physician and ad- 
vocate of social reforms (3,480); a woman college student 
(3,416); and a dentist (8,129).* 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





§ 818. Commentaries on Fig. 778 and Table VI.—AI- 
though I believe the number of mated hemicerebrums 
is larger than in any previous tabulation it is still too 


+ parietal f. 
paroccipital yvadum 


_paroccipital isthmus 
-cephalic ramus 
cephalic stipe 

- occipital f. 
~paroccipital g. 













-—-. 
-~ 






~ paroccipital zygon 
~ >> caudal ramus 
~>eaudal stipe 


I. Left Continuity and Right Separation; 44 per cent. 


II. Bilateral Continuity ; 33 per cent. 
III. Bilateral Separation ; 17 per cent. 


IV. Left Separation and Right Continuity ; 6 per cent. 
Fic. 778.—Diagrams of the Paroccipital Fissure. 


§ 316. Taste VI.—PERCENTAGES OF OCCURRENCE OF THE FOUR PARIETO-PAROCCIPITAL COMBINATIONS IN THE 
Srx Groups oF INDIVIDUALS. 














a 





ek : | L. Continuity. 
Group. Character. Number. | I. | R. Separation. 
A Educated and orderly ... 
B Ignorant or unknown ...| & 
C TR SATIOH cre mete a akeleacaiaiciets y 
D MUrderers: "fae cists s ciete mere 
E ASTIGAIIS arepesleraltterstaeleeteree 
F INTATMTS se eactns don stetrce as 

















§ 317. Mig. 779 illustrates: A. The complexity of this 
paroccipital region (compare Figs. 774 and 777). 

B. The narrowness of the isthmus between the paroc- 
cipital and the parietal. 

C. The extension of the fissure marked 36’, over the 
margin of the hemicerebrum, a feature not distinctly 
apparent in Fig. 770. 


* A somewhat different ratio existed among twenty unmated hemi- 
cerebrums. 

+ This was the educated suicide mentioned in § 285; he was, how- 
ever, highly esteemed by others besides myself. 


200 








| R. and L. 
| Separation. 


R. and L. | 
Continuity. | 


L. Separation. 


Iv. | | R. Continuity. 








small for final results; especially is this the case with 
groups, A, D, E and F. Hence the following remarks 
must be regarded as suggestive rather than conclusive. 

§ 819. Paroccipital Integrality.—Superficially there are 
more cases of continuity (116) than of separation (84). 
But when the known or presumptive vadums are taken 
into account the balance of evidence seems to be the other 
way. It is certainly more convenient to speak of the 
paroccipital fissure than of the “occipital” or “ posterior 
portion of the intraparietal complex.” 

§ 320. Symmetry and Asymmetry.—In 33 brains there 


” 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





is double continuity; in 17, double separation. In 44 
there is right separation and left continuity; in 6, left 
separation and right continuity. In 50, therefore, the 
conditions are symmetrical and in the other 50 unsym- 
metrical. 

§ 821. Postpartum Changes.—Condition III., bilateral 
separation, occurs in only 17 per cent. of the total, but 












Fic. 779.—The Paroccipital Region of Chauncey Wright. 
to those on Figs. 770 and 788. 
the addition of prime. 
cephalic ramus of the paroccipital at 2, where there is a vadum; on the right the isthmus 
is narrow and slightly depressed. The fissure marked 36, 37, and 38 is somewhat deep and 
eet from the occipital by a visible vadum ; on the right (36’) it enters the paroccipital 

ure. 


O and O’, the occipital fissures. 


in 40 per cent. of the five infants. So far as this small 
number goes there is borne out the conclusion of Cun- 
ningham that in many cases the union is delayed until 
after birth. 

§ 822. Fig. 780 illustrates: A. The least common of 
the four possible combinations of the paroccipital and 
parietal fissures of the two sides, viz., right 
continuity and left separation. 

B. The continuity of the parietal and 
postcentral fissures on both sides, but with 
differences that are unusual and somewhat 
perplexing. 

C. The existence, on the right, of a clearly 
defined triangular fissure, 3. 

D. The unusual extension of the caudal 
ramus of the paroccipital, 4. 

E. The appearance of the trench (6) due to 
the pressure of an artery. 

§ 828. Parieto-Paroccipital Combinations in 
Individuals.—Four different combinations are 
possible (Fig. 778), viz.: I. Left continuity 
and right separation; II. Continuity on both 
sides; III. Separation on both sides; IV. Left 
separation and right continuity. Amongst 
the 100 individuals tabulated (all that were 
accessible to me at the time), combination 
I. existed in 44; II. in 33; III. in 17; and LV. 
in only 6.* 

§ 824. May Combination I. (Right Separa- 
tion and Left Continuity) be Regarded as Nor- 
mal?—Among the ten educated and moral 
whites (Group A) combination IV. does not 
occur (but neither does it among the five 
murderers). Combination I. occurs in 60 per 
cent. of Group A, in 48 per cent. of Group 
B (ignorant or unknown); in 40 per cent. of 
C (insane), and in 20 per cent. each of D (murderers) 
and E (Africans). 

& 825. There are many questions, general and spe- 
cial, that arise in connection with the paroccipital, but 


A 


* Mr. E. A. Spitzka informs me that this combination exists in the 
brain of Dr. Edouard Seguin. (See his papers, 1900, a, b.) 


On the left, the numbers correspond 
On the right, homologous parts have the same numbers with 
The left parietal fissure joins the 





Brain, 
Brain, 


space permits mention of only two which were briefly 
discussed in my paper (1900, @): (1) In tabulating should 
not the cases in which the vadum equals in height more 
than one-half the greatest depth of the “ parieto-paroc- 
cipital combination” be included under “separation ”? 
(2) What weight is to be assigned to the condition in apes 
and monkeys where continuity is the rule, perhaps with- 
out exception? The developmental 
conditions in other primates than 
man are not known. 

§ 326. Mig. 781 illustrates: A. 
The location and common form of 
the insula. 

B. The existence of fissures and 
51’ intervening gyres, radiating in gen- 
eral from its summit. 

C. The division of the whole by 
a somewhat deep fissure, the trans- 
insular (2), into a cephalic region, 
preinsula and a caudal, postinsula. 

§ 827. Supergyres and Subgyres. 
—The ectal surfaces of two adjoin- 
ing gyres are commonly at about 
the same level, excepting for a 
marked change in the general con- 
tour of the cerebrum, as, ¢.g., at 
its several margins. But sometimes 
one gyre may be developed much 
more than its neighbor, and en- 
croach upon it so as to conceal 
it more or less completely. The 
covering gyre is here called a 
supergyre, and the covered a sub- 
gyre. 

§ 328. Superfissures and Subfis- 
sures.—These terms are employed herein to designate 
the fissures which result from the formation of super- 
gyres and subgyres. The line of overlapping of a 
supergyre is a superfissure, as also is the line of junc- 
tion of two supergyres meeting from opposite direc- 
tions. <A subfisswre is one which is concealed by a 


cephalic ramus 
paroccipital isthmus 
parietal f. 


“le 


central f. 


postcentral f. 
1 


parietal f. 
9 


~ 


paTcccniea! f 


occipital f. 


Fig. 780.—Dorsum of the Occipital Half of the Cerebrum of an Insane Swiss 
Woman, Fifty-Three Years Old; 2,964. 0.6. I al 
1, A fissure apparently, but not really, connected with the paroccipital ; 2, the 
cephalic stipe of the paroccipital; 3, a triangular depression ; 4, an unusual 
and deep extension of the paroccipital ; 5, undetermined fissure. 
6, a vascular trench between the parietal and occipital; C.. central fissure ; 
Pac., paracentral; P., parietal; O., occipital; Pao., paroccipital. 


Her mother was also insane. 


On the left, 


supergyre, and invisible until the lips of the superfis- 
sure are divaricated. 

§ 329. Normal, human subfissures are the cireumin- 
sular, which encircles the insula (Fig. 782), the transin- 
sular and others crossing the surface of the insula (Fig. 
781), and those which indent the ental or insular surfaces 
of the operculums (Fig. 783). Unusual subfissures ap- 


201 


sae gg REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain. 





pear in Fig. 786, after the removal of the unusual super- | and postoperculum (parietal and temporal operculums). 
gyre; superfissures are shown also in Fig. 787. Owing to the non-development of the other two oper- 
§ 330. The énsula (“island of Reil”) and the operculum | culums the cephalic portion of the insula is exposed like 


Gi 


et mee we 4 3 


Fic. 781.—Right Adult Insula, Exposed from the Lateral Aspect ; 480. 1. 1, Cen- 
tral fissure; 2, transinsular fissure; 3, olfactory tract; 4, optic nerve; 5, optic 
tract; 6, crus; 7, pregeniculum ; 8, postgeniculum. 





the rest of the cortex, and the “suleus limi- 
tans” of Reil (part of my circuminsular fis- 
sure) is represented by a “fronto-orbital sul- 
Cuss 

I regret that this interpretation is not borne 
out by the study I have been able to make of 
the material at Cornell University. There 
are more than fifty brains of monkeys and 
lemurs, and during the past sixteen years I 
have prepared with special care ten fresh ape 
brains (one gorilla, three chimpanzee, and six 
orang); all have been photographed; some 
have been sectioned or partly dissected, and 
one (chimpanzee) has been drawn. Still I 
hesitate, and am not sure that it will be pos- 
sible for me to decide until there is available 
a fetal ape brain displaying the region in 
question in process of formation. 

§ 334. The operculum is not strictly a sin- 
gle gyre but includes portions of at least 
two, the precentral and the subfrontal. It is 
as if the eastern half of the southern extrem- 
ity of Africa were owned by the Dutch and 
the western by the English, each half having 
its own territorial designation; we might 
still speak of the Cape of Good Hope com- 
posed by the two countries. In general the 
same may be said of the postoperculum, sub- 
operculum, and preoperculum. 

§ 385. Mig. 783 illustrates: A. The ex- 


constitute normal and typical examples of subgyres | tent to which the several operculums lap over the 
and supergyres. As may be seen in Figs. 663, 667, 752, | insula, constituting so many supergyres. 


and 782, and in the diagram, Fig. 759 (B), 
the insula is a part of the cortex, which, at 
one period wholly superficial, is gradually 
covered, more or less completely, by con- 
verging folds of the adjacent regions. The 
insula thus becomes a subgyre, while the 
operculum, preoperculum, suboperculum, 
and postoperculum are supergyres. For 
other supergyres see §§ 336 and 342. 

§ 331. Mig. 782 illustrates: A. The exist- 
ence of two zones of the lenticula, an ectal, 
the putamen, and a second, entad of the 
first, as seen in Fig. 739. There is still a 
third, but it does not extend sufficiently far 
dorsad to appear in this or Fig. 788. 

B. The constitution of the insula as an 
elevation of the lateral region of the hemi- 
cerebrum, its cortex and medulla being con- S) 
tinuous with the rest and with the overlap- a 
ping operculums. & 

C. The peculiar form and location of the 
claustrum, a thin, subcircular disc of cin- 
erea, between the putamen and the insular o 
cortex, of which it is probably a dismem- 
berment. 

§ 3382. The insula has notable topograph- 
ical relations with (@) the several oper- 
culums, (?) the claustrum and - lenticula. 
Although perhaps, upon the whole, most 
developed in man, relatively to the size of 
the entire brain, it is perfectly distinct in 
apes and monkeys, in dogs, the porpoise, 
and many other mammals; its comparative 
anatomy and its human variations are fruit- 
ful and important subjects for further ob- 
servation; see especially the papers of E. C. 
Spitzka (1879, a) and (Clark, 1896). 

§ 833. The Insula in Apes.—According 


thalamus 





ren 


to Cunningham (1897, 3, II., 22), he and al claRenge es RNIN Ue 
Marchand have reached independently the Fa. 782.—Longisection of the Right Insula and Adjacent Parts ; 2,397. Enlargement 
conclusion that in apes (orang, chimpanzee, of the porresnont ou fgkee of Fig. 8S) i, @ Zones othe lenticuls, whe — and 

= : ; ‘ arger the putamen ; 3, the stratum of alba between the putamen and claustrum, 
aE ne and pyboR only the caudal portion sometimes (most undesirably) called “‘ external capsule’; 4, opposite the circum- 
of the insula is covered by the operculum insular fissure. Internal capsule should be simply capsula. 


202 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





B. The fissuration of the ental surface of the oper- 
culums. 

C. The distinctness of the supercallosal fissure, and the 
absence of a fronto-marginal between it and the dorsal 
margin of the hemicerebrum. 

D. The length of the postrhinal fissure, partly con- 
cealed by the optic nerve. 

§ 336. Subfrontal Fissure and Gyre (*“ Broca’s convolu- 
tion”).—From every point of view, anatomical, histo- 





preoperculum 
chiasma we : 0 
optic nerve : = dh, 


FIG. 783.—The Mesal Aspect of the Right Operculums of a Child at 
mermsalseo. <1. 

Preparation.—The hemicerebrum had been hardened in alcohol 
while resting on the meson, and hence is a little thinner and wider 
than natural, but thereby better suited to the desired object. A 
probe was pushed througb from the lateral aspect at the triangular 
place of divergence of the Sylvian, basisylvian, and presylvian fis- 
sures; from the hole so made upon the mesal aspect, cuts were car- 
ried in various directions, cautiously, until most of the thalamus, 
caudatum, lenticula, and insula were removed, thus exposing the 
ental or mesal surfaces of the operculum, postoperculum, and pre- 
operculum, with the intervening Sylvian and presylvian fissures. 

Defects.—The inclusion of the occipital region would have ren- 
dered the figure somewhat more intelligible. The suboperculum 
and subsylvian fissure are not exposed; the cut surface at the ven- 
tral side should be traversed by a line starting from just cephalad of 
the chiasma to represent that part of the basisylvian fissure. - 


logical, physiological, psychological, anthropological, 
and zoological, a most interesting and important cortical 
region is that which Broca first showed to be related to 
the faculty of articulate speech. Although the condi- 
tions are often, perhaps usually, complex and perplexing, 
there seem tome to bea sufficiently large number of cases 
like those represented in Figs. 663 and 784 to warrant de- 
scribing the gyre as curving about the presylvian fissure, 
and the fissure as zygal and U-shaped; the topography is 
much like that of the 
paroccipital fissure 






ee and gyre. 
; ms eo § 3387. Hig. 784 tl- 
- brecentrall. Justrates: A. An un- 


usually simple condi- 
tion of the subfront- 
al gyre as a U-shaped 
region about the pre- 
sylvian fissure. 
preoperculum B. An unusually 
insula simple zygal form of 
subsylvian f. the subfrontal _fis- 
sure, comparable 
with that in the in- 
fant brain shown in 
Fig. 663. 

C. The complete 
separation of the sub- 
frontal fissure from 


subfrontal f. 
subfrontal g. 


— presylvian f. 
operculum 


Fic. 784.—Left Subfrontal Gyre (*‘ Broca’s 
Convolution’) and Adjacent Parts of a 
Man about Thirty-Three Years Old. 
.5. He was the son of a clergyman, 
but was found dead after a drunken 
debauch. 


Brain, 
Brain. 








paracentral f. 


operculum 


presylvian f. 


. hippocampal f. 








the precentral and the bifurcation of the latter at the 
point reached by the line from the name. 

D. The relatively large size of the preoperculum as 
compared with the suboperculum; these proportions also 
are as in Fig. 663, and the reverse of those in Fig. 752. 

E. The (probable) partial exposure of the insula in the 
adult brain. 

§ 338. The Subfrontal Gyre in Apes.—A paper on this 
subject has been published by Hervé (1888). I am not 
prepared to discuss Hervé’s conclusions as to the degree 
of representation of the subfrontal gyre in apes; but I 
am compelled to dissent from the statement (p. 22) that 
of the two branches of the Sylvian fissure “as- 
cending” and “horizontal” (corresponding re- 
spectively to my presylvian and subsylvian) the 
latter is the more constant. 

§ 339. Recalling my own earlier erroneous 
interpretation of the parts, I am compelled to 
insist upon the necessity of exposing them fully 


Sylvian f. by removing the postoperculum, and of deter- 
mining whether or not a given fissure cuts 
postoperculum through the entire thickness of the operculum. 
callosum § 340. Supergyres and subgyres occur by ex- 
ception in other parts of the cerebrum, espe- 
pulvinar cially the occipital (see Figs. 785 and 786), and 
s normally in many monkeys, the poma, § 351, 
f Fig. 787. 
optic tract § 341. Figs. 785 and 756 illustrate: A. The 


presence of a postcuneal fissure along the cau- 
dal margin of the cuneus; its dorsal end is free, 
but ventrad it has a very shallow connection 
with the calcarine. 

B. The concealment, in the undissected brain, of the 
convexities of the paroccipital fissure and gyre and part 














centralifn, oan sees ; paracen- 
postcen- S- tral f. 
tra] f. te § postcen- 
aR tral f. 
%.— { precune- 
al f. 
supertem- .-parietal f. 
poral f. paroc- 
-< cipital f. 
as (ce) 
exoccipi- } ee p aroccipi- 
tal Bis tal g. 
Cyivin £ H~-occipital f. 
3 : paroc- 
; -< cipital f. 
(ed) 
1 
2 
subtem- Ps 
poral f. 


-~~--.calcarine f. 


Fic. 785.—Dorso-Caudal Aspect of the Left Hemicerebrum of an Adult 
Male Mulatto; 322. x .8. 1, Nearly straight fissure along the cau- 
dal margin of the cuneus, the postcuneal f. (?) ; 2, unidentified oc- 
cipital f.; 3, margin of a supergyre overlapping the paroccipital 
fissure, part of the paroeccipital gyre, and the lateral end of the oc- 
cipital fissure; 5, near the margin of the same supergyre ; 6, ventral 
part of the postcentral f. The interrupted L-shaped line from op- 
posite 1 to the middle of the length of the parietal fissure indicates 
the lines of incision by which the supergyre was removed, as seen in 
Fig. 786, where the two fissures are commented upon (see § 341). 

For the preparation, see Fig. 757. 


of the occipital fissure by an extensive supergyre, anal- 
agous to, though probably not homologous with, the 
poma (occipital operculum) of monkey brains (Fig. 787). 
C. The conversion of the paroccipital fissure and gyre 
into a subfissure and subgyre. 
D. The apparent continuity of the exoccipital with the 
occipital in the undissected brain. 


203 


Brain. 
Brain. 





E. In general, the desirability of checking all con- 
clusions based upon the obvious features of the cerebrum, 
by an examination of the concealed conditions. 

§ 342. The so-called “external occipital,” or “external 
perpendicular,” fissure of monkeys is a superfissure, 


».€xoccipital f. 






-paroccipital g. 
3 ..... occipital f. 


paroccipital f. 


Fig. 786.—Dorso-Caudal Aspect of the Left Hemicerebrum of an Adult 
Male Mulatto, Partly Dissected; 322. »% .8. 1, Junction of the 
parietal and postcentral fissures; 2, a fissure connected with the ex- 
occipital. 

Preparation.—By two incisions along the L-shaped line shown 
in Hie: 785 the supergyre there indicated by 3 and 5 has been re- 
moved. 


factitious, variable, and heterogeneous, resulting from 
the lapping of a supergyre, the poma (“occipital oper- 
culum”), upon the parts cephalad of it; it may therefore 
be called the pomatic fissure. 

§ 3438. Mig. 787 illustrates: A. The relation of the 
poma (“occipital operculum”) of monkeys, as a typical 
supergyre, to the paroccipital and part of the supertem- 
poral, which are here subgyres. 

B. The relation of the pomatic (“external occipital”) 
fissure of monkeys, a typical superfissure, to the paroc- 
cipital and occipital fissures, which are here wholly or 
partly subfissures. 

C. The, so to speak, factitious nature of the pomatic 
fissure, since it results, not from the opposition of two 
adjoining and approximately equal gyres, but from the 
lapping of one over the crests of those adjoining. As may 
be seen by comparing the two sides, it really comprises 
three distinct parts, viz., a lateral, between the pomatic 
margin and the ectal surface of the temporal gyre; an 
intermediate, coinciding with the cephalic stipe of the 
paroccipital fissure; a mesal, formed by the pomatic 
margin and the paroccipital gyre; finally, since the dorsal 
termination of the occipital fissure is covered by the 
poma, there resultsan apparent continuity of the pomatic 
and occipital fissures. 

D. The continuity (depth not determined) of the paroc- 
cipital fissure with the parietal; see § 325. 

E. The junction of the Sylvian and supertemporal 
fissures. 

F. The distinctness of the “angular gyres.” 

G. The existence gf peculiarities and complexities 
which, in my judgment, render monkey brains ess ser- 
viceable than those of human fetuses for the elucidation 
of fissural problems. 

§ 344. Under the various titles “external perpendicu- 
lar,” “external occipital,” “temporo-occipital,” “ape- 
fissure,” “vordere occipital,” etc., have been included 
several different human fissures or combinations of fis- 
sures, viz.: (A) The dorsal outcrop of an unusually deep 
occipital fissure; Marshall, “The Brain of a Bushwoman,” 


204 





REFERENCE HANDBOOK OF THE MEDICAL SGIENCES. 





Philosophical Transactions, cliv., p. 511, Figs. 1, 9, 2; (B) 
a fissure on the lateral aspect caudad of the supertem- 
poral, and having a general dorso-ventral direction; the 
vordere occipital of Wernicke (“Das Urwindungssystem 
des menschlichen Gehirns,” Arch. fiir Psychiatrie, 1875, 
pl. v., Figs. 19 and 22, k); called exoccipital in the 
present article in order to avoid using the more natural 
mononym, preoccipital, already applied elsewhere by 
Meynert; (C) the combination of A and B,* on account 
of a supergyre which covers the dorsal end of the true 
occipital fissure (A) and permits the adjacent end of B 
apparently to become continuous with it, as in Figs. 785 
and 786. 

§ 345. No one of the fissures or fissural combinations 
mentioned in § 344 is identical with the pomatic fissure 
of most monkeys; but the exoccipital may exist in the 
true apes and in Afeles (Huxley, Zool. Proc., 1861, pl. 
xxix.). It is doubtful whether the term “ape-fissure ” is 
a desirable one to retain.+ 

§ 346. What Significance Has the Arrangement of the 
Fissures?—The query is warranted by two classes of 
facts, viz.: (1) with the mammals whose cerebrums are 
fissured a more or less definite fissural pattern has been 
recognized in most of the species studied in that respect; 


—_—— "12 
—_— 


————_—— il 



















—- 


—-10 


eee Od 


-—--——9 





-....central 2, 
a. -----parietal f. 


gee Sylvian f, 
—.. § supertem- 
“5 poral f. 


4 
-paroccipital f. 
....occipital £ 


-paroccipital g. 
eoeeecee POMA 


pomatic f. 


poma 


¥1G. 787.—Dorso-Caudal Aspect of the Brain of a Monkey (Macacus), 
the Right Poma Lifted; 1,807. 1. 1, Caudal end of right occipital 
lobe; 2, surface caudad of poma; 3, unidentified fissure; 4 (light 
line), line of detachment of the pomatic margin; 5, superfissure re- 
sulting from the union of the Sylvian and supertemporal ; 6, post- 
central (?) f.; 7-15, undetermined frontal fissures; 16, left central 
f.; 17, left parietal f.; 18, left postcentral (?) f.; 19, left Sylvian f. ; 
20, left supertemporal f.; 21, fissure on the mesal surface of the oc- 
cipital lobe, seen also on the right. 

Preparation.—The fresh brain was exposed in brine, and left in 
the base of the skull for support; on the right side, the margin of 
the overlapping poma (‘‘ occipital operculum ’’) was freed by tearing 
the arachnoid with the syringotome (see article Brain: Methods), 
and the poma reverted and kept in position with absorbent cotton 
wet with brine. The whole was then placed in 95 per cent. alcohol 
so as to harden rapidly in the desired shape. When firm it was 
photographed from the dorso-caudal aspect, the lifted poma being 
greatly foreshortened. The parts on the left were undisturbed. 


(2) the fissures of idiots are commonly peculiar in some 
way. There is, therefore, no reason, @ priort, why one 
should not seek fissural correlation with sex, family, 
race, capacity, attainment, and character. 

347. Some idea of the problems involved and the 
difficulties of their solution may be gained from the com- 


* “The so-called ape-fissure has been so termed because it imitates 
in disposition the opercular [my pomatic] fissure of the apes. It is, 
however, not a perfect homologue of that fissure, though its presence, 
when it is due to the fusion of the external occipital with the internal 
perpendicular sulcus, is a significant sign of disturbed cerebral 
growth” (E. C. Spitzka, ** Insanity,’’ 1887, 286). 

+ For some years I have been gathering materials for the elucidation 
of one of the most perplexing subjects in cerebral topography, the 
so-called “ ape-fissure,’’ but this is not the occasion for a full presenta- 
tion of either facts or opinions. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





parison of the cerebrums of the two philosophers, Wright 
and Oliver, the Swedish carpenter, and the unknown mu- 
latto (Figs. 664, 762, 767, 770, and 788). The first two 
differ markedly not merely in detail but in general aspect; 
architecturally speaking, the gyres of Oliver are Corin- 
thian in style, those of Wright, Egyptian. An approxi- 
mation to this is seen in the mulatto. The mechanic’s 
cerebrum is fissured to an unusual degree and the insula 
completely hidden; the philosopher had a larger brain, 
but its lateral aspect presents an equally unusual absence 
of fissural complexity and the insula is exposed. 

§ 248. Comments upon Fig. 788.—Pending the detailed 
study and description of this very interesting brain by the 
writer, to whom it has been generously loaned from the 
Museum of Harvard Medical School, with the consent of 
its preparator and first describer, Dr. Thomas Dwight, 
the professor of anatomy, the following points may be 
noted: A. The great length of this hemicerebrum as 
compared with that of the mulatto (Fig. 762). 

B. The special length of the caudal part, whether the 
central or the Sylvian fissure be taken as the dividing 
line. 

C. The height of the frontal region. 

D. The apparently slight extent of the prefrontal lobe; 
apparently, because, as is shown upon the dorsal aspect 
(Fig. 770), a large part of this region is invisible from the 
side, and is of unusuai width. 

E. The simplicity of the visible gyres, due to the few 
contortions of the main fissures, and the comparative 
infrequency of minor ones; visible, because the unseen 
cephalic surface of the prefrontal lobe presents a much 
greater complexity. 

F. The condition of the minor fissures as sharp incisions 
rather than as slight depressions, like those in the Swe- 
dish brain (Fig. 767). 

G. The visibility of the insula, at least equal to that 
in the mulatto (Fig. 762). Whether any of this condition 


supercentral f. 


precentral f. 


subfrontal f. 


orbital f. 


presylvian f. 
olfactory f. ‘ 


basisylvian f. 


INSULA 


central f.—V 










is due to the pressure during hardening which may have 
occasioned alsoa peculiar roundness of the temporal lobe, 
it is impossible to determine, and Dr. Dwight does not 
recall the condition of the parts when the brain was re- 
moved. 

H. The great length of the supertemporal fissure, and 
its dorsal subdivision. 

I. The bifurcation of the Sylvian fissure, constituting 
perhaps an episylvian and hyposylvian as in the mulatto. 

J. The complete independence of the precentral and 
subfrontal fissures. 

K. The union of the proximal parts of the presylvian 
and subsylvian fissures, so as to separate the pre- and 
postoperculum. 

L. The presence of an unusual, curved fissure (14) 
ventrad of the subcentral. 

M. The crossing of the temporal region ventrad of the 
supertemporal fissure by several irregular fissures (trans- 
temporal). 

N. The complication of the zygal form of the orbital 
fissure by a branch extending cephalad from the middle 
of the zygon. 

O. The complete interruption of the central fissure by 
an isthmus which is more clearly indicated in Figs 770 
and 771. 

P. The fulness or “ plumpness” of the gyres, remarked 
by Dr. Dwight. 

§ 3849. Is There a Criminal Type of Fissures ?—Bene- 
dikt and others have held that, in murderers for example, 
there is a tendency to fissural confluence or to a condition 
resembling that in certain carnivora. The materials at 
my disposal lead me to share the doubts expressed by 
Donaldson (Amer. Neurol. Transactions, 1892, p. 54), 
Schwekendiek (Amer. Jour. Neurol. and Psychiatry, i., 
569-573), and Schiifer (“Quain”), 1893, 161. Upon the 
whole, notwithstanding the able contributions of Dercum 
(1889, 1892), Mickle (1896), Mills (1886), Weinberg (1896), 


central f.—D 


18 postcentral f. 
parietal f. 
occipital f. 


paroccipital f. 


Fic. 788.—Lateral Aspect of the Left Hemicerebrum of Chauncey Wright, a Distinguished Philosophical Writer, who died in 1875 at the age of 


forty-five. X .85 


Preparation.—The brain was removed with care (in the usual way) and hardened in zinc chloride; there seems to haye been consid- 


erable dorso-ventral sinking and lateral spreading. 


In the absence of a cast or measurements of the cranial cavity, it is of course impossi- 


tensive this distortion has been; enough, probably, to account for the flatness of the dorsal surface, and the consequent 
es of the fissures of that region as seen from the side, but not sufficient to have produced the great width of the prefrontal 
lobes, noted under Fig. 768. The figure accompanying Dwight’s suggestive remarks upon this brain (American Academy Proceedings, 
1877, ‘xiii, pp. 210-215) is stated to be somewhat diagrammatic, largely, apparently, for the sake of exhibiting the entire lateral aspect to 


better advantage. 


205 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








Wilmarth and others, Iam disposed to regard as premature 
any conclusions as to fissural correlation, and to urge re- 
newed and systematic efforts in three directions, viz. : (1) 
The determination of the standard fissural pattern for the 
average well-born, orderly, and educated white male ; (2) the 
collation of the conditions in large numbers of individuals 
of the other sex, of other races (especially the African), 
and mental and moral conditions; (8) the detailed de- 
scription and portrayal of the fissures of individuals of 
marked characteristics. 

§ 850. The Value of Organization.—In France there has 
existed for many years a “Societé mutuelle d’Autopsie.” 
In 1890 was formed the American Anthropometric Soci- 
ety, which has already received the brains of Harrison 
Allen, Edward D. Cope, Joseph Leidy (its first president), 
of his brother, Dr. Philip Leidy, and Dr. James W. White. 
I had already prepared a “Form of Bequest of Brain” 
which was first executed in 1889, and which, as since 
amended, is here reproduced: 


FORM OF BEQUEST OF BRAIN. 


Ly eninoicer ne omiiioe Selene s MLO WisOlias once c secerettislers re. sfeinanvis , student of 
OR OLIAD ODO SOOIOUe FPO 60. cree cece cece cece LO veseccscreeeeeeenenny 
ANC: CTAAUALER TOMI ew cies cn aiietcisls es TT cy ete cferscreters , recognizing 


the need of studying the brains of educated and orderly persons rather 
than those of the ignorant, criminal, or insane, in order to determine 
their weight, form, and fissural pattern, the correlations with bodily 
and mental powers of various kinds and degrees, and the influences 
of sex, age, and inheritance, hereby declare my wish that, at my 
death, my brain should be entrusted to the Cornell Brain Association 
(when that is organized) or (pending its organization) to the curator 
of the collection of human brains in the museum of Cornell Univer- 
sity, for scientific uses, and for preservation, as a whole or in part as 
may be thought best. If my near relatives, by blood or by marriage, 
object seriously to the fulfilment of this bequest, it shall be void ; but 
I earnestly hope that they may interpose neither objection nor obsta- 
cle. Iask them to notify the proper person promptly of my death ; if 
possible, even, of its near approach. 

SISMAUITCS wee vine teets ste acclclale vels'aiv eratelarcietererstars 


NotTeEs.—l. A duplicate copy of this form should be filled out and 
retained by the testator. 

2. The bequest should be accompanied by a photograph and a sketch 
of life or character, or a reference to published biography. 

3. The testator should give notice of any change of address, not 
merely on account of the bequest, but also in order that copies of 
circulars or other publications may be sent. 

4. A brain is safely transmitted in a tin pail of some liquid of nearly 
its own specific gravity (about 1.04) in which it will just float without 
either pressing on the bottom or rising above the surface. The most 
readily prepared is nearly saturated brine, made by dissolving in wa- 
ter as much common salt as it will dissolve, then pouring it off, and 
adding a little water till the brain is just suspended. Preservation as 
well as safe transportation may be assured by adding sufficient salt to 
water containing three, four, or five parts of commercial (forty per 
cent.) formalin.* 

5. The lid of the pail should be secured with surgeon’s adhesive 
plaster; the pail should be addressed as follows: Anatomical De- 
partment, Cornell University, Ithaca, N. ¥. Specimen of Natu- 
ral History. Perishable. 

6. Copies of provisional diagrams of the fissures will be mailed upon 
application. For a statement of reasons for the study of the brains 
of educated persons, see Buck’s REFERENCE HANDBOOK OF THE 
nee SCIENCES (Wm. Wood & Co., New York), VIII., 163, and 
IX., I 


Besides the nine named in § 315 whose brains have 
already come into our possession, the “Form” has been 
filled out by more than fifty, including undergraduates, 
alumni, and teachers in this and other institutions of 
learning. 

§ 351. The Public should be Educated in This Respect. 
—From the physiological and psychological standpoint 
it is clearly desirable to study the cerebrums of persons 
whose mental or physical powers were marked and well 
known.+ The present condition of things is illogical and 
unprofitable. We scrutinize and record the characters 
and attainments of public men, clergymen, and friends, 
whose brains are unobtainable. We study the brains of 





*For other liquids adapted to the transportation and preservation 
of the brain, see the article, Brain: Methods. 

+ Among the individuals best adapted to subserve this object are 
college professors, who have usually somewhat sharply defined capac- 
ities and attainments, and are the subjects of prolonged and discrim- 
inating observation and discussion among their trustees, colleagues, 
and students; no professor’s brain should be lost to neurological 
science. 


206 








paupers, insane, and criminals, whose characters are un- 
known or perhaps not worth knowing. 

It isat onceareproach and an irreparable loss to science 
that the community has not yet been convinced that the 
preservation and study of one’s brain is an honor to be 
coveted. Who can set a limit to the results that might 
have been attained from the examination of the brains 
of soldiers like Grant, Sherman, and Sheridan; of preach- 
ers like Beecher, Brooks, and Howard Crosby; of natural- 
ists like Agassiz, Gray, and Jeffries Wyman; of lawyers 
like Tilden, Conkling, and Benjamin Butler? How long 
must science wait for a general sentiment such as is em- 
bodied in the declaration of an eminent historian, that 
science is as welcome to his brain as to his old hat, and 
that he wishes he had ten of them? * 

§ 352. Brain Wetght.—This interesting topic is dis- 
cussed from the human side in the article Brain, Growth 
of the, but a few words may be added here as to com- 
parative weight. + 

§ 353. In absolute weight the human brain is exceeded 
by those of whales and porpoises (2,265-8,171 gm., 5-7 
pounds) and of elephants (4,530 and upward, 10 pounds 
or more). The lowest of these figures approximates the 
greatest weight claimed for a non-hydrocephalic { human 
brain. A negro brain described by Dr. ©. Tompkins, 
Virginia Med. Monthly, January, 1882, pp. 291-293, 
weighed 1,988.80 (70 ounces or 4 pounds 6 ounces). Van 
Walsem has described (Newrologisches Centralblatt, xviii., 
No. 13, 1899) the brain of an epileptic idiot which 
weighed, when fresh, 2,850 gm. (90 ounces, or 5 pounds 10 
ounces)! 

§ 354, But in no animal other than those mentioned 
above is the brain as heavy as the smallest human, viz.. 
that of a Bushwoman, 871 gm. (80.75 ounces). In a bull 
it was 337 gm., in a lion, 198, and in an adult gorilla 
only 425 (15 ounces) (Owen, iii., 144). The largest ape 
brain is then only half as large as the smallest normal 
human. 

§ 355. The relative weights of the body and brain vary 
greatly according to the condition of the former at death. 
Most of the cases tabulated were of persons dying after 
more or less prolonged disease, and the figures are as fol- 
lows: for 81 males, 1 to 36.50; for 82 females, 1 to 36.46; 
according to Bischoff, 1 to 35.20. Quain concludes that 
in healthy individuals dying suddenly from disease or 
accident, the ratio is probably about as 1 to 45. In com- 
paring man with animals in this respect this last ratio 
should commonly be adopted. 

§ 356. Owen estimates the adult male gorilla at 200 
pounds, or 90,720 gm., and the brain would be as 1 to 
218; in a bull it wasas 1 to 2,000, and in a lion as 1 to 
555. On the other hand, in a sparrow the ratio was as 1 
to 25; and in a marmoset (Midas) 1 to 20 (Owen, iii., 
142); and in Jacchus vulgaris (No. 664, Cornell Univer- 
ity Museum), as 1 to 19. But it is to be noted that in 
these small monkeys, as in birds, the cerebrum is not 
Jissured. Perhaps the least misleading mode of stating 
the case is to say that the human brain is relatively 
heavier than that of any animal Jarger than a cat in 
which the cerebrum is fissured. 

VII. RaINENCEPHAL.—§ 357. Olfactory Bulb and 
Tract.—-These parts of the human brain have already 
been shown from various aspects in Figs. 668, 670, 672, 
689, 751, 752, and 765. In Fig. 789 they present almost 
diagrammatic simplicity as a tongue-like extension from 
the region of the postcribrum (“anterior perforated 
space”) more or less completely covering the olfactory 
fissure. 





* Tt is encouraging to know that the brain of the late George Grote, 
historian of Greece, has been described by John Marshall in the Jour. 
of Anat. and Physiol., vol. xxvii., pp. 21-68. 

+ The two papers of Waldeyer (1896) contain the titles of six hun- 
dred and thirty-seven books and papers relating to fissures, gyres, 
commissures, and brain weight, and published, for the most part. be- 
tween 1879 and 1898. 

t¢ The brain of a Chippewa Indian squaw, eighty-five years old, rach- 
itic, in the Army Medical Museum, Anatomical Section, No. 1,031, 
weighed when fresh 73.5 ounces (2,083.72 gm.), but it was hydroceph- 
alic, and the curator informs me that the “ventricular liquid was 
probably included in the weight.” . 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





§ 358. Fig. 789 illustrates: A. The length of the 
olfactory bulb at this period, as compared with its tract, 
which latter is the longer in the adult. 

B. The concealment of the entire olfactory fissure by 
the olfactory bulb; in the adult, usually, the fissure pro- 
jects considerably beyond the bulb (Fig. 672). 

C. The apparent continuity of the insula with the 
lateral root of the olfactory tract. 

D. The partial covering of the insula at this period. 

E. The thickness and roundness of the margin of the 
operculum. 

F. The formation, at this period, of the presylvian 
fissure, constituting the cephalic limit of the operculum, 
but the non-existence of a subsylvian fissure. 

§ 359. The corresponding parts in several other verte- 
brates are shown in Figs. 680 (turtle), 685 (frog), 717 
(salamander), 682 and 686 (cat), and 688, 726, and 794 
(sheep). Any remnant of the former anthropotomical 
idea that the olfactory tracts and bulbs constitute merely 
the first pair of cranial nerves* will probably be dispelled 


frontal lobe 


olfactory bulb =— 
operculum 
olfactory tract —- inant 
optic nerve —- 
chiasma —- temporal lobe 
tuber =-- 


collateral f. 





C 


Fig. 789.—Ventral Aspect of the Left Hemicerebrum of a Fetus, Size 
and Age Unknown; 1,820. Xx 1. The lateral aspect of the same 
preparation is shown in Fig. 751. 


by noting the relative extent of the corresponding parts 
in still lower forms, the lamprey (Fig. 790) and the hag 
(Fig. 791). 

§ 360. Fig. 790 illustrates: A. The representation of 
all the six definitive segments in this lowly vertebrate; 
the mesencephalic lobes (geminum) are prominent; the 
cerebellum is small and was removed with the rest of the 
roof. 

B. The preponderance of the olfactory bulbs over the 
lateral masses presumably representing the cerebral 
hemispheres. 

C. The concomitantly large size of the lateral portion 
of the rhinocele. 

§ 361. Fig. 791 illustrates: A. The most distinctive 
character of the myxinoid brain, 7.e., the insignificance 
of the intermediate region represented in most vertebrates 
by the more or less prominent cerebellum and _ quadri- 
geminum; hence the entire organ naturally divides itself 
into a caudal portion, the oblongata, obviously an en- 
largement of the myel, and the brain proper, comprising 
four pairs of lobes narrowing caudad. 

B. The large size of the olfactory bulbs, especially as 
seen from the ventral side. 

C. The continuity of the olfactory bulbs across the 
meson, as seen from the ventral aspect. 

D. The unusual location or trend of the mesal body pro- 





* For the present it will probably prove convenient at least to avoid 
modification of the accepted numerical designations of the heterogene- 
ous cranial nerves by regarding as the “ first pair” the nervous fila- 
ments which connect the olfactory bulbs with the nasal mucosa. 








visionally named “epiphysis or dorsal sac,” viz., nearer 
the cephalic than the caudal limit of the segment inter- 
preted as the thalami or diencephal. 

E. The vagueness of certain features due to the imper- 
fect condition of the specimen. It was prepared by me 
in 1875 and the 
membranes, in- 
ciuding the meta- 
tela, prematurely 
removed. There 
has not been time 
diacele to prepare an- 
other, and the 
published ac- 
counts and figures 
do not clear up all 
the doubtful 
points. 

§ 362. Rhino- 
cele.—In verte- 
brates generally 
(e.g., the lamprey, 
Fig. 790) and in 
most mammals 
(e.g., the sheep, 
Fig. 792), the ol- 
factory bulb and 
crus contain a 
cavity, the rhino- 
cele, continuous 
with the paracele 
and united with its opposite across the meson by the 
aula. Strictly and by analogy rhinocele should apply to 
the entire cavity of the rhinencephal, but for the pres- 
ent it is at least convenient to employ it also for either 
lateral portion. 

§ 363. The development of the olfactory portion of the 
brain varies so greatly among mammals that Broca, 
Turner, and others have proposed groupings based there- 
on, viz., into macrosmatic, e.g., the armadillo; microsmatic, 
é.g., Man and apes; and anosmatic, the porpoise, where 
the olfactory tract and bulb seem to be wholly absent, 
although the early 
fetal conditions are 
not known. The 
conditions in dogs are 
peculiar, as appears 
in the following ab- 
stract of P. A. Fish’s 
paper, 1891: 

1. The facts do not 
warrant Broca’s 
statement as to the 
existence of a true 


rhinencephaly = 


prosencephal 
diencephal 


mesencephal_{.<2= 


epencephal 


metencephal 





myel myelocele 


Fie. 790.—Diagram of the Brain of the Sea- 
Lamprey, Petromyzon marinus, as if the 
roof of the cavities was removed; enlarged. 
It is based upon several preparations made 
by me in 1874, and would be changed in some 
respects if made from microscopic sections ; 
but the main features are believed to be 
accurate. 


} olfactory bulb 
(rhincephat) 
{ ‘*hemisphere ” 
(prosencephal) 
; epiphysis or 
dorsal sac (?; 
thalamus 
(diencephal) 
geminum 
(mesencephal) 
metacele 


ventricular axis (core oblongata 
of solid material in ttmetenerpral) 
place of the primitive 

cavity) in the olfac- myel 





tory bulb, even in 
rat-terriers. Aiki Roe a 

2. The bulb is not gt AY: a) 
completely but par- x \ i ( jy 
tially occluded, or ae 
perhaps in process at 
of becoming entirely 
so. 

3. The cavity of 
the tract, in some 
wild forms as well as 
domestic, is com- 
pletely closed, there- 
by cutting off all 
communication )be- 
tween the paraceie 
and the cavity of the 
bulb. 

4. The acuteness of 
the sense of smell is 









commissure (?) 
1 





2 
3 


> 


Fic. 791.—Dorsal (Upper) and Ventral 
(Lower) Aspects of the Brain of the Hag, 
Bdellostoma ; 212. X 2.5. 


207 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





not essentially dependent upon the relative size of the 
rhinocele. 

5. Atrophy is not a necessary concomitant of occlu- 
sion. 

6. Domestication, and the consequent disuse of olfac- 
tion as a means for procuring sustenance, may be a factor 
in promoting occlusion. 

7. In the classifications of Broca and Turner the dog 
seems to hold an anomalous position, in that he gives 
every external evidence of macrosmatic power; but by 
the almost total occlusion of his rhinocele he approaches 
structurally the conditions found in the microsmatics. 
Physiologically he is macrosmatic; morphologically he is 
microsmatic. 

§ 864. Precommissure. —As stated in §§ 45 and 210, 
this fibrous bundle, single at the meson, soon divides into 
a cerebral portion (pars temporalis) and an olfactory (pars 
olfactoria). The gross relations of the two are well shown 
in Fig. 792. For the microscopic arrangement of this 
and other fibrous constituents of the olfactory apparatus 
see the article Brain, Histology of the. 

§ 365. Fig. 792 illustrates: A. The divergence of the 
plfuctory and aa divisions of the precommissure 
just laterad of the meson. 

B. The relatively large size of the olfactory division in 
the sheep. 

C. The large size of the rhinocele, but the narrowness 
of the strait connecting it with the precornu. 

§ 366. Crista.—In the cat, adult as well as fetal, the 
caudal or celian aspect of the terma, between the columns 
of the fornix, presents (Fig. 686) a mesal hemispherical 















rhinocele 





strait 
precornu 


caudatum 








septum 


pars olfactoria 
precommissure 


“pars temporalis 


—& medicommissure 


pons 










cerebellum 
trapezium 
pyramid 





Fa. 792.—Brain of Sheep Dissected to Show the Two Divisions of the 
Prenoutacnres ; 2,653. x .9. Prepared by P. A. Fish. The cere- 
brum was cut from the ventral side in two planes meeting at about 
a right angle along the line indicated by the shadow just caudad of 
the line from the word medicommissure. The cephalic slope was 
then very carefully sliced to a deeper level, so as to leave the pre- 
commissure in relief. Unfortunately the pars olfactoria on the 
left (right of the picture) has since been broken, accounting for the 
interruption in the figure. Just within the aula may be dimly seen 
the crista. Compare with the medisected brain (article, Brain: 
Methods), and that of the cat (Fig. 686). 


body which is translucent when fresh. In some lower 
vertebrates it seems to be represented by a membranous 
mass. It has been observed in comparatively few forms, 
and its structure, connections, and significance are unde- 
termined. I have never seen it inadult human brains, but 
it is perfectly distinct in the preparation represented in 


208 


Fig. 793. 
is to be regarded as one of its constituents. 

§ 367. Mig. 793 tllustrates: A. The presence of the 
crista in a child at term. 

B. The dorsal limitation of the aula and the two portas 
by the line of reflection of the endyma constituting a ripa. 

C. The narrowness of the body of the fornix as com- 
pared with that of 
the cat and most 
other mammals. 

D. The division 
of the caudo-ven- 
tral surface of the 
fornix, by the ripa 
mentioned under B, 
into an entocelian 
area, covered by en- 
dyma and forming 
the cephalic wall of 
the aula and the 
two portas, and an 
ectocelian area, Cov- 
ered by pia, the 
dorsal or fornical 
layer of the velum. 

§ 368. The Word 
Rhinencephaton 
Used in Several 
Senses.—Some con- 
fusion may be 
avoided if it is 
clearly recognized 
that one and the 
same word has at 
least five different 
significations. 

1. Owen applied 
rhinencephalon to 





Fic. 793.—The Crista and Adjacent Parts of 
a Child at Term; 4.  X 1.5. 

Preparation. ‘—‘After | transection at 
about the middle of the diacele, the thal- 
ami were torn from their continuity with 
the fornix, leaving the irregular surface 


at and ventrad of 1. The lateral parts 
were then removed, as indicated in the 
drawing. The paraplexus was torn from 


If there is a rhinencephalic segment the crista 


the margin of the fimbria, constituting” 


the two olfactory 
bulbs and their 
tracts (or crura) 
without apparent 
reference to any 
mesal or connecting 
constituents. * 

2. Turner pro- 
posed (1890) to re- 


the lateral part of the fornix ; the short 
line at the right ascends from the fimbria, 
crossing the intervening space, paracele. 
On the left the similar line begins more 
nearly at the middle of the fornix, and 
crosses first the callosum itself, and then 
the callosal fissure. Before photograph- 
ing, the crista was touched with white 
paint. 

Defects.—The brain was ill preserved, 
and broke apart during dissection; the 
shading is too heavy. 


gard the  prosen- 

cephal as divided horizontally by the rhinal fissure (olfac- 
tory and postrhinal) into a ventral portion, the rhinence- 
phalon, and a dorsal, the pallium. 

3. Shiifer proposed (Quain, 1898, 160) to include under 
rhinencephalon the remainder of the so-called “limbic 
lobe” (the hippocampal gyre), and the callosal or “gyrus 
fornicatis.” 

4. His considers (1898) that the bulbs and tracts, the 
precribrums (“anterior perforated spaces”) and some 
other parts, under the name rhinencephalon, constitute 
one of three components of the dorsal zone of the most 
“anterior ” segment, which he names telencephalon. This 
view has been adopted by the Anatomische Gesellschaft 
and is indicated in the Table in the article, Brain, Devel- 
opment of ; see also my Table I. 

5. In the report of the Committee on Anatomical 
Nomenclature which was adopted by the Association of 
the American Anatomists in 1897 (Proceedings, p. 47) the 
rhinencephalon was regarded as a definitive segment 
consisting of the olfactory bulbs and tracts and some 
other parts united across the meson by the pars olfactoria 
of the precommissure, the lateral cavities being connected 


* The mesal contact or coalescence of the bulbs inefrogs and toads, 
and (as observed by Mrs. Gage, 1895) in certain turtles and birds, is a 
secondary condition that has no bearing on the segmental constitution 
of the parts. 

* Since the name and notion of a “lobus limbicus”’ seem to be 
sometimes adopted without adequate inquiry, I cannot refrain from 
pointing out that, as is clear in Shifer’s diagram (Fig. 109), its alleged 
boundaries are not continuous in man, and I am not aware that they 
are in any animal. 


- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 


mm 


by the mesal aula. The other constituents of the rhin- 
encephal are named in Table I. (See above § 718). 

§ 369. Commentaries on Fig. '194.—Besides facilitating 
the recognition of certain important parts and their rela- 





epiphysis 





thalamus 







cerebrum 





cyclopia (see Fig. 712 and the article Teratology), not 
only the cerebrum but also the olfactory portion of the 
brain may be single and mesal. A very instructive case is 
described and figured by Cunningham and Bennett, Royal 
Trish Acad. Trans., xxix., 101-122. 

§ 871. Limits of the Rhinencephal.—These 
were not defined in the report adopted by the 
A. A. A., and cannot yet, perhaps, be deter- 
mined with accuracy. But as an individual 
I may here express the opinion that in mam- 
mals the caudal boundary coincides practi- 
cally with the origin of the medicerebral 
(“middle cerebral”) artery, or with the place 
of junction of the Sylvian fissure with the 
“rhinal,” including by this the olfactory and 
the postrhinal (amygdaline) together. This 
leaves the tip of the temporal lobe, the lobus 
hippocampi, and the whole hippocampal gyre 
as parts of the prosencephalic pallium, al- 


RS Ry RS none postoblongata though they may contain the cortical centres of 
s » cS the olfactory sense. In the lower mammals, 
Ss & the elevation sometimes called protuberantia 

s natiforns similarly lies caudad of the rhinen- 


Fic. 794.—Left Side of the Sheep’s Brain After the Removal of Portions of the Cere- 
brum and Cerebellum, So as to Display the Segmental Constitution of the Organ. 


(From ** Physiology Practicums ”’ ; compare Fig. 688.) 


1, 3, Olfactory tract; 2, a part of the pallium which has not been cut; 4 
(indistinct), chiasma; 5, pregeniculum (external or anterior geniculate body), 
distinct in man but here little more than a lateral portion of the thalamus; 6, 
tuber (cinereum), the slight convexity to which the hypophysis is attached; 7, 


medipeduncle ; 8, trapezium. 


The short lines on the ,surface of the olfactory bulb represent the olfactory 
The cut end of the left optic nerve is dotted to indicate its fibrous 


nerves. 
structure. 


Excepting the unshaded areas, representing cut surfaces, all the parts seen in 


this figure were covered by pia. 


Preparation.—The cerebellum is left of its natural height, but the cephalic 
and caudal conyexities are sliced away so as to expose the parts which are over- 
hung by them. The cerebrum has been cut down to the level of the thalami ; 
the caudal portion cut away along the oblique line of its projection over the part 
marked 5; the lateral portion so as to expose the part marked 3; also the cephalic 


projection which overhangs the olfactory bulbs. 


tive positions, this figure ‘well illustrates the segmental 
constitution of the brain, which is obscured in the entire 
organ by the preponderance of the cerebrum and cere- 
bellum. There is a series of more or less distinct masses 
demarcated by constrictions of greater or less depth. 
Admitting that there is still some doubt as to number 
and limits of the segments, the following assignments 
may be accepted provisionally: 


Olfactory bulbs and tracts } RHINENCEPHAL. 
Cerebrum | PROSENCEPHAL (fore-brain). 
Thalami, epiphysis, hypophysis, DIENCEPHAL 
chiasma, and geniculums (inter-brain). 
Geminums and crura } MESENCEPHAL (mid-brain). 
Cerebellum, pons, and 
preoblongata 
Postoblongata | METENCEPHAL (after-brain). 


t EPENCEPHAL (hind-brain). 


See the fuller Table on page 153. 

§ 370. Is there a Rhinencephalic Segment ?—That I am 
at present disposed to answer this question in the affirm- 
ative is indicated in diagrams (Figs. 674 and 675), Tables 
(I. and II.), and remarks (§ 45) in the earlier part of this 
article; see also Figs. 790, 791, and 794. The whole sub- 
ject is still under discussion and likely to be for some 
time to come, and this is not the occasion for detailed 
argument. ‘There may be stated here, however, three 
facts that may not be familiar to all students of normal 
human anatomy : 

1. Inthe lamprey and hag, although the olfactory bulbs 
are paired, the olfactory sac and nostril are single and 
mesal. 

2. In the lancelet (Amphiozus or Branchiostoma) the 
olfactory bulb is single and approximately mesal, al- 
though, like several other organs of this peculiar verte- 
brate, not quite mesal. 

3. In the malformation called monophthalmia or 


Vou. II.—14 





cephalic boundary. 

§ 3872. Postrhinal Fissure—Although re- 
garded as lying within the pallium and thus 
in the prosencephal rather than the rhinence- 
phal its associations are such that a few words 
may be added here as to its apparently differ- 
ent locations in man and in the lower mam- 
mals. In the latter both it and the olfactory 
fissure are visible from the lateral aspect. 
But in the lower monkeys the greater de- 
velopment of the pallium crowds them to 
the ventral side, and in man and apes the 
postrhinal fissure becomes actually mesal 
(Figs. 765, 766). 

TX. MENINGES (THE ENVELOPES OR MeEmM- 
BRANES OF THE BRAIN AND SPINAL CoRD),— 
§ 373. Definitions.—Meninges is the plural of 
mening, from the Greek ujveyé, signifying any 
membrane or coating, as of the eyeball, and even the 
scum upon milk or wine; but, as stated by Hyrtl (“ Ono- 
matologia,” p. 3824), the word was restricted by Aris- 
totle (“ Hist. Anim.,” lib. i., cap. 16) to the coverings 
of the brain (and myel?), and the limitation has been 
since maintained. The synonyms of meninx are: Fy., 
méninge ; It. and Sp., meninge ; Ger., Hirnhaut. 

§ 3874. The Three Meninges.—Nearly all anatomists 
recognize three chief membranous envelopes between the 
substance of the neuron (brain and spinal cord) and the 
craniospinal canal, viz.: an ental, the pia, an ectal, 
the dura ; an intermediate, the arachnoid. Their relative 
positions when the cranium is opened are indicated in 
Figs. 795 and 796. Properly speaking the pia pertains 
to the neuron, and the dura to the craniospinal canal, 
while the arachnoid has more or less varied relations to 
both the other meninges. All three present differences 
according to their location within the cranium or the 
spine, and there are transition conditions in the cephalic 
portion of the latter which are not yet fully made out.* 

§ 375. The term pachymeniny (tough envelope) is 
sometimes used for the dura, irrespective of the recog- 
nition of a parietal layer of arachnoid. In like manner 
leptomenineg (tender envelope) is sometimes used for the 
pia and the commonly admitted visceral layer of arach- 
noid. The pathological terms, pachymeningitis and lep- 
tomeningitis are derived from these words. 

§ 3876. Hig. 795 illustrates: A. The successive cov- 
erings of the brain, hairy scalp, periosteum, calva 





* The conditions of investigation of the meninges are peculiar. The 
pia and arachnoid are relatively delicate; they are easily torn and 
their attachments ruptured; they are surrounded by an unusually 
tough membrane, the dura, and the whole is enclosed within a case of 
bone, which must be sawn or otherwise forcibly opened by measures 
which are almost sure to rupture the pia and arachnoid. It is much 
to be desired that the subject be reviewed by some anatomist having 
the use of a mechanical bone-cutting apparatus, ¢.g., the electro-osted- 
tome of the late Dr. M. J. Roberts. 


209 


Brain. 
Brain. 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





(calvarium) dura (ental periosteum), arachnoid, and 
pia. 

B. The shadowy appearance of a fissure covered by 
the piarachnoid and the sharper outline when it is re- 
moved (Fig. 802). 

C. The difficulty of separating the arachnoid from the 


pia; in a transection of a fissure, however, the former 





Fig. 795.—Outline of the Dorso-Lateral Aspect of the Left Half of the 
Head of an Adult Man, with the Brain Exposed in the Region of the 
Central Fissure; 811. X .3. 

Preparation.—The entire head was alinjected by continuous 
pressure for a week, and medisected as shown in Fig. 670. From 
the general region of the central fissure was removed a disc of the 
scalp about 6 cm. in diameter (A) ; in the centre of the area so ex- 
posed, a disc of the calva (calvaria, cranial vault) was removed with 
a trephine 2.5 em. in diameter, and the corresponding disc of dura 
eut out (B). The further preparation of the specimen is described 
under Fig. 796 ; the present outline is mainly given in order that the 
region may be located approximately upon the head. 


will be seen to pass across the fissure from gyre to gyre, 
while the latter, with blood-vessels, dips into the fissure 
as a fold (Fig. 735). 

D. The presence on the ental surface of the piarachnoid 
of a pial fold, the ruga, lying in the fissure. 

E. The minutely punctate aspect of the depiated cortex 


OAL MEM 


d: 
fi ¢ 


~ 
=> 
it ea 
a 


3 
4 
: 
4 


Ww 
NIN \\ 


x 





Fic. 796.—The Several Coverings of the Brain Exposed as a Series of 
Terraces; 811. x .9. 1, The arachnoid, the ectal layer of the pi- 
arachnoid ; 2, a fissure, still covered by the piarachnoid ; 3, ruga, 
the fold of pia that has been pulled out of the fissure 6; 4, ental 
(pial) surface of the flap of piarachnoid everted from the surface of 
5, a gyre, between fissures 2 and 6; 6, a fissure from which the ruga 
and adjacent piarachnoid have been removed. 

Preparation.—The region here included is a square of the region 
shown in Fig. 795. The outer line corresponds with the circle A, 
and the inner with circle B. The scalp was divided obliquely so as 
to expose a converging surface. A disc of periosteum was cut out a 
little smaller than the ental line of the scalp. The original trephined 
orifice in the calva was then enlarged with nippers, so as to leave a 
converging surface, the ectal circle a little smaller than the hole in 
the periosteum, and the ental about as much larger than the hole in 
the dura. Two fissures could be seen; over the caudal the piarach- 
noid was left undisturbed ; at the cephalic side of the dural orifice a 
semilunar flap was lifted and reflected so as to expose the ental sur- 
face and the fissure and adjoining gyres which it had covered. 


210 


by reason of the extraction of minute vessels entering 
from the pia. The ental surface of the pia, here repre- 
sented smooth, should have a flocculent appearance, called 
tomentum, from the attachment of these vessels. 

§ 3877. Fig. 797 illustrates: A. The subcylindrical 
form of the myel, and the relations of the areas of alba 
and cinerea at this level; see the article, Spinal Cord. 

B. The existence of a dural sheath (theca) of the myel, 
independent of the periosteum, the two being united in 
the cranium. 

C. The somewhat loose adhesion of the arachnoid to 
the dura, leaving slight and scattered subdural spaces. 

D. The presence of the septum posticum at this level; 
it is said (Shiifer, iii., 188) to be most perfect in the cer- 





Fic. 797.—Transection of the Myel and Its Meninges in the ‘* Upper” 
Thoracic Region. (Enlarged somewhat from Key and Retzius, Taf. 
i., Fig. 7, after Shafer: Quain, iii., Fig. 132.) a, Dura (not the spinal 
periosteum, but representing the ental layer of cranial dura); b, 
arachnoid: ¢, septum posticum; d, e, f, trabecule in the subarach- 
noid space, those at f supporting the dorsal (posterior) nerve roots; 
g, ligamentum denticulatum; h. ventral (anterior) nerve roots, cut 
off; k,l, subarachnoid spaces. The pia is not designated, but may 
be recognized as the double outline of the myel dipping into the 
dorsal fissure as a narrow septum and into the ventral as a fold. 

Vote.—The foregoing is substantially the description in Shafer. 
But some of my observations lead me to suggest that the spinal, like 
the cranial, arachnoid comprises two layers, a dural and a pial, 
connected by the reflected layers of the septum posticum. This 
view, however, would homologize the space k, 1, with the intrarach- 
noid space of the cranium, and hence their free communication 
with the postcisterna would be difficult to explain. 


vical region, and more or less incomplete farther caudad.* 

E. The size of the subarachnoid space traversed by the 
spinal nerve roots, the trabecule, and the ligamentum 
denticulatum. 

F. The location of the ligamentum denticulatum at 
either side of themyel. This isa fibrous band connected 
with the pia, and reaching the dura by a triangular ex- 
tension in the intervals between the nerve roots; but op- 
posite the roots (as in this figure) it is narrower, and does 
not reach the dura. 

§ 378. Dura.—This -mononym is rapidly replacing 
dura mater and the German harte Hirnhaut.+ As shown 
in Figs. 796, 799, and 804, the cranial dura is apparently 
a single sheet, dense, strong, fibrous, and unyielding, 
lining the bones and constituting their ental periosteum 
(endocranium). But a closer examination detects two 
layers, an ectal and an ental, which gradually separate 
in the cephalic part of the cervical region, and in the 


* Septicum posticum is an undesirable term, but septum dorsale 
might be confounded with the prolongation of the pia into the dorsal 
fissure of the myel. 

+ The reduction of the polyonyms, pia mater and dura mater, to 
the mononyms pia and dura was urged by me twenty years ago (1880, 
f). The use of pia and dura, and of the natural adjectives, pial 
and dural, has now become quite general. The simplification has 
been recommended by the Association of American Anatomists 


_ (December 27th, 1889), by the American Association for the Advance- 


ment of Science, 1890 and 1892, and by the American Neurological 
Association, June 5th, 1896. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain. 





spine maintain diverse relations, the one with the canal, 
the other with the myel. 

§ 879. Theca.—The ental or myelic portion of the 
It is 


spinal dura constitutes a fibrous tube, the theca. 





OO ce ey ee 
eY* we ew nee 





¢ 


Fic. 798.—Schematic Transection of the Parietal Region of the New Born, to show the Relations of 
} to M (From Langdon, 1891.) 
falx; S, longitudinal sinus; xxx, subserous connective tissue between the dura and the ectal 


the Meninges to the Cerebrum and Cranium. 


arachnoid. 


Defects.*—The mesal dark area dorsad of S (the longitudinal sinus) represents the liga- 
mentous connection of the two parietal bones; it should be continuous with the periosteum and 
ectal dura. The ‘“‘subserous dura,’’ between the dura and the arachnoid, represented by the 


series of crosses, is made too wide in proportion. 


considerably longer and larger than the myel itself, and 
separated from the periosteum constituting the wall of 
the canal by venous plexuses and much areolar tissue. 
The cavity between the pia and the dura is occupied by 
cerebro-spinal fluid (neurolymph), and is divided by the 
curtain-like arachnoid into the spaces subdural and sub- 
arachnoid. Within the latter the myel, closely covered 
by pia, is suspended, being kept in position by a ligament 
on each side, ligamentum denticuiatum (Fig. 797), which 
fixes it at frequent intervals to its sheath, and by the 
roots of the spinal nerves (Fig. 797, f), which cross the 
space from the surface of the myel to the intervertebral 
foramina. 

§ 380. Fig. 798 illustrates: A. The existence of two 
layers of dura in the cranium, the one corresponding 
with the periosteum of the spinal canal, the other with 
the dural sheath of the myel, Fig. 797, a. 

B. The existence of two layers of arachnoid—an ental 
or pial, and an ectal or dural. 

C. The propriety of regarding the so-called subdural 
space as an intrarachnoid space, analogous with the 
serous sacs in other parts of the body (see § 399). 

§ 381. Fig. 799 dllustrates: A. The formation of a 
nerve root from the union of several funiculi or rootlets. 

B. The extension of the myelic dura upon the root at 
its exit from the spinal canal, to be lost in the sheath of 
the nerve. 

§ 882. Hpidural Space.—In the spine, since there are 
two layers of dura, an ectal (periosteal) and an ental 
(myelic), the interval between them constitutes an epi- 
duralspace. In the figures this is nowhere clearly shown, 
but it may be represented in Fig. 797 by drawing around 
the present ectal outline, the myelic dura, a second at a 
little distance therefrom; the interval would be the epi- 
dural space. 

§ 383. Two questions naturally arise in connection 
with the epidural space. 

1. Does it communicate with the subdural space? If 
so, where? 

2. If not, what is the source of the liquid occupying 
the space. and what is its nature? 

§ 884. Fig. 800 illustrates: A. Therelation of the dura 
to the cranium as a complete lining of considerable 
thickness. 





*Dr. Langdon informs me that the cut does not represent the 
original drawing quite fairly in some respects. 












B. The relation of the falx (1) and falcula (13), as mesal 
extensions of the dura, to the tentorium (8) asa transverse 
extension. 

C. The tent-like form of the tentorium, the lateral 
margins coinciding approximate- 
ly with the long axis of the cra- 
nium, the intermediate portion 
rising toward the meson at an 
angle rapidly increasing from 


—periosteum the occiput cephalad. 
D. The inversion of the fal- 
yy" —calva cula as compared with the falx. 
: E. The general arrangement 
—dura ie of the more prominent fibres of 


the falx; there is a marked di- 
vergence or radiation from about 
the place of intersection of the 
free margins of the falx and the 
tentorium. 

F. The locations of the prin- 
cipal sinuses along the lines of 
attachment of the dural folds 
to one another or to the cra- 
nium. 

G. The direction of the cur- 
rent in the principal sinuses: in 
the longitudinal (2) and tentorial 
(6) (with the falcial) (4) toward 
the torcular; in the lateral (9), 
toward the exit in the base of 
the skull at the jugular vein (4), 
in the superpetrosal and subpetrosal (10, 11) to the lateral. 

The entrance of the supercerebral veins into the longi- 
tudinal sinus at the points indicated by the black spots 
in the course of the latter and at others not indicated. 

§ 385. Tentorium.—The cerebral region of the cranium 
is partitioned off from the region containing the cerebel- 
lum by a fold of the ectal layer of the dura, which, from 


‘ 

» | —ectal arachnoid 

\ = " 

. —intrarachnoid space 
' . 

\ —ental arachnoid 


—subarachnoid space 
—pia 


C, C, Cerebrum; F, 





Fia. 799.—Section, Lengthwise, of a Ventral Nerve Root at Its Place of 
Exit from the Spinal Canal Enlarged. (From Key and Retzius, 
Taf. i., Fig. 10; after Shafer: Quain, iii., Fig. 128.) a, Four funic- 
uli uniting to constitute the root ;-b, dura refiected upon the root at 
its emergence through the intervertebral foramen (the periosteum 
is not shown) ; ¢, arachnoid ; d, reticular lamella of the arachnoid 
reflected upon the root (compare Fig. 797, f) ; s, subdural space 
s’, subarachnoid space. 


its arched shape, is called the tentoriwm (cerebelli), Fig 
800. See also the article Brain, Circulation of. 

The tentorium exists in most, if not all, mammals, but 
not, so faras I am aware, in other vertebrates; in the 
carnivora it is ossified. 

§ 386. Falz.—From the cerebral side of the tentorium 
extends cephalad a mesal duplicature of the dura, the 


211 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











falx, well named from its sickle shape (Figs. 800 and 
The narrower cephalic end is attached to the erésta 
The distance between the free margin of ‘the falx 


801). 
galt. 





Fic. 800.—Mesal Aspect of Right Half of Medisected Skull Retaining the Dura. X .5. 


(From Sappey, iii., Fig. 462; after Shafer: Quain, iii., Fig. 129.) 


adherent to adjacent parts, and their margins are easily 


detached, their relations are sometimes not clearly ap- 
preciated. But if an infant or fetal cranium be divided 
across the prefontanel diagonally so as 
to include either parietal bone and the 
opposite frontal, the cut edge will pre- 
sent three layers, viz., an ental, the dura, 
representing the endyma; an cctal, the 
pericranium, representing the pia; an 
intermediate, the bone, representing the 
nervous parietes. At the fontanel this 
third element is absent, and the conjoined 
dura and pericranium contribute a mem- 
branous area quite comparable with a 
tela and available for illustration thereof. 

A defect in the analogy is this: The 
cranial bone is of nearly uniform thick- 
ness, and thins out at the margin of the 
fontanel. But in the brain, although 
the immediate margins of the telas may 
be thin, the general parietes are com- 
monly very massive, and there is usually 
a parallel zone specially differentiated, 
é.g., the habena.* 

§ 890. Mg. 801 illustrates (in addi- 
tion to the points mentioned under Fig. 
687 and in § 66): A. The degree of re- 
‘tention of the dura in this specimen is 
greater than with any brain ever seen 
or heard of by me. The brain was most 
skilfully removed, according to my direc- 
tions, by Prof. W. C. Krauss, a former 
student (see the article Brain: Methods). 

B. The existence, in the caudal three- 
fifths of the cerebrum, of a distinct and 


and the callosum increases cephalad. 


Defects.—As usual, there is no indication of the change that occurs at or near the 
foramen magnum, by which the apparently single dura of the cranium divides into a 
true dura related to the myel (Fig. 797) and a spinal periosteum; see, however, 
Shafer (Quain), iii., Fig. 182. The region of the postoccipital sinus (12) is so heavily 
shaded as to give the impression of its considerable width ; as shown in the original 
of Sappey, this sinus is no longer than the subpetrosal; according to Browning 
this is merely a constituent of the irregular basilar plexus of venous channels. 
The vein of Galen (25) here joins the tentorial sinus at an angle of about 45°; really, 
as shown in Fig. 801, it curves about the rounded splenium and joins at nearly a right 
angle. 

1, Falx ; 2, longitudinal sinus; 3, concave ventral margin of falx ; 4, falcial (in- 
ferior longitudinal) sinus; 5, base of the falx where it joins the tentorium ; 6, ten- 
torial (straight) sinus or s. rectus ; 7, cephalic, narrow end of falx, a little dorsad of 
the crista galli to which it is attached; ventrad of the line is a frontal (air) sinus, 
seen also in Fig. 670; 8, right side of tentorium, sloping latero-ventrad from the at- 
tachment to the falx to the side of the cranium along the Jateral sinus (9) ; X, the tor- 
cular, the place of confluence of the two lateral sinuses, the longitudinal and the 
falcial ; 10, the superpetrous (superior petrosal) sinus: 11, the subpetrous (inferior 
petrosal) sinus ; 12, postoccipital (posterior occipital) sinus ; the arrows indicate the 
direction of the blood in the larger sinuses; the lateral sinus is continuous with the 
entojugular vein; 13, faleula (falx cerebelli); 14, optic nerve; 15, oculomotor 
nerve; 16, trochlearis nerve; 17, trigeminus (trifacial) nerve; 18, abducens nerve ; 
19, facial and auditory nerves; 20, glosso-pharyngeal, vagus, and accessory nerves ; 
21, hypoglossal nerve ; 22, 23, first and second cervical nerves ; 24, cephalic end of the 
ligamentum denticulatum (see Fig. 797) ; 25, union of the velar veins to constitute 
the vein of Galen opening into the tentorial sinus (see Fig. 801). 


The relations of 
the falx to the longitudinal and falcial sinuses are shown 


considerable mesal depression, contain- 
ing the longitudinal sinus, so that here 
the retreating surface of the dura is 
seen beyond its dorsal cut margin; pre- 
sumably this corresponded with a mesal 
thickening of the cranium. 

C. The distinctly sickle-shape of the 
mesal extension of the dura between 
the two hemicerebrums, whence its 
name fala. 

D. The non-correspondence of the 
width of the falx with the area dorsad 
and cephalad of the larger part of the 
callosum. 

E. The location, form, and extent of 
the medicisterna (césterna ambiens), the 
irregular space between the cerebellum, 
the splenium, and the geminums, roofed 
by the arachnoid and tentorium. 

F. The location, form, and extent of 
the ventricisterna (czsterna intercruralis), 


between the crura, the pons, and the tuber (tuber cine- 
reum), infundibulum and hypophysis. 


It forms a very 


in Figs. 800, 1; 801. 

§ 387. Faleula.—This name (wrongly printed faleicula) 
Was proposed by me as a mononym for fala cerebelli, 
designating the mesal fold of dura which extends ventrad 
from the tentorium to the foramen magnum, where it 
bifurcates. It is vaguely shown in Figs. 800 and 801. 

§ 388. Hontanels (Fr. fontanelles).—These are the in- 
tervals between the corners of the infantile parietal bones 
before these corners have formed sutural union with the 
adjacent bones. There are six fontanels, two mesal and 
two pairs of lateral. The lateral, at the cephalic and 
caudal angles of the ventral border of the parietal bone, 
are small, irregular, and of comparatively little interest. 
The two mesal fontanels are at the ends of the sagittal 
suture; their more common designations, anterior and 
posterior, may appropriately give place to prefontanel 
and postfontanel. 

§ 389. Analogy of the Fontanels with the Telas.—The 
structure of a tela was described in § 22. But since, in 
mammals at least, the telas are always more or less closely 


212 


deep indentation of the ventral outline of the brain, cor- 
responding with the cranial or mesencephalic flexure 
(Fig. 671). It is bridged by the arachnoid, following 
substantially the line of the dura, and thus includes the 
arteries of this region. 

G. The location, extent, and form of the postcisterna 
(cisterna magna cerebello-medullaris), the interval between 
the dorsum of the oblongata, the cerebellum, and the ad- 
jacent portion of the cranium, or strictly the ectal layer 
of arachnoid in that region, represented by the black line 
marked 10 (see Figs. 806 and 807, § 408). 

H. The location of the metapore (foramen of Magen- 
die), the orifice in the metatela (tela choroidea inferior), 
constituting the roof of the metacele or metencephalic 
portion of the “fourth ventricle” (see §§ 78-88). In this 





*Tt is proper to add that, although this analogy between the telas 
and the fontanels had already occurred to me, I was reimpressed with 
it on listening to an admirable lecture upon the anatomy of the brain 
by Prof. D. K. Shute, at_ the Columbian Medical College, Washington, 
D. C., December 16, 1889. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





specimen its relations are complicated by the postcere- 
bellar artery, a loop of which lies just dorsad of it (see 
under Defects). 

I. The location of the postcerebellar artery. This is 
not named on the figure and is imperfectly shown. The 
central portion, from its origin at the vertebral, is invisi- 
ble here, but shows in Figs. 691 and 806. Just at the 
side of the metapore it turns sharply upon itself, forming 
a loop, somewhat as in Fig. 806; butin the present figure 
the peripheral portion of the artery alone is seen, and 
looks as if it began in the metapore. The two principal 
divisions are as here represented. There is apparently 
considerable variation in the course and subdivision of 
this vessel. 

J. The length of the longitudinal sinus, equalling 
nearly the greater curvature of the cerebrum; its cephalic 


able interval and communicate by a slender precom- 
municant artery. Here, however, they unite by their 
full width and again diverge. 

Q. The origin of the termatic artery from the place of 
junction of the two precerebrals; its course, parallel with 
the terma and copula, then around the genu at least to 
the dorsum; its short branches to the terma and adjoin- 
ing parts of the hemicerebral meson. 

R. The location of the postcerebral artery. The be- 
ginning of this, severed from the basilar, is represented 
by the circular spot between the hypophysis and the 
convexity of the pons. From it are seen small arteries 
entering the crura. For the two large vessels repre- 
sented in the ventricisterna, see under Defects. 

$ 391. Pia.—This was formerly more often called pia 
mater, sometimes also meninx vasculosa (Ger., diinne 


end was probably not quite 
reached. 

K. The presence of the 
falcial sinus (2) along the 
ventral, free margin of the 
falx. This is said to be often 
wanting. I suggest that the 
alleged absence of this sinus 
in the fetus sometimes may be 
due to its non-detection. 

L. The straight course of 
the tentorial sinus in line 
with the falcial, along the 
ventral margin of the caudal 
fifth of the falx, where the 
latter is continuous with the 
tentorium (Fig. 800, 8). The 
tentorial sinus is not named 
or otherwise designated on 
this figure, but in Fig. 800 it 
it is numbered 6; it is also 
called straight sinus or sinus 
rectus. 

M. The junction of the 
mesal longitudinal and ten- 
torial sinuses at the torcular 
(Herophili). The course of 
the lateral sinuses thence is 
indicated in Fig. 800. 

N. The location of the 
right velar vein (3) between 
the splenium of the callosum 
and the conarium, and its 
junction with its opposite at 
the point indicated by the 
circular spot at the edge of 
the splenium, just in line 
with the dotted line from 
that word. The two velar 
veins form the short vein of 
Galen. 

O. The brief course of the 
vein of Galen about the 
splenium, and its entrance at 
4 into the tentorial sinus, at 
the place of continuity of the 
latter with the falcial when 
this is present. 

P. The location of the right 
precerebral artery (anterior 
cerebral). Branches of this 
are seen dorsad and cephalad 
of the callosum. The main 
trunk extends dorso-cephalad 
from the chiasma. The dark 
spot between the dotted lines 
leading from the words ¢er- 
ma and precommissure repre- 
sents the junction of the two 
precerebral arteries at the 
meson; in some cases they 
are separated by a consider- 


fornicommissure 
porta } medicommissure 
i Hy ? i 
atte 8) 1160 Gn ee 
Saree teats cs F / habena 
gentle deme ect ea OS 2 


supracommissure 
epiphysis 
splenium 








termatic a, { 











Ee 
__Pregeminum’; 
--7--mesocele fs 
gx Postcommissure AY 
\ \postgeminum “G 
mB _Valvula *: 
lingula,, 
epicele J 



















9 4 ce 
precerebral a. / § 
copula’ / } 









/ 4 
eg / 
aula // / 
precommissure 
terma * ! 
by flea 
opticn, + { ' 
chiasma | ! 
hypophysis ~ | \ . 
albicans 
. a 
osteribrum ee ae SO | 
4 ou i \ Se ee DOCU 
5 10 metatela 
myel | metapore 
myelocele 


Fic. 801.—Mesal Aspect of the Right Half of the Brain of an Adult White Man; 376. X .65. 1, Auli- 
plexus; 2, falcial sinus; 3, right velar vein; 4, orifice of Galen’s vein into the tentorial sinus; 5, 
falcula or ‘“‘ cerebellar falx”’; 6, tentorial sinus; 7, uvula, a mesal division of the cerebellum; 8, 
tuber (“tuber cinereum”’) ; the line seems to stop at the artery, but should reach the thin floor of 
the diacele just caudad of the hypophysis ; 9, ventral end of the falx ; 10, cut edge of the ectal layer 
of the arachnoid, § 408; the line is too heayy and should be white instead of black ; at a point be- 
tween the lines from 6 and 7 it becomes attached to the cerebellar piarachnoid ; 11, longitudinal sinus. 

Preparation.—The brain was removed inthe dura. It was duly supported and injected through 
the basilar artery with the starch mixture containing alcohol described in the article Methods, etc. 
The injection caused the brain to fill the dura completely, and presumably assume its natural form. 
It was then hardened in alcohol and medisected. The same specimen was the basis for two figures 
in my paper, 1885, b, and this figure is reproduced in the work of C. K. Mills, 1897; the mesal cay- 
ities are shown on a larger scale in Fig. 687. 

Defects.—Although one of the purposes of the preparation of this figure was to indicate the 
relations of the dura to the brain, the word dura is omitted altogether. Fala designates its mesal 
extension between the halves of the cerebrum, as shown in Figs. 800 and 804. Along the longi- 
tudinal sinus (11) should be indicated the points of entrance of the supercerebral veins (see Fig. 
800). The sinus, dorso-caudad of the cerebellum, between the torcular and the point marked 4, 
should be named tentorial sinus. On the precerebral artery, dorso-cephalad of the chiasma, are 
two orifices. The more caudal, at the root of the termatic artery, is caused by the removal of the 
left precerebral (see § 390, P). The more cephalic, between the lines from copula and aula, should 
be omitted, together with the intervening depressed area; they represent an accidental excavation 
of the artery. The arteries in the ventricisterna, the interval between the pons, the crura, and the 
tuber, are vaguely and inaccurately shown (see § 390, F). The postcerebellar artery (undesignated 
but lying between the lines from metapore and metatela) looks as if it begins in the metapore (see, 
however, § 390, H). The pia is nowhere distinctly represented. The black line marked 10 is the 
ectal layer of the arachnoid (see Fig. 806) ; the ental layer, in contact with the cerebellum, may be 
recognized ; they unite just dorsad of the line from 7. The curved white line about midway be- 
tween the callosum and the fornicommissure is due to an error; the surface of the hemiseptum 
forming the lateral wall of the pseudocele should be uniformly shaded. For other defects see Fig. 687. 


213 


Brain. 
Brain, 





Hirnhaut, weiche Hirnhaut ; Fr., pie-mére). It is deli- 
cate, fibrous, highly vascular, and intimately connected 
with the neuron (central nervous system), into the sub- 
stance of which it sends numerous nu- 
trient small vessels. When stripped 
off, these vessels commonly break at a 
short distance from the pia, and their 
number and minuteness impart to the 
ental surface of the membrane a floc- 
culent or woolly aspect, the tomentum 
(§ 376, E). 

§ 392. Myelic Pia.—This is thicker 
and firmer than the encephalic, less vas- 
cular, and more closely adherent to the 
nervous substance. It has sometimes 
been called the “neurilemma of the 
cord.” 'T’wo layers are recognized: the 
ental, sometimes called ¢ntima pia, 
sends a fold into the ventral (“anteri- 
or”) fissure, and into the dorsal a la- 
mina not recognizable asa fold. Along 
the ventri-meson the pia presents a con- 
spicuous fibrous band, the linea splen- 
dens, not represented in Fig. 797. 

§ 393. Hneephalic Pia. — According 
to Shiifer (Quain, iii, 186), only the 
ental of the two myelic layers of the 
pia is represented on the brain, but 
where and how the other layer dis- 
appears is not stated. The pia fol- 
lows all the undulations of the ence- 
phalic surfaces, dipping into the fissures 
and rimulas as folds or rugas of cor- 
responding depth (see Fig. 796). At 
the bottom of the intercerebral fissure, 
the mesal cleft between the dorsal por- 
tions of the two hemicerebrums, the pia 
enters the callosal fissure at either side, 
is then reflected, and crosses the cal- 
losum * 

§ 3894. Telas and Plewuses.—For these 
structures of the pia see §§ 22-24. 

§ 395. Fig. 802 illustrates: A. The 
different aspect of the cerebral surtace 
(a) before the removal of the piarach- 
noid or leptomeninges, as in the ceph- 
alic (upper) third of the figure; (0) 
after it has been removed completely, as in most of the 
caudal two-thirds; and (¢) when there remains the in- 


supercentral 
fissure 


central 
postcentral 





parietal 
paracentral 


Fic. 802.—Central Region of an Adult Brain, Partly Denuded of Pi- 
arachnoid and Exhibiting on the Right a Departure from the More 
Common Relation of the Postcentral and Paracentral Fissures ; 
4,222.  .5. 1, The caudal end of a fissure which is mostly covered 
by the pia; 2, a small spur of the postcentral representing the usual 
caudal branch, which is marked 5 on the left; 3, an undetermined 
fissure; 4, a triangular depression comparable, perhaps, with the 
expansion of 5 on the left; 6, the cephalic branch of the left post- 
central. 


trafissural fold, as in the left central and the part of the 
right central crossed by the line. 





* Since the pia is practically the ectal surface of the brain, its cut 
edge is not commonly represented excepting when the figure is on a 
very large scale; but on blackboard diagrams its vascular character 
may be instructively indicated by a red line. On such diagrams the 
endyma (‘‘ ependyma”’ or lining of the cavities) may be represented 
by yellow or green. 


214 






REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





B. The usual relation of the central fissures to the 
paracentrals on both sides. 
C. The usual relation of the left paracentral fis- 


intercerebral fissure 
olfactory fissure 


olfactory bulb 


olfactory tract 
Sylvian fissure 


optic nerve 
entocarotid artery 


hypophysis 
oculomotor nerve 
~ crural cisterna 


basilar artery 
trifacial nerve 
tentorial interval 


vertebral artery 


postoblongata 
spinal artery 


myel 


postcisterna 


Fig. 803. —Base of the Brain of a Man Estimated at Sixty-Five Years, Before the Removal of 
the Piarachnoid and Blood-Vessels ; 4,206. > .5. 
olfactory bulb and opposite the point where the arachnoid ceases to pass directly from 
one hemicerebrum to the other and is carried into the intercerebral fissure by the falx 
(compare Figs. 801 and 804) ; 2, cut or torn margin of the arachnoid at the crural cis- 
terna ; 3, an artery on the right lateral lobe (pileum) of the cerebellum, cbl.; 5, 5, indi- 
cate approximately the lateral boundaries of the postcisterna (Fig. 807); O., occipital 
lobe of the cerebrum ; 7., temporal lobe; F’., frontal lobe. 


1, Between the meson and the right 


sure to the dorsal fork of the postcentral (compare 
Fig. 769). 

D. The iess common condition of the dorsal end of the 
right postcentrai, the caudal branch being short and the 
cephalic so long as to intrude between the central and the 
paracentral and render that portion of the postcentral 
gyre quite narrow (§ 11, D; compare Fig. 664). 

§ 396. The Arachnoid.—The word arachnoid is derived 
from the Greek apéyvy (signifying either a spider or a 
spider’s web), and eldoc (form or likeness).* In general 
the arachnoid may be described as a non- vascular mem- 
brane, enveloping the brain and closely attached to the 
pia, excepting where the latter dips into the intervals be- 
tween the masses or into the fissuresand sulci of the cere- 
brum and cerebellum. These depressions are bridged, so 
to speak, by the arachnoid, excepting where the dural 
folds, falx and falcula, carry it for a certain distance 
into the intercerebral fissure and the interval between the 
cerebrum and cerebellum. Wherever the arachnoid re- 
mains the outlines of parts are more or less vague, as in 
Figs. 796, 802, and 803. 

§ 397. Hig. 803 clustrates: A. The general aspect of 
the base of the brain when tirst removed from the cranium ; 
the outlines are less distinct than after the removal of the 
piarachnoid (compare Figs. 672 and 689), and certain 


* The open-meshed discs of the common garden spiders, Epeira, 
Argiope, ete., are not comparable ; rather the compact glazed sheet 
constructed by one of the house spiders (Tegenaria) which will hold 
water, or the still more substantial nest of the water spider (Argyro- 
netra), which is like a stationary diving-bell and retains the air placed 
under it against considerable pressure. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


features are wholly invisible, ¢.g., the chiasma, precrib- 
rum, and crura. 

B. The varying relations of the arachnoid to the inter- 
vals between the masses. For nearly half of the distance 
between the optic nerves and the cephalic end of the cere- 
brum the arachnoid crosses directly from one frontal lobe 
to the other so that the intercerebral fissure is barely 
recognizable as a slight mesal depression. But at the 
point indicated by 1 the fold of dura constituting the falx 
(Figs. 801 and 804) begins and forces the arachnoid into 
the depths of the fissure. The arachnoid dips slightly 
into the Sylvian fissure, and deeply into the interval be- 
tween the cerebrum and the cerebellum on account of the 
dural fold, tentorium (Fig. 800, 8). 

C. The existence of a considerable interval, the crural 
(“peduncular ”) cisterna just caudad of the hypophysis, 
between the crura and adjacent brain surfaces and the 
arachnoid; the latter was torn and cut in removing the 
brain, and the sharp artificial margin is indicated by 2. 

D. The existence of the postcisterna (“ cisterna magna ” 
or “cerebello-medullaris”) between the oblongata and the 
cerebellum; by blowing dorsad at either side of the ob- 
longata, where the arachnoid is torn, air entered the post- 
cisterna and it expanded so as to have a convex outline 
as in Fig 807; but when the photograph was taken most 
of the air had escaped and the extent of the cisterna is in- 
dicated only by the greater vagueness of the cerebellar 
outline as far as 5 at either side. 

§ 398. As to details, however, our knowledge of the 
arachnoid is even less complete and satisfactory than that 
of the dura and pia, and there are direct contradictions in 
the accounts by different anatomists which I have as yet 
been unable to reconcile. As stated by Langdon (1891), 
Bichat described (1802, 1813) the arachnoid as a serous, 
shut sack, conforming in 
all essential particulars 
with the serosa of the 
other cavities. But most 
recent writers follow K®6l- 
liker (1860) in denying the 
existence of a parietal lay- 
er in contact with the 
dura, and Tuke regards 
(1882) even the visceral 
layer as merely an element 
of the pia. 

§ 399. On February 
17th, 1888, I made and re- 
corded the following ob- 
servation upon a child, 
still-born, at term, No. 
2,258: In removing the 
parietal dura, a delicate 
membrane separated from 
it more or less easily in 
different localities on the 


Brain, 
Brain, 





inseparable in this region in the adult. At the base of the 
skull it is demonstrable as a separate membrane, even in 
the adult. To assert that the parietal layer of arachnoid 
is absent because its subepithelial connective tissue has 
fused at the vertex with the dura (connective tissue), is 
as incorrect as to describe the great omentum as one layer 
of peritoneum, because its original four layers have be- 
come matted and adherent.” 

§ 401. During the preparation of the article Meninges 
in the first edition of the REFERENCE HANDBOOK I verified 
the correctness of the previous observation as to the pres- 
ence of an ectal or dural layer of arachnoid, and noted its 
reflection upon the carotid and vertebral arteries to be- 
come continuous, presumably, with the ental, pial, or vis- 
ceral layer. But no such reflection occurs at the nerve 
roots unless at some depth within the foramens of exit, 
and this point I have as yet not had time to determine. 

§ 402. Hig. 804 illustrates: A. The relative positions 
of the meninges (compare Figs. 796 and 798). 

B. The formation of the longitudinal sinus within the 
substance of the dura. 

C. The projection of the arachnoid villi into the sinus 
and the parasinual spaces; see the article Pacchionian 
Bodies. 

D. The accumulation of the villi at one point, on the 
right, to such an extent as to cause the protrusion of the 
dura, and presumably a depression of the ental surface 
of the cranium. 

E. The separability of the arachnoid from the pia, leav- 
ing a distinct subarachnoid space increased along the 
fissure lines. 

F. The conterminousness of the arachnoid and the 
falx, and their separation by a distinct interval. 

§ 408. Fig. 805 illustrates: A. The complete circum- 





two sides; it was observed Fic. 804.—Transection of the Dorsal, Mesal Region of the Cerebrum, to Show the Meninges and Arach- 


also by my colleague, 
Prof. 8. H. Gage.* 

§ 400. On December 
29th, 1890, Dr. Langdon’s 
paper (1891) was presented 
before the Association of 
American Anatomists. He 
records observations made 
upon two children, at 
term, and one adult. His 
summary is as follows: 


tertile Slightly enlarged. (From Key and Retzius, Taf. xxix., Fig. 4; after Shafer: Quain, iii., 
g. 134. 

Preparation.—The spinal subarachnoid space (Fig. 797, k, 1) was injected with a fine blue mass, 
which filled (and distended ?) the corresponding space upon the cerebrum and entered the arachnoid 
villi. The original figure is appropriately colored and on a larger scale. Judging from the relation be- 
tween the width of the falx and the interval between it and the callosum, the plane of section was not 
far cephalad of the splenium (see Fig. 801). c¢.c., Callosum; f, falx ; s, longitudinal sinus; s.a. (at the 
left), subarachnoid space. 

Defects.—The pia is not so distinct as I would makeit. The relation of the arachnoid to the ven- 
tral margin of the falx is not quite clear. There is no extension of the cortical cinerea upon the dor- 
sum of the callosum as an indusium (see § 217). There is no indication of the existence of the two 
layers of the dura, e.g., periosteal and encephalic, described by Langdon (Fig. 798). The falcial 
(inferior longitudinal) sinus may have been absent in this case, as it is said to be in many. The 
lacuncee laterales are somewhat indistinct, probably in consequence of the reduction from the original 
figure, where they are much more clearly shown. 


“The arachnoid is a 
true shut sac, similar in 
structure and function to the serosa of the other great cav- 
ities. Its parietal layer is easily separable from the dura at 
the vertex in the fetus and young infant, but practically 


* Although this distinctly indicated the existence of a parietal (ec- 
‘tal) layer of arachnoid,’at that time I supposed the subject, Meninges, 
-would be treated by another, and was, moreover, then fully occupied 
-with the articles already undertaken ; hence the observation was not 
“made public and the point has not been followed up. 


scription of the true encephalic cavities, excepting at the 
metapore. 

B. The non-communication of these cavities with the 
pseudocele (fifth ventricle). 

C. The presence of considerable, irregular intervals, 
subarachnoid spaces, or cisternas, between the pia and 
the arachnoid. 

D. The continuity of the largest of these, postcisterna, 


215 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





between the cerebellum, postoblongata, and occipital part branes. The editors of Quain have represented the missing meta- 
of the cranium, with the spinal subarachnoid space. 

















Fig. 805.—Medisection of the Cerebellum and Adjacent Parts. (From 
Key and Retzius, 1875, Taf. viii., vii., Fig.1; after Shafer: Quain, 


iii., Fig. 131, reduced and somewhat modi- 
fied.) Compare Figs. 670, 800, and 801. 
1, 1’, Atlas vertebra; 2, 2’, axis vertebra ; 
8, diacele (third ventricle) ; 4, epicele, the 
cephalic or cerebellar portion of the 
‘* fourth ventricle’ ; C, cerebellum ; C.C., 
callosum; C’, callosal gyrus; M, post- 
oblongata; P.V., pons; X, faleula (falx 
cerebelli) ; ¢, medicommissure ; ¢.c., just 
dorsad of (behind) the myelocele (central 
canal of the cord) ; f.M., metapore (°° for- 
amen of Magendie’’); », hypophysis ; 
t, torcular. 

Preparation.—A blue mass was inject- 
ed into the spinal subarachnoid space ; the 
head was then frozen and medisected. 
The original includes the mesal aspect of 
the entire head, less the integument and 
mandible. The true encephalic cavities 
and thesubarachnoid spaces are colored, 
so only the actual mesal parts appear. 

Defects.—In the original there is no in- 
dication of the arachnoid, although the 
circumscription of the subarachnoid space 
was the very feature supposed to be illus- 
trated. Should it be claimed that the 
arachnoid is sufficiently indicated by the 
ental boundary line of the dura, the an- 
swer would be that, although in places the 
two meninges may be in contact, they are 
not in all; furthermore, as distinctly 
shown upon Taf. vi. of the same work, 
in Figs. 801, 806, and 807, there is a point 
near the crest of the cerebellum (nearly 
opposite t) where the arachnoid (or its 
ectal layer) leaves the cerebellum and 
passes directly to the dura at the foramen 
magnum. There is no boundary between 
the metepicele (fourth ventricle) and the 
subarachnoid space; even if, as in other 
cases, the membranous roof of the meta- 
cele (metatela) adheres to the caudo-ven- 
tral surface of the cerebellum, the plexuses 
and the endyma constituting its ental 
surface must end somewhere. 

Since the cavities are not colored, they 
appear as white areas without perspec- 
tive, as if the preparation were a thin 
mesal slice. Most unfortunately, probably 
through some defect in execution, there 
is left a clear line between the epiphysis 
and the splenium, as if there were a pass- 
age from the diacele (third ventricle) to 


the irregular subarachnoid space between the splenium, epiphysis, 
pregeminum, and cerebellum. This is altogether misleading, for, as 
shown in Figs. 670, 687, 759, and 801, and stated in § 66, H, the dia- 





tela by the dotted line from near the number 4 to near the abbrevia- 
tion f.M. A continuous line would have been more appropriate, 
and separated farther from the metacelian fioor ; that could not be 
changed in the present copy, but the interval representing the meta- 
pore (foramen of Magendie) has been enlarged; this, however, is 
conventional, and as if to correspond with the perhaps unusual con- 
dition shown in Fig. 690. Finally, the falcula (falx cerebelli), 
which was unmarked in Quain, is here designated by a cross (x). 


mesal portion, vermis, of the cerebellum. In Fig. 707 this 
is obscured by the fact that part of the left lateral lobe 
remains. 

§ 404. The Cisternas.—At several regions the ental 
layer of arachnoid is separated from the pia by consider- 
able spaces, called cisternas by Key and Retzius, 1875, p. 
93.* They are enumerated and described by Browning. 

§ 405. Fig. 806 illustrates: A. The general appearance 
of this aspect of the cerebellum together with the oblon- 
gata and pons; in Fig. 697 these two parts were omitted. 

B. The extent of the postcisterna (cisterna magna or ¢. 
cerebello-medullaris) upon about one-half the entire caudal 
aspect; there is, however, considerable variation in this 
respect. 

C. The definite dorsal and lateral limitation of the 
postcisterna, although the boundary line is undulating 
and asymmetrical. 

D. The lack of ventral boundary of the cisterna; the 
ectal layer of the arachnoid is attached to the dara so 
that this cisterna is continuous with the spinal subarach- 
noid space. : 

E. The union of the two vertebral arteries to form the 
basilar. 

F. The origin of the postcerebellar arteries from the 
vertebrals near their junction. 


vallis 


7 


postvermis 
6 


5 


metaplexus 
tonsilla 


myel 


postcerebellar a.. 
vertebral a. 


basilar artery 
pons 


Fic. 806.—Caudal (Lower) Aspect of the Cerebellum, etc.; 876. xX .9. 


Preparation.—Through the kindness and skill of Dr. W. C. Krauss (a former student, 
now professor in the Medical Department of Niagara University, the brain was received 
fresh and in the dura. The cavities were injected with alcohol; the arteries first with al- 
cohol and then with the starch mixture (see article Brain: Methods). The alcohol passed 
through the metapore into the postcisterna and thoroughly preserved all the parietes ; it 
had access also about the myel, where the arachnoid was cut in removing the brain. The: 
ectal layer of the arachnoid was cut away along the line of its attachment. 

Defects.—The perspective of the postoblongata is defective. The metapore is vaguely 
indicated and few of the vessels are shown. Of the lobes only the tonsillas are outlined. 
The flocculi and nerve roots are omitted, also the rimulas (interfoliar crevices) on the left. 
side. The most serious defect is the non-indication of the dorsal limit of the endyma which 
presumably accompanies the metaplexuses ; see § 417. 

1, 3, Branches of the postcerebellar artery, the former passing between the cerebellum 
and the oblongata, the latter apparently supplying the corresponding metaplexus ; 2, 6, edge 
of the ectal layer of arachnoid bounding the area whence it had been cut away ; 4, loop of 
postcerebellar artery, an example of its tortuous course; 5, main trunk of the artery near 
where it reaches the crest of the cerebellum ; its branches are omitted; 7, mesal ridge 
formed by the vein which divides into a right and left branch upon the caudal surface; 
the arachnoid here forms a somewhat sharp angle. 


G. The length and course of the postcerebellar artery, 
and the tortuous course of its central portion. ‘ 


cele is completely circumscribed at that point by the endyma reflect- 


ed from the velum upon the epiphysis. In the present copy this de- 
fect has been remedied so far as it could be by uniting the epiphysis 
and splenium so as at least to block the passage; but it should 
be remembered that it is closed not by nervous tissue but mem- 


216 


* Admitting that most of the cisternas do lie between the arachnoid 
and the pia, as commonly described, my later observations lead me to 
regard the postcisterna as between two layers of the ental arachnoid 
itself (see Figs. 805 and 807). 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





H. The passage of a branch of the postcerebellar artery 
mesad toward the metapore, apparently supplying the 
metaplexus, 


arachnoid 


piarachnoid 


prevermis 





{noid 
dura and its arach- 


= = 1 intrarachnoid space 
ee a ht ectal layer of ental 
arachnoid 
A _ posteisterna 
[arachnoid 
ental layer of ental 


pia 


parayermian sulcus 


postvermis 
| pial fold 





Fia. pad .—Sections of the Cerebellum and Postcisterna ; semidiagram- 
matic. 

A. Dorsal (cut) surface of the ventral portion of the cerebellum, 
together with the adjacent dura and the large “subarachnoid 
space,’ postcisterna, commonly called cisterna magna or ¢. cere- 
bello-medullaris. At the meson appears the postvermis, separated 
by the paravermian sulci (1) from the large lateral lobes; 3 is the 
ental layer of the arachnoid. The meninges are here represented 
by lines only. 

B. Enlargement of the meso-caudal region of A. The meninges 
are here represented by zones conventionally shaded ; 2, the place of 
junction of the two layers of the ental arachnoid at the margin of 
the postcisterna. 

Preparation.—An adult cerebellum (2,891) was divided at a plane 
corresponding with the line X—Y in Fig. 806, so as to separate the 
dorsal two-fifths ; on Fig. 801 the plane of section would be indi- 
cated approximately by a line across the unshaded (cut) surface 
connecting the points where the dotted lines from the words nodu- 
lus and epicele intersect the margin of that surface ; as seen in Fig. 
806 it passes dorsad of the plexuses. The ectal layer of arachnoid is 
represented as the continuous caudal boundary of the postcisterna, 
while in Fig. 806 it is supposed to have been trimmed closely along 
the line of its depression from the ental layer 3. 

Defects.— For readier comparison with Fig. 806 the figures should 
have been inverted so as to have the postcisterna nearer the reader. 
In B the postcisterna is enlarged two diameters, but the several 
zones representing the meninges are disproportionately widened, 
and their shading is conyentional for discrimination only, and not 
for the indication of histological structure. The ectal or dural layer 
of arachnoid was inadvertently omitted, and there is no indication 
of the two layers of the dura itself. The numerous rimulas and in- 
tervening foliums that were divided in the section are not indicated, 
and the usual relations of the pia and arachnoid to each other and 
to narrow encephalic depressions generally are illustrated only at 
the parayermian sulci. According to the ,present view * that the 
metapore is the orifice of an evagination, the postcisterna may be 
lined, in part at least, by endyma; but it was not recognized in this 
preparation, and even in the embryo represented by Blake (1898, 
Fig. 26) it seems to have disappeared at a lower level. 


I. The extension of the metaplexuses dorsad from the 
metapore upon the cerebellum. 

§ 406. Postcisterna.—Notwithstanding the presumption 
that all the cisternas form a continuous series, my obser- 
vations, up to the present time, induce me to regard the 





* At the time § 83 was made up into the page I was unaware that 
the German edition (1894) of Minot’s ‘* Embryology ”’ has this passage, 
p. 698: ** The foramen of Magendie (Wilder’s metapore) and the open- 
ings of the lateral recesses, according to this view, would be not true 
perforations of the ependyma, but the outlets of evaginations.”’ 





space in the angle between the cerebellum and the ob- 
longata as presenting an important peculiarity. viz., as 
lying, not between the pia and the visceral arachnoid, 
but between two layers of the latter. The facts upon 
which this view is based cannot be detailed here. The 
view is indicated upon Fig. 807. 

I am aware of the difficulties involved in its acceptance; 
without question, the postcisterna communicates on the 
one hand with the true encephalic cavities through the 
metapore, and on the other with the spinal subarachnoid 
space; its free communication with the other cisternas, 
although commonly accepted, seems to me not yet clearly 
demonstrated. 

§ 407. Is there Direct Communication of the Subarach- 
noid Spaces with the Intrarachnoid (or Subdural) Space ?— 
Whatever view they adopt regarding the constitution of 
the arachnoid as a whole, most writers agree that the 
arachnoid covering the brain and myel is continuous, ex- 
cepting for the capillary spaces about the nerve roots re- 
ferred to in § 401. Hence, while the neurolymph may 
pass to and fro between the true encephalic cavities and 
the postcisterna through the metapore, and may thus 
enter the other cisternas (§ 406) and the spinal subarach- 
noid space, it is nevertheless confined thereto. 

But Dr. Langdon (1891) holds that “at the base of the 
cranium there are two points where the visceral [ental] 
arachnoid is deficient, one on either side, in the ‘ bridge’ 
of arachnoid which stretches across from the cerebellar 
lobes to the under [ventral] surface on the oblongata. 
These foramina measure about half an inch (12 mm.) in 
longitudinal diameter by one-fourth inch (6 mm.) trans- 
versely, and are crossed by three or four fibrous bands, 
the attachment of which to the edges of the openings 
produces a multiple crescentic appearance of their mar- 
gins, which suggests the name ‘lunulate foramina.’ ” 

It will be noted that the location of these alleged lunu- 
late foramina in the arachnoid corresponds with that of 
the ventral ends of the lateral recesses. Hence, on the 
one hand, if both are natural, the transfer of the neuro- 
lymph from the true encephalic cavities to the arachnoid 
space is provided for; on the other, the relation of the 
nerve roots to both the piaand the arachnoid renders both 
liable to rupture during extraction or manipulation of the 
brain. Hess implies (1885, Fig. 10, a.) that the arach- 
noid was cut and reflected at this point. On the whole 
subject, and on the metapore see the later observations 
of Blake, 1900. 

§ 408. Mig. 807 tllustrates: A. The usual relation of 
the meninges in these respects, viz., the independence of 
the dura; the adhesion of the pia to the brain substance; 
the dipping of the pia into the narrow depression at either 
side of the vermis as a vascular fold; the adhesion of the 
arachnoid to the pia over most of the cerebellum, so as 
to constitute a piarachnoid (Fig. 796). 

B. On the caudal aspect of the cerebellum, the forma- 
tion of a considerable space, the postcisterna, by the 
separation of an ectal layer of the ental or visceral layer 
of the arachnoid. 

§ 409. The inadequacy of the foregoing account of the 
postcisterna and its relations with the metapore is fully 
conceded. It is no disparagement to the labors of Blake 
and others to add that no account known to me is alto- 
gether clear, consistent, correct, and complete. The dif- 
ficulties involved can be fully appreciated only by those 
who have already attempted to elucidate the subject. 
The material must be specially prepared for the purpose 
and examined by improved methods, both anatomical and 
histological. Burt G. WILDER. 


§ 410. The following list includes treatises upon the 
gross anatomy of the brain, mostly recent, likewise a 
few special papers ; other papers are named in the text. 
Other things being equal, preference is given to such as 
contain full bibliographies. The history of Neurology 
up to 1822 is given in Burdach. For current literature 
consult the Jowrnal of Comparative Neurology ; Anato- 
mischer Anzeiger ; Index Medicus ; Neurologisches Centrat- 
blatt; Brain; L’ Encéphale; Nevrdve; Jahresberichte 


217 


Brain, 
Brain, 





fiir Anatomie, etc. See § 12. A. A. A. Proc. stands for 
Proceedings of the Association of American Anatamists. 


BIBLIOGRAPHY. 


Blake, J. A., 1900: The Roof and Lateral Recesses of the Fourth 
Ventricle Considered Morphologically and Embryologically. Read 
before the Assn. Amer. Anat., December 28th, 1898. Jour. Comp. 
Neurol., x., 79-108, 7 plates. 

Broca, P., 1888: Mémoires sur le cerveau de ’homme et des pri- 
mates, O. 

Burckhardt, R., 1895: Der Bauplan des Wirbelthiergehirns. 
logische Arbeiten, iv., 181-150, taf. viii., 1895. 

Burdach, K. F., 1822: Vom Baue und Leben des Gehirns, Q., 3 vols. 

Clark, T. E., 1896: Comparative Anatomy of the Insula. Journ. of 
Comp. Neurol., vi., 59-100, 5 plates. 

Dalton, J. C., 1885: Topographical Anatomy of the Brain, Q., 3 vols. 

Dana, C. L., 1893: Text-Book of Nervous Diseases; Being a Compen- 
dium for the Use of Students and Practitioners of Medicine, O., 
illustrated, New York. 

Dejerine, J., 1895: Anatomie des centres nerveux, R. O., 2 vols., Vol. I., 
pp. xiii. and 816, 401 figures. [The macroscopic anatomy occu- 
pies pp. 233-517 of vol. i.] 

Eberstaller, O., 1890: Das Stirnhirn; ein Beitrag zur Anatomie der 
Oberfliche des Grosshirns, O., pp. 140, with 9 figures and | plate; 
Wien. 

Edinger, L., 1896: Vorlesungen tiber den Bau der nervésen Central- 
organe des Menschen und der Thiere. Fifth edition, R. O., pp. 386, 
258 figures, Leipsic. (See also Hall, translator, 1899.) 

Edinger, L. u. Wallenberg, A., 1899: Bericht tiber die Leistungen auf 
dem Gebiete der Anatomie des central Nervensystems. (566 titles, 
1897, 1898, with commentaries.) Schmidt’s Jahrbiicher der Ge- 
sammte Medicin, cclxii., pp. 72. 

Findlay, J. W., 1899: The Choroid Plexuses of the Lateral Ventricles 
of the Brain, their Histology, Normal and Pathological (in relation 
especially to Insanity). Brain, vol. xxii., 1899, pp. 161-202; 3 plates. 

Fish, P. A., 1890: The Epithelium of the Brain Cavities. Amer. Soc. 
Micros. Proc., 140-144, 1 plate, 1890. 

, 1893: The Indusium of the Callosum. Journ. Comp. Neurol- 

ogy, iii., 61-68, 1 plate. 

, 1899: The Brain of the Fur Seal, Callorhinus ursinus, with a 
comparative description of those of Zalophus Californianus, Phoca 
vitulina, Ursus Americanus, and Monachus tropicalis, O., pp. 20, 
4 plates. From the report on the Fur Seals and Fur-Seal Islands of 
the North Pacific Ocean, part iii. 

Flatau u. Jacobsohn, 1899: Handbuch der Anatomie u. Vergleichenden 
Anatomie des Centralnervensystems der Saéugetiere, I., Makro- 
skopischer Teil, R. O., pp. 578, 6 plates, 120 figures in text, Berlin. 
[Contains a good bibliography. ] . 

Gage, Mrs. S. P., 1895: Comparative Morphology of the Brain of the 
Soft-Shelled Turtle (Amyda mutica) and the English Sparrow 
(Passer domestica). Proc. Amer. Micros. Soc., xvii., 185-228, 5 
plates. 

, 1896: Modifications of the Brain During Growth. Abstract of 
paper read before the Amer. Assn. Adv. Sci., August 24, 1896. 
Amer. Naturalist, xxx., 836-837, October, 1896. 

Gerrish, F. H. (editor and collaborator with Bevan, A. D., Keiller, W., 
MeMurrich, J. P., Stewart, G. D., and Woolsey, G.), 1899: A Text- 
Book of Anatomy by American Authors, R. O., pp. 917, 950 figures, 
Philadelphia and New York. 

Giacomini, C., 1884: Guida allo Studio delle Circonvoluzioni Cerebrali, 
O., Turin. 

Gordinier, H. C., 1899: The Gross and Minute Anatomy of the Central 
Nervous System, R. O., pp. 589, 48 plates and 213 figures, Philadelphia. 

pond, G. M., 1900: Suggestions to Medical Writers, O., pp. 180, Phila- 

elphia. 

Hall, W. S., 1899 (translator of Edinger, *‘ Vorlesungen,’’ 1896): The 
Anatomy of the Nervous System of Man and of Vertebrates in Gen- 
eral, R. O., pp. xi. and 446; 258 figures, Philadelphia. 

Hervé, G., 1888 : La Circonvolution de Broca, O., pp. 275, Paris. 

Hill, Alex., 1890 (translator and annotator of Obersteiner’s ‘‘ Anlei- 
tung ’’ (1887) : The Anatomy of the Central Nervous Organsin Health 
and in Disease, O., pp. 432, with 198 illustrations, Philadelphia, 1890. 

Hill, Charles, 1900: Developmental History of Primary Segments of 
the Vertebrate Head. Contribution from the Zool. Laboratory of the 
Northwestern Univ. Zodlogischer Jahrbiicher, Abt. f. Anat.gu. On- 
togenie der Thiere, xiii., pp. 393-446, 3 plates and 4 figures in text. 
[Preliminary paper in Anat. Anzeiger, 1899, 353-369]. 

His, W., 1895: Die anatomische Nomenclatur. Nomina anatomica, 
Verzeichniss der von der Anatomischen Gesellschaft auf ihrer IX. 
Versammlung in Basel angenommenen Namen. Eingeleitet und 
im Einverstindniss mit dem Redactionsausschuss erlaiitert von 
Wilhelm His. Archiv fiir Anatomie und Physiologie, Anat. Abth., 
Supplement Rand, 1895, O., pp. 180, 27 figures, 2 plates. 

Ibanez, G., 1899: Die Nomenclatur der Hirnwindungen. 
Dissertation, Berlin, pp. 37. 

Key u. Retzius, 1875: Studien in der Anatomie des Nervensystems, 
F., 2 vols., Stockholm. 

Krause, W. [editor], 1880: Handbuch der Menschlichen Anatomie, 3 
ee O. Hanover. [A later edition, 1899, is in course of publica- 
tion. 

Langdon, F. W., 1891: The Arachnoid of the Brain (read before the 
Association of American Anatomists, December 29th, 1890). New 
York Medical Record, August 15th, 1891, 177-178, 2 figures. 

Mickle, W. J., 1895: Atypical and Unusual Brain Forms, especially in 
relation to Mental Status. Presidential address (British) Medico- 
Psychological Association, 1895. Brit. Med. Jour., September 28th, 
1895: Journ. Ment. Sci., July, 1896 et seq. 

Mills, C. K., 1886: Arrested and Aberrant Development of Fissures 
and Gyres in the Brains of Paranoiacs, Criminals, Idiots and 
Negroes. Preliminary study of a Chinese brain. Presidential ad- 
dress, Amer. Neurol. Assoc., 1886. Journ. Nery. and Ment. Disease, 
xiii., September and October, 1886, pp. 37, 2 plates. 1897: The Ner- 
vous System and Its Diseases, R. O., pp. 1056, 459 figs., Philadelphia. 


218 


Morpho- 











Inaug. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Minot, C. 8., 1892: Human Embryology, R. O., pp. 815, 463 figures, 
New York. German edition, 1894. 

Obersteiner, H., 1896: Anleitung beim Studium des Baues der Ner- 
vosen Centralorgane im gesunden und kranken Zustande, third 
edition, O.,; pp. 572, 205 figures, Leipzig und Wien. (See also Hill, 
translator of second edition.) 

Parker, Andrew J., 1896: Morphology of the Cerebral Conyolutions 
with Special Reference to the Order of Primates. Journ. Acad. 
Nat. Sci., Philadelphia, N. S., x., Q., pp. 247, 15 plates, 31 figures in 
text. 

Parker, T. J., and Haswell, 1898: A Text-Book of Zoology, 2 vols., O., 
London and New York. 1900: Manual of Zoology, O., New York. 
Pfister, H., 1899: Ueber die occipitale Region und das Studium der 
Grosshirnoberfliche, O., pp. 86, 4 plates, bibliography of 108 titles. 
Stuttgart. [Discusses particularly the human homologue of the 

** ape-fissure.”’ ] 

Quain, 1890-1898: See Shiéfer. 

Reichert, C. B., 1861: Der Bau des menschlichen Gehirns, O. 

Retzius, G., 1896: Das Menschenhirn: Studien in der Makrosko- 
pischen Morphologie, F. and Text, pp. viii. and 167, xiii. (really 141) 
figures. Atlas, xcvi. plates, Stockholm. 

Shifer, E. A., 1893: Neurology, Part i. of vol. iii. of the tenth edition 
of Quain’s Anatomy, edited by Shafer and Thane, London and New 
York, 1890-1898. 

Spalteholtz, W., 1900: Handatlas der Anatomie des Menschen, Mit 
Unterstiitzung von W. His bearbeitet., Bd. iii., Abt. 2, Gehirn. 
(Announced.) 

Spitzka, E. C., 1884: Contributions to the Anatomy of the Lemniscus. 
N. Y. Medical Record, xxvi., 393-397, 421-427, 449-451, 477-481, 16 
figures, October and November, 1884. 

Spitzka, EK. A., 1900, a: The Brains of Two Distinguished Physicians, 
Father and Son. A Comparative Study of their Fissures and Gyres. 
Illustrated with 20 plates, and several figures in the text. To be 
read before the Association of American Anatomists, December, 1900. 
1900, b: A Contribution to the Question of Fissural Integrality of 
the Paroccipital; observations on one hundred brains. Idem. 
1900, ¢: The Mesial Relations of the Inflected Fissure ; observations 
on one hundred brains. Idem. 1900, d: Preliminary report, with 
projection drawings ilustrating the Topography of the Paraceles in 
their Relations to the Surface of the Cerebrum and the Cranium. 
Idem. 

Stilling, B., 1878: Neue Untersuchungen tiber den Bau des kleinen 
Gehirns des Menschen, etc., Q., pp. 357 and lxxviii., folio atlas of 
21 plates, Cassel. : 

Stroud, B. B., 1895: The Mammalian Cerebellum. Part I., The De- 
velopment of the Cerebellum in Man and the Cat. Journ. Comp. 
Neurol., v. 71-118, 8 plates, 1895. 1897, a: A Preliminary Account 
of the Comparative Anatomy of the Cerebellum. A.A. A. Proc., May, 
1897, pp. 20-27, 1 plate. 1897, b: The Morphology of the Ape Cere- 
bellum. A. A. A. Proc., December, 1897, 107-126, 1 plate. 1899: If 
an ‘‘ Isthmus Rhombencephali,”’ why not an Isthmus Prosencephali ? 
A. A. A. Proe., December, 1899, 27-29, 2 figures; Abstract in Science, 
March 16, 1900. 

Studnitka, F. K., 1895: Zur Anatomie der sog. Paraphyse des Wirbel- 
thiergehirns. Sitzungsber.der K. B6hm, Ges. Wiss. Math.-Nat. Cl., 
1895, pp. 13, 1 plate. 

, 1899: Ueber den feineren Bau der Parietalorgane von 
Petromyzon marinus. Idem., 1899, pp. 17, 1 plate. 

Turner, Prof. Sir W., 1890: The Convolutions of the Brain. Journ. 
Anat. and Physiol., xxv. 1-53, 42 figures. 

Van Gehuchten, A., 1900: Anatomie du systéme nerveux de l’homme, 
38me edition, R. O., 2 vols., pp. xxiv. and 527-579, 702 figures, Louvain. 
(The macroscopical anatomy occupies 186 pp. of vol. i.) 

Weinberg, R., 1896: Die Gehirnwindungen bei den Esten, eine anat- 
omisch-anthropologische Studie, Q., pp. 96, 5 double plates, Cassel. 
Waldeyer, W., 1896: Hirnfurchen und Hirnwindungen. [447 titles, 
with commentaries.] Ergebnisse der Anat. u. Entwickelungs- 

geschichte, 1896, 146-193. 

, 1899: Hirnfurchen u. Hirnwindungen. Hirnkommissuren. 
Hirngewicht. [190 titles, with commentaries.] Idem., 1899, 362- 
401, 8 figures. 

Wilder, B. G., and Gage, S. H., 1892: Anatomical Technology as 
Applied to the Domestic Cat, third edition, from the second re- 
vised, O., pp. 600, 1380 figures, and 4 lith. plates (chap. x., pp. 400- 
503, is devoted to the brain), New York and Chicago. 

Wilder, B. G., 1896, h: Neural Terms, International and National, 
Journ. of Comp. Neurol., vi., December, 1896, pp. 216-352, including 
7 tables; Parts vii-ix. have also been reprinted under the title 
“Table of Neural Terms, with Comments and Bibliography.” 
1897, ¢: What is the Morphologic Status of the Olfactory Region of 
the Brain? A. A. A. Proc., December, 1897, 94-99; Science, Febru- 
ary 4, 1898, vii., 150-152. 1899, a: Historic, Ethical, and Practical 
Considerations Respecting the Names and Numbers of the Definitive 
Encephalic Segments. Abstract A. A. A. Proc., December, 1899, 3-4. 
Science. March 16th, 1900. 1899, b: Comments upon the Figure of 
the Mesal Aspect of an Adult Brain as published by His and repro- 
duced in the B. N. A. Abstract A. A. A. Proc., 1899, Science, March 
16, 1900. 1899,¢: The Basis and Nature of a Segmental Schema of 
the Brain. Abstract A. A. A. Proc., 1899, Science, March 16, 1900. 
1899, d: Is Neuron Available as a Designation of the Central Ner- 
vous System? Abstract A. A. A. Proc., 1899, Science, March 16, 1900. 
1900, a: Further Tabulations and Interpretations of the Paroccipital 
Fissures. Abstract A. A. A. Proc., 1900. 1900, b: Revised Schema 
of the Cerebral Fissures. Abstract A. A. A. Proc., 1900. 1900, ¢: 
Revised Interpretation of the Central Fissures of the Educated 
Suicide’s Brain which was exhibited to the (Amer. Neurol.) Asso- 
ciation in 1894. Journ. Nery. and Ment. Dis., October, 1900, 536-539, 
vol. xx. For note as to earlier titles, see § 12. 


BRAIN, ABSCESS OF.—Cerebral abscess is always 
the result of the introduction of pus-producing germs 
into the tissues of the brain. The organisms which are 
found most frequently are streptococcus pyogenes and 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


staphylococcus pyogenes aureus. Staphylococcus pyo- 
genes albus and citreus are also found occasionally, but 
are always associated with the former ones. When the 
pus from the brain lesion has been compared with that 
from the primary wound or otorrhoea, the same organisms 
have frequently been found in both places. Bacillus 
pyogenes feetidus has been found in one case in the 
abscess and in the discharge from the ear. Fraenkel’s 
diplococcus pneumoniz was obtained in a meningeal 
abscess which accompanied an abscess in the cerebellum. 
In one case the observer was unable to decide whether 
the germ was Eberth’s bacillus entericus or Neumann’s 
bacillus meningitidis purulente. In several cases pyo- 
genic organisms were associated with Gessard’s bacillus 
pyocyaneus. In two cases oidium albicans was dis- 
covered; in one of these the brain contained small ab- 
scesses which were filled with the fungus. 

Sabrazés reports a case of abscess of the centrum ovale, 
abscess of the apex of the right lung, anthracosis of the 
lungs and purulent softening of an infarction in the right 
kidney. The pus of the abscesses contained a micro-or- 
ganism which was regarded as-a~-streptothrix. It is 
probable that the lungs were the primary point of en- 
trance of the germs. Ferré and Faguet also found a 
streptothrix in a cerebral abscess. Fraenkel obtained 
pure cultures of tubercle bacilli from the pus of a tuber- 
culous abscess of the brain. 

These various germs may be derived from any part of 
the body, but in the large majority of cases the primary 
lesion is located in the vicinity of the head and is due 
either to injury of the head or to ear disease. 

When the disease is due to injury of the head the pyo- 
genic organisms are sometimes introduced directly from 
the outer world. For example, in punctured wounds of 
the skull, the foreign body (splinter of wood, dagger, 
etc.) may be the direct carrier of the staphylococci and 
streptococci into the brain. Sometimes the skull itself is 
infected, then infection thrombi develop in the diploic 
vessels, and the bacilli pass along the perivascular sheaths 
to the brain. The infective injury to the skull may also 
be produced without fracture, if the outer table has been 
laid bare. 

In the majority of cases due to injury the abscess is 
found in the vicinity of the injured part of the skull; but 
in exceptional instances it is found on the opposite side 
of the brain (contrecoup). 

A similar pathological condition is presented by affec- 
tions of the face and scalp, which may set up thrombosis 
of the veins and thus communicate with the brain. 

Next in importance—perhaps even equal—to traumatic 
causes stand inflammations of the middle ear. The 
primary lesion is generally present from early childhood, 
as a sequel of one of the infectious diseases common to 
that period of life. It terminates in caries of the petrous 
portion of the temporal bone, attended usually with sup- 
purative otitis media. 

Caries in the tympanic cavity usually extends most 
markedly in certain directions. When it spreads through 
the antrum and involves the mastoid cells, some of which 
are adjacent to the sigmoid groove, the latter is apt to be 
involved and exposed. When the caries attacks the roof 
of the middle ear, perforation into the middle fossa of the 
skull frequently results. When the petrous portion is the 
site of extensive disease, suppurative leptomeningitis of 
the basal ganglia and cerebellum is apt to occur; even 
when the destruction is much less marked and the in- 
ternal auditory meatus is exposed, the infective inflam- 
mation may pass along the sheaths of the facial and au- 
ditory nerves. In perforation of the tegmen, the abscess 
is situated in the temporo-sphenoidal lobe; in perfora- 
tion into the sigmoid groove, the abscess is generally 
located in the cerebellum. 

The mode of development of the abscess may vary 
considerably. 

If the tegmen is involved the overlying dura mater be- 
comes inflamed and adherent to the adjacent pia mater, 
and thus the veins and lymphatics of the latter are 
directly affected. The arterial vessels become throm- 








Brain, 
Brain, 


bosed, and particles from the resulting emboli are carried 
with the pathogenic cocci to the interior of the temporo- 
sphenoidal lobe where they give rise to an abscess. As 
in cases of injury, the process may also creep along the 
perivascular sheaths. 

When the perforation takes place into the sigmoid 
groove, the outer wall of the sinus undergoes inflamma- 
tion; this extends through to the inner wall and thus 
induces thrombosis. The thrombus offers a nidus for the 
micrococci which pass along the cerebellar veins to the 
cerebellum. It must be remembered in this connection 
that the current of blood in the superficial veins may 
flow in either direction. The cerebellar arteries may also 
be thrombosed, and thus convey infected emboli to the 


interior of the cerebellum. 


Cerebellar abscess may also be due to direct extension 
of the inflammation through the dura on either side of 
the sigmoid sinus. 

In young children the infection often-travels through 
the petroso-squamosal suture. 

Cerebral abscess from ear disease is much rarer after 
acute suppurative otitis media than after the chronic 
form. In rare cases it follows tuberculous and syphilitic 
affections of the temporal bone. 

Otitic abscesses occur generally in the temporo-sphe- 
noidal lobe or the cerebellum on the same side as the 
aural lesion. In 119 cases collected by Koerner, 79 de- 
veloped in the cerebrum and 40 in the cerebellum. 

Infection from the nose and its appendages is much 
rarer. In a case reported by Dreyfuss, the infection, 
which started from suppuration of the antrum, was due 
to thrombophlebitis of the pterygopalatine and ophthal- 
mic plexuses. In another case the process extended to 
the adjacent ethmoid cells and caused perforation of the 
lamina cribrosa. When the primary lesion affects the 
frontal sinuses, the posterior wall usually undergoes per- 
foration or the iafection takes place through the diploé. 
In very rare cases the primary infection is located in the 
orbit. In almost all of this group of cases the abscess is 
situated in the frontal lobes. 

Embolic abscesses of the brain may be due to infection 
in any part of the body. "They are observed particularly 
in association with pulmonary Tiga putrid bronchitis, 
empyema, gangrene, tuberculous cavities). They are 
less frequent after septic endocarditis, suppurative proc- 
esses in the abdomen, joint and bone suppuration. 
They have also been seen after typhoid fever, scarlatina, 
diphtheria, glanders, and general pyzemia. Boettcher re- 
ports a case after pulmonary suppuration in which lung 
pigment was found in the brain. In two instances the 
abscess was due to the presence of oidium albicans. 

The category of so called idiopathic abscesses of the 
brain is being continually narrowed. Although the ex- 
istence of such cases cannot be absolutely denied, still 
none should be pronounced idiopathic until careful search 
has been made unsuccessfully in all the organs for some 
possible source of infection. 

PaTHOoLoGicAL ANATOMy.—An analysis of 458 cases 
collected by Le Fort and Lehmann showed that the ab- 
scess occurred in the cerebrum in 827 cases, in the cere- 
bellum in 113 cases, in the cerebrum and cerebellum in 
11 cases, in the pons Varolii in 5 cases, in the cerebral 
peduncle in 1 case, and in the fourth ventricle in 1 case. 

According to Macewen 93 per cent. of traumatic ab- 
scesses and 87 per cent. of otitic abscesses are solitary. 
The majority of metastatic abscesses are multiple. Ab- 
scesses of the brain vary extremely in size. Some of 
the multiple abscesses occurring in the course of pyeemia 
or ulcerative endocarditis may be the size of a pea. Old 
chronic abscesses may occupy a large part of a cerebral 
hemisphere, or perhaps a considerable portion of the 
cerebellum. ; 

Acute abscesses contain a thin pus, usually of a color 
varying from yellow to green, sometimes of a darker 
shade, from admixture with blood. Under the micro- 
scope this is found to contain pus corpuscles, drops of 
myelin, granular matter, and detritus of the nerve ele- 
ments and the pathogenic micro-organisms. The walls 


219 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of the abscess are usually irregular and jagged, and tear 
readily from the contact of the fingers. The cavity is 
irregular in shape at first, but at a later period it tends 
to become more rounded. For a varying distance around 
the cavity the brain substance may have a reddish, 
speckled appearance from enlargement of the blood- 
vessels and the presence of capillary hemorrhages. Still 
more externally the brain tissue is stained slightly yel- 
low and softened from inflammatory eedema. The latter 
phenomenon is observed sometimes over a large area, and 
often appears to be the immediate cause of death. Some- 
times the abscess ruptures into one of the lateral ven- 


The membrane rarely insures a complete standstill of 
the process, inasmuch as it undergoes suppuration in 
places and this attacks the surrounding brain tissue. 
The new focus may again be surrounded by a fresh 
membrane. 

The contents of the cavity are usually somewhat viscid, 
and consist of broken-down pus globules, drops of fat, 
cholesterin crystals, and granular matter. In a very few 
instances the contents have been found condensed to a 
thick, cheesy consistence, and in one case it is stated that 
earthy matter was present (calcification). When the ab- 
scess is of large size, fluctuation can usually be detected 





Fic, 808.—Abscess Cavity in the Brain. 


tricles, and in rare cases the pus makes its way through 
the foramen of Monro into the opposite ventricle. In 
such cases death almost always occurs before ependymitis 
supervenes. Softening may extend to the ventricles and 
produce ependymitis even though perforation has not 
occurred. In other cases the abscess ruptures through 
the cortex (almost always at the convexity), and in this 
event, likewise, death may supervene before the develop- 
ment of meningeal inflammation. But in a large num- 
ber of such cases meningitis occurs at the site of rupture 
and rapidly spreads over the entire meninges. Quite a 
number of cases have been reported in which the pus 
made its way through the original site of injury to the 
skull, through the external auditory meatus, through the 
sphenoid bones into the nasal cavity, or through the 
orbital plate into the orbit. 

In the majority of cases the amount of healthy tissue 
between the cortex and abscess does not measure more 
than a few millimetres in thickness. In rare cases the 
abscess may be situated an inch or even more from the 
cortex. The abscess may be connected by a narrow fis- 
tulous tract with the meninges. 

Chronic abscesses are usually round or ovoid in shape, 
and are provided generally with a connective-tissue mem- 
brane of variable thickness which lines the cavity. Ru- 
dolph Meyer states that about seven weeks usually elapse 
before the formation of a well-defined membrane.  Lal- 
lemand found an abscess surrounded by a soft vascular 
membrane in a case which proved fatal thirteen days 
after the onset of the first symptoms. Huguenin found 
no membrane in an abscess which had lasted thirty-two 
days. Equally varying statements are made by other 
writers. 


220 


(Specimen in the collection of Prof. M. Allen Starr, M.D.; photograph taken by Dr. Edward Leaming.) 


upon the convexity; the convolutions are flattened upon 
the side of the lesion, and sometimes the falx cerebri is 
pushed toward the opposite side of the brain. 

When the abscess is situated in such a position (particu- 
larly the cerebellum) that the escape of fluid from the 
ventricles is interfered with, internal hydrocephalus may 
be the result. 

The complications of cerebral abscess include suppura- 
tive meningitis, extradural suppuration, and thrombosis 
of thesinuses. All these conditions may also precede the 
development of the cerebral abscess. 

According to Hessler, among 106 abscesses of the cere- 
brum 67 were uncomplicated, in 13 there was thrombosis 
of the sinuses, in 26 meningitis. Among 59 cerebellar 
abscesses 48 were uncomplicated, thrombosis of the 
sinuses was present in 10, and meningitis in 6 cases. 

Macewen has reported a remarkable case of suppura- 
tive meningitis in the posterior fossa, while simple serous 
meningitis was found in other parts. 

Widespread cedema of the brain is found not infre- 
quently in cases of cerebral abscess, even in those pro- 
vided with a thick membrane, and which do not appear 
to have given rise to much pressure. General cerebral 
anemia is also observed quite often under such cireum- 
stances. The development of these sequelee is still un- 
explained. 

CLINICAL History.—The symptoms of an acute ab- 
scess of the brain after injury vary to a remarkable ex- 
tent. Perhaps the immediate symptoms of the traumatism 
have been very slight; the scalp has been wounded, but 
the bones have escaped injury, and the patient is not 
supposed to be seriously injured. Or the patient has 
presented for a few days the signs of cerebral concussion, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


and then apparently recovers. Fora variable length of 
time (from a week to two or three months) he continues 
in apparently good health, but then begins to complain 
of headache, dulness, and irritability. The headache is 
one of the most constant and earliest of all the general 
symptoms. It is rarely absent but varies greatly in in- 
tensity. It is especially severe during the growth of 
the abscess, and usually slight during the period of 
latency. It is sometimes felt over the entire head, but is 
generally more severe on the side of the abscess. In 
Koerner’s twenty-one cases of cerebellar abscess, the pain 
was located in the occipital region only eight times. Pain 
in the back of the head is sometimes observed in frontal 
abscesses. Headache is often accompanied by rigidity of 
the back of the neck, particularly in abscesses of the 
posterior fossa. 

In the majority of cases, according to Macewen, the 
temperature is normal or even subnormal during the en- 
tire course. When the symptoms begin suddenly fever 
may be. present, but it is probable that the febrile move- 
ment is partly due, in many cases, to the primary disease 
or to complications. 

As a rule, the pulse is slow at the height of the dis- 
ease. Toynbee and Wreden described cases in which 
it fell to 10-16 per minute. The slowness of the pulse 
may persist during an increase of the bodily tempera- 
ture. 

After a while the headache increases in severity, and 
the patient may be confined to bed on account of the 
general malaise. The irritability and excitement like- 
wise increase, delirium supervenes, and epileptiform con- 
vulsions may make their appearance. 

Then the delirium changes into hebetude, somnolence, 
and coma; the pulse becomes rapid and irregular. Death 
either ensues rapidly or recovery slowly occurs, and the 
patient is restored apparently to health, with the excep- 
tion, perhaps, of a monoplegia or hemiplegia, or even 
without any local symptoms. He then enters upon the 
so-called latent stage. Thesymptoms described are very 
like those of acute meningitis, and, indeed, this lesion 
may be associated with the encephalitis from the begin- 
ning, or it may develop secondarily. 

Sometimes the symptoms begin with great suddenness, 
and at once assume an alarming aspect. 

In another series of cases the symptoms of concussion 
‘or compression of the brain, due to the original injury, 
continue without intermission or improvement, and are 
rapidly merged into those due to the developing en- 
cephalitis and abscess formation, so that it is impossible 
to tell when the one process ends and the other begins. 
Such cases usually run a more rapid course than the 
former variety. 

Finally, not a few cases have been reported in which 
the abscess has remained entirely latent for a long period, 
without giving the least indication of its presence. In 
fact, the autopsy alone may reveal the existence of a 
hitherto unsuspected chronic abscess. Ina case observed 
by Nauwerk, the period of latency lasted twenty-eight 

ears. 

Af Sometimes the sole symptom of the so-called latent 
stage has been the occurrence of epileptiform convulsions, 
so that the case has been regarded as one of ordinary 
epilepsy. In other cases, chills, followed by a hot stage 
and sweating, occur at irregular, or, in rare cases, per- 
fectly regular intervals, so that a diagnosis of intermit- 
tent fever has been made. An instance of this kind has 
come under my own observation. Usually, however, 
such patients also suffer from violent headache, fre- 
quently localized in the vicinity of the abscess. 

Abscesses of the frontal lobe are more apt than others 
to be unattended with symptoms during the stage of 
latency. In a case of this kind, observed by me in the 
person of & lunatic, the mental condition seemed to be 
somewhat improved during the period of latency (one 
month). The night before her death, she had what were 
supposed to be hysterical convulsions (irregular twisting 
movements without loss of consciousness), as the patient 
had exhibited other hysterical symptoms for a year (the 





Brain, 
Brain, 








injury which gave rise to the abscess was received a 
month before the onset of the convulsive seizures), On 
the following morning the patient was found dead in 
bed. The autopsy showed an abscess of the frontal lobe, 
which had burst (evidently shortly before death) through 
the convexity. 

The clinical history of otitic abscess of the brain is 
modified by the symptomatology of the primary disease 
of the ear. The initial symptoms usually consist of pain 
in the ear, vomiting, vertigo, tinnitus, and rise of bodily 
temperature. Inasmuch as all these symptoms may be 
the result of simple retention of pus in the diseased ear, 
it may be impossible to determine for some time whether 
the brain has really become involved. The condition is 
still further obscured by the fact that in these cases we 
observe frequent complications with purulent meningitis, 
pachymeningitis, and thrombosis of the sinuses. 

In the majority of cases the abscess runs an acute or 
subacute course, 

Mental obtuseness generally becomes noticeable soon 
after the onset of the disease. The patient answers 
questions correctly but slowly, and, when the eyes are 
open, stares into vacancy. The somnolence may deepen 
quite rapidly into coma. 

When the disease runs a chronic course, the history is 
essentially the same as that of the traumatic variety. 

On account of their embolic origin metastatic abscess- 
es usually develop suddenly. In the majority of cases 
the emboli enter the middle cerebral artery and are carried 
to terminal branches, so that we generally find evidences 
of an affection of the motor region of the brain. Pure 
Jacksonian epilepsy is not an uncommon feature of these 
cases. Paralytic symptoms are much more frequent. 
Various aphasic disturbances have also been observed. 
In a considerable proportion of cases the abscesses are 
multiple and the focal symptoms are thus obscured. 

The brain symptoms are often associated with evi- 
dences of general infection, viz., fever, chills and sweats, 
and rapidly developing cachexia. 

It is unnecessary to say that, if the abscess is situated 
in such a position that it either involves the cortex in 
some part which presides over a special function, or 
destroys the white matter in such a manner as to cut 
across the fibres leading to such portions of the cortex, 
the corresponding symptoms will be produced. Thus, 
hemianopsia, aphasia, word-deafness, paralysis of indi- 
vidual nerves (very rarely), monoplegia, or hemiplegia 
may be produced in this manner. As occurs likewise 
in the clinical history of tumors of the brain, hemiple- 
gia results usually from a succession of ‘monoplegias, 
due evidently to a gradual spread of the destructive 
process from one set of fibres to another. This fact 
may be of invaluable service in making a regional diag- 
nosis. 

But, unlike tumors of the brain, cerebral abscesses 
rarely give rise to paralysis of cerebral nerves. Choked 
disc is also much less frequent and less marked than in 
tumors. According to Oppenheim, choked disc is much 
less frequent than optic neuritis. The affection of the 
optic nerve is sometimes confined to one eye. In opera- 
tive cases the optic disturbances may disappear gradu- 
ally after the operation. 

The frequent absence of choked disc may be accounted 
for, perhaps, by the fact that the encephalitis spreads by 
causing adjacent parts of the brain to become directly 
involved in the inflammatory process, and in this way 
less pressure is produced upon adjacent parts. 

In a certain proportion of cases all “head symptoms ” 
are entirely wanting during the so-called latent stage, 
and we are sometimes astounded at the autopsy at dis- 
covering the great apparent disproportion between the 
amount of brain tissue destroyed and the slight character 
of the symptoms which had been produced. This is es- 
pecially striking if we compare the symptoms with those 
which usually result from cerebral hemorrhages, even 
when much smaller in size. It must be remembered, 
however, that the latter lesion is usually situated in such 
a position (internal capsule and surrounding parts) that 


221 


Brain, 
Brain, 





comparatively slight destruction of tissue interferes ma- 
terially with the conduction of nervous impulses. 

Vomiting is a not infrequent symptom, and may occur 
when the stomach is either full or empty. 

In certain rare cases, the sole symptoms observed dur- 
ing the period of latency are those of mental derange- 
ment, and the patient is supposed to suffer from insanity 
as the result of injury to the head. In a case recently 
under our observation, such an error in diagnosis was 
made by a very eminent neurologist, and the true na- 
ture of the case was revealed only at the autopsy, 
as the psychical symptoms persisted, uncomplicated 
with any other manifestations, until the terminal men- 
ingitis set in. 

As a general thing, the latent period is brought toa 
close by a sudden irruption of symptoms, beginning 
either with an epileptiform convulsion or a series of 
convulsions, with great exacerbation of the headache, 
mental irritability and delirium, or with sudden coma. 
The symptoms which follow are very similar in character 
to those which we have described above as occurring in 
acute abscess. After a short period (varying usually 
from a few hours to several days), the symptoms either 
terminate fatally (this is the rule) or they gradually clear 
up. But sooner or later, after another period of latency, 
in which the symptoms are more violent than in the first 
period, a second outburst occurs, which terminates fa- 
tally. 

From the reports of a few isolated cases it seems prob- 
able that chronic abscesses may undergo spontaneous re- 
covery, inasmuch as the pus becomes cheesy or even 
calcareous. Butsuch an event, if it happens at all, must 
be extremely rare. 

DraGnosis.—In making a diagnosis of abscess of the 
brain great importance attaches to etiological consid- 
erations. We are rarely justified in making the diag- 
nosis unless we obtain a history of a previous in- 
jury to the head, of a purulent disease of the ear, 
nose, or other adjacent parts, or of some source of in- 
fectious emboli in distant parts of the body, notably 
in the lungs. 

Injury to the head is followed, in rare cases, by tumor 
of the brain. But in such cases it will usually be found 
that the primary wound was not infectious in character, 
and, moreover, the symptoms follow one another in a 
steadily progressive manner. Furthermore, choked disc 
is much more constant and pronounced in tumor cerebri, 
while the subnormal temperature, or the fever and chills 
of abscess are wanting. 

Injury to the head may also give rise to other symp- 
toms which simulate abscess of the brain but which are 
in reality due to hemorrhagic encephalitis. In the latter 
affection the symptoms begin suddenly. They may 
terminate in complete recovery or rapid death, or the 
majority of the symptoms may disappear and leave per- 
manent focal symptoms. 

In considering suppurative disease of the middle ear 
as a factor in the diagnosis of cerebral abscess, it should 
not be forgotten that severe cerebral symptoms may be 
produced by the mere retention of pus in otitis media 
independently of the existence of cerebral lesions. A 
number of cases have also been reported in which optic 
neuritis or choked disc was associated with simple otitis 
media. This peculiar combination has been explained in 
various ways, viz., as the result of thrombosis of the 
sinuses, of infection of the carotid canal and extension 
along its lymph channels to the sheath of the optic nerve, 
and of serous meningitis. 

Extra-dural abscess often cannot be distinguished from 
cerebral abscess; indeed, in many cases the two lesions 
are combined. According to Jansen, extra-dural ab- 
scesses exhibit the following characteristic features: («) 
thickening of the bone, subperiosteal abscess or cedema- 
tous swelling behind the mastoid process; (0) pain on 
pressure and percussion in this region; (¢) impaired 
mobility of the head, particularly around the sagittal 
axis; (¢) nystagmus of both eyes, on voluntary motion, 
chiefly toward the side of the healthy ear. 


222 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Otitic thrombosis of the sinuses is also difficult of dif- 
ferentiation. In the majority of cases there is consider- 
able intermittent fever, and the pulse is irregular and 
rapid. Many cases are attended with chills, sweats, and 
profuse diarrhcea. Insome casesall these symptoms may 
be wanting. In thrombosis of the cavernous sinus we 
find cedema of the eyelids and surrounding parts, and 
protrusion of the eyeball. In thrombosis of the trans- 
verse sinus, certain symptoms may be due to implication 
of the upper part of the jugular vein. This vein is 
tender on pressure and may be felt occasionally as a hard 


cord. Small abscesses may develop in surrounding 
parts. (idema behind the mastoid process is very fre- 
quent. 


Focal symptoms are usually wanting in thrombosis of 
the sinuses. 

When abscess and thrombosis are combined the condi- 
tion becomes still more difficult of diagnosis. 

It is also difficult in many cases to differentiate menin- 
gitis from abscess. The former disease usually runs a 
more rapid course than abscess, is attended with con- 
siderable fever and acceleration of the pulse, general 
convulsions are frequent, and there is also hyperesthesia 
of the entire skin in many cases. Rigidity of the neck is 
a common symptom, together with retraction of the ab- 
domen and increase of the tendon reflexes. In children 
all these symptoms are sometimes produced by retention 
of pus in the middle ear and may be relieved by evacua- 
tion of the pus. 

The regional diagnosis must be made according to the 
principles laid down in the articles on Diagnosis of Local 
Lesions and on Functions of the Cerebral Cortex (both in 
the present series of brain articles). 

Proenosis.—The prognosis of this affection has been 
modified very materially in the last fifteen years by the 
progress in antiseptic surgery. Spontaneous recovery 
by caseation or calcification of the abscess or by rupture 
externally is extremely rare. But operative interference 
now promises a good measure of success. Oppenheim 
found that in 53 cases of operation upon traumatic cere- 
bral abscess 36 terminated in recovery. Koerner col- 
lated 92 operative cases of otitic cerebral abscesses; 51 
cases recovered and death occurred in 41 cases. Mac- 
ewen’s results were remarkably favorable. Among his 
25 cases of cerebral abscess he operated upon 19, and of 
these 18 recovered. 

The poorest chances of successful surgical interference 
are presented by metastatic abscesses in which there is 
general pyzemic infection. Complication with thrombosis 
of the sinuses or meningitis also makes the prognosis 
more unfavorable. 

TREATMENT.—Medical treatment of this affection, 
apart from meeting the individual symptoms as they 
arise, is utterly useless, as we possess no remedy which 
will cause the absorption of the pus after it has once 
formed. 

Prophylactic measures are useful, perhaps, in prevent- 
ing encephalitis after injuries to the head. The chief 
measures are absolute mental and bodily rest (the patient 
kept on his back, not allowed to sit up, to read, or to talk 
with those around him), which should be continued, if 
the injury has been violent enough to produce uncon- 
sciousness, for at least a week or two after the subsidence 
of the cerebralsymptoms. Inaddition, the bowels should 
be kept thoroughly open by some mild saline, or by small 
doses of calomel. 

Prophylaxis may also prove of benefit in diseases of 
the ear and nose. Free vent to the pus should always 
be secured, and paracentesis performed as soon as reten- 
tion of pus develops. 

As soon as the diagnosis is assured, operative interfer- 
ence is indicated. In some cases this has proved success- 
ful, even when the patient was in a moribund condition 
or a complication with purulent meningitis had de- 
veloped. In some instances repeated operations have 
been necessary, either because the abscess refilled or be- 
cause fresh abscesses developed in the immediate vicinity 
of the primary one. Leopold Putzel. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





BRAIN, ANAEMIA OF.—Anzemia is a condition and 
not a disease in the proper sense of the term. Moreover, 
it is a condition which rarely or never exists uncompli- 
cated. The causes which produce it are very apt to pro- 
duce independently irritation and inflammation, or the 
same conditions which at first bring about an anzemia of 
the brain may, if their action be longer continued, excite 
in its place a cerebral hyperemia. In the present state 
of our knowledge it is, moreover, often impossible for us 
to prove whether certain symptoms are really produced 
by an anzemia or by a hyperemia of the brain, and in such 
cases we are forced to come to a decision on very imper- 
fect grounds. 

Of the fact that the anzemia in itself acts as an irritant 
on the nerve centres there can be no doubt, but its chief 
effect on them is produced through the deprivation of 
nutrition which it causes. In considering anzmia of the 
brain, it is not possible for us to differentiate the symp- 
toms caused by deprivation of nutrition to the cerebral 
tissues through loss of blood and those caused by de- 
privation of nutrition to the same parts on account of 
the poverty of the blood in nutritive material suited to 
their needs. Hence the term cerebral anzemia has come 
to denote not only that condition in which there is an 

- absolute diminution of the amount of blood in the brain, 
but also all those, so long as no toxic element is involved, 
in which the blood supplied to the brain is, from its com- 
position, incapable of affording due and sufficient nourish- 
ment to the tissues. As a change in the condition of the 
blood is inmost cases concurrent with a diminution in its 
amount, we may fairly say that cerebral anemia, when 
universal, is usually “a complex condition, depending 
not merely upon a deficiency of the quantity of blood 
supplied to the brain, but also upon a change in its 
quality, and upon a diminution in the intracranial press- 
ure ” (Ross, ii., 611). 

Anzemia of the brain may be either universal or partial, 
according as the whole or a portion only of the organ is 
involved. Partial anzmia, except when caused by oc- 
clusion of a blood-vessel through pressure, thrombosis, 
or embolism, is rare, and its symptoms are often not 
recognizable during life. 

We shall hence consider here only universal cerebral 
anemia. This may be either acute or chronic, and it 
may be due to a condition confined to the brain alone or 
may form part of a general anemia. 

Acute universal anemia of the brain is always the result 
of the sudden withdrawal of a large quantity of blood 
from that organ. It occurs typically in ligature of the 
large arteries in the neck, the innominate, the carotids, 
or the vertebrals. These operations are performed usu- 
ally either on account of injury, or for some tumor or 
aneurism. The vertebrals were formerly sometimes tied 
as a cure for epilepsy. 

1. The most common cause of acute cerebral anemia 
is, however, undoubtedly hemorrhage. This may oc- 
cur from any part of the body, provided only that 
sufficient blood be lost with sufficient rapidity. Put- 
ting aside hemorrhages due to injuries, the more com- 
mon forms are metrorrhagia, especially post partum, 
epistaxis, heemoptysis, and hemorrhages from the stom- 
ach and intestines; occasionally also the rupture of 
aneurisms. 

In cases of hemorrhage from injury the influence of 
shock must always be taken into account, as there are 
few cases of severe injury in which it does not exist toa 
greater or less degree. The pathological condition exist- 
ent in shock is as yet unknown. One hypothesis is that 
maintained by Groningen, that the complex of symptoms 
known by this name is due to an exhaustion of the 
medulla oblongata and of the spinal cord, produced by 
violent and severe drains upon their strength. Other 
writers consider shock as due to sudden changes in the 
calibre of the blood-vessels. Thus it is defined by Fischer 
as a reflex paralysis of the vaso-motor nerves, especially 
of the splanchnic, produced through a traumatic con- 
cussion. However this may be, cerebral anzemia is cer- 
tainly produced by sbock, and, as Travers says of shock 





and fainting: “They differ in degree and duration more 
than in kind.” 

2. Acute cerebral anemia may be produced by any 
sudden change in the distribution of the blood im the 
body at large. Any cause which suddenly attracts a 
large quantity of blood to one portion of the body will 
naturally reduce the amount which can go to the other 
parts, and hence will-induce an anemia in them. This 
sudden change in the general distribution of blood in the 
body is said to occur after violent labor, when, the uterine 
vessels being suddenly released from pressure, large 
quantities of blood enter them freely and are thus with- 
drawn from the rest of the body. To this cause are prob- 
ably in part also due the serious symptoms which some- 
times occur after the withdrawal of large quantities of 
fluid from the pleural or peritoneal cavities. Another 
example of this form of disturbance is given in the action 
of Junod’s boot, which, if carelessly used, may prcvoke 
dangerous symptoms. 

3. A third cause of this form of anemia is want of 
energy in the action of the heart. This is a common 
cause of chronic anemia, but the acute form may readily 
be produced by any sudden demand for increased exertion 
on the already weakened heart. This is readily seen in 
anemic persons and those suffering from insufticient 
action of the heart, in their liability to faint on any slight 
exertion, or even on rapid change of position. More 
especially is this the case in convalescents from acute 
febrile diseases, and it is particularly apt to occur after 
acute pneumonia. This frequently takes place when the 
patient rises suddenly from the horizontal position, the 
change in the distribution of the blood, which under 
normal circumstances would not be perceived, making 
itself felt. 

In organic diseases of the heart cerebral anzemia in the 
acute form frequently occurs, more especially in aortic 
regurgitation, in which death from syncope is not un- 
common. Persons suffering from myocarditis or from 
fatty degeneration of the heart are likewise peculiarly 
liable to attacks of fainting. 

Anemia of the brain may in like manner be produced 
by irritation of the vagus nerve through its action on the 
heart. Brown-Séquard and others have found that 
crushing of the right semilunar ganglion causes stoppage 
of the heart, and the deaths which sometimes occur from 
syncope in nervous and delicate persons, who are suffer- 
ing from hepatic colic, may perhaps be referred to some 
similar cause. We may also mention here, though with- 
out any special reference to the method of their causa- 
tion, those cases of syncope and collapse which occur in 
perforation of the stomach or intestines, and in which 
death is not infrequent. Hill believes that “the cerebral 
circulation is controlled by the vaso-motor centre acting 
on the splanchnic area.” 

That intestinal disturbances even of a light character 
are especially liable to produce syncope is well known. 
Even a transient abdominal pain or a slight attack of in- 
testinal colic frequently causes the symptoms of faintness 
or even actual syncope. Syncopal cardialgia and a 
tendency to faint are said to be especially common in 
those suffering from the dyspepsia of gout. 

4. Again, a diminution of the amount of blood in the 
brain, sufficient to produce the symptoms of cerebral 
anemia might be caused through the spasmodic contrac- 
tion of the cerebral arteries. This is supposed to occur, 
when, from emotion or mental excitement, there is pallor 
of the countenance, and even loss of consciousness, with- 
out any failure of the action of the heart. The not un- 
common occurrence of fainting at the sight of surgical 
operations, or at the sight of blood, would come under 
this head. Syncope, and even sudden death, may be 
caused by the sudden advent of any strong emotion— 
surprise, terror, grief, or joy. How far ‘shock or the 
irritation of the vagus comes into play in these cases is 
yet undecided. 

Nothnagel considers it possible that in attacks of epi- 
lepsy we have to deal with a spasmodic contraction of 
the cerebral blood-vessels, due to the irritation of a cere- 


223 


Brain. 
Brain. 





bral vaso-motor centre; but this cannot in the present 
state of our knowledge be considered as proved. Hill 
states that there is no evidence of the causation of cere- 
bral anzeemia by spasm of the cerebral arterioles. 

The occurrence of vaso-motor nerves on the vessels of 
the pia seems probable according to the latest investiga- 
tions (Obersteiner, Hill). 

Hill states that “in every experimental condition the 
cerebral circulation passively follows the changes in the 
general arterial and venous pressures. ” 

That cerebral anseemia may also be excited by irritation 
or stimulation of the sensitive nerves is well known. In- 
tense pain may produce faintness or even syncope, but 
the exact method of action by which this effect is brought 
about must still be considered undecided. Nothnagel’s 
and Krauspe’s experiments on the sciatic and crural 
nerves do not appear conclusive, more especially in the 
face of the conflicting results obtained by Riegel. Ross 
states that these symptoms “may result from reflex irrita- 
tion of the vagus or direct irritation of the sympathetic. 
But the direct effect produced on the nerve centres must 
also contribute to the result.” Nothnagel considers the 
cerebral anzemia caused by catheterization to be likewise 
due to irritation of the vaso-motor centres. 

5. Cerebral anzemia may in like manner be produced 
by the sudden introduction of foreign substances into the 
cavity of the cranium, thus inducing compression of the 
blood-vessels. The most common cause of this is an 
effusion of blood; but in cerebral or meningeal hemor- 
rhage the pathological condition is a complex one, and 
it does not properly come within the limits of this article. 

6. It is probable that acute universal anszemia of the 
brain may be induced by certain poisons, but direct proof 
in this regard is still wanting. 

Chronic universal anemia of the brain may be produced 
not only by all the causes mentioned above, provided 
that their action be gradual and continued for a sufficient 
length of time, but also by all conditions of the system 
in which theamount of bloodasa whole is much lessened 
or its active power much diminished. Hence in all 
vases of general anzemia and chlorosis we find a corre- 
sponding anemia of the brain. This is especially apt to 
occur after long and wasting diseases, such as phthisis 
pulmonum, Pott’s disease, or long-continued suppuration 
in anyform. More particularly is this the case whenever 
large quantities of fluid of any sort are steadily withdrawn 
from the body for any length of time, as in chronic diar- 
rhea. Hyperlactation is a not infrequent cause. Noth- 
nagel, moreover, considers that many of the symptoms 
occurring in cases of starvation are directly referable to 
cerebral anzemia, although in these cases there probably 
always exists a greater or less amount of cerebral irrita- 
tion. 

Anemia of the brain and meninges is specially apt to 
occur in the convalescent stage of acute febrile diseases, 
“the late cerebral anzemia of severe fevers” of Jaccoud, 
who considers, however, that this is not a simple anemia 
but an aneemia with dyscrasia. 

Affections of the heart, moreover, are not uncommon 
factors in the etiology of chronic anemia. Whenever 
there exists a weakness of the cardiac action, whether 
due to functional causes or to organic lesions, we may 
suspect anzemia of the brain. This is probably always 
present to a greater or less extent in cases of fatty de- 
generation of the cardiac walls and in most cases of un- 
compensated valvular disease. It is most frequent in 
insufficiency of the aortic valve. 

How far chronic anemia may be brought about by the 
presence of extraneous substances in the cranial cavity 
is an open question. The presence of inflammatory exu- 
dations, transudations, or tumors is supposed at times to 
cause an anemia by pressure, but in many cases an 
inritative process seems to preponderate and a hypersemia 
exists. 

Partial or circumscribed anemia of the brain is caused 
by the diminution of the calibre of the blood-vessels sup- 
plying a portion of the brain, or by their occlusion. 
Unilateral anzemia is produced by ligature of the carotid. 


224 








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In many cases it is but temporary, and the symptoms 
soon disappear, but in others they are said to remain and 
become more or less permanent. This depends, at least 
in »art, on the condition of the communicating arteries of 
the circle of Willis, irregularities in which were found by 
Ehrmann in from nineteen to twenty per cent. of the 
bodies taken at random and examined by him. 

The commonest cause of partial anzemia in the brain 
is thrombosis, or embolism, by which a blood-vessel is 
partially or wholly occluded. The presence of tumors 
or exudations may likewise cause a partial ansemia by 
pressure exerted over a vascular area, or on a special 
blood-vessel. How far local spasm of the cerebral blood- 
vessels may cause circumscribed anzemia is still doubtful. 
Nothnagel states that it may occur in hemicrania and in 
the petit mal (epilepsy). Eulenburg says: “The -group 
of symptoms called hemicrania sympathico-tonica is to 
be explained by supposing a unilateral tonic spasm of the 
vessels of the head caused by tetanus in the cervical 
region of the sympathetic, or in the spinal centre of the 
cervical sympathetic.” 

SymMPToMATOLOGY.—Experiments made on compression 
of the carotids in healthy male adults show that the fol- 
lowing effects are produced. In the first place, there is 
pallor of the countenance, then convulsive efforts to close 
the eyes are seen, with contraction, to be followed later 
by dilatation of the pupils, a sighing respiration, dizzi- 
ness, staggering, and finally unconsciousness. A sensa- 
tion of choking may occur, and sometimes vomiting and 
general convulsions. How far these symptoms may de- 
pend on the anzmia pure and simple, and how far they 
may be due to other causes, we cannot consider here. In 
the present condition of our knowledge it is not possible 
to determine with absolute certainty, in regard to many 
of the symptoms which are present in conjunction with 
anemia, as to whether they are due to the anemia itself 
or to various concomitant conditions; while, on the other 
hand, there are many conditions in which the symptoms 
generally ascribed to angzemia are present, and in which 
the condition and circumstances of the general body 
would point most strongly to an ansemia of the brain, 
and yet in which, on post-mortem examination, the actual 
state of the cerebrum would seem to be rather hyperemic 
than anemic. Thus Flemming, in the “ Pathologie und 
Therapie der Psychosen,” says: “The fluctuations in the 
quantitative relations of nutrition in the brain vary be- 
tween the extremes of lack and of excess of blood, anzemia 
and hyperemia. Under circumstances which, as well 
from-the precedent injuries as from the whole behavior 
of the organism, would lead us to conclude, in so dispro- 
portionate a blood supply (oligsemia), that even the brain 
could not readily be provided with its normal needs, we 
still see the psychical functions altered ina manner which 
points far more to an increased supply of blood. The 
autopsy also, in such cases, shows the opposite of what. 
we should expect from the general oligsemic condition of 
the body. It shows the brain throughout, or partially, 
on its surface, or in its internal portions, reddened by the 
blood seen through the tissues, while the cut surface is 
dotted with numerous bloody points and the vessels are 
distended with blood. In short, there where we expected 
anemia it shows far more a hyperemic condition.” 

Hence, in describing the symptoms which are usually 
referred to anzemia of the brain, we desire that these facts 
be constantly borne in mind, that in many cases symp- 
toms have been ascribed to anemia which were in all 
probability due to other conditions of the brain, and even 
when the anzemia coexists there is in a large proportion 
of cases no proof that the symptoms are due to it alone. 

In acute anemia of the brain we have a series of symp- 
toms extending all the way from general weakness to 
profound insensibility, and which are known according 
to their intensity by the names eclysis, lipothymia, and 
syncope. All these are apt to be classed together under 
the name of fainting fit. These symptoms are subjec- 
tively usually as follows: A personabout to faint usually 
notices first a slight oppression in the breathing, and a 
sensation of lightness in the head. He is often inclined 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


to gape, and finds difficulty in fixing or concentrating 
his attention. Gradually the respiration becomes deeper 
and more labored, and a feeling of nausea and weight in 
the epigastrium comes on. At the same time his face 
becomes paler and paler, and he becomes more and more 
dizzy, until he finds it difficult to maintain his equi- 
librium. His head feels tense and his ears begin to ring, 
a mist comes over his eyes, and at times he is scarcely 
able to see, though still able to stagger toward the fresh 
air. He is often nauseated, and perhaps vomits. Sur- 
rounding voices can be heard but not distinguished, and, 
unless relieved, he becomes insensible and falls without 
a cry to the ground. If now left to himself he generally 
soon recovers, but recovery can be readily hastened by 
the presence of fresh air, or by gentle stimulation of the 
olfactory nerves. Objectively, the principal symptoms 
noticeable are, in the first place, the extreme pallor of 
the face, especially marked on the mucous membrane of 
the lips, the gaping and deepened respiration, then the 
staggering or loss of control over the equilibrium. The 
pupils contract at first and then dilate, and the pulse be- 
comes small and its tension is diminished. The skin is 
pale and cold, and a cold perspiration breaks out over the 
forehead and sometimes over the entire body. This stage 
ends in the abolition of consciousness and of voluntary 
movement. 

These are the usual symptoms in a slight attack of 
fainting coming on gradually from exposure to heat and 
close air, or from mental emotion. When the fainting, 
however, comes on rapidly, the prodromal symptoms 
may not appear, but the patient turns pale and falls in- 
sensible almost immediately. In severe cases, in addition 
to the previous symptoms, we may have Jacksonian 
epilepsy or generalized convulsions, sometimes extremely 
violent, and resembling in all respects epileptic convul- 
sions. These are liable to occur in all cases of sudden 
and profuse hemorrhage in previously strong and healthy 
individuals. 

When the anemic condition is produced more slowly, 
either from long-continued undernutrition of the body or 
as the result of a severe physical strain, as a serious fever 
or other acute illness, the symptoms present themselves 
in a somewhat different form. In children, after any 
severe strain on the physical forces, and particularly 
after intestinal diseases, in which a considerable amount 
of fluid is rapidly withdrawn from the tissues, we meet 
with the so-called hydrencephalotd disease, for our knowl- 
edge of which we are still principally indebted to its first 
describer, Marshall Hall, who “first gave a cursory 
sketch of this morbid affection in a little volume of 
‘Medical Essays’ published in 1825.” He there says: 
“The state of exhaustion is very apt to be induced in 
early infancy, and as the reaction is feeble at this period 
of life, the case soon assumes the character of sinking. 
- This state of things is often mistaken for inflammation of 
the brain or hydrencephalus.” 

In adults as in children, chronic universal anzemia of 
the brain is liable to be characterized by a condition of 
abnormal stimulation, both mental and physical. In 
both there is the same restlessness, uneasy sleep, and in- 
tolerance of light and sound; while in adults the mental 
irritability is probably more prominent only because it is 
more readily shown. In the severer forms, and more 
particularly in cases of starvation, delirium, the “ delirium 
of inanition,” is liable to occur. This is usually active 
and frequently maniacal in character, and is accompanied 
by hallucinations, illusions of sight and hearing, and 
not infrequently by delusions of persecution. Noth- 
nagel states that there is almost always an undertone of 
sadness, and that hence the symptoms as a whole belong 
to the type named melancholia agitans. It is said that 
occasionally this may pass into permanent insanity. In 
regard to the delirium of starvation, Longet writes as 
follows: “There is some consolation for us, after con- 
sidering the pathological conditions in which hunger 
presents itself, with the character of inexorable irresistible 
force, in turning to the analogous phenomena which are 
produced in the healthy individual when deprived of 


Viol. 1I—15, 








Brain, 
Brain, 





food. We are compelled to believe that under these cir- 
cumstances there supervenes a pathological state; a 
peculiar delirium, that of hunger, the delirium of starva- 
tion appears; were it not so, we should refuse to admit 
that the sentiment of egotism could reach the degree to 
which we see it carried in the starving man. Hunger 
speaks louder than laws, religion, feelings; all is hushed 
before its imperious commands.” 

In the case of Lieutenant Greely, who was exposed to 
slow starvation in the late Lady Franklin Bay Expedi- 
tion, the following record was made by Dr. E. H. Green, 
June 22d, 1884, the day of rescue: “On admission fainted 
after being carried below in the wardroom, and vomited. 
Nervous system: excitable and irritable, at times almost 
emotional, eyes wild and staring; insists on talking, 
craving news, and demanding food, complains of no 
pain.” His bodily weight was then one hundred and 
twenty pounds. In August, 1883, it had been one hun- 
dred and sixty-eight pounds. The next day: “No sleep, 
mind more tranquil but too active, great desire to talk 
and read; less persistent in demanding food; complains 
of soreness in limbs. June 25th, marked improvement, 
mind more tranquil; talks quietly without excitement; 
slept two or three hours naturally, awoke refreshed.” 
After this there was steady improvement. The details in 
regard to the other organs of the body are purposely 
omitted, as not being relevant to our subject, but ‘there 
was no organic lesion anywhere. All the symptoms here 
present were probably due to lack of food. 

We must here again emphasize the fact that in these 
cases it is impossible in the present state of our knowl- 
edge to decide how far these symptoms are actually due 
to a condition of cerebral anemia, or whether, as some 
observers think, there is present a fluxional hyperemia 
of the brain. 

Some of the symptoms present in cerebral anzemia de- 
serve especial consideration, and among these we should 
place first the disturbances of the organs of special sense. 
Tinnitus aurium is one of the commonest symptoms of 
cerebral anzemia, even in its lighter forms, and is usually 
accompanied or followed by partial deafness. It is prob- 
able that these symptoms are due, at least in part, to 
irritation of the auditory nerve, for although the blunt- 
ing of the mental perception might readily be adduced 
as the cause of deafness it could hardly be held to pro- 
duce a ringing in the ears. Abercrombie’s oft-quoted 
case of a much-weakened and anszemic patient, who was 
deaf when he sat upright but could hear well when he 
lay down, or when his face was reddened, would tend to 
confirm this view. In the same way the appearance of 
specks before the eyes and the blurring and dimness of 
vision which so frequently occur may be referred to 
irritation of the optic nerve. The occasional occurrence 
of total amaurosis would also seem to point to this. It 
is most common after severe hemorrhage, especially from 
the stomach, rarer in connection with inanition. It may 
or may not be accompanied by severe pain in the head. 
It may come on suddenly in the course of a few hours or 
it may take several days to develop. Travers says: “It 
succeeds somewhat abruptly to uterine flowing and large 
and sudden depletion for acute diseases. The pain is not 
confined to the region of the orbit, though it affects 
chiefly, if not exclusively, the same side of the head; it 
is that peculiar nervous pain to which women are subject 
after uterine hemorrhage, attended with a sense of defined 
pressure, as of an iron finger on the brain, and sometimes 
a distressing, jarring noise, like that of a mill or thresh- 
ing-floor, or the rattling of the shingles as a heavy wave 
of the sea recedes.” Samelsohn found cause in one case 
to suspect hemorrhage into the sheath of the optic nerve. 
A. von Graefe in his cases found nothing on immediate 
examination, but afterward atrophy of the optic papilla. 
Schweigger (Transl., Philadelphia, 1878) declares that 
the relation between loss of blood and disease of the 
optic nerve is wholly unexplained and that the latter can- 
not be due to simple anemia. 

Disorders in the sphere of the motor nerves may be 
either convulsive or paralytic. Kussmaul and Tenner 


225 


Brain, 
Brain. 


have shown conclusively that in rabbits convulsions are 
almost uniformly produced in cases of rapid, profuse 
hemorrhage, or where the great arterial trunks leading 
to the brain are ligatured, except in the case of very 
weak animals or in such as were under the influence of 
ether. They found, however, that closure of all four of 
the arteries, both carotids and both vertebrals, was neces- 
sary in order to produce rapid convulsions. In all their 
cases the convulsions weie epileptic in character. 

In man convulsions have been noticed in connection 
with fainting, from the earliest times. Hippocrates says 
in his Aphorisms: “ Zzacpodu yivovtac % id TAypdo.og 7} 
Kevootoc”” (convulsions arise either from plethora or from 
anemia). Marshall Hall, in his observations on blood- 
letting, declares that “convulsion is, after syncope, the 
most familiar of the immediate effects of loss of blood. 
It is most apt to occur in children and in cases of slow 
and excessive detraction of blood.” . . . And again: “It 
is most apt to occur in cases in which the patient has 
been freely bled in a more or less recumbent position, in 
which the blood has flowed slowly, or in which time has 
been lost during the operation.” 

Anzemic convulsions rarely occur except after hemor- 
rhage, when the amount of blood lost must be consider- 
able. The loss must occur all at once, or nearly so, and 
the patient must not have been previously in a much de- 
bilitated condition. Thus, children in a hydrencephaloid 
state, and persons suffering from chronic anemia, are 
not likely to be attacked with anemic convulsions. 

In contradistinction to convulsions complete paralysis 
without coma does not occur in universal cerebral anzemia, 
though after ligature of a carotid temporary hemiparesis 
and paralysis are not uncommon. If the paralysis be 
permanent there is probably some organic lesion pres- 
ent. 

The general weakness of the limbs in syncope may be 
regarded asa form of paresis. “Cheyne-Stokes respira- 
tion and Traube-Hering blood-pressure curves are very 
common in states of partial anzemia of the bulbar centres ” 
(Hill). 

The Dracnosts of anemia of the brain, except in those 
cases of partial aneemia due to the obliteration of blood- 
vessels, which do not come under consideration here, can 
be made only through consideration of the accompanying 
general symptoms. Inasmuch as in hyperemia of the 
brain the local symptoms are in many cases the same as 
in anemia, the differentiation of these two opposite con- 
ditions will depend much on the history of the case. 
Even the condition of the vessels of the face and head is 
no positive proof of the condition of the internal vessels, 
nor would an increase or diminution in the supply of 
blood in the retina afford more than a presumption that 
the same condition existed in the meninges. The condi- 
tion of the heart and the influence of vosture and of al- 
coholic stimulants afford further aid in determining the 
diagnosis. 

The PRoGNosis in common cases of syncope is decided- 
ly favorable, although even in ordinary cases of fainting 
from mental infliiences fatal results now. and then occur. 
Less favorable is it in cases due to severe hemorrhage, 
even when not complicated by shock. On the other 
hand, in those cases of acute syncope where we have 
reason to suspect some weakness or lesion of the heart, 
—for example, in all cases of cardiac disease, and in con- 
valescence after acute febrile diseases,—the prognosis is 
more serious. This especially applies to those cases in 
which the immediate cause of the syncope is some sud- 
den change of position. In cases of chronic anemia in 
the adult, syncope, as a rule, is not in itself a very seri- 
ous symptom, but whenever a prolonged coma occurs, 
especially if accompanied by convulsions, there is cause 
for anxiety. In the hydrencephaloid condition in chil- 
dren, if the patient be seen and the disease recognized in 
time, recovery is probable under judicious treatment. 
The prognosis must in all cases depend, in this as in 
other diseases, in great part upon the severity of the 
symptoms. - The condition of the pupils is said to form 
an important element in the prognosis, contraction al- 


226 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ways preceding dilatation, while they become normal 
again as the patient approaches recovery. 

TREATMENT.—In simple syncope from mental emotion 
or from reflex irritation but little treatment is needed, 
except that the patient should be placed in a horizontal 
position and should be allowed plenty of fresh air, when 
recovery generally occurs quickly. Stimulants, such as. 
ammonia, applied to the mucous membrane of the nose 
and air passages, are of assistance. As the syncope be- 
comes more severe, we employ cutaneous stimulants, the 
simplest and best of which is the sprinkling of cold water 
over the face and chest. Mustard may be applied to the 
skin, especially over the cardiac region; but the most. 
effective external stimulant is the electric brush. Internal 
cardiac stimulants, such as coffee, alcohol, or ether, are: 
often of decided benefit. The carbonic dioxide in cham- 
pagne is said to promote the rapid absorption of the al- 
cohol, and hence this form should, when convenient, be: 
used. In the severer cases, when the unconsciousness. 
becomes prolonged, especially in those in which the loss. 
of blood has been very great, the limbs should be ban- 
daged, so as to drive all the blood as far as possible into. 
the body and head. As a last resort, transfusion should 
be attempted. 

In cases of chronic anemia all means should be used 
to improve the general condition and strengthen the 
bodily forces. Milk is often the best form of nutriment, 
but when it can be borne a generous diet, including eggs. 
and meat, is advisable. Wine is frequently of benefit 
when given in suitable doses, and in severe cases it is- 
often indispensable. Alcohol is generally of much im- 
portance in cases of hydrencephaloid, and in these Noth- 
nagel recommends the early use of musk. In all cases- 
the surface of the body should be kept warm, if neces- 
sary, by the direct application of heat. 

When mental excitement exists, all cutaneous stimu- 
lants or irritants are to be avoided, as they are said to- 
increase the pain and restlessness. Under these condi- 
tions opiates often act well, better probably than chloral, 
which has also been recommended by good authorities. 

William N. Bullard. 


BIBLIOGRAPHY. 


Hall, Marshall: Medical Essays, London, 1825, 

Gooch: Account of Some Diseases Peculiar to Women, 1829. 

Abercrombie: Pathological and Practical Researches on Diseases of 
the Brain and Spinal Cord, Edinburgh, 1829. 

Hall, Marshall: Researches, Principally Relative to the Morbid Effects: 
of the Loss of Blood, London, 1830. Observations on Blood-Letting, 
London, 1836. Lectures on the Nervous System and Its Diseases, 
London and Philadelphia, 1836. 

Cooper, Sir Astley: Guy’s Hospital Reports, vol. i., 1836. 

Kussmaul and Tenner: On the Nature and Origin of Epileptiform 
Convulsions Caused by Profuse Bleeding, etc. Translated bv Bron-- 
ner, New Sydenham Society, 1869. (Original in Moleschott’s Unter-- 
suchungen, iii., Frankfort, 1857.) 

Nothnagel: Virech. Arch., Bd. xl., 1867. 

Jolly and Riegel: Virch. Arch., Bd. lii., 1871. 

Krauspe: Virch. Arch., Bd. lix. 

Fischer: Ueber den Shok. Volkmann’s Vortrage, No. 10. 

Nothnagel: Article, ‘* Anzemia, Hyperzemia, Thrombosis, and Embo-- 
lism of the Brain,’ in Ziemssen’s Cyclopeedia, vol xii., 1877. 

Jaccoud: Traité de pathologie interne, Paris, 1879. 

Ross: Diseases of the Nervous System, vol. ii., New York, 1888. 

Boston Medical and Surgical Journal, exi., No. 8, 1884. 

Green: Boston Medical and Surgical Journal, exi., No. 10, 1884. 

Hill: The Physiology and Pathology of the Cerebral Circulation,. 
London, 1896. . 

Obersteiner: Jahrb. f. Psychiatrie u. Neurol., xvi., 215, 1897. 


BRAIN AND NERVES, CHEMISTRY OF.—The pro- 
portion of water in the nervous tissues varies at different. 
ages and in different parts. It is more abundant in the 
gray than in the white matter and in early than in adult: 
life. In the gray matter of the adult it forms about 
eighty-five per cent. of the total constituents, in the: 
nerves about sixty-five per cent. 

The solids comprise the following: 

1. Proteids, including nucleo-proteids, globulins, and, 
according to some, albumins. 

2. Substances rich in combined phosphoric acid: nu- 
clein, protagon, lecithin. 

3. Complex nitrogenous substances, yielding a carbo- 
hydrate on decomposition and known as cerebrosides. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


4. Cholesterin, a complex alcohol (C.;H,,OH). 

5. Neurokeratin, a substance resembling ordinary ker- 
atin (from hair, etc.) and found in neuroglia and the 
medullary sheaths. 

6. Extractives: Kreatin, xanthin, hypoxanthin, inosit, 
lactic acid, uric acid. 

7. Inorganic salts. 

Several of the above call for a brief note. 

Nuclein is a compound formed by the union of a pro- 
teid with nucleic acid. Nucleic acid is phosphoric acid, 
P.O;, combined with a member of the purin group (xan- 
thin, hypoxanthin, adenin, guanin). 

Protagon, discovered in 1865 by Liebreich, was stated 
by Hoppe-Seyler and others not to be a definite substance 
but a mere mixture. Recently, however, its existence 
has been confirmed by numerous workers. Gamgee and 
Blankenhorn suggest CisoHsosNsPOs5, as its empirical 
formula, but others claim that it may be found in several 
closely related varieties. On decomposition it yields one 
of the cerebrosides and the decomposition products of 
lecithin (fatty acids, glycero-phosphoric acid, and cholin). 
It may be obtained as a loose, white powder. It dissolves 
in eighty-five per cent. alcohol at 45° C., but separates on 
cooling as a snow-white, flaky precipitate consisting of 
balls or groups of fine crystalline needles. 

The Cerebrosides are complex nitrogenous substances, 
yielding among their products of decomposition fatty 
acids and a carbohydrate (galactose). A number of 
varieties have been described, among which the best 
recognized are cerebrin, homocerebrin, and encephalin. 
Kossel and Freytag give the formula of cerebrin as 
C3 oHi40.N2013, and of kerasin or homocerebrin as C7oHise- 

On2. 

The relative proportions of the above-mentioned sub 
stances vary in different parts of the nervous system, but 
the following figures are probably approximately correct. 

The total solids vary from 10 to 40 per cent. and are 
made up as follows: Of the total solids: Proteids, 25 to 
55 per cent. ; nuclein, 1 per cent.; protagon, 5 to 10 per 
cent. ; lecithin, 10 to 80 per cent. ; cerebrosides, 0.5 to 10 
per cent. ; cholesterin, 10 to 50 per cent. ; neurokeratin, 
3 to 6 per cent.; salts, 0.5 to 2 per cent. 

The proteids are most abundant in the gray matter, 
cholesterin and the cerebrosides in the white matter. The 
salts are given as follows by Geoghegan in parts per 
1,000 of brain: 





POLAT ASD so 1s;0.0 e106 2 
Potassium ....... 0 
Sho15 0010 00 Ree OO A 7 
Magnesium 2 
Calcium ......... 09 


The reaction of the central nervous system, especially 
the gray matter, has been stated by many writers to be 
acid during life, but according to Halliburton it does not 
become so till shortly after death. 

T. Wesley Milts. 
William 8S. Morrow. 


BRAIN, ANEURISM OF ARTERIES OF.—Aneurisms 
of the cerebral vessels (independently of the miliary aneu- 
risms which are treated of in the discussion of Cerebral 
Hemorrhage) are comparatively rare, though Coats makes 
the surprising statement that, “in persons under forty 
years of age cerebral hemorrhage is due to the rupture of 
aneurisms in the great majority of cases.” 

These aneurisms are situated commonly on the arteries 
of the circle of Willis, and, according to Lebert, the ves- 
sels are affected in the following order of frequency: 
basilar, middle cerebral, internal carotid, and posterior 
communicating, and the artery of the corpus callosum. 
The middle cerebral and basilar are involved in more 
than half the cases. The other vessels are only excep- 
tionally the site of this lesion. Robertson reports a case 
in which an aneurism had burst into the right lateral 
ventricle. It wassituated on a branch of the right middle 
cerebral artery, and had hollowed out a bed for itself in 


the substance of the corpus striatum and optic thalamus. | of the vessel. 











Brain, 
Brain, 








According to the majority of writers, the vessels of the 
left side appear to be affected more frequently than those 
of the right side, but in Coats’ eleven cases all were situ- 
ated on the vessels of the right side of the brain. The 
male sex seems to furnish a mueh larger proportion of 
the cases than the female sex. 

The anatomical structure of cerebral aneurisms is en- 
tirely similar to that of similar lesions in other vessels of 
the body, and therefore need not be discussed here. They 
vary from the size of a pea to that of a hen’s egg, though 
tumors of the latter dimensions are extremely rare. As 
a rule, they do not exceed the size of a hazelnut. 

The immediate causes of the origin of this lesion have 
not been ascertained very clearly, but there appears to 
be little doubt that it does not bear such close relations 
to atheromatous degeneration as aneurismal dilatation of 
other vessels of the body. Ina considerable proportion 
of cases the aneurism is the result of embolism, and this 
explains its comparative frequency at an early age (endo- 
carditis, heart disease). Imperfect closure of the vessel 
by the embolus leads to inflammatory changes in the 
walls of the vessel, and, as the lumen is still partly open 
for the passage of blood, the weakened walls yield to the 
blood pressure and an aneurism is gradually produced. 

Syphilis acts in a similar manner by weakening the 
walls of the vessels. 

The lesion has also been attributed to the effects of in 
jury to the head. 

The aneurism produces various local effects. When 
situated in the circle of Willis it may cause erosion of the 
bones at the base of the skull. Asa matter of course, it 
also produces pressure on adjacent soft parts, and as the 
circle of Willis is usually involved, the various cerebral 
nerves are mainly subject to compression, then the me- 
dulla oblongata, pous Varolii, and crura cerebri. Klippel 
reports a case in which an aneurism of the right posterior 
communicating artery, as large as a wainut, had com- 
pressed the adjacent brain substance from the edge of 
the pons to the right optic nerve. During life the pa- 
tient had suffered from ptosis of the right side and com- 


| plete immobility of the right eye, with disturbance of 


vision on both sides. 

The aneurismal sac may also press upon adjacent ves- 
sels and give rise to thrombosis, with its usual train of 
sequences. In other words, the pressure effects are very 
similar to those of other forms of tumor situated at the 
base of the brain. An aneurismal murmur has been 
heard in a few cases, on auscultation of the skull. In 
still rarer cases this murmur has been heard by the pa- 
tient himself. 

When the aneurism is situated upon the basilar artery 
it is apt to giverise to hemiplegia. According to Lebert, 
this occurred nine times in thirty-one cases. Schmidt re- 
ports a case in which a diagnosis of cerebral hemorrhage 
had been made: 

A man, aged fifty-seven, had an apoplectic attack with 
unconsciousness, left hemiplegia, including the facial 
nerve; the pupils were sensitive to light; sensibility was: 
intact. The condition of the lower limb improved con- 
siderably, the arm became contractured. Death occurred: 
two years later from pneumonia. 

The autopsy disclosed a cylindrical aneurism of the 
basilar artery, extending from the lower end of the pyra- 
mids on the left to the corpora candicantia on the right. 
There was a depression of the pyramids in the medulla 
oblongata, and its edges were softened; also a depression 
in the pons, chiefly on the right side. There was distinct 
gray degeneration of the left lateral column of the cord 
and median bundles of the right anterior column. 

Although, as I have stated above, the symptoms of 
cerebral aneurism are usually very similar to these of 
other kinds of tumors situated at the base of the brain, it 
differs from them in the fact that choked disc is a very 
rare symptom in the history of the former affection. In 
this respect it is somewhat similar to cerebral abscess, and, 
like the latter, it may also remain latent until the occur- 
rence of a sudden apoplectiform attack, due to the rupture 
In quite a number of instances it has been 


227 


Brain. 
Brain, 


found that the first rupture of the vessel did not prove 
fatal, and that a second rupture occurred after a variable 
period, sometimes extending over a couple of years. 

The majority of writers assert that the rupture of the 
aneurism gives rise to meningeal hemorrhage; but this 
opinion should be revised in view of the fact that in all 
(eleven) of Coats’ cases, and in a number reported by 
other observers, the hemorrhage took place into the sub- 
stance of the brain. The extravasation is generally so 
extensive that it breaks through the brain tissue into the 
lateral ventricles, and often also into the other ventricles. 

Treatment of this affection is altogether futile. The 
most that can be done is to relieve the pain (which is 
often even more excruciating than that caused by other 
forms of cerebral tumor) by the administration of mor- 
phine. Trial may be made of potassium iodide, as, in 
aneurism in other parts of the body. 

Leopold Putzel. 


BRAIN, ATROPHY OF.—As applied to the brain, the 
term atrophy embraces the results of three different kinds 
of morbid processes. In the first two there is really 
atrophy in the ordinary meaning of the term—that is, 
loss of substance through previously existing disease. 
Thus: First, loss of substance, either from idiopathic 
disease inherent in the brain, progressive general paraly- 
sis; or associated with general disease, infectious fe- 
vers; or, from failure of nutrition, senescence, insanity. 
Second, loss of substance from destruction of tissue, or 
from a sclerosis secondary to localized destructive lesions. 
In the third class there is no proof that a tissue once ex- 
isting has been destroyed, and the term atrophy can be 
used only by a certain license. But for practical conveni- 
ence there are many reasons for ranking the cases in 
question with the atrophies. They are, third, cases of 
imperfect development of the brain, cerebral agenesia, 
partial or general (microcephalus). 

This classification of cerebral atrophies is traversed by 
another division into congenital and acquired; since 
many cases of arrested development of the brain are 
clearly traceable to diseases identical with those which 
occur after birth. The agenesia is then secondary, and 
except from its intra-uterine origin, could be referred to 
the second class of cases. 

CONGENITAL, PRIMARY, AND GENERAL ATROPHY OF 
THE BRAIN constitutes microcephalus, the rarest form of 
idiocy (Ireland). No destructive lesion is discernible, but 
the size of the brain as a whole is much below normal, 
and the internal proportion of its parts isdisturbed. The 
dimensions of the cranium correspond to those of the 
brain, and thus during life the size of the latter can be 
estimated by measurements of the former. Normal 
mental faculties are impossible with an adult head of 
from eleven to thirteen inches in circumference and from 
eight to nine inches from the root of the nose to the pos- 
terior border of the occipital bone. A circumference of 
fourteen to seventeen inches and an antero-posterior 
diameter of eleven to twelve decimetres implies a brain 
too small for ordinary intelligence (Voisin). Ireland calls 
microcephalic all adult heads below seventeen inches in 
circumference. 

The lightest human brain on record weighed six ounces, 
in a child five months old (Sanders). In this the circumfer- 
ence of the head was less than six inches. Several brains 
are described of seven ounces (normal weight for men, 
forty to fifty-two and one-half ounces; for women, thirty- 
five to forty-five ounces. In microcephalic brains, the 
frontal lobes taper to a point; the occipital lobes either 
taper, or are much shortened, in either case exposing 
more or less of the cerebellum. The parietal and temporo- 
sphenoidal lobes are the best developed. The corpus 
callosum is often thinned, or shortened at its posterior 
end. The island of Reil may be left uncovered. The 
convolutions are remarkably simple; few secondary folds 
are developed. The disposition of many sulci is changed, 
the fissure of Sylvius shaped like a V, instead of a Y 
(Vogt); the calcarine fissure is prolonged so as to sepa- 
rate the gyrus fornicatus from the gyrus hippocampi 


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(Putnam-Jacobi), the bridging convolutions of the occip- 
ital lobe are indistinct or wanting (Betz). Ina celebrated 
hypothesis, microcephalic brains have been considered to 
constitute anatomic reversion to the ape type (Vogt). 
There is, however, no constant resemblance between the 
two; the brain of the microcephale may be simpler than 
that of orang or chimpanzee, it is not similar (Gratiolet, 
Adriani). , 

The intelligence of microcephalic individuals who sur- 
vive is rudimentary, but at various degrees removed from 
imbecility, complete aphasic idiocy. There is no definite 
proportion between the degree of intelligence and the 
size of the brain. Inthose whoattain adult age a certain 
amount of speech is often possible, and there is some 
power of attention, memory, and emotionality. Some- 
times the amount of intelligence is remarkable, if we 
consider the dimensions of the cranium (case, Antonia 
Grandoni; circumference of head, at age of forty-one, 
thirteen inches). There is usually full and restless use 
of the limbs, and the impressions of the senses are lively. 
The absence of local or general paresis distinguishes cases 
of pure microcephalus from those in which the arrest 
of cerebral development is associated with destructive 
lesions. Sometimes, however, the muscles are notably 
feeble, the characteristic restlessness of microcephaly is 
exchanged for immobility, varied by rhythmic, swaying 
motions (Meynert). In these cases there is probably 
nutritive alteration of the brain tissue; or deficient 
elaboration of its minute structure (Jastrowitz). There 
may be persistence of the molecular substance which 
precedes the formation of the medullary sheaths to the 
nerve fibres, or of the large granular fat cells, which be- 
long to the transitional stage, and have been sometimes 
taken as evidence of congenital inflammation (Virchow). 

CONGENITAL PRIMARY (?) AND PARTIAL ATROPHY.— 
In this class of cases, one or more portions of the enceph- 
alic masses are absent, and no traces remain of destruc- 
tive lesions sufficient to account for their disappearance. 
Thus they have been explained by a primary aberration 
of development. The explanation is most plausible in 
regard to partial or total defect of the corpus callosum 
(Hitzig). This great commissure begins to develop 
toward the end of the fourth month,of pregnancy, by 
buds which appear on the internal lateral surfaces of the 
hemispheres, and grow simultaneously inward and back- 
ward. In partial defect it is the posterior portion of the 
corpus which is wanting, showing an arrest of the partly 
completed process. The arrest sometimes involves the 
fornix trigonum and septum lucidum, sometimes these 
are intact. In all recorded cases, the anterior white com- 
missure is preserved. The lateral ventricles are dis- 
tended. This fact suggests that an undeveloped corpus 
has been destroyed by a ventricular effusion, the latter 
subsequently reabsorbed. The cerebellum has several 
times been found defective. In one celebrated case, 
unique according to Hitzig, the organ was completely 
wanting, being reduced to two small knobs, at the base 
of a serous cyst which occupied its place under the ten- 
torium (Cruveilhier and Combetta, case Labrosse). 
Hitzig explains this case by an arrest of development; 
the author, much more plausibly, by a serous apoplexy 
which had occurred in early or in fetal life. The loss 
of the cerebellum was accompanied by total absence of 
the pons; the pyramids arising directly from the cerebral 
peduncles. In Otto’s case, the cerebellum was very much 
reduced in size by filling up of the occipital fossz, 
through inflammatory thickening of the bones. The 
atrophy was therefore again a secondary lesion. Atrophy 
of the cerebral hemispheres is usually evidently traceable 
to destructive lesions. Sometimes, however, the traces 
of these have disappeared, and the atrophy then seems 
primitive. Cruveilhier describes the reduction of one 
hemisphere to one-third the size of the other. The space 
beneath the dura mater was filled with serous fluid. Iso- 
lated groups of convolutions are often atrophied: thus, 
lower part of the central convolution, with supramar- 
ginal and superior temporo-sphenoidal (Beach); central 
convolutions on one side (Virchow’s Archiv, July, 1882); 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





central convolutions on both hemispheres (McNutt); 
right ascending parietal convolution (Bastian); right 
cerebrum, right crus, pons, and pyramid, left lateral 
pyramidal tracts (Pick); paracentral lobule, superior ex- 
tremity of left ascending parietal convolution (Varigny). 
In many of these cases a primitive arrest of development 
has been assumed; in none is it demonstrated, or even 
probable (Steffen, Brouardel, Hasse). The entire class 
of cases should therefore be consolidated with secondary 
atrophies. 

CONGENITAL SECONDARY ATROPHY.—This is partial or 
general, according either to the extent of the destructive 
lesion, or of the interference with the general develop- 
ment of the brain which may have been exerted by a 
localized lesion. Nutritive processes throughout the 
brain may be so disturbed that nerve tissues cease to 
grow, nutrition is diverted to the cranial bones, prema- 
ture ossification of the skull occurs, with some degree of 
microcephalus. 

On the other hand, with a fetal hydrocephalus, all 
the brain above the medulla may be destroyed and con- 
verted into a serous cyst, while the cranial bones con- 
tinue to grow, until after birth the head attains a cir- 
cumference of two feet (Cruveilhier). 

The lesions leading to congenital cerebral atrophy are 
produced during fetal life, and do not differ essentially 
from those which may be occasioned during the process 
of parturition, or so soon after birth that the symptoma- 
tology becomes identical with that of strictly congenital 
lesions. They are, in addition to the hydrocephalic effu- 
sions just mentioned, hemorrhage, inflammation, and soft- 
ening by steatosis. 

Throughout fetal life the rapidly growing brain is 
exposed to a graded series of accidents, corresponding to 
varying tendencies to effusions from the cerebral blood- 
vessels—now serous, now sanguinolent. At a certain 
degree of intensity these dropsies or hemorrhages result 
in complete malformation of the brain (hydrencephalon, 
or anencephalon); more limited in extent, the effusion 
results in the formation of a cyst, whose contents may 
be clear serum, or serum stained with the coloring matter 
of blood. The cyst replaces whatever nerve tissue has 
been destroyed. Intra-uterine cerebral hemorrhage is 
much more liable to occur into the meninges than into 
the substance of the brain itself. A clot is then formed 
in the cavity of the arachnoid, and lying upon one or 
both cerebral hemispheres, which it is destined to com- 
press during the process of its shrinkage. The subjacent 
tissues atrophy under the double influence of the pressure 
and of the sclerosis excited by its irritation. 

Precisely such arachnoid hemorrhage, with consecu- 
tive atrophy, is a not uncommon accident of a difficult 
parturition; and is thus the efficient cause of many cases 
of idiocy and spastic contracture. Hemorrhage is also 
possible, but much less frequent, during the first months 
or year after birth. The cerebral atrophy, however, can 
be called congenital only when dating from accidents 
which occur previous to all distinct psychic develop- 
ments, thus hardly after the first month. 

Meningo-encephalitis is, during the period immediately 
succeeding birth, more frequent than hemorrhage, and 
also occurs before birth. An intense form, occurring at 
the third or fourth month of pregnancy, is probably the 
cause of the pseudencephalic monstrosity. Traces of a 


more tolerable, and even extensive, grade of inflamma- » 


tion are found in thickened brain membranes, enclosing 
shrunken masses of nerve tissue, or even empty of these. 
All but the most limited and localized cases of menin- 
gitis are liable to be complicated by hemorrhage from 
the tender blood-vessels. Localized basal meningitis 
may interfere with the development of the brain, and 
thus, if the paradox be permitted, cause a species of 
primary atrophy, with premature ossification of the 
skull. The most striking effect of such lesion, from its 
proximity to the optic chiasma, is a descending neuritis 
and atrophy of the optic nerves. 

When a portion of the brain has been destroyed by 
either hemorrhage or inflammation, serum is poured out 








to fill the threatened vacuum. This non-encysted fluid 
is found both in the ventricles, in the cavity of the 
arachnoid, and in the subarachnoid space. It constitutes 
the so-called hydrocephalus e vacuo, which must always 
be interpreted asa secondary lesion, and not as the essen- 
tial cause of the symptoms observed during life. 

In certain cases a portion of the nerve tissue of the 
brain is found to have simply disappeared, sometimes 
throughout the entire depth of the hemisphere, thus 
leaving an opening which leads from the convexity pia 
to one of the ventricles (porencephalic defect, Kundrat), 
This lesion is not entirely peculiar to the new-born, for 
it has been found in adults after chronic brain disease 
(Cotard). In the new-born, however, it is due to a pecul- 
jar lesion, a steatosis of the nerve substance, which re- 
sults in red or white softening, according as it is or is 
not complicated by vascular congestion and capillary 
hemorrhage (Parrot). The foci of steatosis contain a 
great number of granular corpuscles, due to the fatty 
infiltration of neuroglia cells; also free granulations and 
species of cylinders, resulting from deformation of the 
corpuscles of Gluge. The veins are occluded by thrombi. 
The nerve tissue is reduced to a milky pulp, and, if the 
process lasts long enough, is gradually reabsorbed. The 
lesion may be circumscribed to a mass the size of a filbert, 
or may extend nearly throughout a hemisphere. In the 
first case it is usually multiple; in the second, the corpus 
callosum is the most affected. 

One of the most important anatomical consequences of 
any of the above-described lesions of the brain is a de- 
generation of the motor tracts which lead from the seat 
of the lesion to the lateral and innermost fasciculus of the 
anterior columns of the spinal cord (crossed and pyram- 
idal tract). This degeneration involves two elements: 
atrophy of the myeline sheaths of the nerve tubes, and 
proliferation of the neuroglia tissue between them. These 
elements are combined in various proportions, and when 
the atrophic process predominates, it is difficult to say 
that a simple agenesia of the spinal cord has not com- 
plicated an arrest of development of the brain. The 
fibres of the pyramidal tracts assume their myeline 
sheaths much later than the other segments of the cord, 
beginning at the fifth month; but they should be com- 
pleted at birth in the cord (Flechsig), though still incom- 
plete in the cerebral peduncles (Parrot). Simple defect 
of these sheaths, therefore, without sclerosis, might, at 
birth or a little before it, result from a check to the de- 
velopmental process, dating from some epoch of the 
sixth, seventh, or eighth month of intra-uterine life. <A 
lesion occurring during the last month, at birth or 
shortly afterward, can determine only atrophy of the 
myeline sheaths through propagation of a nutritive irri- 
tation, which is further revealed in a co-existing prolifera- 
tion of neuroglia. This, therefore, serves to distinguish 
between a primary and a secondary atrophy of the brain, 
the latter, except in steatosis, always involving irritation 
(see case McNutt). This degeneration can be traced by 
a column of grayish color, contrasting with the normal 
white, in the cerebral peduncle, half of pons and pyramid, 
on the same side as the lesion; and in the cord, through 
the posterior portion of the lateral column on the opposite 
side (Tiirck). A similar but much narrower gray tract 
occupies the inner part of the anterior column on the 
same side as the cerebral lesion. When the primary 
lesion is bilateral, the second is so as well. Under the 
microscope, the proliferated connective tissue is readily 
traced by its brilliant coloration with carmine. Descend- 
ing degeneration may be observed after the steatosis of 
the brain, but much more rarely and less completely 
than at other ages or after other lesions; a fact which 
Parrot attributes to the incomplete development of the 
cerebral portion of the pyramidal tracts. The same con- 
dition should tend to avert sclerosis after any lesions 
which occur early in fetal life. Conversely, in the cases 
in which the symptoms of “spastic paralysis” indicate 
an extensive amount of secondary sclerosis, we may date 
the primary lesion back to near the moment of parturition. 

According to Charcot, no cerebral lesions occasion sec- 


229 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ondary degeneration unless they involve the fibres of the 
anterior two-thirds of the internal capsule. These con- 
tain the superior fibres of the pyramidal tract. Atrophic 
lesions of the cortex are followed by diminution in the 
size of the corpus striatum on the same side, and, what 
is more singular, of the thalamus as well. The hemi- 
‘sphere of the cerebellum opposite to the lesion shares in 
the atrophy. When the lesion is localized primitively in 
one side of the cerebellum, the upper motor tracts are 
unaffected, but the olivary body on the opposite side 
wastes. Atrophic lesions of the basal ganglia are similarly 
followed by atrophy of the tracts below them, while those 
above remain unaffected. Lesions in the white substance 
of the hemispheres occasion no primary atrophy but 
what is due to direct loss of substance, and no secondary 
atrophy, unless they involve the fibres of the pyramidal 
tract (see wt supra). 

Symptoms of Congenital Cerebral Atrophy.—These are 
of two kinds: 1, Visible lesions; 2, disturbance of func- 
tions. 

1. Hemiatrophia facialis has been observed at birth, 
and then, plausibly, referred to a cerebral hemiagenesia 
(Emminghaus). No autopsies exist to confirm or annul 
this hypothesis. The hemiatrophia of the brain, if exist- 
ing, could be a coincidence only of the lesion of the tri- 
geminus, to which this singular affection is usually 
referred. The majority of reported cases are acquired 
after birth. 

Unilateral or even monoplegic atrophy of the limbs is, 
however, frequently in cerebral hemiatrophia associated 
with motor paralysis and different forms of rigidity of 
the same limbs. Of the three symptoms, the paralysis is 
alone congenital; the atrophy of a limb or a segment of 
a limb, as a hand, is associated with diminished size of 
Ferrier’s cortical motor centre for the part. It is ques- 
tionable whether the cerebral atrophy is then the cause 
or the consequence of the peripheric lesion. Similar 
wasting of the cortical motor centre has been seen in an 
individual in whom the leg had been amputated many 
years before death. The cerebral atrophy was there evi- 
dently secondary. Many cases of congenital loss of the 
segment of a limb are due to intra-uterine amputation 
through ligature by amniotic bands. The accident then 
essentially resembles that of extra-uterine life. 

Atrophy, in congenitally paralyzed limbs, appears 
after a time to be much more extensive than that of 
acquired cerebral paralysis. This is because the diminu- 
tion of size depends principally upon interference with 
development. There is not loss of substance once ac- 
quired, but the affected limb remains behind its fellow 
in growth. Structural defects of the eye and ear are not 
unusual; thus,coloboma of the iris, eyelids, or retina, de- 
formities of the external ear. Associated with the latter, 
as coincidently developed from the superior branchial 
arch, may be malformations of the mouth, harelip, cleft 
palate, etc. It is difficult to say, however, in what pro- 
portion the probability of such defects is increased by 
the existence of a cerebral atrophy compatible with life. 
Cerebral malformations of non-viable subjects are usu- 
ally associated with other malformations of the body. 

2. Disturbance of function. There are three in the 
motor sphere: Paralysis, rigidity, and convulsion; and 
to these must be added defect of intelligence. The sensi- 
bility is obtuse but not specifically affected. The paraly- 
sis is rarely complete, and by no means always localized. 
A general paresis of all the muscles of the body is the 
most frequent and earliest form of motor disturbance, 
even in well-defined unilateral cerebral lesions. The in- 
fant is able to move all its limbs, but cannot grasp with 
the hands, stand on the feet, sit up, or even hold its head 
up. Often after one, two, three, or four years the child 
acquires a certain amount of power in thisrespect. The 
motor paresis tends gradually to disappear, as in animals 
upon whom lesions of the cortical motor centres have 
been inflicted. When this happens, the cerebral lesion 
in children may also be referred to the cortex, and the 
basal ganglia be presumed to be intact. It is not infre- 
quent, even, that congenital cortical lesions which render 


230 











children incurably idiotic are unattended by any paraly- 
sis whatever. 

The symptoms of rigidity are especially interesting. 
The muscles of a single limb, an arm, may be affected 
with transient attacks of rigidity, but they rarely assume 
the permanently rigid contraction seen as a late symptom 
in acquired hemiplegia. The most characteristic form is 
the spastic paraplegia of the lower extremities. This is 
by no means exclusively due to cerebral agenesia, for it 
exists without cerebral symptoms, as a symptom of 
primary cord disease. But when it is congenital, asso- 
ciated with defective intelligence or disorders in the 
range of the cranial nerves, it may certainly be referred 
to atrophia cerebralis. Many entirely superfluous hy- 
potheses have been made in regard to this disorder. 
There are two forms. In one the muscles of the lower 
limbs are permanently rigid, and principally the abduct- 
ors of the thighs, the hamstring muscles, and the gastroc- 
nemii. From retraction of the rigid muscles the thighs 
are abducted, the legs partly flexed on the thighs, the 
feet on the legs. In the other form the muscles are sup- 
ple while the child is recumbent; but the attempt to stand 
or walk is immediately followed by spasm in the muscles 
indicated, or only in the abductors, so that the limbs are 
approximated or even crossed. 

The bilateral character of spastic paraplegia does not 
always imply a double lesion of the cerebrum, though 
this was demonstrated in one remarkable case (McNutt) 
and inferred in another (Hutchinson). The immediate 
antecedent of all the spastic symptoms observed is, as in 
the late rigidity of acquired hemiplegia, secondary scle- 
rosis of the pyramidal tracts in the lateral columns of the 
cord. Ninety-one to ninety-seven per cent. of the fibres 
of these tracts are normally crossed, the remainder direct 
(Charcot). The probabilities are, therefore, that the scle- 
rosis and rigidity remain limited to the side opposite 
the cerebral lesion. But in children bilateral spasm may 
occur, either because the relatively minute extent of scle- 
rosis on the same side as the lesion in the direct pyramidal 
tract exercises a greater functional effect, or because the 
proportion of decussating fibres has varied, leaving a 
much larger number in the direct portion of the tract, or 
because there has been a second decussation of motor 
fibres in the cord below the pyramids (Charcot). 

When spastic symptoms have developed, paresis of the 
rigid limbs is liable to be masked by them. 

The third motor symptom, convulsion, is irregular in 
the time and frequency of its occurrence, and variable in 
its intensity. Convulsions coming on within the first 
week or two after birth generally indicate that the cere- 
bral lesion upon which the atrophy depends has been 
caused during parturition. In cerebral atrophy of in- 
tra-uterine origin convulsions are delayed for several 
months after birth. They often coincide with the first 
symptoms of rigidity in the limbs, or precede these a 
little, and seem, therefore, to mark the development of 
the irritative lesion of degeneration. Convulsions are 
never due directly to the atrophy itself, but only to the 
secondary lesions, as they descend through the pons and 
medulla. The convulsion may consist in a momentary 
stiffening of the body, followed by clonic agitation of 
one or more limbs, or it may be a complete epileptiform 
paroxysm. The slighter forms are often frequently re- 
peated, sometimes even in a single day; the complete at- 
tacks occur at longer intervals, of weeks or even months. 
The close approximation of severe convulsions is danger- 
ous, and a not infrequent cause of death. The intel- 
ligence is invariably impaired when the atrophy affects 
either cerebral hemisphere, or both, and is often deficient 
even in atrophy of those portions of the encephalon 
whose share in mental processes is not well understood, 
as the corpus callosum or cerebellum. It is probable in 
these cases that the finer structure of the cerebral cortex 
is imperfectly elaborated, even when no gross lesion is 
visible. 

The degree of mental defect varies from simple flighti- 
ness and moral obtuseness (cases of atrophy of the cere- 
bellum) to complete idiocy, and all intermediate stages 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





of imperfection of the intelligence are observed. The 
speech is sometimes disproportionately affected. There 
may be complete aphasia, yet the expression of the face 
and the actions indicate considerable intelligence. It is 
possible, then, as Gerhardt suggests, that the lesion is 
localized in the speech centre. In other Gases there is 
no true aphasia, or inability to frame verbal conceptions, 
but articulation is interfered with by spasms of the facial 
muscles, analogous to those excited in the limbs by the 
attempt to use them. 

Complete idiocy can be recognized in babies of three 
or four months old by the vacant expression of face, the 
inability of the child to recognize its mother or nurse, 
its inattention to all the usual objects of baby interest, 
the absence of the smiles and cooings of a healthy child. 


The slighter the degree of mental defect the later is its. 


recognition possible, as it will become apparent only as 
the conditions of existence become complete. 

The cranial nerves are often involved in either the 
primary lesions which have caused the atrophy or in the 
lesions secondary to them. Optic neuritis with secondary 
nerve atrophy may occur independently of any conditions 
of increased intracranial pressure. It is then attributable 
to a descending cerebritis. Early blindness in an infant 
renders detection of mental defect difficult or impossible. 
With or without blindness, irritative lesions of the sixth 
or third nerve may occasion strabismus or nystagmus. 
Coloboma of the iris, as well as congenital defects of 
other parts of the body, is not infrequently present. 

ACQUIRED CEREBRAL ATROPHY.—This is always sec- 
ondary, but may be general or partial. 

General atrophy of the brain is found to a certain ex- 
tent in all prolonged wasting diseases, especially phthisis. 
It is conspicuous in senile decay, but is not associated 
necessarily with any particularage. The brain is heaviest 
at thirty, but while some brains begin to degenerate at 
sixty, others resist decay at eighty or even older. The 
brain is always wasted in alcoholism, and also in chronic 
insanity, usually as a whole, sometimes more markedly 
in one hemisphere, or in certain lobes, especially the 
frontal. The most conspicuous general atrophy is seen 
in diffuse meningo-encephalitis (general paresis of the 
insane). The total weight of the brain may sink in this 
disease below 1,000 gm. (minimum normal weight for 
man, 1,130 gm.), and abundant serum may accumulate 
in the sulci. The frontal lobes are the most shrunken; 
after them the central convolutions; the cerebellum is 
always intact (Hitzig). 

In all cases of chronic insanity, and most markedly in 
those of general paresis, the ganglionic cells of the cortex 
degenerate, become filled with fatty and pigment gran- 
ules, and lose their protoplasm, nucleus, and axis cylin- 
ders. 

In general cerebral atrophy both hemispheres are found 
sunken, retreating from the cranial bones, and the con- 
volutions are thin and small, separated by wide furrows. 
In these enlarged sulci, as also in the dilated lateral and 
third ventricles, a serous effusion replaces the brain sub- 
stance, as in congenital atrophy. The cortical cover of 
the ventricles may be so atrophied that the arachnoid and 
pia come in contact with the ependyma entirely, or in 
limited spaces, constituting an acquired porencephaly. 

Generalized atrophy may also result from localized 
lesions of the cortex, whose ganglionic cells seem to have 
an influence on the general nutrition of the brain, an- 
alogous to that of the ganglionic cells of the cord on the 
peripheric nerves. Finally, mental inactivity predisposes 
the brain, as other unused organs, to atrophy. Thus 
probably is explained the frequeney of premature senile 
atrophy among peasants and other uneducated people. 

Partial atrophies occur at the seat of a destructive 
lesion, and also in regions functionally correlated with 
this. Of such lesions, hemorrhage is relatively less 
prominent than in fetal life: embolism and thrombosis 
from atheroma of blood-vessels are the most frequent. 
Both are attended by red or white softening, or even by 
true localized encephalitis; the brain cortex may be in- 
filtrated with leucocytes following the track of blood- 


vessels, and evidently exuded from them; and also with 
the granular corpuscles of Gluge, resulting from fatty 
infiltration of neuroglia cells. To these processes are 
due the characteristic yellow patches so frequently found 
on the cortex of the brain, varying from an entirely in- 
significant size to the entire surface of a hemisphere, and 
sometimes penetrating its entire thickness (Cotard). 
Cysts and sclerosis may be found in adult life as in con- 
genital agenesia, and the waste of nerve tissue may re- 
sult, in either case, in simple defect; but the yellow 
patches are peculiar to acquired atrophy. The cysts are 
surrounded by an ochre-colored zone, where the nerve 
tissue has been stained by hemorrhagic effusion. Local- 
ized meningitis, or the outward-bearing pressure of a 
ventricular effusion, may also determine atrophies, either 
partial, or, in the latter case, symmetrical and general- 
ized. 'Tumorsof the brain necessarily determine atrophy 
of the nerve tissue they replace; but on their periphery 
there is an irritative hypertrophy, due, however, to pro- 
liferation of the neuroglia cells (Adamkiewicz). A band 
of this same sclerosis surrounds the focus of any destruc- 
tive brain lesion. In senile atrophy occurs the vacuola- 
tion of the brain, long knownas “1’état criblé ” (Durand- 
Fardel), due to the enlargement of the lymphatic spaces 
surrounding the blood-vessels. This dilatation results 
from prolonged and intense hyperzemia. Hasse observes 
that in partial atrophy the primary destructive lesions 
affect all elements of the brain substance; in secondary 
atrophy the nerve elementsalone. But in general diffuse 
atrophy, as from diffuse meningitis, an irritative process 
is first initiated in the neuroglia, and the nerve elements 
gradually waste. A linear cicatrix never forms in the 
brain, whose tissues are incapable of retracting; but 
there is always a space to be filled by a liquid, or by 
débris, or by newly formed connective tissue. 

The symptoms of acquired cerebral atrophy are essen- 
tially the same as those of cerebral agenesia, but differ- 
ently combined, and existing in different proportions. 
When the lesion occurs in adult life, it can cause no 
arrest of development in the limbs, such as is so common 
in agenesia. Partial paresis or paralysis may be pro- 
duced when the lesion is situated in the motor tracts. 
But superficial patches of atrophy of the central con- 
volutions may be found in persons who had completely 
recovered from the paralysis caused by the initial lesion. 
As in agenesia, the rigid contractions of paretic or para- 
lyzed muscles develop together with the secondary de- 
generations; the “late rigidity ” of hemiplegics is not the 
immediate consequence of the primitive lesion. This 
rigidity occupies by preference the superior extremity, 
and is often confined to that, even when the lower ex- 
tremity is also paralyzed. It acts in the sense of flexion, 
so that the arm is drawn to the side, the forearm partially 
flexed, the two last phalanges of the fingers flexed, while, 
from atrophy of the interosseous muscles, the first phalanx 
is allowed to be extended. Hence results the “claw- 
hand” as characteristic of hemiplegia. Tremors, local- 
ized clonic cramps, and general epileptiform convulsions 
occur. The latter may precede the cerebral atrophy and 
indicate the progress of a localized meningitis, of which 
this atrophy is to be the result; or they may indicate the 
progress of a descending sclerosis toward the pons; or 
they may announce the termination of the whole morbid 
process. Convulsions are most frequent with lesions of 
the cerebellum, the cerebral cortex, and the ventricles; 
but these belong to the primary process, not to the 
atrophy itself. In the former case other symptoms 
coincide—febrile attacks, temporary strabismus, irregu- 
larities of the pupils, headache. In the latter any mental 
deficiency previously existing deepens, even to dementia, 
and as the end draws near the patient becomes comatose. 
In the atrophy of general paresis, the loss of muscular 
power is an early and prominent symptom. There is no 
rigidity. The mental defects in acquired cerebral atrophy 
are even more varying in nature and degree than the 
motor symptoms. Sometimes for many years these may 
be absolutely nil; then, if the atrophy progresses, the 
mental powers become gradually impaired. Simple fail- 


231 


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ure of the intelligence is usually proportioned to the ex- 
tent of the lesion; qualitative alterations of special 
faculties bear a more or less definite relation to the seat 
of the lesion. The dissociations of the speech faculty 
are numerous, giving rise to aphasia, amnesia, agraphia, 
alalia, and their combinations. Failure in memory, as in 
all chronic cerebral disease, is one of the earliest mental 
defects; the moral sense, dependent on the ethical mech- 
anisms, the most delicate of all (Griesinger), is blurred. 

Localized atrophies have been of great service in in- 
vestigating the problems of localization in cerebral func- 
tions. 

Prognosis of cerebral atrophy depends upon the extent 


of lesion, and upon its stationary or progressive charac- . 


ter. When only a limited amount of brain tissue is de- 
stroyed, its function may be vicariously performed by 
another portion, and the loss thus repaired. This is im- 
possible with extensive acquired lesions. In the famous 
cases of congenital atrophy of the cerebellum or corpus 
callosum, however, the functions of these parts must 
have been performed by other organs, for their defect 
could not be diagnosed during life. 

A broad distinction exists between the prognosis of con- 
genital and that of acquired atrophy, in that the former 
far more frequently coincides with an arrested morbid 
process, the latter with one that is either continuously 
progressive or liable to renewal after temporary arrest. 
The mental defects due to atrophy of any portion of the 
adult brain cannot be repaired; the utmost to be expected 
is their limitation; the probabilities are that they will 
steadily or intermittently increase. On the contrary, in 
a brain partially atrophied while still in process of de- 
velopment, a vigorous psychic education may often hope 
to develop faculties by exercise of the intact portions. 
The difficulty of doing so increases with any form of dis- 
turbance of the speech faculty. Congenital paresis tends 
spontaneously to diminish, and muscular power may 
be greatly increased by systematized gymnastics. The 
paresis of acquired atrophy, unlike the paralysis due to 
destructive lesions, tends to permanence or to increase; 
the latter case being the rule in the general paresis of the 
insane. Muscular rigidities, contractures, and the de- 
formities of limbs caused by them, increase for a long 
time in congenital cases, first as a result of the extend- 
ing spinal degeneration, then as a consequence of malposi- 
tion and adaptive shortening. The latter cause may be- 
greatly palliated by appropriate apparatus; and the 
prognosis in respect to deformity, and to the power of 
walking and other use of the limbs, is hopeful in direct 
proportion to the influence of malposition, and inversely 
to that of the lateral sclerosis. Corresponding to the 
lesser extent of the brain lesion, the deforming contract- 
ures of acquired atrophy are much more limited, and 
therefore of less importance; their degree of amenability 
to therapeutic palliation is about the same. General ac- 
quired atrophy is not followed by deformity, for all the 
muscles are equally affected. The duration of life is 
quite indefinite. Death is never the direct consequence 
of the atrophy, but results from asthenia due to the pro- 
gressive impairment of brain nutrition; from cedema, as 
the walls of the blood-vessels become more altered; from 
convulsions, especially associated with extension of sec- 
ondary irritation; or from renewal of the primary ac- 
cidents (hemorrhage, thrombosis, meningo-encephalitis, 
etc. ). 

Treatment is palliative, and in the directions implied in 
the remarks on prognosis. The primary morbid process, 
if still going on, must be treated by appropriate meas- 
ures; and an important point of the diagnosis is the de- 
cision whether this primary process is or is not arrested. 
In congenital atrophy, the mental faculties must be 
awakened as far as possible by psychological education, 
which, to attain the end, must be both persevering and 
profound. The muscular paresis must be combated by 
gymnastic exercises, the deformities by apparatus able 
gradually to stretch retracted muscles, to support limbs 
in proper position, and by means of springs and artificial 
muscles to facilitate attempts at voluntary movements. 


232 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





The proposal to relieve the deformities due to rigidity of 
the adductor femoris muscles by circumcision—an opera- 
tion intended to relieve a hypothetical genital irritation 
—is most irrational. If relief ever follow this operation, 
it can be only in cases of entirely different character, a 
purely functional spasm, possibly associated with mas- 
turbation, and having nothing to do with lateral sclerosis 
of the cord. The convulsions which are so common in 
congenital atrophy require the usual treatment. For 
the eye symptoms (blindness, strabismus, nystagmus) 
nothing can be done. 

In acquired atrophy treatment mainly consists in avert- 
ing conditions which are likely to revive the primary 
accidents, and in treating these as they arise. The earlier 
in life the cerebral lesion occurs the more the conditions _ 


‘approach those of congenital atrophy; and when the ac- 


cidents date from the first years of childhood the prac- 
tical treatment is identical for the two classes of cases. 
Conversely, as a patient approaches old age, both the 
primary accidents and the atrophy are more liable to be 
progressive, and the role of the therapeutist becomes 
more purely passive. There can be no longer question 
of developing a brain, checked in its evolution, but only 
of shielding it. from new injuries which would cause 
fresh deterioration of faculties; hence mental strain and 
excitement of all kinds are to be avoided. The key- 
note of the treatment is the necessity for repose for the 
nervous processes proper and for the cerebral circulation. 
Regulation of the social medium is the principal factor 
for the first; of exercise and climate for the second. 
Apparatus for deformity is less needed and less tolerated 
than in children. The contractures principally affect 
the upper extremities, instead of, as in children, the 
lower; and it is much more difficult to facilitate the 
functions of the arms than of the legs by prothetic ap- 
paratus. Still, with ingenuity, this may sometimes be 
accomplished. 

Diagnosis.—In congenital or early cases it is principally 
necessary to distinguish between primary and secondary 
cerebral atrophy, and bétween the latter and the various 
lesions upon which it depends, as hydrocephalus, hemor- 
rhage, meningo-encephalitis. Primary atrophy may be 
inferred from deficient or idiotic intelligence, without 
motor disturbances or lesions of the special senses, while 
hydrocephalus may be excluded from the size of the head. 
The extreme degrees of diffuse primary atrophy consti- 
tute microcephalic idiocy, and are recognizable usually 
from the minute proportions of the cranium. The diag- 
nosis cannot, however, always be made, for, though 
rarely, large portions of the encephalon may be absent, 
without any more defect in the intelligence than is often 
observed without gross cerebral lesion at all. And, on 
the other hand, the destructive lesion causing a secondary 
localized atrophy may be so limited that the descending 
degeneration occasions no characteristic symptoms, yet 
the finer mechanisms of the brain may be so jarred that 
the evolution of the mind is permanently impaired. In 
any case in which the associating fibres or the super- 
added convolutions (Broadbent) are affected, while the 
motor fibres prolonged from the crus remain intact, im- 
becility with preservation of muscular function is pos- 
sible. In secondary atrophy, if the primary morbid 
processes have been arrested before they bave been dis- 
covered, or at birth, it is often difficult, in the latter case 
impossible, to distinguish between them. Congenital 
hydrocephalus is recognizable when the head is already 
enlarged at birth, and may be a cause of dystocia. 
When the head begins to enlarge within a few weeks 
after birth, it is probable that ventricular effusion has 
already begun before. The probability is greater if 
spina bifida coexist. In such cases it is sometimes the 
symptoms of the effusion, sometimes those of the atrophy 
and spinal sclerosis, that predominate. An extra-uterine 
cerebral hemorrhage or attack of meningo-encephalitis is 
indicated by the usual signs; but these are liable to be 
masked in infancy by convulsions and fever, common to 
both, and also to so many other infantile disorders. Per- 
sistence of an inflammatory process may be indicated by 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





irregular recurrence of fever, associated with pain, re- 
traction of head, pupillary symptoms, and other charac- 
teristic signs of meningeal irritation. Still these may 
also be aroused by the irritative process of degeneration, 
especially when this reaches the motor tracts in the pons 
and medulla. It may be said that in secondary atrophy 
at any age, the diagnosis may be made by the coincidence 
of three symptoms: mental defect, muscular paresis, and 
muscular contracture; these coming on gradually or after 
a period of stormy cerebral accidents. The various other 
symptoms enumerated may or may not be present; 
among them lesions of the cranial nerves are of the same 
order as the rigidities of the limb muscles, and, like them, 
may be referred to the descending sclerosis accompany- 
_ing the atrophy. Convulsions and fever may be due to 
this or to persistence or revival of the primary process. 
Mary Putnam-Jacobi. 


BRAIN: CEPHALOCELE.—(Synonyms: Encephalo- 
cele, Hydrocephalocele, Hydrencephalocele, Cephalhy- 
drocele, Meningocele, Hydromeningocele, Craniocele, 
Hernia seu Fungus seu Ectopia Cerebri). Hernia of the 
brain or meninges is a name given to a protrusion of a 
portion of the contents of the cranial cavity through an 
opening in the skull beneath the scalp. There is need of 
greater simplicity in what is now a rather confusing ter- 
minology, and it would seem that the best designation for 
all of these tumors as a class is cephalocele. There isa 
correspondence in application between this word and en- 
terocele because of the similarity of their constituents. 
There is a hernial canal or opening in the skull, a hernial 
sac consisting of the dura mater, the hernial contents com- 
posed of whatever substance or fluid may be forced out 
from the cranial cavity, and, finally, the various coverings 
of the hernia, such as the pericranium, fascia, and skin. 
It is necessary, in a true cephalocele, that the dura mater 
form the hernial sac. The tumors formed beneath the 
scalp in traumatic lesions of the skull and dura, by the 
pouring out of cerebro-spinal fluid, are not true cephalo- 
celes, and are more properly termed pseudo-meningoceles. 
Protrusion of brain substance in compound fractures of 
the skull is not considered here, though sometimes im- 
properly called a hernia cerebri; the correct designation 
is prolapsus cerebri. 

The varieties of cephalocele depend upon the contents 
of the tumor. Hence we have a meningocele where the 
hernial contents are cerebro-spinal fluid alone pressing 
out the dura mater; a hydrocephalocele, where the tumor 
consists of an internal hydrocephalus expanding and 
forcing outward the ventricular walls; and, finally, an 
encephalocele, composed wholly of brain substance with 
more or less fluid usually surrounding it. 

These tumors are mostly of congenital origin, but 
there are certain rare cases in which they are acquired 
after birth, through disease of the cranial bones or trau- 
matism. It is usual, therefore, to distinguish two forms 
of cephalocele, the congenital and the acquired. In de- 
scribing the latter it will be best to use the prefix pseudo. 

CoNGENITAL CEPHALOCELE.—These tumors almost al- 
ways have their peduncles at or in the immediate neigh- 
borhood of some cranial suture. The great majority are 
in the antero-posterior median line, as a rule either in the 
frontal or in the occipital region. According to Giovanni 
Reale, who collected 68 cases of cephalocele, 10 were at 
the nasal root, 9 in the frontal suture, 5 at the posterior 
fontanelle, and 22 in the occipital bone, the rest arising 
from some of the lateral sutures. Larger tabulated 85 
cases, 44 of which were occipital and 41 frontal or sin- 
cipital. The favorite location of the sincipital tumors is 
at the root of the nose, either at the inferior part of the 
frontal suture or at the junction of the ethmoid and 
frontal bones. The hernial canal or opening is generally 
bounded by the separated or more or less malformed 
ethmoid, frontal, nasal, or lachrymal bones, and some- 
times even by the nasal process of the superior maxilla. 
Fenger (Am. Jowr. Med. Sciences, 1895, cix., 1), in an 
article entitled “Basal Hernias of the Brain,” describes 
such sincipital tumors as differ from the others in not 








protruding in the face. The least uncommon form is 
the spheno-pharyngeal cephalocele, protruding into the 
nasal or naso-pharyngeal cavity. These may be more 
common than is supposed. They may be mistaken for 
nasal polyps. The occipital cephaloceles are the most 
frequent of all. They are situated either in or near the 
posterior fontanelle, or lower down under the occipital 
protuberance, where the hernial opening may be con- 
joined with the foramen magnum. Hernial protrusions 
from other sutures are much more rare, although they do 
occur in the greater fontanelle, in the squamous suture, 
or between the ethmoid and sphenoid bones at the base 
of the skull. 

Cephalocele is uncommon, Trélat finding but 3 in 
12,000 births, and Vines 1 in 5,000. It is said to be more 
common in females than in males, though Z. Lawrence, 
quoted by Erichsen (“ Surgery, ” vol. ii., p. 878), collected 
39 cases, 21 of which were males. 

The tumors vary in size from that of a pea to that of 
a child’s head. The occipital are always the largest, and 
are usually hydrocephaloceles. The sincipital tumors 
are, aS a rule, small and simple encephaloceles. Menin- 
goceles may exist in either place, but are more common 
behind. Hydrocephaloceles are rarely sincipital, owing 
to the positions and conformations of the ventricles, 
which are more apt to dilate posteriorly. 

The occipital hydrocephaloceles are usually constricted 
at their base, often pedunculated, almost globular in 
form, and seldom attached by broad bases. They gen- 
erally contain the dropsical posterior horns of the lateral 
ventricles or their fetal analogues. Those in the lower 
occipital region enclose the cerebellum and the hydropic ' 
fourth ventricle. In some of the largest hydrocephalo- 
celes have been found a great part of the cerebrum, the 
cerebellum, the fourth ventricle, and the quadrigeminal 
bodies. The protruding cephalic parts are commonly of 
inferior or defective development, often difficult to recog- 
nize as brain substance, owing to cystoid degeneration and 
sclerosis (Huebner). P. Berger (Revue de Chir., 1890, x., 
269) reports an extirpation of an encephalocele and a case 
by a colleague (Périer) in which both specimens were care- 
fully examined by Ranvier and Suchard, showing features 
not hitherto described. In both were found histologically 
a mixture of nervous elements of both cerebrum and cere- 
bellum without lines of demarcation, and Berger regarded 
these tumors as forming a variety of central neuromata 
such as have been described by Virchow (tumors formed 
in the ventricles of subjects afflicted with congenital hy- 
drocephalus). Berger proposes the term encephalome for 
this species of encephalocele. Sometimes the constriction 
at the hernial opening is so great that there is marked stasis 
of blood in the pia, which may lead even to extravasa- 
tions. Occasionally these tumors present longitudinal 
constrictions caused by the venous plexus or by the falces 
of the dura. The quantity of fluid contents varies, but 
may reach two quarts. It has been found to be rich in 
albumin, with a specific gravity of 1.010-1.012. 

The meningoceles of the occipital region are quite as 
large as the hydrocephaloceles, and similar in shape, 
while those of the sincipital and lateral areas of the skull 
are much smaller. One very large meningocele held fluid 
which had a specific gravity of 1.004, and contained a 
small quantity of albumin, uric acid, chloride of sodium, 
and biliary coloring matters (Heineke). 

The encephaloceles are usually small tumors with broad 
bases, having a diameter as a rule between 1 and 3 cm., 
generally occupying a position at the root of the nose, 
and containing often, besides cerebral substance, a small 
quantity of subdural fluid. 

Pathology.—There are several theories advanced to ac- 
count for the origin of these congenital tumors. One is, 
that there is a limited ventricular dropsy, which by 
pressure at some certain circumscribed portion of the 
skull expands and separates the cranial bones and thus 
protrudes. From a hydrocephalocele thus formed an 
encephalocele may be produced later, by reabsorption of 
the dropsical fluid; or a meningocele, by a recession of 
the cerebral substance into the cranial cavity. The 


233 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





arguments against this hypothesis are, that there would 
scarcely be a circumscription of the dropsy as imagined, 
but rather a tendency to a general hydrocephalus; and, 
furthermore, Ackermann and Heineke have determined 
that there is a diminution, and not an increase, of intra- 
cranial pressure in cases of cephalocele. 

A more probable theory as to the etiology of these 
tumors is, that they originate in the early embryological 





Bes Fe ae 


Fic. 809.—Double Cephalocele, in Which the Anterior Tumor is Coy- 
ered by the Skin, the Posterior by the Dura Mater. (After Taruffi.) 


periods, when the cerebral vesicle and its fluid contents 
are in process of growth, and their osseous capsule is not 
yet developed. There is then an arrested or defective 
evolution of the cranial vault, as a result of which com- 
plete closure of the skull does not take place, and a cir- 
cumscribed portion of the fetal brain vesicle protrudes. 
According to this hypothesis, hydrocephalocele would 
belong to an earlier stage of development, and encephalo- 
cele to a later, when the protruding portion of brain no 
longer exhibits the configuration of the fetal brain vesicle 
as it does in the former. In like manner, meningocele 
may originate either by the mere extrusion of the dura 
mater through pressure of the subdural fluid, or by the 
bursting of a hydrocephalocele, or it may be the remnant 
of a disorganized encephalocele. Meningocele might also 
spring from the cerebral vesicle in the earliest stages of 
development, as a mere membranous cyst without brain 
substance. Yet, if the defect in the skull were the only 
factor in the formation of these tumors, it would be diffi- 
cult to understand why they are not present in every 
child in the open cranial spaces, the fontaneiles. We 
are compelled, therefore, to recognize, as another factor 
in their causation, a general or partial hydrocephalus, 
either internal or external. 

This conception of the embryological origin of cephalo- 
celes is corroborated by the fact that most of them are 
found in front of and behind the head, in the median line, 
which is the most marked direction of growth of the 
cerebral vesicle; and that other defects and malforma- 
tions of the skull, face, spine, feet, etc., are often ob- 
served in connection with these cases. Thus, striking 
departures from the normal shape of the skull are par- 
ticularly noticeable in hydrocephalocele and the large 
meningoceles, where there is often asymmetry, thicken- 
ing of the sutures, microcephalus, flattening from before 
backward, and sometimes hydrocephalus; while in the 
simpler tumors the skull presents, as a rule, a wholly 
normal configuration. 

What may be the ultimate causes of these defects can 
only be surmised. Premature union of the meninges 
with the amnion, and injuries to the fetal head in utero, 
may sometimes be the occasion of their development. 


234 











Benger (doc. ett.) reviews all the theories in detail (intra- 
cranial pressure from limited dropsy, arrest of fetal 
cranial development, fetal craniotabes) and_ believes 
himself that an encephalocele is a primitive protrusion 
of part of the brain previous to the formation of the 
cranial vault. He agrees with Fleischmann and Niemeyer 
that the cause of a simple encephalocele may lie in a 
hyperplasia of brain substance. 

Lindfors occupies a whole number of the Klin. Vortrdge 
(Leipsic, 1898, Nos. 222, 228) with a discussion of the his- 
tory, etiology, and surgical treatment of congenital cere- 
bral hernias, bringing the whole subject well up to date 
(April, 1898), and citing three full pages of literature. 
He believes there are many different forms and a variety 
of causes, that even within one class there may be special 
individual modifying causes. The etiology of hydren- 
cephalocele is probably the same as that of hydrocephalus, 
but acting in a limited area. In other varieties, hydro- 
cephalus, new growth, hygroma of meninges (Virchow), 
amniotic adhesions, rachitic condition of bones, may all 
have a place in the etiology of special cases. 

Clinical Features.—The cutaneous surfaces of the 
cephaloceles are usually smooth, more or less distended, 
and sometimes very vascular. Occasionally they are ex- 
coriated, or present old cicatrices. Angiomata and lipo- 
mata have been described as forming upon cephaloceles 
(Larger, Ried). Hydrocephalocele and meningocele ex- 
hibit a distinct sensation of fluctuation, while the enceph- 
aloceles have more of a sensation of softness and elas- 
ticity, but also show fluctuation if surrounded by a 
sufficient quantity of fluid. When the coverings are 
thin, from great tension by fluid contents, these tumors 
may be translucent. They frequently pulsate synchro- 
nously with the pulse and respiratory movements; and 
their tension is often variable, as there may be a sinking 
of the tumor in sleep, and marked bulging out in the 
acts of crying or coughing. They may sometimes be 
diminished in size by pressure, which if moderate does 
no harm, but if great not infrequently produces symp- 
toms of brain compression, such as vomiting, retardation 
of the pulse, unconsciousness, and convulsions. Pulsa- 


tion is, as a rule, absent in meningocele and hydro- 
cephalocele, but this naturally depends directly upon 
the size of the hernial opening in the skull, and the inter- 
communicability of the contents of the sac with those of - 





Fic. 810.—Section of Cranium in a Case of Sincipital Cephalocele. 
(After Vannoni.) 


the cranium; these tumors also show generally little 
variation during sleep, coughing, or crying, or upon 
the application of pressure, unless the hernial foramen is 
large. Symptoms depend to a great extent, too, upon 
the physiological value of parts protruded; and in ceph- 
aloceles such parts are often very different from their 
analogues in the normally developed brain. In the light 
of the recent discoveries in cerebral localization these 
cases might often afford very interesting results by care- 
ful study. 
Prognosis.—Many children affected with meningocele 
or hydrocephalocele die before or during birth. Some- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





times the tumor bursts during parturition. Those born 
living rarely last many years, partly on account of the 
imperfect conditions of their brains, and partly because 
the tumor often rapidly increases to such size, by the 
superaddition of cerebro-spinal fluid, that it bursts spon- 
taneously, causing death either speedily, in coma or con- 
vulsions, or slowly, from a consecutive meningitis. Re- 





Fic. 811.—A Case Observed by Dr. Irving C. Rosse, of Washington, 
D. C.? 


covery after such evacuation of the tumor takes place 
but rarely. Death occurs usually in the first two or three 
years of life, but a few children with meningocele have 
attained the age of twelve, and even seventeen years. 

The encephaloceles being smaller and simpler than the 
varieties just mentioned, still-birth and rupture are less 
common in cases affected with them, although they do 
occur. As a rule, this class either grows slowly or re- 
mains stationary. Whatever disturbance is excited is 
due to disorder of brain function, but patients suffering 
from the frontal variety live longer and with fewer cere- 
bral symptoms than those afflicted with the occipital 
variety. Children with occipital encephaloceles are gen- 
erally idiots, whereas with the frontal or sincipital tumors 
they are more commonly of quite normal intelligence. 
Many have reached adult age. 

Spontaneous recovery from encephalocele and menin- 
gocele has occurred, according to the observations of 
Wernher, Textor, von Bruns, and Held, by closure of the 
cranial defect and the complete isolation of the tumor as 
a cyst on the outside of the skull. Operative procedures 
have proved successful in some instances. 

Diagnosis.—Every tumor of congenital origin situated 
along the median line of the head, in the region of the 
root of the nose or in the glabellar or occipital regions, 
should excite suspicion of a cephalocele; and defects or 
malformations in other parts of the skull or body would 
be corroborative evidence. The fact of its being con- 
genital must first of all be determined; then its relation 
to the various cranial sutures. The diagnosis is easy 
when the tumor is in one of the situations that have been 
described, when there are pulsation and a sensation of 
fluctuation, when there isa change in tension during sleep 
or in crying, and when there is a recession of its contents 
into the skull upon pressure. If, at the same time with 
the recession of the brain substance or cerebro-spinal fluid, 
symptoms of irritation or compression of the brain de- 
velop, if there is an increase in the pulsatory or respira- 





* The case shown here is that of an illegitimate male child of eight 
months. The tumor, about the size of a walnut, protruded from an 
opening in the right parietal bone just above and behind the protu- 
berance. The child was club-footed, ectrodactylic, and had double 
harelip. Being unable to feed, it died after three days from inanition. 
The mesenteric glands were found to be enlarged.—I.C.R. | 


Brain, 
Brain, 





tory brain movements, and particularly if the edges of the 
hernial opening in the skull can be felt, a cephalocele is 
certainly present. But sometimes most of these pathog- 
nomonic symptoms are absent, and the diagnosis can 
be made only from the seat and history of the tumor. 
Although seldom necessary, a fine aseptic hypodermic 
needle may be introduced to determine the character of 
the contents and the presence or absence of an opening 
in the skull, 

The recognition of these hernias in the occipital region 
is easiest, because other congenital tumors of similar 
form are of extreme rarity in this position; but der- 
moids, angiomata, and sarcomata of prenatal origin may 
have their seat at the nasal root, in the frontal region, 
or at the inner canthus of the eye, and thus lead to con- 
fusion. In the case of these latter, the mode of develop- 
ment must be carefully studied, and note taken of varia- 
tions in tension, compressibility, and pulsation, and of the 
appearance of cerebral symptoms upon pressure. <An- 
giomata exhibit pulsation and tension changes, and 
may be often completely compressed, but without brain 
symptoms or the discovery of an opening in the skull. 
Pulsation and compressibility are lacking in dermoid 
tumors. Cranial sarcomata which are congenital, or 
which appear shortly after birth, may present brain 
symptoms on pressure; there may also be an opening in 
the skull which pulsates; and finally these growths may 
havea similarity of feel, but,they grow much more rapidly 
than cephaloceles, and usually are wanting in the more 
characteristic symptoms of the latter. The differentiation 
of the varieties of cephalocele can be made from the pe- 
culiarities that have already been described. In naso- 
pharyngeal varieties it is well to remember their occasion- 
ally close resemblance to nasal polypi. 

Treatment.—The most difficult class to treat are the 
hydrocephaloceles, but measures can at least be taken to 
prevent sudden death by spontaneousrupture of the sac. 
This is still more important in meningocele and cepha- 
locele if there be a rapid increase of fluid and tension, as 
a cure is possible in many of these cases. Equable press- 
ure should be made by means of cotton batting and a 





Fic. 812.—An Irregular 'Tumor Proceeding from the Cranial Cavity by 
a Large Opening Situated Immediately in Front of the Sphenoid, and 
Behind the Still Cartilaginous Ethmoid. Naso-pharyngeal cephalo- 
cele. (Virchow.) 


bandage, care being taken not to produce brain symptoms 
by too strong compression. If the distention increases 
puncture should be made with a hypodermic needle, with 
antiseptic precautions, and the fluid slowly aspirated—all 
of it if the tumor be small, but only a portion in the case of 
large sacs. Then cover with aseptic cotton and continue 
the compression. Puncture may be repeated at appropri- 


235 


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Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ate intervals. Ifrupture has already taken place, the an- 
tiseptic dressing and pressure bandage should nevertheless 
be applied. By this procedure rupture may be prevented, 
the tumor may be gradually diminished in size, and oc- 
casionally even dissipated. Youths or adults who are 
occasionally observed with stabile encephaloceles should 
-wear protective plates properly curved, with bandages, 





(After Holmes.) 


Fic. 813.—Posterior Hydrencephalocele. 


and sometimes compression may be made use of, if it be 
deemed expedient,to do anything, but great care isneeded 
to avoid the production of brain symptoms. Puncture 
in simple encephaloceles is permissible only in case of 
continual augmentation in size—no other operative pro- 
cedure is advisable. This is about all that can be done 
without risk. In many cases in which incisions have 
been made into these tumors, through a mistaken diagno- 
sis, the result has been death from meningitis. Puncture 
and the injection of iodine have been fatal. 

Meningoceles are more amenable to treatment, as a 
tule, than the other forms of cephalocele. Occasional 
punctures, together with compression, have met fre- 
quently with good results. Little is to be expected from 
iodine injection, although Paget was successful with it 
in one instance. The stabile meningoceles should, as a 
rule, be let alone, because they communicate almost al- 
ways with the cranial cavity. Annandale in one case 
ligatured the peduncle and removed the tumor, the child 
recovering completely in spite of an attack of measles. 
Thompson has also cured a case by ligation. Schatz 
cured a case by the gradual compression of a clamp 
applied to the sac. Sklifasowsky removed an occipital 
cephalocele from a nine-months child with a ligature, 
the result being successful The procedure is permissible 
in proper cases under strictly antiseptic precautions. 
Many operations in these cases have been undertaken 
since the inauguration of the new era of brain surgery, 
and much can now be achieved in the treatment of con- 
genital cephaloceles, guided by the light of the latest dis- 
coveries in cerebral localization and by our improved 
technique in cranio-cerebral operations, which was for- 
merly impossible. Fenger (loc. cit.) operated success- 
fully on a nasal type, first removing the polypoid mass 
with the écraseur, There was free discharge of cerebro- 
spinal fluid. The nostril was packed with iodoform 
gauze preparatory to radical operation to close the hollow 
peduncle. He then did an osteoplastic resection of the 
superior maxilla (as devised by von Langenbeck), and 
transfixed and ligatured the peduncle. Aspiration of the 
tumor for fluid had been twice negative. He considers 
in this class that extirpation should always be practised 
even if the tumor is small and causes no more disturb- 
ance than an ordinary polyp, as there is always danger 
of meningitis from accidental injury or surface inflam- 
mation. Preparatory operations are necessary, and these 
vary with the different situations in the nose. 

Moller (Deutsch. Zeitschr. f. Chir., 1898, xlviii., 23) 
has an article on the surgical treatment of hydrencepha- 
locele, in which he says that the old rule of Heineke 
against operation has now been overthrown, since the 
day when von Bergmann openly advised radical opera- 
tion wherever possible (1888). Mdller cites de Ruyter’s 
(von Bergmann’s assistant) rules, as follows: 


236 


Meningocele should certainly be operated, because of 
possible ulcerations, because the tumer presents a point 
of lessened resistance in which a meningitis may originate, 
and because the patient is greatly burdened by the pres- 
ence of the tumor. 

Encephalocele should be operated unless it contains 
too large an amount of brain tissue. It usually holds a 
somewhat unimportant part of the brain, part of the 
occipital or frontal lobe. 

Hydrencephalocele should not be operated because of 
its communication with a ventricle. 

To combat this last rule of de Ruyter, Méller cites a 
case of successful operation on an occipital hydren- 
cephalocele, where the tumor was nearly the size of the 
infant’s head. The peduncle was solid, the lumen having 
been obliterated. Examination of the child one year 
after operation showed it to be in good condition and of 
apparently normal mental development. 

Schmitz (St. Petersburg. med. Woch., 1898, N. F., xv., 
193) reviews the forms of cephalocele and methods of 
operation, giving his experience of seventeen cases. He 
concludes that the permanent results of operation are 
very unsatisfactory. Life is prolonged, but in the case 
of hydrocephalocele, the child dies of hydrocephalus, or 
remains hydrocephalic. This he says is also true of - 
meningoceles which show any signs of hydrocephalus. 
If there be no hydrocephalus, the prognosis is much 
better. Schmitz thinks the prognosis is best for the 
pure encephaloceles or solid tumors. It is important to 
note whether the tumor remains of original size or is dis- 
posed to grow, and whether it grows slowly or rapidly. 
In the latter case we must assume increasing intracranial 
pressure, and we have therefore a hydrocephalocele, or 
such a type is developing from the originai encephalo- 
cele. Another question concerning the advisability of 
operation relates to the contents of the tumor. Jf sin- 
cipital, the middle frontal convolution is involved, and 
we may feel justified in removing a small portion. No 
motor and little mental disturbance will result. In the 
occipital class there is usually cerebellar tissue (hemi- 
sphere) and less frequently parts of the occipital lobe, 
and no symptoms are likely to follow removal of small 
peripheral portions of the cerebellum. In case of large 
prolapsus of brain substance, excision should not be 
practised. 

Berger (loc. cit.) believes radical operation to be justified 
in cases in which the tumor is growing and in which the 
prognosis is bad without interference. 

Tilmann (Berlin. klin. Woch., 1895, xxxii., 1055) says 
that the old methods of compression, puncture, iodine in- 
jections, and use of ligature are not now considered in the 





Fic. 814.—Tumor Divided in Two. 


(From Reali.) 


treatment of meningocele. Even if infection is avoided 
there isalways danger of meningitis. He cites two cases 
of cephalocele operated at Bardeleben’s clinic. The first 
was an occipital meningocele, the sizeof an apple, re- 
moved a few weeks after birth. The child developed 
normally. The tumor had a very small lumen and thick 
walls of cedematous fibrous tissue. The second case 
presented a congenital occipital meningocele the size of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





the child’s head. Operation was performed one day after 
birth because of insistence of the father. One litre of 
fluid was aspirated and the tumor sac then removed. 
There was improvement at first, but the child died on 
the twenty-third day with paralysis and convulsions. 
The case was one of meningocele with chronic internal 
hydrocephalus. He discusses fully methods of operation. 

ACQUIRED CEPHALOCELE OR PSEUDO-CEPHALOCELE,— 
Among the cephaloceles which originate subsequently to 
birth, through disease of the cranial bones or subcutaneous 
fractures, the most common is the pseudo-meningocele. 
This is observed almost exclusively in infancy or early 
youth, but, in very rare cases, sometimes in adults after 
healing of the superficial skull coverings in fractures. 
Conner* has written the best article upon pseudo-menin- 
gocele that is to be found in American literature. Under 
the name traumatic cephalhydrocele he describes 2 
cases occurring in his own practice, and makes an analy- 
sis of 22 others collected from general literature; 19 of 
these were due to subcutaneous fractures of the skull, 2 
to old gunshot wounds of the skull and membranes 
where the scalp had reunited, and 1 was the result of 
trephining; 17 of the cases were under three years of 
age. G. Vivien has collected 8 cases, and Thomas Smith 
(St. Barth. Hospital Reports, vol. xx.) reported 2, and 
described 20 analogous cases. Allof Smith’s were under 
sixteen years of age. 

The history is usually that a child falls upon its head, 
and that, several hours or days after, a fluctuating swell- 
ing develops under the scalp, which may at first be dif- 
fuse, but later, as a rule, assumes the form of a sharply 
bounded cystic tumor. It may reach the size of the fist 
or be larger. It is over the injured spot, fluctuates, and 
often pulsates. There is sometimes a hardened border 
to the tumor. Occasionally, by firm pressure, the fluid 
may be made to recede more or less completely into the 
skull cavity, when the fractured bone may be felt. 
When this is not possible, the break may often be felt 
after puncture and evacuation of the tumor. In many 
of these cases puncture has shown the contents to be 
cerebro-spinal fluid. In post-mortem examinations which 
have been made, the fluid has been found to lie under 
the pericranium, lifting it with its outer coverings like a 
cystic sac; a cleft is observed in the bone, and one of 
the same size or smaller in the dura mater, through 
which the sac and subdural cavity communicate. Oc- 
casionally the cortex has been injured, and in recent 
cases there would be signs of softening and of laceration 
of the othermembranes. Inacase of Lucas, the pseudo- 
meningocele communicated with the open inferior horn 
of the left ventricle. Two or three cases may be men- 
tioned in illustration of this traumatic form. Southam 
(British Medical Journal, May 12th, 1888) gives the details 
in the case of a male infant, aged six months, that fell 
downstairs and sustained a subcutaneous fracture in the 
right parieto-occipital region. Fourteen days later there 
was a swelling over the fracture, oval, soft, fluctuating, 
and pulsating. Moderate pressure was applied with a 
pad of lint and a bandage. In a month the swelling had 
disappeared and the child recovered. There was still a 
marked depression in the bone. Conner’s first case was 
a boy twelve and a half years of age, who fell froma 
wagon, a wheel passing over his head. He was not un- 
conscious, and walked into a house near by. There was 
a simple depressed fracture of the right half of the oc- 
cipital bone, and a non-pulsating swelling over the frac- 
tured area, which he supposed to be due to extravasated 
blood. A week later, serum began to ooze from the nose, 
and there was puffiness of the right eyebrow. He punc- 
tured and drew off four ounces of a pale straw-colored 
fluid. The sac rapidly refilled, and four weeks later five 
ounces were removed. There were four subsequent tap- 
pings, the fluid withdrawn aggregating nineteen ounces. 
The specific gravity was 1.007; noalbumin; sodium chlo- 
ride, 6.6 parts per 1,000. The boy was never unconscious 





* Phineas 8. Conner: American Journal of the Medical Sciences, 
vol. Ixxxviii., 1884, page 103. 





or delirious, but there were some insomnia and mental irri- 
tability, and the pulse ranged from 100 to 120. Conner’s 
second, case was a hydrocephalic and rachitic colored 
child about two years of age that fell a distance of five 
feet upon its head. There was no scalp wound, but a 
swelling appeared very quickly over the right parietal 
bone. In a few days it measured four and a half by 
three and a half inches, and exhibited pulsation and 
fluctuation. A radiating fracture could be felt through 
the tumor. No treatment was undertaken, and nine 
months after the accident the swelling had disappeared. 

There are several facts which explain the almost ex- 
clusive prevalence of traumatic pseudo-meningocele in 
children. Possibly the flexibility of the skull gives a 
peculiar character to the fracture. The intracranial 
pressure is certainly relatively greater in children than in 
adults, anda more active secretion of cerebro-spinal fluid 
is probably another factor. The increase in subdural 
fluid may be due in part to the injury to the head, or in 
part to nutritive disturbance, rachitis, or some such 
thing, which does not give rise necessarily to a general 
hydrocephalus. The pouring out of the fluid, its aug- 
mented secretion, and the expansive power of the grow- 
ing brain, all aid in preventing closure of the osseous 





(After Vannoni.) 


Fic. 815.—Sincipital Cephalocele. 


fissure, and, indeed, may actually cause its enlargement, 
and even eversion of its edges. But pseudo-meningocele 
is not a constant result of subcutaneous fracture in child- 
hood, and it is likely that various causes and conditions 
conduce to its formation. 

There are not many observations as to the further 
course of traumatic pseudo-meningocele in children. 
Conner found that fifty per cent. of the cases collected 
by him died of meningo-encephalitis. In some patients 
the tumor remains unchanged in spite of frequent punc- 
ture, and in others itis cured by thismeans. Spontaneous 
retrogression may take place. The cleft in the skull 
generally remains open, and hence the prognosis is al- 
ways relatively unfavorable. These cases are often of 
considerable forensic interest. Bayerthal (Deutsch. med. 
Woch., 1898, xxiv., 37-58) relates the case of a man aged 
eighty-one years, with a pseudo-meningocele still per- 
sisting, due to a brick falling upon his head when he was 
nine months old. The man was always normal, except 
that he did not learn to walk until four years of age, and 
that he developed epilepsy at the age of seventy-nine 
years. ‘This is the only recorded case of such long persist- 
ence of a pseudo-meningocele. 

Pseudo-meningocele in adults has been observed several 
times after gunshot wounds of the skull, when the 
scalp wound has healed, and once after recovery with 
defect of bone from trephining. Vivien mentions three 
such cases. As a result of subcutaneous fracture in 
adults it has apparently not been observed, and, if it 
occurs, must be extraordinarily rare. 


237 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








Pseudo-cephalocele sometimes results from syphilitic 
or tuberculous caries of the skull and perforation of the 
dura mater, and.from complicated fractures accompanied 
with prolapsus cerebri. Such cases have been reported 
by Bennett, Tavignot, Bryk, Podrazki, Spring, Hawkins, 
Talko, Bruns, and Kusmin. In one case only did the 
dura mater protrude. 

These tumors vary from two to five inches in diameter, 
and are usually of a soft, elastic consistence. The skin 
over them is either smooth, glossy, and pale red, or in- 
flamed, indurated, and presenting fistulous openings. 
Sometimes there are pulsation and fluctuation. Dizziness, 
retardation of the pulse, and even unconsciousness can, as 
a rule, be produced by pressure upon these tumors with 
the finger. Partial replacement may be brought about 
by compression, and in one case there was complete return 
of the hernia by gradual pressure. When the brain has 
protruded, this was doubtless due in many cases to the 
formation of cerebral abscess or to collections of ‘pus in 
the cavity of the skull; insome cases, probably to edema 
or encephalitis with tumefaction of the brain in the 
neighborhood of the diseased or injured skull. 

Treatment.—In pseudo-meningocele continuous and 
equable pressure should be employed, ‘when practicable, 
but this should be done early. If the tumor is large and 
tends to increase in size, operative interference is allow- 
able, and this is best carried out according tec the 
methods described by von Bergmann below. Strict 
antiseptic precautions should be observed, and a com- 
press subsequently applied. Irritative injections are 
not advisable. If the opening in the skull remains pa- 
tent, it is well to keep it shielded by a plate and bandage 
for the prevention of a renewal of the tumor or injury to 
the brain. Tonics, nutritious diet, and lime preparations 
are indicated. 

Other forms of pseudo-cephalccele are treated accord- 
ing to the nature of the bone disease or injury. In sup- 
purative processes we must be on the lookout for pus 
deposits in the brain or skull cavity, and remove them, 
if feasible, with careful asepsis. It is best not to operate 
on the prolapsed brain itself, but in this we must be 
governed by what we have recently learned with regard 
to the physiological value of the different convolutions. 
Hitherto such heroic measures have been carried out 
usually as a result of error in diagnosis, and in these 
cases death has followed from meningitis, encephalitis, 
or hemorrhage. Compression should naturally be re- 
sorted to in these cases only when there are no symptoms 
of inflammation or suppuration. In the rare pseudo- 
cephaloceles of adults we may cautiously puncture and 
make use of the compress, but we should always be on 
the lookout for symptoms of inflammation and abscess. 

Bayenthal (doc. cit.) advances the singular theory that 
the presence of a pseudo-meningocele may be of advan- 
tage to the patient as a safety valve for increased intra- 
cranial pressure, and that it might be more advanta- 
geous to enlarge it, than to remove it, in cases showing 
cortical irritation. 

Von Bergmann (on “ Cephalhydrocele Traumatica,” St. 
Petersburg. med. Woch., 1897, N. F., xiv., 61) says that 
in these cases he always presupposes a fracture of the 
skull—in the majority of the cases of the lateral aspects 
of the skull—the lined fractures being vertical. The in- 
terval often observed between the bones in such cases is 
doubtless due to subsequent absorption. A laceration 
of the dura has always been found at autopsy. He con- 
siders compression of service only in a few cases, and 
only when applied early. Puncture is successful in a 
few; but meningitis is to be feared. In 33 cases of 
Rahm, where puncture was employed, 6 were cured and 
9 died. Of 3 cases treated by puncture and iodine, 2 
died and T recovered with prolapsus cerebri. Two cases 
treated by incision and drainage died. He cites Krén- 
lein’s two cases, in which the sac was removed and 
drainage employed. Both recovered. One had to wear 
a plate, and in the other epileptic convulsions returned 
seven to eight months after operation. Von Bergmann 
concludes as follows: 


238 





—————— 


1. Puncture should not be practised. Injections with 
iodine are still more inadvisable. 

2. Compression should first be tried (with compress 
and bandage or with a plate). If the tumor is thereby 
kept small and flat, radical operation can be delayed. 

3. If the tumor increases in size, the method of Slajmer 
and Dembrowski is simple and less dangerous than the 
method of Krénlein. This consists of making a flap of 
skin, periosteum and bone to cover the defect in the skull, 
first emptying the sac and dissecting it away from the 
edge of the bone. Frederick Peterson, 


BRAIN: CEREBELLAR DISEASE.—An etiological 
factor with specific predilection for the cerebellar tissue 
does not exist. Whatever causes disease of other organs. 
and tissues of the body, produces occasionally also cere- 
bellar lesions. Chronic purulent otitis media is of par- 
ticular etiological significance; cerebellar abscess, a com- 
mon affection of the cerebellum, is one of its frequent. 
complications. 

Prenatal intrauterine and intrapartum accidents and 
mishaps may occasionally lead to disease of the cere- 
bellum, although this occurs more rarely here than in 
the other parts of the nervous system. 

Ataxie héréditaire cerebelleuse (Marie, Nonné) is be- 
lieved to be a hereditary disease of the cerebellum; the 
final proof that the cerebellum only and primarily is the 
cause and seat of this disorder is, however, still wanting. 

Cases of congenital atrophies and scleroses of the cere- 
bellum are on record. Their etiological explanation is. 
still very obscure. For some of these cases, possible 
intrauterine inflammations or traumatisms or intra- 
partum accidents may furnish a probable etiology, an- 
alogous to similar results wrought by the same factors 
on the brain, and occasionally on the cord. 

Specific acute infectious diseases like poliomyelitis and 
poliencephalitis do not occur in the cerebellum. 

If any damage is done to the cerebellum in the course 
of acute infectious diseases, it has not been recorded. 

The chronic infectious diseases—syphilis and tuber- 
culosis—are quite frequent causes of cerebellar disease. 
Neither appears to injure the cerebellum directly, and 
the metasyphilitic toxins, of so great an etiological im- 
portance for the brain and cord, show no affinity for the 
cerebellar tissue. 

The cerebellar degenerations found, in cases of tabes, 
are manifestly secondary to the primary disease. 

Solitary tubercles are frequently found in the cere- 
bellum, and localized basal tuberculous meningitis may 
occasionally damage the cerebellum. : 

Formation of gummatous tumors is apparently rarer 
than that of the tuberculous variety, and the syphilitic 
meningitis, in the vicinity of the cerebellum, is more 
frequent than the tuberculous. 

Finally, it is to be remembered that syphilis, by injur- 
ing the blood-vessels, is occasionally at the bottom of 
cerebellar mischief. It is true, this is vastly less often 
the case here than in the brain or cord, partly on account 
of causes explained further on. 

Exogenous intoxications do not seem to harm the cere- 
bellum, although the picture of acute alcoholism is be- 
lieved to be caused by cerebellar disturbance. 

General pathological conditions (aneemias, diabetes, 
carcinosis, etc.) do not directly influence the cerebellum. 

Arterio-capillary fibrosis is the only general state of 
etiological significance. 

Hemorrhages, embolisms, and thromboses of cerebellar 
blood-vessels are not very frequent. 

Embolism of cerebellar arteries is apparently a great 
rarity. This is in part due to the anatomical peculiarities 
of the cerebellar vascular supply. All three cerebellar 
arteries (arteria cerebelli inferior posterior, arteria cere- 
belli inferior anterior, and arteria cerebelli superior) leave 
their principal branches at a right angle, and therefore 
an embolus will be carried away by the circulation 
through the wider basilar artery, and will be finally 
lodged in the arteria cerebri posterior. 

Thromboses of cerebellar arteries are quite rare; occa~ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





sionally thromboses of the vertebral arteries may lead to 
patches of softening in the cerebellar hemispheres. 

Hemorrhages of cerebellar blood-vessels are also not 
very frequent. 

The cerebellar arteries are very much smaller than the 
cerebral, and the only larger artery, the arteria corporis 
dentati, is accordingly the one that is most frequently 
ruptured. 

Some cases of acquired cerebellar atrophies and scle- 
roses are perhaps interpretable in a similar way on an 
arteriosclerotic basis, as are analogous conditions of the 
cord or brain. 

Inflammations of the cerebellar tissue are occasional 
findings, but apparently most of the time they are second- 
ary purulent infections. 

The autochthonous and metastatic tumors of the cere- 
bellum have here the same causes as in the other parts 
of the body. 

Disease of the bones, meninges, and other contiguous 
tissues, and various external injuries, lead to a variety 
of secondary pathological states of the cerebellum. 

Symptoms.—About twenty years ago, Nothnagel wrote 
in the classical monograph embodying the clinical 
thought of that time that there is more diversity of opin- 
ion and controversy concerning the symptomatology of 
diseases of the cerebellum than of any other part of the 
brain. 

At present there are still some who have this opinion, 
and occasionally reports are heard of cases of disease of 
the cerebellum “ without symptoms”; in other words, the 
cerebellum is still to be classed under the “ silent areas.” 
Increased clinical minuteness diminishes considerably, 
however, the number of cases of disease of the cerebellum 
“without symptoms.” 

At an earlier date, experimental methods were em- 
ployed to clear up this question, and indeed greater 
unanimity was reached. The results obtained by ex- 
perimental physiologists (Flourens, Magendie, Weir 
Mitchell, Luciani, Ferrier, and Turner), by their efforts to 
ascertain the symptoms of irritation and paralysis of this 
part of the nervous system, furnish a safe basis for the 
construction of the symptomatological picture. How- 
ever, a great many points of the symptomatology are 
still under discussion, because focal and distant symp- 
toms are not kept sufficiently asunder as yet. 

The symptoms of cerebellar disease that may be termed 
focal evidently do not depend upon the nature of the 
causative lesions. Tumors, abscesses, softenings, degen- 
erations, etc., will necessarily give symptoms more or 
less identical of irritation or paralysis of function. 

Differences of degree only and not of kind are fre- 
quently observed. These are dependent upon the char- 
acter of the lesion, whether slow or rapid, destructive or 
stationary. 

Territorial variations of the lesions do not seem to 
exert any considerable influence. 

The point particularly dwelt upon by Nothnagel, that 
only a lesion of the vermis leads to symptoms, while 
lesions of the hemispheres have no clinical manifesta- 
tions, has not been corroborated as fully as it was origi- 
nally claimed. 

All of the foregoing will be better understood when a 
few cardinal points of the physiology and pathology of 
the cerebellum, about which all clinicians and experi- 
mental physiologists seem to agree, are borne in mind. 
These points are, first, the fact of the anatomical and 
physiological homogeneity of the cerebellum. 

Microscopically, the structure of the cerebellar hemi- 
spheres is found to be the same all over, and on that 
basis, as well as on clinical and experimental evidence, 
physiological identity is conjectured. Thusit is evident 
that one part can easily take up the function of the other. 

It is further established by clinical and experimental 
evidence that the functions of the cerebellum are taken 
up by other parts of the nervous system, particularly by 
the someesthetic cortical areas (Luciani). 

The above-mentioned dissensions are easily understood, 
when one considers that the experimental physiologists 


Brain, 
Brain, 


observe the animal throughout the whole time of the 
disease, see it, as it were, during the flourishing period 
of the symptoms, and in the period when, through estab- 
lishment of direct or indirect compensation, a good part 
of the symptoms are disguised or obscured; and that, on 
the other hand, clinical observations most of the time 
extend over a limited period only, and by some observers 
cases are seen with fully established compensation, and 
by others cases more or less compensated or not at all. 

After these remarks it is safe to state that the symp- 
toms of disease of the cerebellum, no matter what lesion 
gives rise to them, are symptoms referable to disorder of 
the equilibration, regulation and adjustment of the vol- 
untary movements, and are comprised in the name of 
cerebellar ataxia. 

Luciani attempted to analyze this compound phe- 
nomenon and claims that it is composed of the following 
three elements: asthenia, atonia, and astasia. All these 
three elements give rise to a disorder of motor function 
that he calls motor dysmetry. 

The point to which the compensation has progressed, 
necessarily influences the intensity of the ataxia. Not 
all agree, however, with Luciani, and particularly the 
asthenia and the atonia are denied by others. 

In addition to this cardinal and direct or focal symptom 
of disease of the cerebellum, a number of symptoms are 
described in cases of cerebellar disease, the greatest part 
of which can manifestly not be taken as focal but must 
be designated as indirect or distant symptoms. 

The principal focal symptom of cerebellar disease is 
the cerebellar ataxia. This ataxia manifests itself on the 
patient, first by disturbance of the general equilibrium in 
the form of swaying that becomes markedly increased 
when the eyes are closed and the feet put together. The 
gait designated as cerebellar gait, and according to the 
French (démarche d’ivresse) gait of drunkenness, is very 
much altered; the patient progresses in a zigzag line, 
the individual steps are irregular and unequal, the feet 
are lifted unduly high from the ground and brought. 
down heel first with undue force. 

These evidences of static and locomotor ataxia are dif- 
ferentiated from the same symptoms in cases of genuine 
tabes by the fact that patients with cerebellar disease 
show little or nothing of this ataxia when in bed. 

This disorder of the muscular apparatus is in most 
cases evidenced exclusively or predominantly in the 
lower extremities. 

A group of motor phenomena, called forced attitudes 
and forced movements, form the focal symptom next 
in importance. The head and trunk of the patient are 
either permanently deviated toward one side, or the pa- 
tient performs queer rotatory movements around his own 
axis toward one side or the other—movements evidently 
not purposeful, and having clearly a character of forced 
propensity (manége movements). 

The side toward which the permanent deviation or the 
forced movement is directed is differently reported by 
different observers. According to some, the head or the 
trunk deviates or the patient moves toward the side of 
the lesion; according to others, toward the opposite side; 
and according to still others, the passive deviation is 
toward the opposite side, while the active movements 
are toward the side of the lesion. 

Another explanation of this diversity is based on the 
fact that lesions are either irritative or paralyzing; irri- 
tative lesions are thought to produce forced movements 
toward the same side, and paralyzing lesions forced at- 
titudes toward the opposite side. 

It is otherwise stated that forced movements and forced 
attitudes are dependent upon the situation of the lesion, 
and they are then interpreted as focal symptoms of the 
cerebellar peduncles, particularly of the middle ones. 

The forced attitudes are clinically more frequently 
observed than the forced movements. A good illustra- 
tion of a forced attitude is given in the accompanying 
picture of a patient in whom a tumor of the right cere- 
bellar hemisphere was found, in which the deviation 
toward the same side is seen when the patient is in a re- 





239 





Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








clining position, and more marked when she is standing 
. (Fig. 817). 

The two symptoms already named, 7.e¢., the cerebellar 
ataxia and the forced movements and attitudes, are the 
cardinal focal symptoms of cerebellar disease. But in 





Fig. 816.—Case of Cerebellar Tumor, Showing Peripheral Facial Palsy. 


almost every case there are additional symptoms re- 
corded; some evidently not focal, others mooted as to 
their localizing significance, which are discussed seriatim 
below. 

Motor Symptoms: The upper extremities do not al- 
ways escape the characteristic motor disorder. Here the 
ataxia is not so marked, but is often replaced by atacti- 
form tremors and unsteadiness, occasionally simulating 
the intentional variety. The head may show similar mo- 
tor unsteadiness, although rarely. 

Localized unilateral and generalized muscular spasms, 
with and without loss of consciousness, are frequently 
mentioned, and by most observers are interpreted as dis- 
tant symptoms. 

Motor paralysis sensu strictiori is occasionally observed. 
Hemiplegias, paralysis of one-half of the body, are fre- 
quently mentioned in older histories of cerebellar cases. 
Here, too, the side upon which the paralysis occurs is not 
uniformly named; at one time the paralysis was homo-, 
at another heterolateral to the cerebellar lesion. 

In view of the fact that experimental evidence has 
proven the homolateral influence of the cerebellum, it is 

| - to be assumed that hemiplegic symptoms are dependent 
‘upon encroachment of the lesion upon the pyramidal 
tracts, and not upon lesion of the cerebellar tissue proper. 
This is well illustrated by the accompanying photograph 
(Plate XIV.), which represents a case of tumor of the 
cerebellum in which the observed left-sided hemiplegia, 
which was produced, as can be easily seen from the 
photograph, by pressure upon the left-sided pyramidal 
tract, gave rise to diagnostic difficulties. 

Various disorders of the ocular musculature, nystag- 
mus, strabismus, ptosis, paralysis of individual ocular 
muscles or muscle groups, are also frequently mentioned. 
The greatest part of these symptoms are evidently due 
to pressure upon the corpora quadrigemina or oculo- 
motor nuclei; but some of them must necessarily be taken 
as focal symptoms. 

Experimentally, deviations of one or the other eye 


240 


toward the same or the opposite side of the lesion were 
frequently ascertained. 

The facial musculature is also frequently reported to 
have suffered. Occasionally this disturbance is only 
slight and transient, and probably of a nature similar to 
the motor disturbance of other muscles—7.e., a cerebellar 
motor dysmetry; but most of the time it is due to com- 
pression of the adjacent seventh nerve. It is then a 
paralysis of the peripheral type, involving all the three 
branches and showing more or less disturbance of the 
electrical reaction. This is well illustrated in the accom- 
panying photograph (Fig. 816). 

The motor portion of the fifth nerve is sometimes 
found defective, evidently through pressure upon the 
peripheral course of the nerve. 

In the sensory sphere no symptoms directly referable 
to the cerebellum are observed. 

The sensibilities (tactile, algesic, thermal and kines- 
thetic) are mostly unaltered. If sensory disturbances 














Fig. 817.—Case of Cerebellar Tumor, Showing Hemiplegia and Devia- 
tion. 


are found, as in a case of cerebellar abscess lately ob- 
served by the writer, they are easily traced to the 
spreading of the disease into the sensory pathways. 

Of the special senses sight and smell are frequently 
found impaired. Choked disc and optic atrophy are fre- 
quent and early accompaniments of compressing lesions 


REFERENCE HANDBOOK 


PLATE XIV 


OF THE 
MEDICAL SCIENCES 











TUMOR OF THE CEREBELLUM 


eon : LU M3 4 
iv Ra aba pid) ie pai i 
; . ee : " hil 
lhe , + 1. al: 
“ nas A Sry na 
t 
LIB : 
OF ine 
NVERSITY of LLINOIS 
; 
: ‘ : i 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain. 
Brain. 





of the cerebellum. The old belief, however, that the 
cerebellum is in any physiological or anatomical connec- 
tion with the visual centres, has long since been dis- 
carded. Similarly, anosmia, the loss of sense of smell, 
is not a focal symptom, but is dependent upon the press- 
ure of hydrocephalic fluid, a frequent consequence of 
cerebellar disease, upon the olfactory bulbs. 

The other cranial nerves may occasionally suffer in- 
directly. 

About the state of the tonus of the muscles, the reports 
are almost diametrically opposite. According to some 
there is a normal tonus or even a hypertonia; according 
to others a unilateral or bilateral hypotomia; and accord- 
ing to still others there is at one time some rigidity, at 
another flaccidity. 

In keeping with this, the reports about the reflexes, 
particularly the knee reflexes, are equally contradictory. 
They are reported to be present or exaggerated, or ab- 
sent or diminished. Jackson and others report variabil- 

~ity of the findings, and I have found it so in the patient 
whose picture is here reproduced, and whose tonus and 
reflexes were frequently examined. 

Disordered trophic functions are reported by the ex- 
perimental physiologists. But such symptoms have not 
been ascertained clinically. Occasionally the pes cavus 
is mentioned in this connection, but this is evidently the 
result of the static ataxia. 

Visceral functions are rarely disturbed. Control of 
the sphincters is damaged only when the state of con- 
sciousness is interfered with. In this connection it is 
well to draw attention to the symptom complex that the 
French call syndréme_ bulbo-protuberantielle — which 
consists of attacks of bradycardia and Cheyne-Stokes 
respiration. : 

These symptoms are evidently referable to pressure on 
the medulla, and will occur in any lesion in this neigh- 
borhood. The same may be said of the occasionally ob- 
served glycosuria and polyuria. 

The mental functions are primarily not altered in cere- 
bellar disease, and the old conception of the intimate 
connection of the cerebellum with the sexual instinct is 
without foundation. 

The speech is frequently altered. The disturbance is 
of the dysarthric type, commonly called cerebellar dys- 
arthria, and occasionally reminds one strongly of the 
syllabic speech. . 

Draenosis.—The diagnosis of disease of the cerebel- 
lum is made without difficulty when the focal symptoms 
are pronounced. Frequently, however, the picture is 
considerably obscured by a number of distant symptoms 
or by compensation. Joseph Fraenkel. 


BRAIN: CEREBRAL HEMORRHAGE.—ErroLocy.— 
The most frequent cause of non-traumatic cerebral hem- 
orrhage is the occurrence of miliary aneurisms in the 
vessels of the brain. These aneurisms are 0.1—-1 mm. in 
size and are found with extreme rarity in other organs. 
Charcot and Bouchard, who were the first to recognize 
them as the cause of hemorrhage, regard them as due to 
chronic periarteritis, which leads to an excessive prolifer- 
ation of nuclei in the lymphatic sheaths and walls of the 
vessels, and sometimes to atrophy and disappearance of 
the muscular coat. These writers believe that the im- 
plication of the tunica intima, which is always present 
in such cases, is secondary to the affection of the outer 
walls. Almost all the more recent writers attach the 
chief importance to a primary affection of the tunica 
media. According to Roth, the intima is first attacked 
by waxy degeneration. Roth states that, in the begin- 
ning, we find diffuse cylindrical dilatation of the vessel, 
then there is degeneration of the muscular coat, occa- 
sionally of a waxy character. Next, all three layers of 
the vessel undergo aneurismal dilatation, and finally the 
intima and adventitia become thickened in order to com- 
pensate for the atrophy of the media. 

Léwenfeld claims that various vascular changes may 
lead to rupture, viz., simple atrophy, fatty and granular 
degeneration or ordinary atheroma. There is very little 


Viole ——1G 


doubt, however, that these views obtain, if at all, only 
in exceptional cases. 

Miliary aneurisms are always very minute, and some- 
times cannot be seen without the aid of a lens. Charcot 
and Bouchard noticed that they manifested a predilection 
for certain parts of the brain, being found with diminish- 
ing frequency in the following regions: optic thalamus, 
corpus striatum, cerebral cortex, pons Varolii, cerebellum, 
centrum ovale, peduncles, and medulla oblongata. In 
the very large majority of cases they are situated in the 
corpus striatum and optic thalamus, thus explaining the 
great preponderance of hemorrhages in this locality. 

It has long been thought (and many clinicians and 
pathologists hold this view at the present time) that 
atheroma of the cerebral vessels is one of the main causes 
of cerebral hemorrhage. But this view is erroneous. 
Atheroma of the brain is confined usually to the arteries 
of the circle of Willis, and it is not uncommon to find 
these vessels as rigid and unyielding as pipe stems, with- 
out a trace of hemorrhage in the brain. In rare cases, 
even the vessels of the pia mater have been found to be 
exquisitely atheromatous, although no vascular rupture 
had occurred. On the other hand, it is not uncommon 
to find extensive hemorrhage, although atheroma of the 
vessels is entirely absent or very slight. 

Age is an important factor in causation, the large ma- 
jority of cases occurring after the age of forty-five years. 
But cases are not very infrequent at an earlier period, 
and they may also occur in infancy and childhood. 
Billard found a clot in the left corpus striatum in an in- 
fant three days old. 

Heredity also appears sometimes to play a certain part 
in etiology, but it acts by inducing the development of 
miliary aneurisms, and not by giving rise to any defect 
in the cerebral tissues proper. 

The disease also occurs quite frequently, during the 
course of Bright’s disease, associated with hypertrophy 
of the heart without valvular lesion. It has been sup- 
posed that the cardiac hypertrophy and consequent in- 
creased arterial pressure are the active factors in this 
condition, but it is more probable that they act only as 
exciting causes, the real cause being found in the changes 
in the walls of the vessels (arteriosclerosis), which con- 
stitute an integral part of Bright’s disease. 

In scurvy, leuksemia, hemophilia, and severe infec- 
tious diseases, minute cerebral hemorrhages may occur as 
the result of the nutritive changes induced in the walls 
of the vessels, but these will not be considered in this 
article. 

Violent muscular strain, mental excitement, cold baths, 
etc., are also adduced as causes, but they prove efficient 
only if a lesion of the vessels is present. They prob- 
ably act by causing active or passive cerebral congestion. 

The large majority of cases occur in the male sex, the 
predisposing and exciting causes being more frequent in 
males than in females. 

PatTHoLoarcaAL ANATOMy.—If the patient dies soon 
after the occurrence of a cerebral hemorrhage, a soft, 
black clot ig found, which can be readily removed from 
its cavity, and is usually mixed with shreds of brain 
tissue. The surrounding tissues are irregularly torn, 
and are softened and blood-stained for some distance 
around the clot. Very little fluid blood is present. The 
size of the clot varies from a minute speck (capillary 
hemorrhages) to a mass of enormous size, which may 
occupy a considerable portion of one lobe. In the latter 
event the blood usually ruptures into the lateral ventri- 
cle, may then pass into the opposite lateral ventricle, 
and also force its way through the third into the fourth 
ventricle. More rarely the hemorrhage breaks through 
the cortex and appears under the pia mater, usually 
upon the convexity. When the hemorrhage is large in 
amount, pressure effects are distinctly perceptible. The 
convolutions may be flattened, the falx cerebri pushed 
forcibly toward the opposite side of the brain, and even 
the nerves flattened at the base of the brain. In such 
cases the cerebral tissues are usually very dry. 

If the loose clot is gently removed and the tissues 


241 


Brain. 
Brain. 








slowly moved to and fro under water in order to remove 
the more adherent shreds, we shall usually be able to 
find the artery upon which the ruptured miliary aneu- 
rism (sometimes more than one) is situated. 

After a variable period, depending chiefly upon the 
size of the clot, the latter begins to contract, finally 
breaks down, as it does in other localities, and absorp- 
tion then begins. The extent to which this occurs varies 
in different cases. Sometimes the absorption is complete 
and perhaps nothing will be left at the site of the hemor- 
rhage but a narrow, waxy, yellowish cicatrix, which 
contains a variable number of hematoidin crystals. The 
latter may also be scattered through the surrounding 
tissues, giving them a reddish-yellow color. In other 
cases the serum is not absorbed, and a cavity remains 
which may be lined with a delicate cyst wall. After the 
lapse of time it often becomes difficult, sometimes im- 
possible, to distinguish these cysts from the remains of 
spots of softening. (Fig. 2, Plate XV.) 

The changes described run their course in a short time. 
The clot remains soft for three or four days; absorption 
then becomes active and reaches its maximum toward the 
close of the second week. If absorption isnot complete, 
the cavity contains serum by the twentieth day, and the 
cyst wall is fully formed in from four to six weeks. 

Hemorrhages within the region of the pyramidal tracts, 
in any part of their course (and also those in the motor 
regions of the cortex), give rise to secondary descending 
degeneration, which extends down through the crus, 
pons, and medulla into the antero-lateral column of the 
opposite side of the spinal cord. In very rare cases the 
degeneration finally extends into the anterior gray horns 
of the cord. 

Among twenty cases of descending degeneration of the 
spinal cord due to unilateral lesions of the brain, Pitres 
found four cases in which the degeneration was present 
in both lateral columns, though more markedly on the 
side opposite to the cerebral lesion. He attributes this- 
phenomenon to very incomplete decussation of the py- 
ramidal tracts in the medulla oblongata—the variability 
of which has been clearly demonstrated by Flechsig. 

After hemorrhages into the occipital lobe secondary 
degeneration is found in the optic radiations and, at a 
much later period, in the external geniculate body, pul- 
vinar, and anterior corpora quadrigemina. After the 
lapse of years this degeneration may involve the optic 
tract and nerve. 

After hemorrhage into the second or the third frontal 
convolution we find degeneration of the dorsal bundle of 
the lenticulo-striate section of the internalcapsule. This 
is followed by degeneration of the median segment of 
the cerebral peduncle, of the fibres to the median nucleus 
of the optic thalamus, and of the anterior portion of the 
lateral nucleus of the same ganglion. 

After hemorrhage into the temporal convolutions de- 
generation of the most lateral portion of the peduncle 
has been observed in several cases. 

After large hemorrhages into the tegmentum of the 
pons, secondary degeneration of the fillet takes place, not 
alone in an ascending but also in a descending direction. 
This extends to the nuclei of the posterior columns on 
the opposite side after the lapse of years, and the gan- 
glion cells there undergo atrophy. 

Almost all cases of old hemorrhage which have come 
under our observation on the post-mortem table have 
exhibited, irrespective of the site of the lesion, an atrophy 
of the brain. This is observed throughout the entire 
cerebral hemisphere on the side of the hemorrhage, and 
in the opposite hemisphere of the cerebellum. The 
atrophy of the latter is proportionately less marked than 
that of the cerebrum, but it appears to affect all parts 
alike. The cause of this phenomenon is obscure, but it 
is due probably to partial disuse of the structures im- 
plicated. 

SymproMAToLoGy.—In the majority of cases there are 
no precursory manifestations of this disease. When they 
are present, they consist of vertigo, headache, ringing 
in the ears, general mental inertia, occasional lapses of 


242 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


memory, and defective speech. Sometimes slight numb- 
ness and a feeling of weakness may be felt upon one side 
of the body. The latter symptoms are generally de- 
pendent on a slight hemorrhage which has already oc- 
curred. The other prodromal symptoms are supposed 
to be due to congestion of the brain. 

As a rule, however, the symptoms begin quite sud- 
denly. Ina considerable proportion of cases the attack 
develops during sleep, the patient going to bed in his 
usual condition of health and awaking in the morning to 
find himself paralyzed on one side of the body. When 
the attack occurs during waking hours, the patient gen- 
erally experiences a strange sensation in the head and an 
increasing feeling of numbness and weakness on one 
side. This is followed rapidly by loss of power on that 
side, and the patient, if standing, falls to the ground, 
and in a certain proportion of cases becomes unconscious. 
It must be remembered, however, that a large number 
of patients retain their consciousness throughout the en- 
tire seizure. Thus it has been noticed that even twenty- 
four hours have elapsed from the onset of the symptoms 
to the development of complete hemiplegia and aphasia, 
the patient retaining consciousness and the control of 
his mental faculties during this entire period. The dis- 
turbance of consciousness in different attacks presents all 
possible grades from this condition to complete and pro- 
found coma. 

In the most severe cases the patient lies motionless, 
with a turgid, sometimes livid face, the pupils varying 
but usually presenting no characteristic appearance, the 
cheeks flaccid and flapping loosely with respiration. 
The pulse is usually slow, full, and hard; the arteries of 
the neck pulsate visibly. Respiration is usually slow, 
labored, and attended with stertor; sometimes Cheyne- 
Stokes respiration is observed and is generally of fatal 
import. All the limbs may be in a condition of complete 
resolution, but more commonly the non-paralyzed side 
manifests a slight rigidity. 

A not infrequent symptom of the apoplectic seizure 
is the so called conjugate deviation of the eyes and head. 
Both eyes are usually turned away from the paralyzed 
side, “as if looking toward the site of the lesion.” 
Nystagmus movements may be noticed at times, but the 
axes of the eyes are not directed beyond the median line. 
The head is also turned in the same direction as the eyes, 
and offers distinct resistance when an attempt is made 
to restore it to the normal position. In extremely rare 
cases this symptom has been observed in attacks of cere- 
bral hemorrhage unattended with loss of consciousness. 

This peculiar phenomenon is usually noticed when the 
hemorrhage occurs in the parietal lobe (especially near 
the inferior parietal lobule), although it is also observed 
at times when other parts of the brain are implicated. 
According to Hughlings Jackson, conjugate deviation 
is of sinister prognostic import with regard to the recov- 
ery of the paralysis. 

When the hemorrhage ruptures into the ventricles, or 
through the cortex beneath the pia mater, contractures 
or convulsions are frequently noticed. Pitres states that 
this symptom depends upon the point of rupture of the 
hemorrhage into the ventricle, and is produced only 
when the fronto-parietal fibres are involved by the lesion. 

It has been stated that severe hemorrhages are attended 
invariably by an initial depression of temperature (one- 
fourth to one-half hour after the beginning of the seizure), 
followed in a few hours by a rapid rise, which continues 
until death in fatal cases, and subsides after a few days 
in the non-fatal cases. In some instances the tempera- 
ture may rise from the very beginning, even though the 
disease has a rapidly fatal termination. 

The cutaneous and tendon reflexes are usually abol- 
ished or greatly diminished during the period of coma. 
But this condition soon gives place to an increase of re- 
flex excitability, with the exception of the cremaster and 
abdominal reflexes, which are found to be diminished. 

As a general rule, the patient slowly rallies from the 
comatose condition, consciousness being restored usually 
in a period varying from an hour or more to a couple of 


_ 


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a 


5 


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i 


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Os a 


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baka a 

sate 
24 


EXPLANATION OF 
PLATE XV. 














ane 


Fig. 


Fig. 


EXPLANATION OF PLATE XV. 


1.—‘“ The inner surface of the dura mater (right half) is covered with a pseudo-membrane 
which is colored a pale red in some parts, a dark red in others, and which clings firmly to 
the dura. On the left side there is presented an irregularly shaped yellowish-green deposit 
which rests upon an older layer of organized exuded material of a dark red color and in- 
filtrated with blood. The explanation of these conditions is this: An infectious fibrino-puru- 
lent inflammation has, in this case, been grafted upon an older proliferative process, a com- 
plication which is observed only in rare instances. The pseudo-membrane, which is applied 
quite uniformly over the inner surface of the dura mater, is composed of a fibrous connective 
tissue which in some parts is rich in cells and everywhere is liberally supplied with blood-ves- 
sels (pachymeningitis vasculosa). In many places throughout the layers of newly formed 
tissue there may be seen hemorrhagic exudations, some of older and others of more recent date. 
It is safe to assume that these hemorrhages have come from the imperfectly developed new 
blood-vessels, through a process of diapecesis ” (Bollinger.) 


2.—Apoplexy of the Right Hemisphere of the Brain (nucleus caudatus and nucleus lentiformis ; 
capsula interna). “Inthe right cerebral hemisphere, ata point corresponding to the location of 
the nucleus lentiformis, and extending from this outward as far as to the capsula interna, is 
an irregularly shaped cavity, somewhat larger than an English walnut, which is filled with 
dark, reddish-brown masses of clotted blood. Its walls in some places show a rusty red dis- 
coloration. Some bloody serum is present in the right lateral ventricle. The rest of the cere- 
bral parenchyma is tough, the brain as a whole being atrophic (it weighs 1,220 gm.). The 
large arteries at the base of the brain are in a condition of marked atheromatous degeneration ; 
the arteria pro fossa Sylvii is obliterated. 

“Among the other pathological conditions found in this woman, who was sixty-nine years 
of age, the following may be mentioned: Chronic interstitial nephritis and hypertrophy of the 
heart (both ventricles), which weighed 475 gm. (the normal weight being from 250 to 300 
gm.).” (Bollinger.) 


} 


REFERENCE HANDBOOK 


Mec eereces PLATE XV, 





FIG. |. 





Piece 


Intracranial Pathological Conditions. (After Bollinger ) 
Fig. |. Pachymeningitis Interna Hemorrhagica. Fig. 2. Apoplexy of the Right Hemisphere of the Brain. 


LIB ¥ 
OF ane ES 
UNIVERSITY of ILLINOIS 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 








days. When consciousness is restored the paralysis 
present is more clearly defined and is found to consist 
usually of hemiplegia of motion, frequently associated 
with aphasia when situated on the right side of the body. 

In a considerable proportion, perhaps the majority, of 
eases it is found, when the patient returns to conscious- 
ness, that sensation is also somewhat impaired on the 
paralyzed side. In addition it is not rare to find that 
hemiansesthesia of the special senses, associated with 
hemiopia, is also present. Gowers thinks that the latter 
symptom can be detected, in the majority of cases, dur- 
ing the first period after the attack. We have verified 
this observation in a number of instances. As a rule, 
the sensory disturbances disappear almost entirely within 
one or two weeks, though exceptionally they continue 
permanently, while the motor symptoms clear up in 
great part or entirely. 

In the majority of cases improvement continues unin- 
terruptedly after the restoration of consciousness until 
a certain definite degree of paralysis is left over. Ina 
small proportion of cases, however, symptoms of cere- 
bral irritation, probably owing to the development of 
encephalitis around the clot, make their appearance at 
the end of a week or ten days, sometimes as early as two 
or three days, after the occurrence of the hemorrhage. 
The patient then complains of severe headache, the tem- 
perature again rises, irritability, and even delirium may 
supervene. These symptoms may increase in severity 
and a fatal termination ensues, or, after lasting for a 
week or more, they may gradually disappear, leaving 
the patient in about the same condition as before the re- 
lapse. In some cases, rigidity or contractures develop 
during this condition, and subside with the other symp- 
toms. 

Acute decubitus (bedsore) may also develop during 
the early period of the attack. If this occurs, it will be 
found usually, from the second to the fourth day, that 
an erythematous patch appears upon the middle of the 
gluteal region of the paralyzed side, followed rapidly 
(usually the next day) by the formation of bulls, and 
then by rapid sloughing of the parts. According to 
Diprat, the acute bedsore is sometimes observed upon 
the healthy side. Charcot states that death almost al- 
ways occurs in such cases. 

Vaso-motor symptoms may also be noticed from the 
very onset of the attack. The paralyzed side is then 
warmer to the feel than the non-affected side, and is 
covered with more profuse perspiration; sometimes the 
radial pulse is fuller on the hemiplegic side; slight edema 
of the skin on this side is also often noticed. These symp- 
toms disappear in proportion as the coma subsides, and, 
at a later period, may give place to vaso-motor symptoms 
of a different character, which will be mentioned later. 

After the immediate effects of the hemorrhage have 
passed off, the patient may live for years without a re- 
currence. Subsequent attacks usually occur, however, 
unless the patient dies from an intercurrent disease. 

The hemiplegia left over after an ordinary attack of 
cerebral hemorrhage presents the following character- 
istics: 

The paralysis is not so well marked, as a rule, in the 
face as in the limbs. There is Jess expression and power 
of motion in the lower half of the paralyzed side of the 
face than on the opposite side, the naso-labial fold is 
partly or entirely effaced, and the angle of the mouth 
droops and sometimes is drawn closer to the median line. 
The frontalis and orbicularis palpebrarum usually act as 
well as those on the non-paralyzed side, though careful 
observation often shows that they do not contract quite 
as vigorously as normally. This is particularly notice- 
able if the patient be directed to close only the eye of 
the paralyzed side. The paralysis of the lower half of 
the face becomes more noticeable during voluntary 
movements, while in laughing both sides of the face may 
contract to an equal degree. Some difficulty in mastica- 
tion may arise from the accumulation of food between 
the teeth and cheek of the affected side; more rarely 
there is slight disturbance of deglutition. The tongue, 


when protruded, may deviate to the side of the paralysis 
on account of the unopposed action of the genioglossus 
muscle on the healthy side. It must be remembered, 
however, that this deflection of the tongue may be more 
apparent at times than real, and that it may be owing to 
the closer approximation of the angle of the mouth on 
the paralyzed side to the median line. If the hemiplegia 
has occurred in early childhood it is commonly found 
after the lapse of a few years (the interval being shorter 
the earlier the age at which the hemorrhage occurred) 
that the bones of the skull and face on the paralyzed side 
are slightly smaller than those on the opposite side. The 
muscles are also atrophied to a slight extent. 

Apart from aphasia, the discussion of which will be 
found in Vol. I., speech is usually not affected very much, 
though sometimes there is considerable thickness and 
slowness of speech from the diminished mobility of the 
tongue and lips, or perhaps from the impairment of men- 
tal power. 

The upper limb is usually paralyzed to a greater ex- 
tent than the lower limb, 7.¢., the latter recovers much 
more rapidly and thoroughly than the former. The 
upper limb, as a rule, is partially flexed in all the joints, 
and the arm drawn alongside the chest. The power of 
executing coarse movements returns first, the delicate 
manipulations of the fingers being restored last. The 
tendon reflexes at the bend of the elbow and the wrist 
are increased. 

In walking the lower limb drags along the ground, 
and there is an evident effort in propelling it along. It 
is swung more at the hip, and the pelvis is raised higher 
upon the paralyzed than upon the non-affected side in 
order to allow the drooping toes to clear the ground. 

As an almost invariable rule in adults the paralyzed 
limbs do not undergo any noteworthy atrophy, although 
the paralysis may have lasted for years; the subcutane- 
ous adipose tissue may disappear to a considerable extent. 
In rare cases, however, rapid atrophy takes place, some- 
times even within a few months, and is more marked in 
the upper limb. It is supposed that this peculiar feature 
is owing to the implication of the anterior gray horns as 
a secondary result of the descending degeneration of the 
lateral columns. In one case under our observation the 
diagnosis of this secondary change in the cord was veri- 
fied by the post-mortem examination. 

In hemiplegia of early childhood marked atrophy of 
all the tissues of the paralyzed limbs always takes place. 
or, at least, their growth does not correspond with that 
of the healthy side. Sometimes thisatrophy is so marked 
as to look, at the first glance, like that resulting from 
acute infantile paralysis. 

The paralyzed limbs are usually cool to the feel, and 
the skin may present a dusky, mottled appearance from 
impaired circulation; not infrequently the radial pulse is 
smaller than on the other side. 

In addition to these vaso-motor disturbances, trophic 
changes may also occur, and are more marked in the 
upper limb. The integument sometimes seems to be 
thinned and atrophic, in other cases it appears thicker 
than normal. The nails may become discolored, lose 
their gloss, and become rough from excessive develop- 
ment of longitudinal striations. The joints, particularly 
the shoulder, hip, and fingers, not infrequently become 
affected. The joint affection is very rarely acute in its 
origin. When this does occur, phenomena not unlike 
articular rheumatism are developed. This form usually 
begins in from two to four weeks after the apoplectic 
attack. Much more frequently, however, chronic, slowly 
progressing changes arise. The articular ends of the 
bones then appear to enlarge, and at the same time a 
certain amount of atrophy appears in the muscles sur- 
rounding the joint. No exudation can be detected, but 
the joint is very tender on pressure, and may be so pain- 
ful on movement that the mobility is interfered with out 
of all proportion to the actual loss of muscular power. 
This condition is extremely obstinate, and frequently 
resists all forms of treatment. 

Late rigidity, or contracture, is a very frequent sequel 


243 


Brain. 
Brain, 





of hemiplegia. The upper limb is involved to a much 
greater extent than the lower limb. As a general rule 
the fingers are strongly flexed, sometimes bent forcibly 
into the palm of the hand; the wrist is flexed upon the 
forearm, and the latter is pronated and at the same time 
slightly flexed on the arm. Contracture of the pectoralis 
major muscle draws the arm against the chest. In the 
lower limb the contracture is confined chiefly to the 
muscles of the calf, which draw up the heel. 

It is very often found, even in advanced cases, that 
the contracture disappears in great part when the patients 
awake in the morning. Then the fingers, which could 
not be extended previously without a very great effort 
on the part of the physician, are relaxed spontaneously, 
and the patient may even be able to execute voluntary 
movements. In a little while, however, the status quo 
ante is restored. This condition is always attended by 
a marked increase of all the tendon reflexes, and some- 
times by increased mechanical excitability of the para- 
lyzed muscles. It is generally believed that this form of 
contracture is due to descending degeneration of the 
lateral columns, but this view is not well founded. We 
have seen one case in which the contracture was absent, 
although well-marked descending degeneration was 
found at the autopsy. Were this theory true, the symp- 
tom in question should be present in all cases of hemor- 
rhage or other lesion affecting the pyramidal tracts, but 
in reality it is not infrequently absent under such condi- 
tions. 

The phenomenon known as “associated movements ” 
is also observed quite often in hemiplegia, particularly 
when it occurs in childhood. As a rule, strong volun- 
tary effort on the part of the non-paralyzed limbs is as- 
sociated with an involuntary movement of the paralyzed 
parts. Much more rarely a vigorous attempt to move 
the paralyzed muscles is attended with an involuntary 
movement of the healthy side. 

Post-hemiplegic chorea is another peculiar phenom- 
enon, allied perhaps to the associated movements just 
referred to. It occurs with greatly preponderating fre- 
quency in the hemiplegia of childhood, but is observed 
not very rarely in adults. The period of its develop- 
ment varies greatly, but it never occurs until a very con- 
siderable amount of improvement has taken place. This 
symptom is also found to be much more pronounced in 
the upper than in the lower limb. 

The movements are manifold in character. Sometimes 
they can be distinguished in no respect from ordinary 
chorea; and, as in the latter disease, in some cases the 
movements are increased on effort, in others they are 
diminished. 

More rarely tremor is produced like that seen in paral- 
ysis agitans, or the movements may be coarser. Some 
cases have been observed in which the movements were 
of an ataxiform character, and it is even claimed that 
true ataxic disturbances may be produced. There is 
very little doubt that athetosis (slow, constant alterna- 
tion of flexion and extension of the fingers, with corre- 
sponding movements, perhaps, in the upper portions of 
the arm, more rarely in the lower limb, particularly the 
toes) is merely a variety of post-hemiplegic chorea, 
though it may also occur independently of cerebral hem- 
orrhage. 

In children, in whom post-hemiplegic chorea is of very 
frequent occurrence, this symptom often becomes com- 
plicated with epileptiform convulsions, affecting at the 
onset only the paralyzed side, but later spreading usually 
to the other side. 

Draenosts.—The recognition of cerebral hemorrhage 
is often attended with great difficulty, and indeed may 
be impossible. The disease is most frequently mistaken 
for cerebral embolism, since the symptoms of both affec- 
tions may be identical. In such cases a provisional diag- 
nosis can be made only from attendant circumstances. 
Embolism is usually associated with cardiac valvular 
disease, thrombosis of the heart, or aneurism of the arch 
of the aorta. Asa matter of course, however, the exist- 
ence of these lesions does not preclude the occurrence of 


244 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





cerebral hemorrhage. If the coma occurs with great 
suddenness, it is due more probably to embolism than to 
hemorrhage, and this is also true if the patient recovers, 
within a week, a considerable amount of power in the 
paralyzed side. Again, embolism is comparatively more 
frequent before the age of forty, though, as we have 
seen above, hemorrhage may also occur at any age, even 
in infancy and childhood. The determination of the co- 
existence of chronic interstitial nephritis favors the diag- 
nosis of hemorrhage, on account of the vascular lesions 
so often present in the former disease. On the other 
hand, it must be remembered that the mere presence of 
albumin in the urine during an apoplectic attack pos- 
sesses no significance whatever. 

Cerebral hemorrhage must also be distinguished from 
cerebral thrombosis. In the latter affection, the coma- 
tose condition, if it develops at all, is usually much 
slower in its onset, though it must also be remembered 
that exceptionally the symptoms of thrombosis occur 
with great suddenness. The disease is peculiarly an 
affection of old age, and the radial, temporal, and other 
superficial arteries are generally found to be very 
atheromatous. When the thrombosis is the result of a 
syphilitic affection of the vessels, it is almost always 
preceded by another train of symptoms, a discussion of 
which will be found under the head of syphilitic lesions 
of the cerebral vessels. 

Hemorrhage into the pons may also be mistaken for 
opium poisoning, if it is attended, as is usually the case, 
with strongly contracted pupils. In the former affec- 
tion, however, the pulse and respiration are not so nota- 
bly retarded as in the latter, and the coma is more pro- 
found. Epileptiform convulsions, also, are not an 
infrequent accompaniment of pons hemorrhage, and do 
not form a part of the history of opium poisoning. Of 
course the obscurity is cleared up if the patient recovers 
consciousness. 

When the hemorrhage occurs during infancy or child- 
hood, the disease must also be differentiated from tuber- 
culous meningitis. This affection may also be attended 
with unconsciousness and sometimes distinct hemiplegia, 
even in cases in which the autopsy shows a tolerably 
uniform distribution of the lesion over both hemispheres 
of the brain. Meningitis, however, is attended with 
more marked prodromal symptoms than cerebral hemor- 
rhage; the hemiplegia, if present, is not very profound, 
and is variable in degree at different times, as are also 
the other symptoms of the disease. In adults meningitis 
rarely simulates the history of cerebral hemorrhage. 

But however careful we may be in the observation of 
the symptoms and of the attendant circumstances, very 
many cases will be encountered in which the diagnosis 
remains doubtful or is only cleared up by a post- 
mortem examination. Indeed, as was remarked in the 
paragraph on the pathological anatomy of the disease, 
even a post-mortem examination, if made long after the 
attack, may fail to decide the nature of the affection. 

Even if a diagnosis of cerebral hemorrhage has been 
made, it is extremely difficult to localize the lesion ac- 
curately with any degree of certainty until the general 
pressure symptoms have cleared up, leaving only those 
which are due to the local lesion. 

In the large majority of cases the most that can be 
done during the comatose stage is to determine the side 
on which the hemorrhage has occurred. The paralyzed 
side of the body is usually more relaxed than the non- 
paralyzed side, is often warmez, and the reflexes are en- 
tirely abolished; if conjugate deviation of the eyes and 
head is present, it is directed usually toward the side of 
the lesion. After the coma and the general pressure 
symptoms have subsided, localization of the lesion must 
be determined according to the principles laid down in 
this HANDBOOK under the headings, Brain: Diagnosis 
of Local Lesions, and Brain: Functions of Cerebral Cortex. 

If the coma is very profound, and rigidity or convul- 
sions make their appearance at the onset, together with 
serious respiratory and circulatory disturbances, the 
hemorrhage has probably occurred into the lateral ven- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





tricles (from surrounding parts). Hemorrhage into the 
pons is frequently attended by marked contraction of 
the pupils and profound coma, and when the paralysis 
can be determined, it is usually found to be alternate, 
7.e., the face is paralyzed on one side, the limbs on the 
opposite side. 

'  ProeGNosis.—This varies according to the size and 
situation of the hemorrhage. Other things being equal, 
life is more endangered the larger the hemorrhage. 
However, even hemorrhages of small size, if situated in 
the pons Varolii or medulla oblongata, are apt to prove 
rapidly fatal, and hemorrhages in the latter locality very 
rarely terminate in recovery. The fatal event is due to 
direct interference with the functions of respiration and 
circulation. Cheyne-Stokes respiration is an extremely 
unfavorable symptom, and is almost always a precursor 
of impending dissolution. 

Large hemorrhages into the hemispheres, or those 
which rupture into the ventricles, also prove fatal, usu- 
ally by direct or indirect pressure on the centres of the 
pons and medulla. The more sudden the development 
of coma, the smaller the chances of recovery. Acute 
decubitus, which occurs during the comatose stage, is 
almost invariably followed by death. The coexistence 
of Bright’s disease is also a very unfavorable complication. 

As regards the extent of recovery from the paralysis, 
very little can be foretold in the first period of the dis- 
ease. In the large majority of cases the sensory disturb- 
ances disappear in great part and very rapidly. 

Power of motion is usually restored much more quickly 
in the lower than in the upper limb. When the reverse 
obtains, it has been generally held that an unfavorable 
termination will ensue, but this opinion does not appear 
to be well substantiated. 

The occurrence of late rigidity must be regarded as an 
unfavorable symptom, insomuch as it interferes, in the 
first place, directly with the power of motion, and, in 
the second place, improvement in the latter usually 
ceases with the appearance of the former. This also 
holds good of post-hemiplegic chorea. 

Symptoms of mental deterioration are usually perma- 
nent, and indeed, in many cases, are steadily progressive. 
As a rule, however, it is only_after repeated attacks that 
a condition of mental impairment, amounting even to 
imbecility, develops. In very exceptional instances, 
epilepsy follows cerebral hemorrhage. 

TREATMENT.—Prophylactic treatment is practically 
nil. If the prodromal symptoms are prolonged, the pa- 
tient should be kept as quiet as possible, mentally and 
physically, and care taken that the bowels be kept thor- 
oughly open. When the onset of a hemorrhage has been 
suspected, I have been in the habit of putting my pa- 
tient to bed for a week, giving bromide of potassium in 
fifteen to thirty grain doses, t.i.d., and a mild laxative 
or enema daily. 

If the hemorrhage has taken place or is occurring at 
the time the physician is called, very little, if anything, 
can be done to check it. Drugs given internally for this 
purpose do more harmthan good. The most that should 
be done is to keep the head slightly elevated, and if the 
carotids and temporals are pulsating strongly, apply cold 
applications to the head or leeches to the forehead. If 
the pulse continues strong during the comatose stage, 
nothing more need be done. When evidences of heart 
failure arise ammonia and stimulants are indicated. 

When the stationary stage of paralysis has developed, 
treatment is useless until after the lapse of a considerable 
period. The natural tendency of the paralysis is toward 
improvement (though complete recovery hardly ever 
occurs), and until this tendency becomes manifest, we 
may rest satisfied either that motor fibres are cut across 
or that pressure is still exerted at the site of the lesion, 
thus interfering with nervous conduction. 

Almost the only means at our command to hasten re- 
covery is the use of electricity. This may be employed 
in two ways, either to the brain itself or directly to the 
paralyzed parts. 

The former method has been very little used hitherto, 








and, indeed, it is not probable that much good can be 
expected from it. The galvanic current alone is em- 
ployed for this purpose. The positive pole is usually 
applied to the side on which the hemorrhage took place, 
the negative pole on the opposite side of the head. The 
current should be mild, and must never be strong enough 
to produce vertigo; the sittings should not exceed from 
two to five minutes in duration. 

The ordinary method (and the one which promises by 
far the best results) of employing electricity in hemi- 
plegia is the direct application of the faradic current to 
the paralyzed muscles. It has generally been held that 
this measure should not be employed until at least two 
or three months have elapsed since the occurrence of 
the hemorrhage, for fear of causing a recurrence of the dis- 
ease. There is very little reason, however, to doubt that 
this fear is entirely unfounded, and that it is perfectly 
safe to begin the treatment within two or three weeks 
after the stationary period has begun. 

The strength of current employed should be merely 
sufficient to produce distinct contraction of the paralyzed 
muscles; the sittings may be held every other day, and 
their duration may vary from five to fifteen minutes. 

In a few cases an astonishing degree of improvement 
occurs after the first two or three applications, after 
which very little, if any, progress ismade. As a rule, 
however, improvement, if it occur at all, is very gradual, 
and the treatment must be continued patiently for 
months. 

When contractures of the paralyzed limbs have de- 
veloped, another method should be employed. The one 
usually adopted is the application of the stabile galvanic 
current through the nerves and muscles (nervo-muscular 
current) of the flexor aspect of the limbs (the parts in 
which the contracture is usually situated) and the faradic 
current to the antagonists. Warm baths and massage 
are also useful for this purpose. 

In some cases painful swelling of the joints is extremely 
annoying to the patient, and this complication is very 
intractable to treatment. It is best combated by the use 
of a strong stabile galvanic current passed directly 
through the joint, with the addition of repeated small 
blisters over the site of pain. 

Iodide of potassium, in doses of from five to ten grains 
t.i.d., is usually administered as a matter of routine, but 
it is more than doubtful whether this drug exerts any 
beneficial effect. 

In our hands ergot has never given good results, no 
matter in what stage of the disease it has been employed. 
Careful attention should always be paid to the condition 
of the bowels, particularly as the patients are apt to be 
constipated for a long time after the attack. 

Leopold Putzel. 


BRAIN: CEREBRO-SPINAL FLUID.—(Synonyms: 
celiolymph ; Ger., Cerebrospinalfliissigkett ; Fr., liquide 
céphalo-rachidien ; Lat., liquor cerebrospinalis. ) 

Anatomy.—The cerebro-spinal fluid is found in the 
encephalic and myelic ventricles, and in the subarachnoid 
and subdural spaces. It varies in amount from 60 to 200 
c.c., increasing somewhat withage. Itis not lymph and 
is sufficiently characteristic in its reactions to be distin- 
guished from other serous fluids. The subarachnoid 
space is the interval between the arachnoid and the pia, 
very narrow on the upper and lateral aspects of the en- 
cephalon, crossed by numerous bands of arachnoid 
tissue, but enlarged in certain regions at the base, above 
the corpus callosum and over the optic lobes, called the 
cistern subarachnoidales. 

These are in communication with one another and 
have as tributaries the clefts along the great fissures 
(flumina), which themselves have as tributaries the spaces 
along the secondary and tertiary fissures (rivi and rivuli 
of Duret). There are prolongations of this'space around 
the optic, olfactory, and auditory nerves, and a connec- 
tion with the lymph spaces around the other cranial and 
spinal nerves. Communications with the lymphatic 
vessels of the nasal mucous membrane and deep vessels 


245 


Brain, 
Brain, 





and nodes of the neck also exist. These connections 
have been demonstrated by the injection of the subarach- 
noid space with colored fluids which have filled the 
lymph vessels of the nasal mucous membrane, traversed 
the lymph spaces of the nerves, and penetrated the deep 
cervical vessels and nodes. The colored fluid has also 
been observed to pass into the dural sinuses through 
the arachnoidal villi, probably indirectly by filtration. 
Flatau,! by the injection of colored fluids, was able to 
make them escape from the nose. Naunyn and Schreiber, 
quoted by Flatau, have demonstrated the same thing, 
using salt solution, the flow from the nose being accom- 
panied by protrusion of the eyeball and chemosis. 

According to Binswanger and Berger? the subarach- 
noid space also receives the lymph from the adventitial 
lymph spaces of the cerebral cortex. They observed 
that in cases of intraventricular hemorrhage in the human 
subject, blood would make its way into the subarach- 
noid space and thence into the intra-adventitial spaces of 
the cortex. Injection of a carmine mixture into the sub- 
arachnoid of a dog likewise filled the cortical intra-ad- 
ventitial spaces. 

These observations confirm those of Key and Retzius. 

Subdural injection of colored material has demonstrat- 
ed the following connections with the subdural space 
(Schwalbe °): 

1. The deep lymph vessels and nodes of the neck. 

2. The subdural spaces of the nerve roots and lymph 
paths of peripheral nerves (Key and Retzius). 

3. The lymph paths of the dura through fine clefts 
(Michel). 

4. The dural sinuses through the arachnoidal villi. 

The ventricles communicate with the subarachnoid 
space by the foramen of Magendie (metapore) and the 
aperture laterales (foramina of Luschka). The connec- 
tion described by Merkel and Mierzejewsky in the de- 
scending horn of the lateral ventricle is probably an 
artefact. The existence of the metapore and the aper- 
ture laterales has recently been confirmed by Blake.* 

There is no direct connection between the subarachnoid 
and subdural spaces, but the lymphatics of the nasal 
mucous membrane, the lymph spaces of the nerves, and 
the cranial sinuses through the arachnoidal villi can be 
injected from both cavities. 

The histology of the choroid plexuses of the lateral 
ventricles has recently been investigated by Findlay,*® 
who finds that there are for the most part several layers 
of cells on the villi and that the surface cells may con- 
tain globules which are extruded, leaving the empty cell 
membrane. These globules may be found in the ven- 
tricular fluid. They darken with osmic acid and are 
probably fatty in nature. 

Blood-vessels are very numerous in the choroid plex- 
uses, and nerves too have been demonstrated in the plex- 
uses of the lateral and fourth ventricles (Benedikt), so 
that structurally they are secretory in character. 

The morphological elements are very scarce in the 
normal fluid and consist of a few leucocytes, endothelial 
cells, and occasional globules of a fatty nature derived 
from the cells of the choroid plexuses. 

The experiments of Key and Retzius,® confirmed by 
Kollman, seem to show that one of the outflow paths for 
the subarachnoid and subdural spaces is by the way of 
the arachnoidal villi into the cranial sinuses. More 
recently it has been demonstrated that normal saline solu- 
tion tinged with methylene blue and injected into the 
subarachnoid space can be traced passing into the sinuses 
and veins, and in a few minutes the blue is found in the 
stomach and bladder; but it is only after one hour of 
steady injection that the deep cervical nodes begin to be 
tinged. Therapid absorption then takes place rather by 
the blood-vessels than by the lymphatics. 

The amount of cerebro-spinal fluid increases with age 
and with brain atrophy, and decreases in those diseases 
in which the volume of the brain is augmented; it also 
varies with the amount of blood in the intracranial vessels. 

PuystoLoGy.—The cerebro-spinal fluid forms a water 
bed on which rests the base of the middle and posterior 


246 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





parts of the encephalon. It performs an important func- 
tion in protecting the brain from injury and the circle of 
Willis from compression. It also helps to dissipate the 
force of a blow, so that less injury is done at the point 
of its reception. This may result in a disruption of 
brain substance in a region far removed from the place 
of injury. For example, a blow received on the front 
of the head in a direction downward and backward may 
cause hemorrhages in the region of the medulla and 
fourth ventricle, as a result of the ventricular fluid try- 
ing to pass through the narrow aqueduct of Sylvius 
(Park "): 

Sudden tapping of this water bed may occasionally 
result in injury to the brain from the sudden changed 
relations of the encephalon to its rigid bony case; also 
where the ventricles have been distended, the sudden 
withdrawal of fluid may leave parts unsupported, re- 
sulting in injury to the brain tissue. 

According to A. and E. Cavazzani® secretion and ab- 
sorption of the cerebro-spinal fluid proceed slowly. To 
test the rate of secretion, ferrocyanide of potassium was 
injected into the peritoneal cavity of a curarized dog. 
The salt did not appear in the cerebro-spinal fluid until 
after an hour had elapsed. 

To test the rapidity of absorption the posterior occip- 
ito-atlantal ligaments were opened and 4 c.c. of a fifty- 
per cent. solution of iodide of potassium was injected 
into the arachnoid space, and the same solution was also 
injected into the encephalic arachnoid cavity. The salt 
was found in the urine in a minimal time of twenty 
minutes, and a maximal time of two hours. The great 
difference of time in absorption was accounted for by the 
ee in pressure of the cerebro-spinal fluid and the 
blood. 

Thomson’s ® observations, in several cases, of the spon- 
taneous flow of cerebro-spinal fluid from the nose show 
that the secretion may be quite rapid, the flow averaging 
500 ¢c.c. in twenty-four hours. Hill!° has shown that the 
rate of secretion depends on the cerebral capillary press- 
ure and that this can be easily raised by (a) compression 
of the abdomen, (4) by assumption of the horizontal posi- 
tion, and sometimes (c) by forced expiration with the 
glottis closed, 7.e., in straining. When, however, the 
amount of fluid is increased, its chemical characters 
change, the proportion of solids decreasing. 

A. Spina! has shown that increased arterial pressure 
due to intravenous injections of suprarenal extract in 
curarized dogs causes a clear fluid to exude from the 
cerebral surface drop by drop. This fluid he considers 
a transudate. It is probable that the cerebro-spinal fluid 
retains its peculiar characters under normal conditions of 
pressure only, and after it is withdrawn, its place is 
taken largely by extraventricular serous transudate. 

There are three sources for cerebro-spinal fluid, and its 
character is dependent upon the proportions furnished 
by the different sources. The first and most important 
origin is as a secretion into the ventricle from the choroid 
plexuses; second in importance, as a transudate into 
the subarachnoid and subdural cavities; and third, from 
the intra-adventitial lymph spaces of the cortex. The 
relative amount of the intra- and extraventricular fluid 
varies from time to time, depending on the intravascular 
and intracranial pressures, a preponderance of the in- 
travascular pressure resulting especially in an increase 
of the extraventricular fluid. The tension of the cerebro- 
spinal fluid is from 5 to 7.8mm. of mercury, and about 
equals that of the blood in the capillaries, varying how- 
ever in different individuals. 

The osmotic tension of the cerebro-spinal fluid is 
greater than that of serum (Zanier). 

The cerebrum increases in volume with the cardiac 
systole and expiration, and decreases with the cardiac 
diastole and inspiration. Accompanying the cerebral 
movements is an ebb and flow of the cerebro-spinal fluid 
from the cranial into the spinal spaces where extra room 
can be had by the expansion of the ligaments and the 
spaces around the spinal nerves. More room may also 
be had for the brain by the expression of blood from the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 








encephalic veins and sinuses. There is, however, very 
little motion of translation of the fluid accompanying the 
cerebral movements (Elder). Whenever the intracranial 
pressure exceeds the cerebral venous pressure, the fluid 
rapidly leaks away, and hence may be left out of account 
in the pathology of compression (Hill). 

The effect of intravenous injection of cerebro-spinal 
fluid has been investigated by Mott and Halliburton.!” 
They found that if the fluid is taken from animals, or 
from cases of meningocele or chronic hydrocephalus in 
man, and injected into the veins of animals, no effect is 
produced. If, on the contrary, the fluid is obtained from 
cases of brain atrophy, especially from cases of general 
paralysis of the insane, then a marked lowering of arterial 
tension is noticed, partly cardiac in origin but principally 
due to the local action of the poison on the neuromuscu- 
lar apparatus of the peripheral vessels, especially in the 
splanchnic area. This is believed to be due to a toxic 
substance called cholin derived from the disintegration 
of the lecithin in the brain. 

CHEMISTRY.—There are several ways in which the 
cerebro-spinal fluid may be obtained for examination. 
{1) From cases of chronic hydrocephalus, either by 
puncture during life or after death. In acute hydro- 
cephalus the fluid is not normal, but is an exudate. (2) 
In cases of meningocele and spina bifida the fluid is 
normal, but only the first tapping can be so considered, 
as its character changes in the later tappings. (8) By 
lumbar puncture. (4) The fluid may be collected in 
cases of fracture at the base of the cranium, as it drops 
from the nose or ear. (5) In cases of spontaneous flow- 
ing from the nose and ear. (6) In animals, by establish- 
ing a permanent fistula, as suggested and employed by 
Cavazzani,'* to study qualitative and quantitative varia- 
tions. 

The cerebro-spinal fluid is a clear watery fluid, slightly 
saline to the taste, of low specific gravity, about 1.007. 
The density increases in proportion to the greater amount 
of transuded to secreted fluid, and it is also higher in the 
morning than in the evening (Thomson). Its reaction is 
slightly alkaline or neutral, being more alkaline in the 
morning than at night. The reaction has been investi- 
gated in diseased conditions by Turner,’ who found. in 
thirty-seven cases of insanity that it was acid to phenol- 
phthalein, alkaline to methyl orange; and in thirty cases 
tested with litmus there was an amphoteric reaction in 
twenty-nine, the red paper finally turning blue, with an 
acid reaction in one case only. These same reactions 
were found whether the test was made immediately after 
death or several hours later. 

The chemical composition of the cerebro-spinal fluid is 
Shown in the following analysis, made by Halliburton, !® 
of fluid removed from cases of spina bifida. 


Case 3. 
Case 1. Case 2. 2 

Female aged Child aged Jeroen ta 

nineteen years,| eleven days, ota niin ; 

in parts per | first tapping, in | *O go pct 
1,000. parts per 1,000. = 000. 
MARCEL costa ciotelo sis.0.0 615 989.75 989.877 991.658 
MIOHOG cinsinss secscenc 10.25 10.123 8.342 
PPOCGIOS iro cske as 4 1.602 199 
Extractives ........ t 9.626 ; .631 3.028 
ORLA Nee aie sc! «016.5 3 3 7.890 5.115 





A comparison of the relative proportion of solids in 
‘several of the watery fluids of the body is shown in the 
‘subjoined table (Beaunis): 





Water. Solids 
95.8 4.2 
95.9 4.1 
98.6 14 
98.2 1.8 
98.8 1.2 





In normal cerebro-spinal fluid, proteids are small in 
amount, and somewhat variable in quantity and kind. 
Fibrinogen is absent, as no fibrin is formed by the addi- 
tion of fibrin ferment. Serum albumin is absent, as all 
of the proteid is precipitated by saturation with mag- 
nesium sulphate. There are probably present, however, 
serum globulin, generally proto-albumose, sometimes 
hetero-albumose, and occasionally peptones. An _ in- 
crease in proteids is likely to occur in tappings subse- 
quent to the first, but never equalling that found in in- 
flammatory hydrocephalus. 

The following analysis, in the case of a boy six months 
old with chronic hydrocephalus, illustrates this (Halli- 
burton 1°): 








*S PROTEID. 
ae 
28 Pi t Kind 
ae ercentages inds ; 
w bo of total of proteid mete tiaees 
proteids. present. Use Msg 
First tapping.| 1.006 0.045 Globulin ....... Traces. 
Proto-albumose. 
Hetero-albu- 
mose. 
Second ‘ 1.010 0.069 Same as first tap-| Fairly abundant. 
ping. 
Serum globulin. 
Third a 1.010 0.272 Serum albumin.} More abundant. 
Traces of albu- 
moses. 














One of the most interesting features of the chemistry 
of the cerebro-spinal fluid is the presence of a substance 
which, like sugar, reduces copper salts. It has been con- 
sidered grape sugar by many observers (Bernard, Cavaz- 
zani, Nawratzki,'® and Panzer ""). 

Nawratzki studied this fluid in the calf, horse, and 
man. In the calf, working with two litres of fluid, he 
found a substance which reduces copper and bismuth 
oxide in alkaline solution, and gives the phenylhydrazin 
reaction. He obtained crystals having the form and melt- 
ing point of phenylglucosazon, 205°-206° C. He failed 
to find pyrocatechin, peptone, or albumose, and con- 
siders the proteid a globulin. He claims that the reduc- 
ing substance disappears shortly after death, and cites 
two cases in which the fluid drawn by lumbar puncture 
during life showed strong reducing action, but in the 
same individuals after death this action was lost. Hal- 
liburton always finds the reducing substance, but claims 
itis not grape sugar, for the following reasons: (1) It 
does not reduce bismuth salts; (2) it does not ferment 
with yeast; (3) it does not rotate the polarization plane; 
(4) it does not yield a crystalline compound with phenyl- 
hydrazin, as does sugar. 

This reducing body can be obtained as follows: 

“ Acidified alcohol is added in excess to the fluid, to 
precipitate proteids; this is filtered off. The filtrate is 
evaporated to dryness over a water bath; the dry residue 
is again taken up with alcohol, filtered, and again evapo- 
rated to dryness” (Halliburton). 

The crystalline deposit is the reducing substance and 
belongs to the aromatic group of organic compounds. It 
is soluble in ether, alcohol, and water, gives a green 
coloration with ferric chloride, brown with caustic alka- 
lies, has a pungent taste and an acid reaction, and its 
crystals are needle-like and similar to those of pyrocate- 
chin. Halliburton considers the reducing substance a 
normal constituent of the cerebro-spinal fluid, contrary to 
Hoppe-Seyler, who finds it subsequent to the first tap- 
ping only. - It certainly increases in amount after the 
first tapping (see analysis). Whether it exists in a com- 
bined or an uncombined state is not known. 

Some observers have noted an unusual preponderance 
of potassium salts, but later ones have found the propor- 
tion no greater than that of the biood, lymph, or transu- 
dates generally. 

Briefly stated, the chief chemical characteristics of the 
cerebro-spinal fluid are the following: 


247 


Brain. 
Brain, 





1. It is a clear watery fluid, faintly alkaline, of low 
specific gravity, about 1.007. 

2. It contains no fibrin and gives no precipitate (mu- 
cin) on adding acetic acid. 

3. On boiling not more than a trace of turbidity (serum 
globulin) is observed. 

4. It reduces Fehling’s solution. 

5. A reducing substance, obtained by evaporating to 
dryness an alcoholic extract of the fluid, is found in 
needle-like crystals having a pungent taste and an acid 
reaction, and resembling pyrocatechin. This reducing 
substance does not ferment with yeast, nor give the 
phenylhydrazin reaction, nor turn the polarization plane. 

6. It contains a small proportion of proteids and gen- 
erally no albumin. 

Pathological. and Olinical Considerations. — Since 
Quincke called attention to the value of puncture of the 
vertebral canal as a diagnostic and therapeutic measure, 


and to the ease with which it could be performed, resort | 


to it has frequently been had. 

The method of procedure is as follows: 

The patient is preferably placed in the recumbent post- 
ure on the left side, with the body strongly flexed in the 
lumbar region. The puncture is made with a long 
aspirating needle between the second and third or the 
third and fourth lumbar vertebrie, a few millimetres 
outside the median line. Ina child of about two years, 
the puncture should be opposite the mid-point between 
the lumbar spines, and at a depth of about 2 cm. the sub- 
arachnoid chamber will be reached. In the adult the 
puncture should be made at a point opposite the middle 
third of the lower border of the spine above, on account 
of the downward inclination of the spines, and the needle 
should slope toward the median line. If the puncture 
be made in the median line, it should be at the mid-point 
between the spines; and in children the needle should 
penetrate in a nearly horizontal direction, while in the 
adult it should slope upward parallel to the spines. 
Sahli1!8 recommends that the puncture be made between 
the fifth lumbar and the base of the sacrum, especially if 
the morphological elements are to be sought for. Anses- 
thesia is, as a rule, unnecessary. 

Where there are symptoms of intracranial pressure and 
only small amounts of fluid can be obtained by puncture, 
the cause will probably be an interruption of the connec- 
tion between the encephalic and spinal spaces, due to 
exudate or tumor, especially of the cerebellum. It is 
possible, however, that the lack of fluid might be due to 
the closure of the aqueduct of Sylvius or the metapore. 
Small quantities of fluid exclude tuberculous meningitis, 
acute hydrocephalus, and tetanus. 

The cerebro-spinal pressure can be judged by the 
strength of flow from the cannula, a strong spurt indicat- 
ing an increased pressure, slow-coming dropsa decreased 
pressure. It can be more accurately measured by at- 
taching the cannula to a mercury, or, better, to a water 
manometer, the normal pressure being from 5 to 7.3 mm. 
mercury. When the pressure is much raised (15 to 60 
mm. of mercury) meningitis or brain tumor is indicated. 
The specific gravity is somewhat variable, but an in- 
creased density points to meningitis, although this affec- 
tion may exist with normal specific gravity. 

Proteids may be found increased in tuberculous menin- 
gitis, decreased in brain tumors and serous meningitis. 
The variation in different cases of the same kind is so 
great that the proportion of proteids loses considerably 
in diagnostic significance. Lichtheim and Quincke claim 
to find sugar in most cases of brain tumor. This does 
not agree with the observations of Fiirbringer, who found 
sugar only in cases of diabetes associated with tubercu- 
losis. 

Microscopic Examination.—A turbid appearance is due 
to leucocytes and indicates inflammation, but in tuber- 
culous meningitis the fluid is clear. 

In tuberculous meningitis, tumor, abscess, and chronic 
hydrocephalus only a few leucocytes and endothelial 
cells are to be found, while in acute meningitis the leuco- 
cytes are more plentiful, and in the purulent form they 


248 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


are very numerous. It is important, before advising op- 
eration in cases of abscess of brain and sinus thrombosis, 
to exclude purulent meningitis. This is often readily 
done by a microscopic examination of the puncture fluid. 

Pure blood in the subarachnoid space indicates either 
extensive brain laceration or intraventricular hemor- 
rhages. In subdural hemorrhages, a small amount of 
blood may be found; but in epidural hematoma, and in 
hemorrhagic pachymeningitis only very small quantities 
of blood are found. In severe traumatic cases the pres- 
ence of nearly pure blood would indicate serious brain 
injury and contraindicate operation, and vice versa; the 
absence of blood might indicate the advisability of an 
operation. In non-inflammatory diseases of the brain, as 
tumors or abscess, no clotting occurs, except a slight one 
in tuberculous meningitis. 

In cases in which tuberculous meningitis is suspected, 
some of the puncture fluid should be centrifugalized and 
examined for tubercle bacilli. Fiirbringer has found the 
bacilli in thirty out of thirty-seven cases. Other organ- 
isms that have been found are the diplococcus intracellu- 
laris (Weichselbaum) in cases of epidemic cerebro-spinal 
meningitis, and the streptococcus and the diplococcus 
pheumonie in purulent meningitis secondary to otitis 
media. The staphylococcus pyogenes aureus and albus . 
are also sometimes found. 

St. Clair Thomson has collected from the literature 
nine cases of undoubted spontaneous flow of the cerebro- 
spinal fluid from the nose, and twelve probable cases. 
This condition he has named cerebro-spinal rhinorrhea. 
It affects the sexes about equally, and is a disease of adult 
middle life, frequently presenting cerebral and eye symp- 
toms. The flow is usually from the left side of the nose 
and is generally continuous day and night, but long or 
short periods of intermission may occur. 

The method of escape of the fluid was found in one 
case to be through an aperture in the cribriform plate of 
the ethmoid. A possible explanation is that the lymph 
vessels of the nasal mucous membrane, which are in com- 
munication with the subarachnoid cavity, may furnish 
the exit. No efficient method of treatment has been 
found. One case of spontaneous flow from the ear is 
recorded in which the membrana tympani was intact and 
no evidence of injury or disease was present. 

Harry B. Ferris. 


REFERENCES. 


1 Flatau: Deutsche med. Woch., October 30th, 1890. 

2 Binswanger und Berger: Beitrage zur Kenntniss der Lymphcir- 
culation in der Grosshirnrinde. Virch. Archiy, cli., 3, p. 525. 

3 Schwalbe : Lehrbuch der Neurologie. 
eas J. A.: Read before the Assoc. of American Anat., December 

th, 1898. 

5 Findlay : Histology, Normal and Pathological, of the Choroid Plex- 
uses of the Lateral Ventricles. Brain, vol. xxii., 1899. 

®° Key und Retzius: Studien in der Anatomie des Nervensystems, 
Stockholm, 1876. 

7 Park, Roswell: In Dennis’ System of Surgery, vol. ii. 

§ Cavazzani, A. und E.: Ueber die Circulation der Cerebrospinal- 
filissigkeit. 

® Thomson, St. Clair: The Cerebro-Spinal Fluid. William Wood & 
Co., New York, 1899. 

10 Hill, L.: The Physiology and Pathology of the Cerebral Circula- 
tion. London, Messrs. Churchill. 

11 Spina, A.: Experimentelle Untersuchungen tiber die Bildung des 
rier Cerebrospinalis. Pfliiger’s Archiv, Ixxvi., September 30th, 


12 Halliburton : Phys. Soc. ‘Assoc., February 18th, 1898. 
13 Cavazzani: Die Cerebrospinalfistel. Cent. f. Phys., Bd. xiii., No. 


14 Turner, J.: Brain, vol. xxii., 1899. 
Gl Halliburton ;: Text-Book of Chemical Physiology and Pathology, 

16 Nawratzki: Zur Kenntniss der Cerebrospinalfitissi¢keit. 
schrift f. phys. Chemie, vol. xxiii. 

17 Panzer, ''h.: Zur Kenntniss der Cerebrospinalfitissigkeit. Wiener 
klin. Wochen., 31, 1899. 

18 Sahli: Lehrbuch der klinischen Untersuchungs-Methoden, 1899. 


BRAIN, CIRCULATION OF.—AlIl the larger intra- 
cranial vessels and most of their easily visible branches 
lie in the enveloping membranes—dura, pia, and their 
processes. Over the convexity only minute branches 
enter or leave the brain proper. The largest arterial 
twigs directly entering the cerebrum are those of the 
(basal) pre- and post-perforated spaces. The largest 


Zeit- 





4 


EXPLANATION OF 
oo FABER O LEE 





EXPLANATION OF PLATE XVI. 


Fie. 1.—The arterial areas of the convexity 


Fic. 2.—Those of the mesial surface. The area supplied by the precerebral is in brown, that by the 
medicerebral is in green, and that by the postcerebral is in blue. The main branches and their 
directions in each case are indicated by shades of the primary color. 


The two figures on this plate were prepared especially for this work. They represent an aver- 
age between the two sides of a brain examined by isolated injection of the individual arteries. 





wh Reh Bee CN be FOS Be bw Nw ZL 


aera Brendes: PLATE XVI ‘ 





iG? ec: 


SCHMOLZE*WERTHER LITHO'CO N.Y 


Arterial Distribution over Convexity (Fig, 1) and Mesial Surface 
(Fig 2): Precerebral in Brown: Medicerebral in Green: Post-Cere- 
bral in Blue. Branches indicated by Shades of the Primary Color. 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





venous rootlets directly from the organ are the corre- 
sponding perforants and some in the ceeles. Hence the 
vessels of the meninges have to be included in any ac- 
count of the encephalic circulation; and the vascular 
distribution—especially the arterial—can be best mapped 
out on the surface. From studies published within the 
last thirty years our knowledge of this subject has been 
greatly developed. Our aim is to reclassify and har- 
monize the often puzzling independent and re-discoveries. 
- NoMENCLATURE.—In this article the simplified terms of 
Wilder (wide amended list in New York Medical Journal, 
November 25th, 1885) will be employed. These are ex- 
tended also—with his approval—to the veins, sinuses, 
and so-called meningeal vessels. As these last lie wholly 
in one of the membranes, the dura, the general term 
meningeal does not accurately define them; for this the 
unequivocal dural is substituted. ~ 


In trinsic Arteries of the Brain. 


; : Abbre- 
; English ins 
Common Latin names. Proposed names. paronyms. “et 
Vertebralis.....+....... Vertebralis....... Vertebral iin.ce +e vrtb. 
Basilaris: (AZ) siscis-eso6:s BASUATIS svete IBastiariecne’ «on bslr. 
Cerebellaris superior ... Precerebellaris ... Precerebellar .... prebl. 


Cerebellaris anterior ... Medicerebellaris . Medicerebellar ... mcbl. 
Cerebellaris inferior.... Postcerebellaris .. Postcerebellar.... pcbl. 


Cerebralis anterior : 

C orporis callost & Precerebralis..... Precerebral...... preb. 

Cerebralis media “ z 

Fossie Syivi a nee Medicerebralis ... Medicerebral..... meb. 
unda cerebri ; : 

Cerebralis posterior { ** Postcerebralis.... Postcerebral ..... peb. 


ans anterior Precommunicans. Precommunicant. prem. 
az.) 

Communicans posterior. Postcommunicans Postcommunicant pem. 
Choroidea anterior..... Prechoroidea .... Prechoroid....... prehrd. 
Choroidea posterior .... Postchoroidea.... Postchoroid...... pehra. 
Perforantes anteriores . Preperforantes... Preperforants.... prpf. 
Perforantes posteriores. Postperforantes .. Postperforants ... ppf. 
Termatica 


Cerebralis ant. »(az.). Termatica ....... Termatic trme. 
media 
Dural Arteries. 
Meninged..... sesso Piste ELT ULIS We fete siete >... Dural. 
Meningea anterior...... Preduralis........ Predural. : 
Meningea media....... Mediduralis...... Medidural. 
Meningea parva ....... Parviduralis ..... Parvidural. 
Meningea posterior .... Postduralis ...... Postdural. 
Meningea inferior ..... Subduralis....... Subdural. 


Sinuses. 


Oy a superior Longitudinalis ... Longitudinal. 
az 


Longitudinalis inferior Falcialis ......... Falcial. 
az.). 
Torcular Hero- 
Pp 
Goatoens sin. KOZ.) TOTCHIAD .. si.5.00 0% Torcular. 
um 
Sphenoparietalis Saae : fi 
‘Ale parvee .... Sphenoidalis ....: Sphenoidal. 
Petrosus superior...... Superpetrosus.... Superpetrous. 
Petrosus inferior....... Subpetrosus...... Subpetrous. 
Petrosus anterior ...... Prepetrosus...... Prepetrous. 
[RQGUMISUROI CS) sietvecsccnsic LONLOTH 4 osccceee Tentorial. 


Lacunz laterales sinu- Lacune parasinu- Parasinual * spaces. 
um. ales. 


Intrinsic Veins of the Brain. 


Cerebri superior........ Supercerebralis .. Supercerebral. 
Cerebri anterior 


eats anterior ex-} Precerebralis .... Precerebral. 
ma 

Cerebri media.......... Medicerebralis ... Medicerebral. 
Fossz Sylvii ........... PVA Vidicreteteleveytiars v:tie Sylvian. 
Basilaris Rosenthali 

Cerebri inferior s. as- + Subcerebralis .... Subcerebral. 


cendens 

Occipitalis lateralis 

Cerebralis lateralis et 
inferioris 

Occipitalis interna 

Cerebri posterior in- 
ferior 

Callosi 
terna. 

Magna Galeni 

Cerebri interna 
communis 

Cerebri interna s. inti- 
ma s. profunda 

Right and left vein of 
Galen 


Postcerebralis.... Postcerebral. 


Suboccipitalis .... Suboccipital. 


posterior ex- Callosalis ........ Callosal. 


(ag). Galentnasesses oc Galen’s. 


* The form parasinual was kindly suggested and approved by Prof. 
B. I. Wheeler, the comparative philologist. 


Corporis striati l ae A 
Lateralis ventriculi f T#Dialis......... Tenial. 
peer ae eGo Precornualis ..... Precornual. 
Septi lucidi aD Ae ; 
Antr.-ventriculi t Paraseptalis...... Paraseptal. 





Cornu posterioris Postcornualis .... Postcornual. 
Ohoroldeawee cnewshuces. Medicornualis .... Medicornual. 
Medullares superiores.. Superalbales ..... Superalbals. 
Rami corporis striati... Striatales ........ Striatal. 
Rami thalami optici.... Thalamici........ Thalamic. 
Ramus thalami optici 

ap et (Rosen- | phalamocruralis . Thalamocrural. 
Pedunculi cerebri 
Azygos conarii ........ Conarialis........ Conarial. 


Cerebelli sup. media.... Supercerebellaris. Supercerebellar. 


Cerebelli sup. lateralis.. Paracerebellaris . Paracerebellar. 

Cerebelli inferior ...... Subcerebellaris... Subcerebellar. 
Dural Veins. 

Durze matris cerebri | : 

Meningea fo LACIE Seo Dural 

Meningea media ....... Mediduralis ...... Medidural. 


Ophthalmomeningea.... Ophthalmoduralis Ophthalmodural. 


ARTERIES. 


The encranial arteries present two distinct systems of 
vessels: 

I. The dural, commonly called meningeal. 

II. The intrinsic, or those of the brain proper. 

These latter do not anastomose with any other arteries. 
Rarely there are marked exceptions to this rule, and per- 
haps oftener slight inosculations about the sella turcica. 

Heubner (1874), from injections in adults, says: “The 
territories of the medidural and of the cerebral arteries 
must be considered as absolutely independent of one an- 
other.” Langer (1877), speaking of infantile and young 
subjects, states: (a) that one or two dural branches of the 
precerebral anastomose in the falx with terminal twigs 
of the dural artery; (0) also that pial branches of the pre- 
cerebral may reach minute dural arteries accompanying 
the supercerebral veins as they spring over to the dura 
near the longitudinal sinus. 

I. THe DuRAL VESSELS ramify in the exterior of the 
dura. Ina general way it is true that the pre-medi- and 
post-dural arteries are branches respectively of the in- 
ternal and external carotid and vertebral arteries. These 
various branches interanastomose freely, so that dural 
infarction does not occur. They are distributed not 
simply to the dura, but also to the diploic cranial bones; 
small twigs may also pass to extracranial parts. 

1. The Branches from the External Carotid supply the 
middle belt, and, in fact, nearly the whole of the dura. 
They are: 

(1) The Medidural, the largest and most constant ofall 
the dural arteries, arising from the internal maxillary 
and entering through the spinous foramen. Its branches 
pass up the divergent sulci meningei (for arteries and 
accompanying veins) of the lateral cranial wall, connect- 
ing at the top with those from the opposite side. Of 
its two main divisions, the larger anterior is often for a 
short distance arched over to a canal. 

The furrows of the medidural artery on the entocranial 
wall deepen with years, and in old age the artery sinks 
quite into them. It has two primary branches, a larger 
cephalic and a caudal, the former again soon (at the 
sphenoidal angle of the parietal bone) separating into two 
secondary rami. The anterior ramus runs up behind the 
coronal suture, though a little more obliquely, being, 
according to Marchant, pretty constantly from 0 to 18 
mm. (averaging 5 to 6 mm.) away at the foot of the 
suture, about 1 cm. at its middle, and 15 mm. at its dorsal 
part. The second ramus starts on the entotemporal sur- 
face 4 cm. behind the pterion, on an average. At its 
middle, on the entoparietal surface, it averages 54 mm. 
behind the coronal suture. Farther dorsad, the distance 
is very variable, 830 mm. more or less. ; 

The primitive caudal branch leaves the temporal 
squama 58 mm. behind the pterion, then goes toward, 
and becomes parallel with, the lambdoidal suture. 

The relations of these vessels to the subjacent cortex, 
important clinically, Duchaine sums up thus: (1) The 
cephalic branch runs up opposite the frontal lobe some 


249 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





centimetres before the central fissure, rather nearer the 
coronalsuture. (2) The midramus starts almost opposite 
the fissure, then runs up some centimetres behind it. (8) 
‘The caudal branch is always a centimetre or more distant 
from the fissure, and is still farther separated above. 

Besides many minute branches to the sinus walls, out- 
going nerves, and orbit (vide infra), it may send to, or re- 
ceive from, the deep temporal region minute rami per- 
forating the interposed wall; in young subjects (Hyrti) 
considerable branches may pass through the anterior 
fontanelle and the sagittal suture to the soft cranial cov- 
erings. 

Oy The Parvidural, an inconstant accessory medidural, 
arising close to the latter, or even directly from it, and 
entering by the oval foramen. It goes to the Gasserian 
ganglion and adjacent dura. 

(8) The Mastoid branch of the occipital (or external 
carotid, 15 in 120 times, Wyeth, 1878), entering by the 
mastoid foramen, within which it always sends a branch 
to the diploé. It is small, variable, and destined for the 
wall of the lateral sinus and adjacent dura. Here again 
‘a reverse course has been observed, where the postauricu- 
lar arose froma duralartery by emerging through a fora- 
men in the mastoid (Bankart). 

(4) Supradural branch or Ramus Parietalis, also from 
the occipital, accompanying the emissary through the 
parietal foramen. It is usually insignificant, and often 
absent. 

(5) The Subdural branches are very small and variable. 
They include twigs from the ascending pharyngeal, oc- 
cipital, and stylomastoid arteries, enter by the pre- and 
post-lacerated, precondyloid, and stylomastoid foramina, 
and partly supply the dura of the posterior fossa and 
basilar sinuses. 

2. Branches from the Internal Carotid.—(1) The cavern- 
ous carotid yields several small rami to the sinus wall, 
the pituitary body, Gasserian ganglion, and dura about 
the sella turcica. These are variously styled receptacular 
and vayed arteries, even predural in case of any prominent 
single branch. Their field of distribution and that of the 
parvidural are evidently complementary. 

(2) The Predural usually refers to the one or more slight 
branches of the ethmoidal arteries, supplying the adja- 
cent dura of the precranial fossa. 

3. Branch from the Vertebral.—The Postdwral artery 
arises opposite or just below the occipital foramen, passes 
with the vertebral into the cranial cavity, and supplies 
the dura of the postcranial fossa, especially the posterior 
portions, as the cerebellar falx, etc. 

The only anastomoses of special interest, between 
dural and extradural arteries, are with those of the orbit. 
Such connections always exist. Often a medidural 
branch enters, through either the sphenoidal foramen or 
some special opening, and supplies the external wall, 
even substituting partly or wholly the lachrymal artery, 
or a branch of the lachrymal may take the reverse course. 
Very rarely the medidural arises directly from the oph- 
thalmic (Zuckerkandl, four cases, Hulston, one), and then 
passes by the sphenoidal fissure to its usual distribution. 
‘This possible origin should be borne in mind in the rare 
operation of tying the medidural at the base of the skull. 

II. Inrrinstc ARTERIES (or those of the pia and 
brain substance).—In removing the brain from the skull 
we sever at its base the four arteries which suffice for its 
entire blood supply. These are, anteriorly, the two car- 
otids entering through the carotid foramen and canal, 
posteriorly, the two vertebrals entering beside the foramen 
magnum. By means of communicating branches at the 
base of the brain—the vertebrals having first united, and 
their common basilar trunk having divided into the two 
postcerebrals—the primary vessels combine to form the 
circle of Willis. From this practically all and only the 
cerebral arteries emanate. Previously, however, several 
branches are given off by the vertebrals and basilar; 
while the carotid yields only the ophthalmic. The latter 
is said always to originate before any of the cerebral 
branches, and some millimetres before the bifurcation of 
the cerebral carotid. 


250 


The Vertebrals and Basilar supply in their course the 
organs of the posterior fossa, viz., cerebellum, pons, 
oblongata, and their adnexa. In approaching the distal 
border of the pons the vertebrals unite to form the mesal 
basilar. This is occasionally divided within by a septum, 
or separates into two vessels which soon reunite. The 
basilar lies in the median sulcus of the pons, directly 
on the basilar process of the occipital bone ; opposite the 
central border of the pons it ends in the two postcerebrals. 
Only occasional variations are attributed to the vertebrals: 
(1) absence of one, the existing vessel being joined by a 
branch from the opposite carotid; (2) both may join the 
basilar on the same side; (8) or one may be represented 
by two or three branches before entering the formation 
of the basilar trunk. 

The lateral branches are: 

1. Postcerebellar, the largest offshoot of the vertebral. 
It passes around the oblongata, beside the pneumogastric 
nerve, to supply the extremity of the cerebellar lobe as 
far as the median line, the subvermis and adjacent sur- 
face, and the plexus of the metepicele. 

2. Recurrent Spinal Twigs, also from the vertebral, are 
given as follows by Kadyi: Immediately after the 
vertebrals traverse the dura there arises from each a 1 
mm. thick branch (dorso-myelic), which, after giving up 
twigs to the restiform body, descends along the dorsal 
border of the lateral columns of the cord. This is homol- 
ogous with other branches entering by the dorsal nerve 
roots. Sometimes this arises from the vertebral in com- 
mon with the postcérebellar. 

Near the union of the vertebral to the basilar there 
arises—usually one on each side, though unequal—the 
myelic branch for the ventromyel. These two, how- 
ever, either soon or oftener after entering the spinal 
canal, combine to form the azygoid ventro-myelic artery. 
They are thus continuousand homologous with the other 
myelic arterioles coming in along the ventral nerve 
roots. 

A full consideration of the minute details of the arterial 
distribution in the oblongata is given by Adamkiewicz 
(vide Plate XVII.). These vessels come wholly from the 
upper (intracranial) part of the vertebrals as they cross 
the ventral surface of the oblongata. 

The main facts regarding the three classes of secondary 
or nutrient arterioles (external or surface vessels) he ac- 
cepts from Duret: 1. The radicals, direct from the verte- 
brals, supply the outgoing nerve roots (facial, acoustic, 
glosso-pharyngeal, vagus, accessorius, and hypoglossus). 
2. The nuclears, at right angles from the one or two 
dorso-myelics in an extent of 3 to4cm. These pene- 
trate the median fissure, at the bottom of which they 
form a kind of sagittal leader, and end beneath the floor 
of the metepiccle (fourth ventricle). 3. Arteries for the 
other portions of the oblongata (olivary bodies, pyramids, 
corpora restiformia), in part at least from the myelics. 

Moreover, on the oblongatal surface is a rich network 
of vessels. The ventromyelics opposite the oblongata 
give off a multitude of twigs that take a very sinuous 
course and soon settle into the furrows. For the dorsal 
surface of the oblongata there is no external supply until 
below the calamus—upper end of myel. Its source is 
the dorsomyelics. These latter, at the first cervical 
roots, turn caudad between the accessory nerve roots 
(nearer the dorsal), and when at the level of the fourth or 
fifth cervical roots they end by also anastomosing with 
vessels of lower origin. 

From the middle portion of the vertebrals, between the 
ventro- and dorso-myelics, arise the largest branches 
(subcerebellars), but these dodge the oblongata and are 
wholly for the cerebellum. 

Topographically, Adamkiewicz distinguishes three sets 
of finer or nutrient arterioles (internal or substantial ves- 
sels) after the manner of the myelic supply. 

(1) Ventro-fissurals, relatively large, dividing in the 
ventral commissure into two branches, one to each side 
for the corresponding ventro-mesal cinerea. In the ob- 
longata these supply principally the pyramidal tracts and 
decussation, lemniscus, interolivary tract, raphé, and the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





following nuclei—gray dorsal columna, n. pyramidalis, 
n. arciformis, oliva, and hypoglossus. 

(2) Dorso-fissurals, of course only caudad of the cala- 
mus. These divide at the dorsal commissure into two 
border vessels, and are for the substance of the dorsal 
columns, nucleus gracilis, accessorius centre, and casu- 
ally the hypoglossus. 

(3) Coronal, radial, or lateral system. These are very 
numerous, penetrate the alba from all sides (excepting of 
course the metepicele), and in part reach the subjacent 
cinerea to then help form its mass of capillaries. A sub- 
class here—nuclear arteries—consists of six to eight rela- 
tively large twigs entering the angulus restiformia oliva- 
ris and running parallel toward the middle of the floor of 
the metepicele, to supply principally the centres for 
glosso-pharyngeus, vagus, hypoglossus, and acusticus. 
The following parts receive these radial or lateral afflu- 
ents—the ventral columns, lateral nuclei, lateral cornu, 
caput of substantia gelatinosa, nuclei cuneati gracilis, ar- 
ciformis et pyramidalis, and the oliva itself. 

3. Medicerebellar, usually from the basilar trunk. This 
passes along the middle cerebellar crus to the preventrad 
surface of the respective cerebellar hemisphere, including 
the flocculus. 

4. Transverse branches, three or fourinnumber. These 
are parallel and accessory to the preceding. 

5. Auditiva Interna. Starts like the last, but passes to 
the internal auditory meatus and structures of the inner 
ear. 

6. Ponticular branches. These immediately enter the 
pons perpendicularly, and supply its substance. They 
represent true terminal arteries (Heubner), quite com- 
parable to the perforants of the cerebrum. From the 
importance of the tracts supplied they have likewise 
great interest to the pathologist. 

7. Supercerebellar. This starts near the end of the 
basilar, passes outward along the front border of the 
pons, winds around the crus cerebri near the optic lobes, 
and is distributed to the supervermis and general dorsal 
surface of the cerebellum: It also supplies the post-optic 
arteries. 

The basilar branches all emanate at practically a right 
angle to the mother trunk. Those going to the surface 
anastomose much more freely than do the cerebral arteries. 
Accordingly Heubner found the pia districts of single 
arteries much less definite over the cerebellum than 
over the cerebrum. Moreover, the branches of the 
two sides communicate dorsad across the median line; 
this is explained by the development of the cerebel- 
lum from a single median vesicle. The only communi- 
cation between this system of vessels and the cerebral— 
except through the basilar trunk—is by small branches 
of the precerebellars and postcerebrals across the crura 
cerebri. 

CrRcLE oF Wiuuis.—The carotid ends at the outer 
angle of the chiasma in two main branches, the pre- and 
medi-cerebral arteries. At about 1 cm. in front of the 
chiasma the two precerebrals are connected by the pre- 
communicant. From either the medicerebral or the 
carotid passes the postcommunicant to the corresponding 
postcerebral. Hence the circle (or polygon) of Willis is 
made up by one precommunicant, two precerebrals, two 
medicerebrals (or two carotids), two postcommunicants, 
and two postcerebrals. This is the classical arrange- 
ment; fromit, however, there are frequent and important 
deviations. Professor Windle found that it held in only 
76, or, overlooking any disproportion in the postcom- 
municants, in 119 out of 200 cases. Only in the apes do 
the vertebrals nearly equal the carotids. In man, Ehr- 
mann, from 157 measurements, found that very constantly 
the basilar trunk was equal to one carotid (7.e., furnished 
one-third of the brain supply). The communicants are 
not simply to re-establish a circulation in case of obliter- 
ation, but they normally act to equalize pressure in the 
local vessels. When this circle is complete and of normal 
structure, an adequate collateral circulation is established 
after occlusion of any one part. From this circle and the 
first few centimetres of its branches originate a multitude 


of arterioles passing to the basal ganglia and adjacent 
structures. 

Dercum offers “ A Collection of Anomalies of the Circle 
of Willis” (Jowrnal of Nervousand Mental Diseases, 1889, 
January), and J. H. Lloyd (Jdzd., 1890, p. 225) gives such 
a case of a type described by Duret (right vertebral absent, 
both precerebrals from left carotid, etc.). St. John Bullen 
(Journal of Mental Science, 1890, January, p. 38) bases the 
following statements on the examination of 1,565 brains 
(from the insane), but holds statistics too uncertain. 
Arterial variations occur much oftener in general para- 
lytics than in those dying of other forms—this applying 
equally to all segments of the circle of Willis. 

The components of this circle and their branches: 

The Precommunicant.—This is a transverse branch 
beneath the rostrum, from 1 to 2 mm. in size, connecting 
the two precerebrals, and forming the anterior side of the 
circle. Windle found it normal in 159, double in 14, in- 
completely so (forked at one extremity) in 6, triple in 1, 
absent in 8, and associated with union of the precerebrals 
in 2. Wilder notes the latter condition in 6 out of 7 
cases, and Starrin 2of 14. Duret says that when double 
one is of normal size, the other very small. Its place is 
sometimes supplied by a fasciculus of small twigs. The 
precommunicant, Bullen finds, may be absent, or merely 
rudimentary, or double. Its branches—more numerous 
when the communicant is unusually long—are: 

1. The Termatica, a mesal vessel at its origin. Wilder 
found this present in all of seven brains examined. “It 
usually divides soon into a right and left portion, which 
supply respectively the cinerea forming the surface of 
the triangular area ventrad of the genu and rostrum, and 
then extend around the genu to the dorsal aspect of the 
callosum.” Windle notesitin nine of hiscases. It passed 
along the longitudinal fissure for two-thirds of the length 
of the callosum, and divided into branches supplying the 
opposed surfaces of the hemispheres. When the com- 
municant is wanting, this vessel may start from the junc- 
tion of the precerebrals. 

2. Small retrograde rami to the lamina of the chiasm. 

3. Arterioles which plunge into the callosal rostrum, 
and very often one or two considerable branches com- 
pletely perforating the rostrum and ramifying on the 
crura of the fornix, the anterior commissure, and the 
septum. 

The Precerebral (vide Plate XVI. and Fig. 818, 3).— 
This at its origin is almost perpendicular to the carotid. 
Often the artery of one side is larger than, and partly 
substitutes, that of the other side. Windle found it nor- 
mal in 181 of 200 cases. In 2 the right was absent, its 
place being partly supplied in one by twigs from the 
right medicerebral, in the other by a small branch from 
the carotid. In1the right was double the size of the 
left; in 1 the two united to a single trunk; and in 8 they 
united for a short distance, six times replacing and twice 
accompanying the precommunicant. Hither precerebral 
may, according to Bullen, (1) be replaced by two small 
trunks; or (2) be absent, its region being supplied by 
branches of the opposite artery. 

The short oblique portion, dorsad of the optic nerve, 
between carotid and precommunicant, represents part of 
the circle of Willis. This portion may give off the fol- 
lowing branches: 1, Arterioles to the optic nerve of the 
same side. 2. Lateral arterioles to the neighboring con- 
volution and the callosal rostrum. 38. When, from pre- 
mature division of the carotid, the precerebral goes over 
a longer course, it much oftener gives large twigs to the 
caudate ( preperforantes). Duret says that these branches 
take one of two courses. In one they penetrate almost 
within the expansion of the olfactory nerve, perforate 
the callosum at its junction with the lower part of the 
caudate head, and divide into five or six almost sub- 
ependymal ramifications not extending ‘beyond the first 
2 cm. of the caudate. In the other, one or two arterioles, 
of about 1 mm. diameter, follow a retrograde course of 
3-4 cm. to the preperforated space beneath the caudate, 
to which latter exclusively they are distributed. 

From the precommunicants on, the precerebrals run 


251 


Brain, 
Brain, 





side by side around the genu and caudad at the bottom 
of the longitudinal fissure. After giving off the first 
few branches the main trunk may divide into three 
branches, as stated by Duret, whose description is largely 
followed; or several successive branches are given off, as 
in the accompanying plate. Together, they supply the 
inner two-thirds of the ventral surface of the frontal 


Fig. 818.—Arteries of the Base. (After Duret.) 


prethalamic (postperforants). 


vian fissure, and also its branches crossing the insula. 


lobe, the anterior four-fifths of the opposed surface of 
the hemispheres, the callosum (largely), and a portion of 
the convexity. 

1. Subfrontal twigs, to the olfactory groove and region 
as far as subfrontal sulcus. 2. Prefrontal branch, to 
mesal surface of superfrontal and convex surface of 
superfrontal and part of medifrontal convolutions. 3. 
Medifrontal branch, to the callosal convolution, and 
paracentral lobule. After doubling the crest of the 
hemisphere it terminates about the dorsal extremity of 
the central fissure. 4. Postfrontal branch, to precuneus 
and the adjacent portion of the convexity, nearly or 
quite reaching the occipital fissure. 5. Cullosal artery. 
This may pass around the splenium to terminate in the 
pineal gland, and even posterior commissure. It goes 
to the callosal convolution and vault, perforating the 
latter and ramifying over the whole extent of the roof of 
the paracceles. 

The Cerebral Carotid (Fig. 818, 1).—As a rule the post- 
communicant is a direct branch of the carotid, though it 
often starts from the medicerebral. In the former case 
the carotid, from this branch to its termination at the 


252 





1, Carotid ; 2, medicerebral ; 3, precerebral; 4, 
postcerebral; 5, preperforants (striate arteries) ; 6, prechoroid; 7, postcommunicants ; 8, 
postchoroid ; 9, medichoroid ; 10, callosals (termination of precerebrals) ; 11, medioptics ; 12, 


The carotids are drawn frontad to show the preperforants. 
The left temporal lobe is cut away, exposing the medicerebral trunk at the bottom of the Syl- 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





commencement of the Sylvian fissure in the pre- and 
medi-cerebrals, forms part of the circle of Willis. In this 
short course a few lateral branches are given off: 

1. Arterioles to the external angle of the chiasm. 
Either these or the chtasmie arterioles from the precere- 
bral supply minute twigs to the first portion of the optic 
nerve. 2. Frequently, one or more of the perforantes to 
the caudate. 38. Prechoroid (Fig. 
818, 6). This may come from the 
medicerebral, or even from the 
postcommunicant; in any case its 
origin is peripheral to that of the 
last named. It is directed oblique- 
ly caudad along the outer side of 
the optic tract to attain the cho- 
roid plexus in the lateral horn 
(through the extremity of the 
transverse or Bichat’s fissure). It 
gives off: (@) internal and slightly 
recurrent branches to the optic 
tract; (0) internal branches for the 
central part of the outer aspect 
of the crus cerebri; (¢) external 
branches to the uncus (a terminal 
arteriole, Heubner); (d) extremely 
fine twigs to the two-thirds of the 
choroid plexus that it is stated to 
traverse. 

In general, Kolisko’s work cor- 
roborates that of Heubner. Ina 
large number of examinations this 
vessel was never absent. It hasa 
pretty constant diameter of 0.5 
mm. In the foetus it is relatively 
very large. In animals (dogs, 
cats, rabbits) it was regularly pres- 
ent, but arose from the Sylvian. 
The branch to the uncus was al- 
ways present, but has free anasto- 
mosis in the pia. The branches 
in plexus and tela also anastomose 
freely with others near; but those 
rae brain substance are termi- 
nal. 

The prechoroid supplies the fol- 
lowing parts: The posterior arm 
of the internal capsule, with the 
lamina medullaris externa of the 
thalamus to the level of the upper 
angle of the midlenticular seg- 
ment—usually only the posterior 
two-thirds; the white substance 
back of the internal capsule as far 
as the roof of the medicornu; the 
inner lenticular segment; the un- 
cus; the optic tract (in its pos- 
terior half); the lateral choroid plexus; the endyma of 
the posterior and lower parts of the paracele; the 
greater part of the tail of the caudatum; exceptionally 
the external parts of the upper half of the thalamus. 

But the posterior arm of the internal capsule is also in 
part supplied by the medicerebral and posteommunicant 
(the anterior third of this part by the latter vessel), the 
deeper parts by the prechoroid and postcommunicant, 
and the upper parts (above apex of midlenticular seg- 
ment) by the Sylvian (lenticulo-optic ramus of Duret), 

Circulatory disturbances in the supply territory of the 
prechoroid cause opposite hemiplegia by softening in the 
posterior segment of the internal capsule, involving the 
pyramidal and cranial-motor tracts. 

Hemianesthesia, hemianopsia, and hemianosmia may 
likewise follow closure of the prechoroid, but are usually 
headed off by collateral supply. 

When the postcommunicant is large, its blocking may 
cause opposite facial and hypoglossal paralysis, since 
these tracts traverse the front part of the posterior arm 
of the capsule. 

The Medicerebral (vide Plate XVI. and Fig. 818, 2).—The- 





EXPLANATION OF 
PLATE XVI. | fs 


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EXPLANATION OF PLATE XVII. 


ARTERIAL SUPPLY OF OBLONGATA (FROM ADAMKIEWIOZ), ENLARGED Srx DIAMETERS. 


Fia. 1.—At Decussation of Pyramids. 


Hs, Dorsal Column. 

Ng, Nucleus gracilis. 

Ne, Nucleus cuneatus. 

Sge, Substantia gelatinosa centralis. 

Cep, Caput cornu posterioris (aut tuberculum Rolando). 
AIT, Root of hypoglossus. 

Vr, Remnant of ventral column. 

Prk, Decussation eminence. 

Py, Pyramid. 

g, Boundary between Py and Vr. 


S, Arteria sulci. 

Sa, A. sulci (at deeper layers). 

Acc, Aa. centrales cornuum anteriorum. 
Aca, Aa. cornu anterioris. 

Anl, A. nuclei lateralis. 

As R, A. tuberculi Rolando. 

Anc, A. nuclei cuneati. 

Ang, Aa. nuclei gracilis, 

F, A. fissure. 


Fie. 2.—Opposite Middle of Metepiccele. 


H, Hypoglossus nucleus. 
Va, Post. vagus nucleus. 
Po, Ponticulus (velum medullare posticum). 
Gi, Glossopharyngeus nucleus. 
Ac, Acusticus nucleus. 
Ib, Longitudinal bundle. 
(Krause’s respiratory fasciculus.) 
Cr, Corpus restiforme. 
X, Ant. vagus nucleus. 
IX, Root of glossopharyngeus. 
Aro, Angulus restiformio-olivaris. 
O, Oliva. 
No, Nucleus pyramidalis. 
Ozs, Interolivary tract. 
R, Raphé. 


Py, Pyramid. 

Na, Nucleus arciformis. 

S, Arteria sulci. 

Sce, Affluents to external nest-like capillary coils, from. 
sulcus artery. 

Sci, Affluents to inner same. 

Aoli, Sublateral olivary artery. 

Aso, Olivary ramus from sulcus artery. 

Aoli, Subolivary arteries. 

Aolm, Medilateral olivary artery. 

Aols, Super-olivary artery. 

An, Arteries of the nuclei (glossopharyngeus, vagus, 
hy poglossus). 

Vn, Nuclear vessels (glossopharyngeus, acusticus). 

F, Arteria fissure. 


Fie. 3.—Longitudinal Section through Olivary Body. 


O, Oliva. 
Br, Pons. 


Aoli, Aa. olive laterales inferiores. 
An, Aa. nucleariz. 





EFERENCE HANDBOOK | | , Plate XVII. 
moe OFTHE : -* 
MEDICAL SCIENCES. 





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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





vessel represents the most direct continuation of the cere- 
bral carotid. It lies at the bottom of the Sylvian fissure, 
as do also the primitive portions of its larger branches 
as they spread out over the insula. When the postcom- 
municant starts from the medicerebral, the previous 
short (4-6 mm. long) portion of the latter participates 
in the circle of Willis. No branches are assigned to this 
art. 

: The medicerebral in its further course yields two classes 
of branches: (a) direct, perforating, or nutrient arterioles ; 
(0) large and small pia arteries. 

(a) A few perforantes (Fig. 818, 5, 5) from the earlier 
part of this artery may pass directly to the caudate head, 
with those described under precerebral and mentioned 
under carotid. Butthe main group from this source take a 
somewhat different course, and, as stated by Heubner, are 
often detached from the trunk farther out in the fissure. 
These have been divided into two sets. The first to leave 
the trunk—lenticular arteries—are the finer, and are simi- 
lar in deportment to the preceding, except that they go 
to the first and second segments (apex) of the lenticular 
nucleus. The second, coarser set runs along the base of 
the lenticular nucleus on the limit of the external cap- 
sule. A portion of these pass caudad and dorsad to the 
thalamic extremity of the lenticular nucleus, and termi- 
nate in the thalamus—lenticulo-thalamic arteries. One 
arteriole, noticeably larger than any of the others and 
the frequent source of hemorrhage in this region, passes 
dorsad and mesad to the third segment of the lenticular, 
where it gives off many side twigs, and finally divides 
into four or five terminal branches, supplying also the 
adjacent internal capsule, etc. Two or three accompany- 
ing arterioles extend toward the third segment, and may 
attain the tail of the caudate. Collectively these are 
termed lenticulo-striate arteries. 

A further group might be made of the small direct 
vessels traversing the insula to gain and supply the 
claustrum ; as this is, however, a derivative of the ex- 
ternal gray layer, these twigs more nearly correspond to 
the general cortical and albal arterioles. 

Of the perforantesas a whole, it may be said that they 
all emanate at right angles from the inner side of the 
mother vessel. Their size varies from 0.5 to 1.5 mm. 
They immediately enter the brain substance, only occa- 
sionally dividing, and never anastomosing before doing 
so. They usually run a further short course before 
branching. The ultimate distribution of each is pencil- 
shaped. They are destined to supply the central gray 
nuclei and the capsules, notably the inner. They are all 
true terminal arteries, without any anastomoses either 
between themselves or with other arteries. According to 
the French school, even their finest capillaries do not con- 
nect, but on this point the Germans teach otherwise. 

(6) Pia branches of the medicerebral. After a course 
of 1 to 2.5 cm. the main trunk, either at one stroke 
or successively, divides into several large branches. 1. 
Previously, however, there are usually a few small rami 
for the adjacent borders of the frontal, and especially 
the temporal, lobes (see Plate XVI.). 

2. Frontal branch. This is generally the first large 
ramus. Like the succeeding, it runs some distance deep 
in the sulcus and subdivides often, at least before ap- 
pearing externally. It is especially destined for the 
subfrontal convolution. It supplies the orbital surface 
of the frontal lobe external to the orbital fissure, and the 
convexity dorsad to the middle of the medifrontal gyrus, 
caudad to the precentral sulcus. Duret found a very 
ent corresponding artery in several species of ani- 
mals. 

3. Preparietal. This nourishes the precentral and ad- 
jacent extremity of medifrontal convolutions, and may 
by an early branch include the postcentral also. 

4, Mediparietal. Thismay gain the fissure of Rolando 
to supply not only the postcentral convolution, but 
dorsad a portion also of the precentral. It may also 
reach the adjacent parietal region. 

5. Postparietal. This is a large branch in the horizon- 
tal Sylvian fissure. Its ramifications do not extend be- 


yond the parietal or occipital fissure, but may pass be- 
yond the supertemporal. 

6. Temporal. This is included under the last by many, 
but it is often an early and large branch of the medicere- 
bral. By its numerous considerable subdivisions it then 
covers practically the whole external temporal surface. 
At least the supertemporal convolution and much of the 
meditemporal are regularly supplied. Its distribution 
extends nearly to the suboccipital convolution. 

There is no special artery for the insula, but it receives 
several small branches from the preceding as they cross it. 

The Postconmunicant.—Connecting the pre- and post- 
(carotid and vertebral) systems. They start from the 
carotid or medicerebral, and run directly caudad to in- 
osculate with the corresponding postcerebral at 5-12 
mm. from the latter’s origin. They pass ventrad of the 
optic tracts and also encounter the crura cerebri. In 
size and occurrence these vessels are variable, and fre- 
quently unsymmetrical. The left is more often the 
smaller or even absent, though some filiform anastomosis 
from a corresponding branch of the carotid usually does 
exist. As a very large branch from the carotid, espe- 
cially the right, it may replace the corresponding postcere- 
bral wholly or in part, or conversely; a large left com- 
municant has been observed to arise from the postcerebral 
and supply the same medicerebral. Aside from disparity 
in size (43 times) the postcommunicants were normal in 
175 of Windle’s cases. Excepting slight anastomosis, 
both were absent in 8 cases, the right in 9, the left in 13. 
In 7 both were very small; in 28 the right was much 
larger than the left; in 15 the reverse. 

Anomalies, says Bullen, are more common in the post- 
communicants than in all the others. Of these vessels, 
either (1) may beabsent; (2) may be replaced by a branch 
from the subcerebellar, internal carotid, postcerebral, or 
two small nutrient branches respectively from the last 
two vessels; (3) may supply unusual regions; or (4) may 
be unconnected with the carotid system. 

This vessel gives off laterally pia branches, (a) internal, 
(6) external, and (c) inconstant penetrating rami. 

(a) 1. Chiasmic branches to the caudal side of the 
chiasm. 2. Twigs to the tuber cinereum and infun- 
dibulum, a descending ramus supplying the pituitary 
body. 3. Two to the mammillary bodies. 

(0) 1. To the optic tract. 2. To the cerebral crura. 
3. Often considerable branches to adjacent temporal gyri. 

(c) 1. Prethalamic Artery (internal and anterior optic 
of Duret). It penetrates between the tuber cinereum and 
mammillary bodies, and ramifies in the more anterior 
part of the aula, on the walls of the infundibulum, etc. 
2. Medithalamic artery (posterior internal optic). At 
times large, it enters the postperforated space and passes 
directly dorsad near the inner thalamic wall, to which 
and the gray commissure it is distributed. This vessel 
comes as often ‘from the postcerebral as from the post- 
communicant. The prethalamic may also have the same 
origin. 

The Postcerebrals, from the end of the basilar to the 
postcommunicants, complete the circle of Willis. This 
part furnishes: (1) three or four arterioles to the internal 
aspect of the crura cerebri, supplying its basal layer, the 
locus niger, etc.; (2) little branches entering the thalamus 
through the postperforated space. These accompany, 
and often include, the above-described medithalamic 
artery. 

Windle found the postcerebral arteries normal in 173 
cases. The vessel was derived from the carotid instead 
of the basilar in 11 cases on the right, 9 on the left, and 
4 on both sides. There were 2 postcerebrals on the same 
side—the smaller from the basilar, the larger from the 
carotid—in 3 cases: 1 on the right and 2 on the left. 
Either of the postcerebrals may (Bullen) (1) be absent; (2) 
be a branch of the carotid system; (3) be replaced by a 
large postcommunicant; or (4) be replaced by two thread- 
like vessels from the basilar. 

This trunk, in passing around the crus, describes a 
kind of semicircle, directed toward the transverse fissure. 
Dorsad of the crus, at about 1 cm. from the optic lobes, 


253 


Brain. 
Brain, 


it turns latero-caudad to gain the calcarine fissure, where 
it breaks up to supply the basilar postcerebral region. 
From its crural portions it supplies, besides other 
branches, nearly all the nutrient arteries of the ceelian 
walls. 

1. Little twigs to the outer part of the crus, penetrat- 
ing almost immediately. Instead of several in the thala- 
mo-crural sulcus, there may be a single larger one, par- 
allel to the main stem. 

2. The fairly constant Medioptic (median quadrigem- 
inal), giving fine offshoots in its course to the crus, and 
terminating in a bunch of fine vessels in the interval of 
the optic lobes. 

3. Postthalamic (so-called posterior and external), two 
or three, or a single larger one, starting midway from 
this portion of the postcerebral, and following the crus 
to enter the thalamus between the geniculate bodies. 

4 Geniculate, emanating directly, or from the thalamic. 

5. Postchoroid (posterior and lateral), starting near the 
optic lobes, and entering between the layers of the velum. 
It always divides into two principal rami: a lateral one 
for the third of the choroid plexus not supplied by the 
prechoroid artery, ¢.¢., for the plexus over the thalamus; 
the other more median one for the velum (ramus velaris). 

6. Medichoroid (posterior and median choroidal), from 
the postcerebral at its nearest approach to the median 
line. It courses beside the conarium, to which it yields 
some rami, and immediately divides into two branches, 
one to the velum of the aula, the other exclusively to the 
choroid plexus of the same cavity. . 

The choroid plexi and velum represent a double layer 
(fold) of the pia, within which the ccelian arteries and 
veins course. Duret states that in all the ceeles the arte- 
ries to the velum are distinct from those to the plexus, 
often even from their origin at the postcerebral, and al- 
ways at their entrance into the corresponding cavity, and 
that they never mingle in their distribution. From the 
velar arteries are detached a multitude of little arterioles, 
which penetrate the thalamus 1 to 1.5cm. They have 
the arrangement of cortical arterioles, and are pencillated. 
The two velar branches terminate in the head of the cau- 
date, either simply subependymal or passing deeply into 
its substance. The velar branches to the aula emit little 
arterioles laterally at intervals of about a millimetre. 
These penetrate perpendicularly the adjacent wall. They 
supply also the posterior and gray commissures, and 
terminate in a fine pencil in the anterior commissure. 
The plexus arteries, on the contrary, do not usually 
participate in the nutrition of the celian walls. They 
divide into four or five long parallel branches from which 
little arterioles pass into the plexuses, properly speak- 
ing. They enter the little tufts by their base, and form 
very attenuated and sinuous capillary meshes. It has 
been suggested that they are the remains of former 
branches ramifying in the embryonic ccelian pia, and 
that they became coiled up when this membrane retracted. 

7. Preoptic (anterior quadrigeminal), very short, com- 
ing from the most median part of the postcerebral, or 
from some branch of the latter. It forms a very delicate 
pencil over the preoptic body. This makes the third 
pretty constant pair of optic arteries, as these lobes are 
very vascular. They have some anastomoses across the 
median line. 

8. Artery of the cornu Ammonis, oftener from some 
branch of the postcerebral than arising directly. It does 
not ramify on the ccelian surface, but passes between the 
Ammonshorn and the hippocampal convolution, to trav- 
erse the cortex in the manner of external arteries. 

9. Variable branches to adjacent temporal gyri. 

Final Divisions of Postcerebral.—These may be brought 
under three general heads (see Plate XVI.). 

1. Pretemporal branches to the uncus in part, and the 
basal surface of the temporal lobe as far as the border of 
the convexity, except the third nearest the apex of the 
lobe, which is supplied from the medicerebral. 

2. Posttemporal to the basal surface of the occipital 
lobe, including a variable amount of the adjacent tem- 
poral region, and doubling the border of the convexity 


254 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








to supply a little of the external occipital region. The 
hippocampus may be supplied from the parent stem, or 
from either 1 or 2. P 

3. Occipital artery. This runs along the calcarine 
fissure, sending a large branch through the occipital 
fissure; it supplies the cuneus and general median sur- 
face of the postcerebral lobe, and a considerable strip of 
the adjacent occipital convexity. Spitzka says that an 
artery large enough to cause fatal hemorrhage enters the: 
gray and white of the right occipital lobe. 

GENERAL FEATURES OF THE ARTERIAL SUPPLY.— 
The distribution of each primary trunk includes: (a) bas- 
ilar or nuclear branches; and (4) pia or cortical branches. 

(a) These are the pre- and post-perforating and ccelian. 
arteries, arising in part from the circle of Willis. They 
supply the central ganglia, coelian structures, and in part 
the centrum semiovale. To the same class belong the 
direct arterioles from the basilar to the nuclei in the pons. 
Excepting occasional and unimportant anastomoses, these 
are all true terminal vessels. They divide within the brain 
substance at an acute, and not a right, angle. 

(6) The pia branches or divisions as described are 
only averages, complementary variations therefrom al- 
ways being present; though it is claimed that while 
“their origin is often very variable, their distribution is 
constant.” The larger arterial trunks correspond to the 
main fissures. To a marked extent it is true that the 
same branch does not supply both sides of a sulcus. 
Branches usually leave the parent stem at almost or quite 
aright angle. Some writers try to show a freer supply 
to the left hemisphere. Duret’s attempted correlation of 
arterial distribution and physiological function was at. 
least premature (1877) and faulty. 

Anastomoses.—The basal circle of Willis comprises all 
the communications readily demonstrable on the unin- 
jected pia arteries of the cerebrum. Only within this. 
circle and over the optic lobes are there any minute con- 
nections across the median line of the hemispheres. 

There has been a dispute as to the extent to which the 
ramifications of adjacent branches on either hemisphere 
are connected. Duret, after numerous, varied, and evi- 
dently careful examinations, says: “Never have we 
found an anastomotic network in the pia.” He also 
notes the frequent superposition in the pia of fine arterial 
ramifications. Nevertheless he found considerable in- 
dividual differences, and regularly some fine (0.2 to 0.25. 
mm.) communications, especially at the periphery, 7.¢., be- 
tween adjacent territories of distribution. On p. 927 he 
acknowledges that in the great majority of cases, owing to 
anastomoses, “however rare and unimportant,” softening 
from occlusion of any of the large basilar trunks spares. 
the peripheral parts of the artery’s territory. In the 
four-months foetus he found abundant fine anastomoses. 
Heubner (p. 174), on the contrary, says: “The chief [pia] 
branches end in a kind of communicating canal system 
or reservoir, which is spread out in the shape of a tubu- 
lar net over the whole surface of the brain.” By inject- 
ing “under weak finger pressure” he found plentiful 
anastomoses up to 1 mm. in diameter. Heubner’s de- 
scription harmonizes with that of older writers, and is 
corroborated by Lucas, who by sufficiently penetrating 
injections was able to demonstrate an abundance of com- 
municating arterioles up to 0.25 mm. (vide Plate XVIIL., 
Fig. 2). It remains true, however, that when the com- 
municants of the circle of Willis are poorly developed, 
the peripheral anastomoses are, in a large number of 
cases, incapable of substituting them. 

Direct or Nutrient Arterioles of the Convolutions.—These 
emanate at right angles from the pia branches, of all 
sizes. They penetrate the crests of the convolutions 
perpendicularly, the inclined surfaces obliquely. They 
are innumerable—scarcely more than 1 mm. apart. Ac- 
cording to size and distribution there are two classes: 

1. Cortical, 0.05 to 0.08 mm. in diameter. The finer 
stop in the cortex proper; the others go to the boundary 
of gray and white. The capillary network from these 
rami has been divided into three somewhat differently 
characterized layers, each parallel to the rolling surface. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


2. Albal (arteriole longs), 0.08 to 0.14 mm. in diam- 
eter. These are almost rectilinear, can be followed a 
distance of from 3to4 cm., and branchat an acute angle. 
They supply a considerable portion of the centrum semi- 
ovale. One often passes down along the axis of the con- 
volution. A group of five or six at the bottom of a 
fissure (in section) diverge on entering. The capillary 
network of the albals is more elongated than that of the 
corticals, and accompanies the fasciculi of nerve fibres. 

Both classes anastomose freely in their finer branches, 
though in general pencillate. 

From the anatomical arrangement it is believed that 


the intravascular pressure is less in the gray than in the 


white substance. 

It has been claimed by many that the thyroid gland 
acts as a safety diverticulum to the cerebral supply; and 
furthermore, that the lack of this regulator explained 
the occurrence of so-called cachexia strumipriva after 
removal of that gland; but any such special function of 
the thyroid is at least not proven. 

Width of Brain Arteries.—To make a relative estimate 
of the capacity of the arteries at the base, Bevan Lewis 
(“Examination of Brain,” 1882, pp. 20-22) determined 
their average diameters in 45 cases (insane). That of the 
vertebral was, r. 3.147 mm., 1. 3.42; of basilar, 3.82; of 
postcerebral, r. 2.658, 1. 2.56; of carotid, r. 3.951, 1. 4.02; 
of medicerebral, r. 3.138, 1. 3.55; and of precerebral, Te 
2.78, 1. 2.66. The sectional areas are of course propor- 
tional to the square of these diameters. Asa rule, the 
united areas of branches equal very nearly the area of 
the parent trunk—excepting the preponderance of the 
vertebrals over the basilar (22.4 to 14.8). 

Loéwenfeld has found that the relation of the artery 
width to the brain weight is, even normally, somewhat 
variable, and that often, though not by any means in all 
cases, the width of the brain vessels rises and falls with 
the width of the aorta; moreover, that not rarely abnor- 
mally small brain arteries occur in otherwise well-devel- 
oped arterial systems. He also made out a difference in 
the two sides, the left carotid being usually wider than 
the right. 

Pressurein the Brain Arteries.—A further matter, noted 
by St. John Bullen (oc. czt.), may partially indicate the rel- 
ative pressures in the main brain arteries. He remarked 
atheroma of the basal vessels in 410 of 1,565 autopsies, 
or 26 per cent. of the total. It was present to a consider- 
able extent, either generally dispersed or in special 
trunks only, in 175 cases, and to a less extent in 2385. 
The relative frequency by location was: medicerebral, 
38 per cent.; basilar, 80 per cent.; postcerebral, 21 per 
cent. ; carotid, 10 per cent. 

Mendel (1891) has found experimentally that the press- 
ure in the cortical arteries is materially less than that in 
the carotids, while that in the striatal arteries is not 
materially less. This he attributes to the fact that the 
latter are terminal vessels, though it is doubtless quite as 
much due to their less circuitous supply. He further 
thus explains the frequency of hemorrhage in the striatal 
region. 

Tedeschi’s conclusions regarding the brain arteries 
refer in part to moot points, but really contain nothing 
new and are deceptive in statement. 


VEINS. 

The venous passages of the pam and its membranes 
include: 

I. The dural veins. 

II. The intrinsic veins, or those of the brain proper. 

III. The sinuses. 

IV. The venous exits from the skull. 

All the intrinsic and most of the dural veins discharge 
into the sinuses, or appendatory spaces, which in turn 
convey the plood to the exits. ‘Otherwise these two sets 
of veins are separate systems, not interanastomosing, 
unless occasionally near their mouths. The intrinsic 
veins without exception have thin, readily collapsing 
walls, while the sinuses are held open by the firm enclos- 
ing dura. 


Brain, 
Brain, 


all these vessels are devoid of muscular elements, though 
occasional unstriped fibres have been observed in the in- 
trinsic veins. From this absence of actively contracting 
fibres, it follows that these vessels play a merely passive 
role in the encephalic circulation. The encranial veins, 
like the external veins of the head, are devoid of true 
valves. However, at the orifices of the diploé veins 
(Dupuytren, Langer, doubted by Trolard) and in the 
ophthalmo-dural vein, valves may occur. It hasalso been 
claimed that the supercerebral veins in part present a 
valvular arrangement at their discharge into the longi- 
tudinal sinus.. The general impression that valves never 
occur in any of the veins above the common jugular is 
therefore incorrect. 

I. VEQUNS OF THE DuRA (including those of the diploé). 
—These are many in number, but all of small size. 
They anastomose so freely that they might almost be de- 
nominated a plexus. In position they are comparable to 
the plexus venosus existing between dura and periosteum 
of the spinal canal. In their ultimate distribution they 
form two vascular nets, according to Langer, one in the 
outer, the other in the inner, layer of the dura. The 
beautiful, almost regular, interlacing of the former, 
figured by Langer from the fcetus, the writer is able to 
corroborate. By means of small veinlets penetrating the 
inner plate of the skull, the dural veins communicate ex- 
tensively with those of the diploé. They include: 

1. Medidural, or Vene Comites, accompanying the 
medidural artery and its branches. The two on either 
side of an artery repeatedly connect with each other and 
with neighboring veinlets. The largest pair is about the 
common trunk of the artery. One of these passes ex- 
ternally through a basal foramen to the pterygoid veins. 
The other ends in the medicerebral vein or its temporal 
sinus, or directly in the sphenoidal or cavernous sinus, 
with which latter it usually at least connects. The 
diploic canals have some special openings into the larger 
medidural veins. 

2. Superdurals. These appear in part as direct con- 
tinuations of the preceding, and then are double. They 
pass to the longitudinal sinus, largely through the inter- 
mediation of its lateral spaces. Labbé suggests that the 
supra- and medi-dural veins may constitute a small col- 
lateral path between the long sinus and basal conduits. 

3. Faleial Trunklets (Fig. 819, &), ranning to the longi- 
tudinal sinusand to the falcial sinus when present, other- 
wise to the tentorial. The tentorials go to the lateral and 
tentorial sinuses, also in part by way of the parasinual 
spaces. 

4, The numerous veinlets for the other dural arteries, 
é.g., in the occipital fossa, have a more independent. 
course and end in adjacent sinuses. 

Venous Canals of the Diploé, even less yielding than the 
sinuses. Breschet’s description is somewhat modified by 
Trolard. The diploé is made up of little areole. These 
canalize in any direction, though in general ventrad to 
discharge near the base. These canals are quite unsym- 
metrical, and do not increase in size in their course, ex- 
cepting where there are casual enlargements; areole, 
conduits, and lacune are lined with a smooth membrane. 
Generally the diploé begins to appear about the tenth 

ear, though small straight veins are evident earlier. 
esorptiod of the cancelli goes on continuously, and 
after fusion of the sutures they may pass from one bone 
to another. In the aged we find a sort of wide-spaced 
venous plexus, no longer canals. There are several ex- 
terior outlets and numerous interior ones. Even the one 
through the supraorbital notch passes to the ophthalmic 
vein and so to the cavernous sinus. Casual mention will 
be made of most of the special terminations. 

II. VEINs oF THE PIA AND BRAIN SUBSTANCE. —From 
their derivation and discharge, these vessels naturally 
fall into three classes: A. The supercerebrals, passing 
to the longitudinal sinus. B. The internal or Galen’s 
system, tributary to the tentorial sinus. C. Basal veins, 
ending in the various sinuses of the base. 

A. The Supercerebral veins return the blood from the 


In general it may be stated that the walls of | convexity as far as the Sylvian fissure, and from the 


255 


Brain, 
Brain, 


median surface of the hemispheres as far as the super- 
callosal fissure. There may be a slight interval between 
the frontal set and the others, or a smaller vein may 
here occur; otherwise they are all fairly equidistant. 
There are usually six to eight large trunks on each side. 
These veins tend to empty into the sinus in pairs. This 
is less marked in the frontal set. It is most easily demon- 
strable in the faetus, owing to theabsence of Pacchionian 
bodies, or thickening, adhesions, etc., at the border of 
the convexity. The last pair ends in the sinus some 8 to 
5 cm. before the torcular. The second or third pair from 
the last may be somewhat larger than the others, and 
then represent the so-called anastomctic vein, though its 
size is quite as much due to the greater width of the 
brain in this part. Although Labbe says this vein runs 
along the postcentral fissure, it is probably identical with 
Krause’s fetal vena sulci centralis. Moreover, each 
supercerebral vein is double, also best seen in the feetus. 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


sinus, while the others open more and more at the side, 
and the last quite at the bottom of the sinus, even com- 
ing up a distance through the falx. 

Toward their field of derivation these trunks pursue 
an indifferently parallel course. In general, over the 
cortical area the finest veinlets are richly distributed 
everywhere, from the bottom of the fissures to the crest 
of the convolutions. 

B. The Internal System, Tributary to the Tentorial 
Sinus.—Along its course this mesal sinus receives only 
unimportant, mostly dural, veinlets. At its commence- 
ment there may be two affluents: (a) the falcial sinus; (0) 
the vena Galeni. 

(a) The inconstant falcial sinus also receives only dural 
twigs in its course, but at its commencement—opposite 
the frontal border of middle third of callosum—may take 
up a small vein or veins coming from the frontal third 
of the callosum, and from the bordering convolutions. 





Fic. 819.—The Vena Galeni. (From the author’s ** Veins of the Brain,” ete.) 


The two constituent veins are of unequal size, the larger 
external one coming from the convexity, the smaller 
inner one coming from the median surface (of hemi- 
sphere). They may soon unite to one trunk, but gener- 
ally, in their further course to the sinus, they lie side by 
side within a common sheath, and do not lose their in- 
tegrity as independent conduits until about to open into 
the sinus. Commonly some of the paired, as well as 
their constituent double veins, are wanting to complete 
the diagram. 

The frontal set take a course very nearly at right 
angles to the sinus, or the first of them may even run 
caudad along the sinus before discharging. They usu- 
ally spring over to the dura a couple of centimetres 
away fromthe sinus. This point has since been more 
carefully gone over by Mittenzweig. In 200 cases he 
found 59 in which the presupracerebals (to only 9 in 
which the postsupracerebrals) jumped over from the 
piarachnoid to the dura at 3 to 4 cm. from the long sinus 
—thus favoring their rupture, as he thinks. Farther 
along the sinus the veins take a more and more oblique 
course until they at last run forward a distance of 38 or 4 
cm., to discharge against the current. At the border of 
the convexity, or farther out in the pia, the vein makes 
the necessary bend to approach the sinus as described. 
It then runs a short distance in the pia, becomes in the 
foetus a free trunk for a further short length, and finishes 
its course in the dura. 

Again, the frontal set open at the lateral angle of the 


256 


Labbé calls this the ¢nterhemispheric vein, and says that 
the 1 to 2 cm. long veinule bifurcates, sending one branch 
to either side. A parallel term, mesolobica, was given by 
Breschet to the precerebral vein. 

(0) Vena Galent. This discharges through a slit in the 
basal wall of the sinus, just caudad of the free border of 
the tentorium. The name is now limited to the short (1 
cm. long, 6 mm. broad) trunk from the union of the velar 
veins to the sinus. Within, it is often divided by a longi- 
tudinal septum. 

The course of Galen’s vein and that of the adjacent 
portion of the velars is very peculiar. The vessels sink a 
little after crossing the optic lobes, then encircle the 
splenium, and become subtentorial before ending in the 
sinus. The latter bears the relation thereto of a tangent 
to a circle (ede Fig. 819). 

Galen’s vein does not usually receive any lateral afflu- 
ents. It arises from the union of the right and left velar 
veins. Each of these consists of two portions, a terminal 
bent part ( portio curvata, Fig. 820, ¢ c) from the conarium 
to the vena Galeni, and a peripheral, or ccelian, straight 
part ( portio recta) from the origin of these veins, opposite 
the foramen of Monro, The two curved portions start 
and end together, but midway diverge 0.5 cm.; they re- 
ceive laterally many large branches. The straight por- 
tions run parallel and adjacent, but receive only few and 
small additions. 

The affluents to the portio curvata are largely of cor- 
tical origin; (1) v. suboccipitalis; (2) v. supercerebellaris; 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


(8) v. callosalis; (4) v. subcerebralis; (5) vv. optici et 
conarialis; (6) v. postcornualis. 

1. The Suboccipital vein (Fig. 819, }) comes from the 
collateral fissure and median portion of the suboccipital 
surface of the cerebrum. 

2. The Supercerebellar vein (Fig. 819, h), oftener a single 
trunk, but occasionally bilateral, empties into the main 
vein near its termination, or even directly into the sinus 
tentorialis. It starts from many little branches over the 
dorsal surface of the cerebellum, the supervermis, and in 
its further course takes up small veins from the crura 
cerebri, and at times also from the optic lobes. 

3. The Callosal vein (Figs. 819 and 820, g) (first men- 
tioned by Labbé, 1879, then independently described by 
the writer in 1884) may be either single or bilateral. It 
is a small but long vessel, and the only one emptying on 
the concave side of the portio curvata. Its origin is near 
the middle of the callosum, and dorsad as far as the cal- 
losal fissure. It runs caudad at the bottom of the longi- 
tudinal fissure, and curves around the splenium close to 
Galen’s vein. In animals (sheep) its size almost equals 
that of Galen’s vein. 

4. The Subcerebral (Fig. 819, e) is a large vein, though 
its derivative territory is very variable. It forms by the 
union of many branches—collectively termed Prebasal 
Veins—opposite the preperforated space. The prebasilars 
include the first five next following: 

(1) The Precerebral vein takes nearly the same path, but 
is too small and uncertain to be well compared to the 
precerebral artery. Itsderivative area is very much less. 
It comes around the genu to the base, where it passes 
before the chiasm to the subcerebral vein. The right 
and left are usually of unequal size, but communicate, 
though by an insignificant branch compared to the 
arterial precommunicant. The two veins may also unite 
before the chiasm and pass to one of the subcerebrals, in 
which case there are one or more slight connections in 
front of the chiasm with the other subcerebral vein. 
This vein receives branches from the genu and adjacent 
median frontal surface. 

(2) The Olfactory is a tiny veinule, very constant, and 
demonstrable as far as the olfactory bulb. 

(8) Subfrontals. One of these is frequently more de- 
veloped, and may empty instead directly into the Sylvian 
or the medicerebral vein. 

(4) The Sylvian vein, as shown by the writer, is dis- 
tinct from and a variable complement of the medicerebral 
vein (vide infra). It lies at the bottom of the basi-Sylvian 

Jissure, covered up, except near its termination, by the 
tip of the temporal lobe. It arises in the region of the 
insula from a great number of radicies. When the medi- 
cerebral is poorly represented, the Sylvian may take up 
twigs from the surface of the temporal and frontal lobes; 
‘some of the venze perforantes pass, as a rule, to this vein. 
There is here often a group of perforantes, separated from 
the others and coming from the brain substance caudad 
of the veins. 

(5) The Vene Preperforantes are small, very variable in 
number, and take a straight course for a short distance 
before splitting up. They come from the striate nuclei 
and adjacent frontal albalis. Their radicles approximate 
those of the precornual veins, yet without observable an- 
-astomoses. 

(6) The subcerebral vein receives, in its course obliquely 
across the optic tracts and crura cerebri, several small 
veinules from the chiasm, infundibulum, mammillary 
bodies, crura, etc. These anastomose freely with one an- 
other, and with those of the other side, thus making an 
outstretched network over these parts which connect 
-on the one hand with a small network before the chiasm, 
and on the other with that across the pons. This corre- 
sponds in general to what Labbé terms the inferior inter- 
hemispheric veins. Frequently there are accessory vein- 
ules from the basal temporal surface. 

(7) The Subcornual vein, in that it comes from the end 
of the middle horn, is comparable to the prechoroid 
artery. It is very constant in occurrence, but not in size. 
‘Though connected with the choroid plexus of the medi- 


VOI Lea 


Brain, 
Brain, 





cornu, it originates in the cerebral substance, sometimes 
even from the lateral wall of the postcornu, oftener op- 
posite the caudad border of the thalamus, where branches 
are received from the albalis lateral to the thalamus or 
from other directions. In its course along the lateral 
wall of the horn it receives many accessions, notably 
from the cornu Ammonis, and as it curves around the 
end of the horn several twigs from the albalis of the 
temporal apex. 

(8) Postperforant, at least one considerable veinule. 
The post-perforating veins come, according to Hédon, 
from the cinerea of the walls of the diaccele, and even 
from the mesal surface of the thalamus. He also claims 
that in the striate nuclei the perforating veins anastomose 
with those going toward the cavities and Galen’s system. 
He further recognizes the communications in the medi- 
cornu between the choroidal and the infracornual veins. 

(9) Crural branches, one in particular, can be followed 
along the crus to the cerebellum. 

5. The fine Conarial vein and variable Optic twigs often 
end in the supercerebellar vein instead of directly in the 
velar. They originate in a fine venous plexus over the 
optic lobes and conarium, which appears to be connected 
across the crura cerebri with the basal network described 
above. 

6. The Postcornual vein is variable, complementary in 
derivation to the subcornual. It may arise in the albalis 
near the tip of the occipital lobe, and then runs subepen- 
dymalalong the cornual wall. The parathalamic branches 
above ascribed to the subcornual, and some from the Am- 
mon’s horn, pass often in part to the postcornual. The 
radiate radicles of this vein are traceable through the 
albalis nearly to the cortex (Fig. 820, g, q). 

There is frequently another vein intermediary between 
(7) and 6, emptying into either the subcerebral or the post- 
cornual, 

The straight portion of the velar vein in its course 
through the velum receives the following, all at right 
angles: 

1. The Splenial veins (Fig. 819, f) are very small, and 
but two or three in number as they come out through the 
fornix. They often combine with thalamic radicles and 
empty as one trunk into the velar. 

2. The Thalamo-Crural vein, usually one on each side, 
but sometimes multiple (Fig. 820, m, m). This begins 
about the cerebral crus, makes its way dorsad and mesad 
through the thalamus, and joins the portio recta at about 
its middle point. It approaches the ventral side of the 
velar, and hence is but too easily overseen. Neither 1 
nor 2 runs any length in the velum. 

3. The Thalamic veinules are very variable in size, 
number, and position. They may even be entirely 
wanting, or run to neighboring veins, e.g., the post- 
cornual. These arise only to a limited extent in the 
thalamus; they come chiefly from the albalis beyond, 
running across or a trifle embedded in it. Where one of 
these is specially large it might be termed the Z'rans- 
thalamic. 

Opposite or toward the apex of the thalamus, the velar 
vein is formed by the immediate or mediate union of 
several small trunks. Most of these are in a cluster 
coming in laterally between thalamus and striatum; the 
latter nucleus appears much richer in veins than the 
former. Of all but the first, the intraccelial course of 
these veins is subependymal. 

1. The Medicornual vein (Fig. 820, 7) takes a sinuous 
course in the outer edge of the choroid plexus, of about 
double the actual distance. Its membranous envelop- 
ment makes it a counterpart of the pia veins, and hence 
the actual continuation of the velar, as held by Bell. It 
begins in the middle horn, where it is said to anastomose 
with the subcornual. It comes out of the horn with the 
plexus, bends to follow the lateral thalamic border, and 
ends in any one of the veins near the commencement of 
the velar. Meanwhile it receives a multitude of radicles 
from the plexus, and some that seem to come from the 
surface of the thalamus. 

2. The Tenial vein comes from the thalamo-striatal 


257 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Nevertheless it has few 
This short trunk is made 
Of these 


groove, beneath the teenia. 
tributaries from the thalamus. 
up by three sets of veinules: (a) Striatal. 


Fic. 820.—The Coelian Veins. 


there are usually two or three larger and several smaller 
branches, coming from the substance and surface of the 
caudate, and passing to the teenial trunk or to either of 
the following: (0) A prealbal trend of veinules, passing 
along the outer ccelian border toward the precornu, and 
thence largely to the albalis of the frontal lobe. (¢) An 
opposite trend, directly caudad, a short distance along 
the outer ccelian wall, and coming from the lenticular 
nucleus, the internal and external capsules, and the 
superimposed portion of the centrum semiovale. Many 
of these various albal radicles can be followed almost to 
the cortex; their angles of union are acute. 

3. The Paraseptal trunk (Fig. 820, 0, 0). This short 
vessel, with its two constituent Precornual veins, is the 
most direct continuation of the velar. Laterally it re- 
ceives small Septal and Genwal accessions. There are 
usually two parallel precornuals (p, p). They come from 
the extremity of the horn and follow its contour around 
to the septum, or run in the adjacent border of the cau- 
date, though they take up no important radicles from 
that nucleus. Their multitude of radicles come from the 
albalis in the basal portion of the frontal lobe, also de- 
monstrable nearly to the cortex. 


258 





(From the author’s ‘* Veins of the Brain,” etc.) 





4. The Superalbals (Fig. 820, n, ) are commonly two 
small trunks that appear at the outer border of the cecele,. 
opposite the body of the caudate, cross the latter, and 
empty through the teenial or para- 
septal trunk. They come from 
the ccelian roof, and the frontal 
and parietal albalis dorsad of those: 
previously described. 

C. Basal Veins (Fig. 821).— 
These do not constitute a system 
in the sense of having a common 
point of discharge—in fact, they 
have already been described in 
part under Subcerebral Vein. A1- 
though they are quite irregular 
in termination—small veins seem 
occasionally to end at any point in 
the basal sinuses—still there are: 
four frequent points of discharge: 
(1) Cavernous and (sphenoidal)- 
sinus; (2) superpetrosal sinus; (3) 
middle of lateral sinus; (4) some 
sinus about the foramen magnum. 

1. Some small veins from the 
pituitary body and other struc- 
tures about the sella turcica have. 
been described as tributary to the: 
vene circle of Ridley. But the 
largest vein discharging at this. 
point is the Medicerebral, a super- 
ficial vessel following the Sylvian 
fissure. This should be distin- 
guished from the smaller though 
complementary Sylvian vein cours- 
ing at the bottom of the fissure. 
The medicerebral is inclined to be 
double, ¢.e., there are then two 
parallel adjacent veins, one taking 
up frontal branches, the other 
only temporal. In this case one: 
vein may receive some of the pre- 
basals above described and empty 
into the sphenoidal or the-cavern- 
ous sinus, while the other runs 
meso-caudad in the dura across. 
the temporal fossa to the middle 
of the superpetrosal sinus. This. 
latter is the course that the whole 
medicerebral vein takes in many 
cases, as Trolard rightly says; the 
dural portion may be termed the: 
Temporal Sinus; by one or two: 
lateral orifices it communicates. 
with the medidural veins which it 
crosses. 

2. The discharge of the subcerebral vein through the 
vein of Gaien, as given above, holds for about one-half 
the cases—not always alike on the two sides. The main 
trunk may be diminished by the termination of some of 
its usual prebasal constituents in the cavernous sinus or 
medicerebral vein. Whether larger or smaller, the trunk 
as often passes to a basal sinus (superpetrosal) by turn- 
ing ventrad instead of dorsad on reaching the cerebral 
crus. 

One or more Precerebellar Veins from the flocculus region 
(Floceular Vein) pass to the superpetrosal sinus, with the 
subcerebral vein, when this terminates at the base; other- 
wise they seem to connect with this by veinules along 
the lateral surface of the cerebral crus. Among the 
cerebellar veins Hédon, referring to Merkel, mentions. 
one that “comes from the flocculus and empties into the 
superpetrosal sinus. An important branch of this vein 
rises from the interior of the cerebellum in the region of 
the dentatum, receives also veins from the cerebellar 
medipeduncle, and emerges with the peduncle under 
the flocculus. The main trunk can acquire a very con- 
siderable size when it receives a branch of the basilar 
vein” (precerebellar vein, Fig. 821). 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





3. The Postcerebral Veins (Fig. 821, MW) usually unite 
into one trunk just at the point where, turning caudad, 
they form an ampulla in the dura and enter the sinus. 
This is at the lateral border of the occipital lobe, opposite 
the exoccipital fissure. These veins come in part from the 
convexity, in part from the basal surface of the occipital 
lobe. The latter may be single or multiple; their deriva- 
tive area is lateral to that of the suboccipital vein. The 
former is represented by one large trunk from the direc- 
tion of the Sylvian fissure; it receives varying temporal 
branches and larger ones from the external occipital sur- 
face. The Paracerebellar Veins are smaller than the post- 
cerebrals, but often empty opposite them, though, of 
course, subtentorialin origin. They come from the lateral 
portion of the cerebellum. The very inconstant Postcere- 
bellar Veins, one or more in number, terminate in the 
lateral sinus near the torcular, or even in the tentorial. 

4. The Subcerebellar Veins include any small vessels at 
the bottom of the posterior fossa discharging into the 
occipital sinus. 

The cerebellar veins,—supra-, pre-, para-, post-, and 
sub-,—are but partially distinct from the cerebral veins. 

Oblongata Region.—The ventro-mesal chain of myelic 
veins (see Fig. 821, 0 ) is continued cephalad on the ven- 
tral surface of the oblongata to the furrow between this 
and the pons, there connecting with a fine venous net- 
work over the surface of the latter 
(Kadyi). This plexus in turn also 
connects with the veins of the cere- 
bellum and of the base forward. 

Besides irregular smaller ones, 
there are in particular two constant 
and considerable veins passing from 
this plexus, one on either side along 
the trigeminal nerve to the sinus 
petrosus (or cavernosus). 

From the above-mentioned chain 
on the ventral surface of the oblon- 
gata, between the pyramids, there 
frequently arises a little trunk (up 
to 0.5 mm. or more thick) that joins 
one of the hypoglossal root bundles 
and passes out with it through the 
precondyloid foramen—doubtless a 
part of Luschka’s plexus venosus 
hypoglossi. 

The dorso-myelic chain of veins 
is continued cephalad over the ob- 
longata. From a constant mesal 
vein here a small veinule traverses 
the arachnoid, covering the cisterna 
magna. Sometimes this adjoins the 
accessory nerve, and Kadyi thinks 
it probably empties into the sinus 
plexus about the foramen magnum. 

GENERAL FEATURES OF THE IN- 
TRINSIC VELNS. — Communications. 
—In this regard the pia veins must 
be distinguished from those of the 
brain substance. In contrast to the 
arteries, the pia veins communicate 
freely, not only indirectly through 
the sinuses, but everywhere on the 
surface by a network of small ves- 
sels, as well as frequently by anas- 
tomoses between larger trunks. 
The veins of the convexity might 
almost be said to radiate from the 
Sylvian fissure (horizontal Sylvian). 
At least several of the larger ones 
connect toward the middle of the 
convexity. Of these, four may be 
specified: (1) One of the frontal 
supercerebrals (fronto-dorsad); (2) 
the second or third from the last su- 
percerebral (caudo-dorsad); (8) the 
external trunk of the postcerebral 
(caudo-ventrad); 4, the medicere- 


Kadyi. 








common arrangements of these veins. 
A, A, Supracerebrals ; B, ramus to olfactory bulb ; C, C, subfrontals ; D, precerebral ;: 
E, E, Sylvian or insular; F, medicerebral (to cayernous sinus); F’, postmedicerebral (per 
temporal sinus to superpetrosal) ; G, G, preperforantes ; H. postperforantes ; I, subcerebral 
(to Galen’s vein); I’, subcerebral (when emptying at base); J, J, subeornuals; K, K, precere- 
bellars and flocculars; L, L, hypoglossals (to precondyloid emissary) ; M, postcerebral (to, 
lateral sinus) ; N, paracerebellar (to lateral sinus) ; O, ventromyelic (anterior spinal). 


bral (fronto-ventrad). Or any two of these trunks may 
communicate independently, e.g., the medi- and post- 
cerebral veins by a large anastomosis directly across the 
temporal lobe (intrapial, of course), There are many 
other connecting veins, not as markedly bridging the 
fissures, however. The great anastomotic vein of Tro- 
lard is No. (4) (medicerebral) when continuous with No. 
(2). Labbé’s illustration includes also No. (8). Trolard - 
says it “sometimes takes origin at the side of the longi- 
tudinal sinus, but oftener it forms by the union of veins 
anastomosing at the middle part of the convexity.” He 
encountered it twenty-five times in thirty subjects. Ac- 
cording to Labbé this anastomosis, instead of being with 
the medicerebral, may, in its absence, be with the deeper 
Sylvian vein. Practically these various anastomoses 
present a collateral path in the pia, between longitudinal, 
lateral, and cavernous (sphenoidal or superpetrosal) si- 
nuses. The basal veins, excepting the perforants and 
the cerebellars, have ample though smaller anastomoses, 
including an indifferent counterpart of the circle of Willis. 
It is evident that the derivative area of the pia veins can 
never be closely defined. 

The internal system must be separated into those veins 
uniting in the curved portion of the velar, and those 
tributary to tne straight portion. The former, as the 
writer has elsewhere shown, have the following sets of 


Fig. 821.—Veins of the Base (34 natural size). The two sides represent respectively the more 


Those of the myel and oblongata are largely after 


259) 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





anastomoses: (1) Between the callosal vein—including 
practically the rare interhemispheric vein—and the me- 
dian branches of the supercerebrals, across the callosal 
fissure; (2) between the suboccipital vein and the basal 
branches of the postcerebral; (3) between the supercere- 
bellar and other cerebellar veins; (4) between the subcere- 
bral vein—when, as in about one-half the cases, this dis- 
charges into the velar—and the many veins adjacent to 
its derivative area. These communications are all in the 
pia; from clinical cases we know that these may suffice 
to compensate fairly when only the tentorial sinus and 
the short common vein of Galen are closed. They do 
not suffice, however, when there is any impediment to 
this collateral discharge, and possibly not when the sub- 
cerebral vein ends elsewhere. Of the veins passing to 
the portio recta of the velar vein, only one, the medi- 
cornual, has superficial anastomoses. As this is a long, 
tortuous vessel, and connects with the subcornual only 
by small and questionable anastomoses, it is of itself 
entirely unable to compensate when the portio curvata 
becomes occluded. We have, remaining, the various 
ceelian veins coming directly from the brain substance, 
to which the postcornual may also be added. Neither 
between these nor between their subdivisions short of 
the ultimate capillaries did the writer succeed in finding 
any anastomoses. The same holds true for the perforat- 
ing veins of the base. There still might be intrasub- 
stantial connections between these vessels and the cortical 
veinules. However, the apparently positive results of 
injections by Duret, and especially by Labbé, are all ex- 
plicable by the surface anastomoses above described. 
There may be such occasional but inadequate connections 
paralleled by the rare ones between the otherwise terminal 
perforating and ccelian arterioles. Hédon (1888) says 
that a few do exist. Clinical evidence also goes to show 
that the veins emanating from the ccelial walls are all 
essentially terminal vessels, and that closure of the velar 
vein—unless just at its mouth—cannot be compensated. 

Cortical Veinules.—Duret found only six or eight in 
the section of a medium-sized convolution, one or two 
emanating perpendicularly at the dorsum of the gyrus, 
and from four to six by the sides. However, they had 
a diameter triple that of the arterioles. They start 
principally from the capillary transition plexus—between 
gray and white—and from the deeper albalis. 

Developmental.—From various peculiarities in the vas- 
cular supply of the human brain, more especially the 
caudad displacement peripherally of the postsupracere- 
bral veins, the writer has adduced evidence favorable in 
a general way to Hill’s theory of a developmental rota- 
tion of the brain, and showing further that in any such 
rotation the brain and pia have glided caudad under the 
dura and brain case. 

Here may be added a casual observation of a persistent 
fetal form, made at the autopsy of a child of twenty- 
two months, dead of tubercular meningitis. The large 
left medicerebral vein took the temporal course in a deep 
groove (per temporal sinus, intradural), and passed out 
at the foramen jugulare spurium instead of passing to the 
suprapetrosal sinus, first, however, connecting with a 
much smaller prepetrosal sinus. No such appearance on 
the right. 

GENERAL RELATIONS OF THE VEINS AND ARTERIES. 
—In the pia, over the convexity and on the median sur- 
face, the arteries lie beneath the veins (Labbé), as gen- 
erally in the body elsewhere. But over the insula, and 
evidently in the sulci generally, the writer has observed 
the reverse; while of the finer pial arborizations Labbé 
asserts that the venous lie beneath the arterial. Though 
the larger veins often jump across from one gyrus to the 
next, the a_tcries go down with the pia more or less 
deeply in*< « -e fissures, to come up near or distant over 
the next gyius. 

Only by a forced comparison can any of these veins be 
said to accompany the arteries. By contrast, the dural 
vessels conform in their general bearing to those else- 
where; they have abundant collateral anastomoses, most 
of the arterial branches are accompanied by two veins, etc. 


260 


Dwight quotes the suggestion that, as the blood in the 
internal jugular and carotid flows in opposite directions, 
the arterial pulsations might interfere with the venous 
discharge, if both lay ina common canal. Trolard drew 
a strong analogy between the vertebral artery, surrounded 
by the vertebral vein and plexus, and the carotid through 
the cavernous sinus. “The supply arteries of the en- 
cephalon bathe (?) in venous blood; the carotids from the 
moment they enter the carotid canal; the vertebrals from 
the moment they penetrate the vertebral canal.” This 
point has been elaborated by Riidinger (vzde abstract 
in Boston Medical and Surgical Journal, 1888, ii., 3238). 
He shows that by this cushioning the pulsatory move- 
ments of the arteries are not abolished as they would 
be if they filled the bony canals. The diameter of the 
carotid canal he gives as 5-7 mm.; that of the artery, 
3-4.3 mm. In the cavernous sinus the artery, though 
situated at one side of the cavity, is not in contact with 
either the bone or the dura. 

The various retarding bends and angles in both classes 
of vessels can only be referred to. They affect very un- 
equally the circulation in the different parts. The exist- 
ence in the pia of vessels larger than capillaries, connect- 
ing the arteries with the veins, has been many times 
asserted and denied—the last investigator, Labbé, con- 
triving todo both. This point still awaits final settlement. 

Ill. Tue Dura Srnuses.—The encranial sinuses are 
all intradural, and all except the tentorial (with the fal- 
cial) lie against the cranial wall. They do not collapse 
on being slit open, nor do they admit of much distention 
—the falcial and the parasinual spaces excepted. They 
are lined by a continuation of the inner membrane of the 
jugular. Allen counts 16 sinuses—10 paired (sym- 
metrical), and 6 unpaired (azygous). But their number 
depends so much on the way they are divided as to cause 
the remark that the easiest piece of anatomical work was 
to describe a new sinus. 

They have been variously classified: (#) In two re- 
ciprocally perpendicular planes, the vertical plane in- 
cluding the longitudinal and tentorial (plus falcial), the 
horizontal including the remaining; or (4) in three hori- 
zontal planes; or (¢c) as connecting at three points, viz., 
the torcular and the two cavernous sinuses (to which 
Trolard sought to add a precondyloid confluens); or (@) 
according to the area drained. 

The Longitudinal Sinus.—This, the longest sinus, runs 
parallel to the sagittal suture, slightly grooving the bone 
in a curved line from near the crista galli to the internal 
occipital protuberance. It lies between the folds of the 
falx, as they diverge to continue as the parietal dura. 
Its section presents a rounded triangle, increasing in size 
from the accession of large veins. Its lumen toward the 
bottom is crossed by numerous irregular strands (trabec- 
ulee, chordee Willisii). The openings from the supercere- 
bral veins are usually larger than those from the para- 
sinual spaces (and dural veins). The sini subalterni of 
Malacarne are often seen in the falx just beneath the 
sinus, and present more or less developed parallel narrow 
passages freely connecting with the main vessel. At the 
torcular this sinus more often turns into the right lateral. 
Rarely it, or its tributaries, drops down through the falx 
to the falcial sinus, or just before the torcular to the 
tentorial, or even divides, following the lambda sutures 
to each lateral sinus. The whole longitudinal sinus may 
be occluded without causing disastrous results. 

Faleial Sinus.—This may run along about two-thirds 
of the free border of the falx or near the border, and then 
represents the continuation of the tentorial sinus. It is 
rather a large dural vein than a sinus. At its commence- 
ment the occasional interhemispheric veins empty. Its 
only lateral tributaries are usually small dural veinules, 
though part of the supercerebral veins or of the longi- 
tudinal sinus have in rare instances been seen to turn this 
way. On the contrary, Knott once saw the falcial pass 
to the longitudinal, and some connection between. the 
two is not uncommon. 

But, as stated by Luschka, this sinus is very variable 
in size and occurrence. In a series of adult subjects the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





writer found that its average occurrence was only one in 
six; in the foetus it was never present. Trolard’s at- 
tempt at presenting this as an important anastomosis 
between the dorsal and internal systems, or as a safety 
diverticle of the latter, was quite overdrawn. 

Tentorial Sinus,—This lies at the junction of the falx 
and tentorium (Figs. 819 and 820, a). It extends in full 
size from the torcular to the intersectiom of the free 
falcial and tentorial borders opposite the point where it 
receives its main tributary, the vein of Galen. Its sec- 
tion is a triangle with narrow base resting on the ten- 
torium. Laterally it takes up small dural radicles, and 
often a supercerebellar vein. It is straight, lies in the 
median line, and is directed caudad. “It opens into the 
lateral sinus by an oval mouth formed by strong pillars 
of fibres.” 

Torticular.—A. confluens sinwum in the sense of the old 
writers does not exist. “The right lateral sinus for the 
most part begins higher than the left, and may be con- 
sidered as the continuation of the longitudinal. In some 
subjects the right or left lateral sinus begins from the 
longitudinal one, while that of the other side is continu- 
ous from the tentorial; and then the lateral sinuses are 
separated at their origin by a membravous isthmus” 
(Charles Bell, 1827). Riidinger speaks of a “valvular 
arrangement” separating the two currents. In 26 out of 
Knott's 44 cases, the tentorial opened into the left lateral 
sinus, in 6 into the right, in 12 mesially. The statistics 
given below, on the larger jugular canal, bear on this 
question. This peculiarity of the paths at the torcular 
tends to prevent a reflux of blood from one into the 
other, or any interference of the currents. 

However, in a considerable minority of cases the cur- 
rents must intermingle. From the arrangements of the 
sinuses at the torcular, thrombosis of the longitudinal 
and right lateral is more often associated than of the 
longitudinal and left. A comparison of the few casual 
cases at hand shows 6 of the former to 2 (or possibly 8) 
of the latter. Of course, much more frequently—in 12— 
all three sinuses were involved. 

Lateral Sinus.—This runs from the torcular, at first in 
the attached tentorial border, then curves (jflezura sigq- 
motdea) to follow the groove in the mastoid and gains the 
jugular canal. It has been seen to take a more basal 
course, running: first in the cerebellar falx, then beside 
the foramen magnum to its usual exit. From the exten- 
sive investigations of Hartmann, Riidinger, Bezold, and 
Politzer, it appears that frequently the sigmoid portion 
approaches within a few millimetres of the posterior 
wall of the auditory meatus. The one into which the 
longitudinal sinus turns, usually the right, is double the 
size of the other, and also a trifle longer. Rarely, one 
lateral is minimal in size or even absent. It receives 
laterally the postcerebral and paracerebellar veins and 
superpetrosal sinus, and gives off two inconstant emis- 
saries. 

Korner (1889) has shown that intracranial disease from 
caries of the petrous is more frequent on the right, and 
from a study of 449 skulls he attributes this to the fact 
that the lateral sinus at its sigmoid flexure enters deeper 
into the mastoid and the petrous pyramid on the right 
than on the left, and thus on the right approaches nearer 
the primary focus of disease. In 22 cases on the right 
and 8 on the left, there were gaps in the bony partition. 
He also holds that in the brachycephali the sigmoid ex- 
cavation goes lower and deeper than in the dolichocephali, 
and that hence in the former such encranial sequele fol- 
low more readily ; but this has been disputed by Schiilzke. 

Birmingham, of Dublin (Brit. Med. Journ., 1890, ii., 
683), from an examination of 100 recent dry specimens, 
points out that the relations of the lateral sinus to the 
surface are extremely uncertain, owing both to variations 
in the sinus curves and to irregularities in the bones. It 
begins opposite the external occipital protuberance in 
50 per cent.; lower (by never more than one-half inch) 
in 83 per cent.; and higher in 17 per cent. It does not 
run forward horizontally, but is distinctly arched. The 
bend of the sinus where it turns down at the asterion 


may vary, within wide limits, from a gentle to a very 
sharp curve. It then runs down in front of the post- 
mastoid margin, about one-half inch behind the meatus, 
and turns into the jugular foramen about one-quarter 
inch below the level of the meatus floor. Occasion- 
ally the sinus is only one-twelfth of an inch from the 
surface. 

Cavernous Sinus (Plate XVIII., Fig. 1), distinguished 
by its irregular outline and cellular or reticulated ap- 
pearance from intercrossing fibrous bands. It represents 
a colossal perivascular structure about the carotid, in a 
way similar to that established by Braune and his school 
for certain lymphatics accompanying veins. The late 
von Langer, in one of his last publications, based on cor- 
rosion and other preparations from infantile subjects, 
showed that the cavernous sinus is originally a plexiform 
network of veins, which, by fusion of its channels, takes 
on its later characteristics. The wall resorption goes on 
to old age, when villous offshoots of the remaining tra- 
becule are often seen to project into its cavity. It is 
traversed by the carotid (cavernous portion). All the 
orbital nerves except the optic pass near or through its 
outer wall. Besides veins and emissaries, it is the com- 
municating centre for all the prebasal sinuses. Frontad 
it tapers to the ophthalmic vein—the swollen end of 
which has been dubbed Sinus Ophthalmicus. 

Laterally, the cavernous receives the Sphenoidal Sinus. 
This runs out along the dependent side of the lesser 
sphenoidal wing. Knott notes great variability in its 
size, though never complete absence, a small vein at least 
being found. Peripherally it receives or connects with 
a medidural vein, and also a diploic canal, and may take 
up the medicerebral and connect with ophthalmodural 
veins. 

The Subsphenoidal Sinus, on the great wing of the bone, 
was found by Knott fourteen times on the right and nine 
on the left side. 

Mesad, the cavernosi connect by the two Transverse 
Sinuses—which alone deserve to be called transverse. 
These follow the walls of the sella turcica, curve slightly 
to enclose the pituitary body, and complete the so-called 
vene-circle of Ridley (Plate XVIII., Fig. 1). 

Sinus Prepetrosus (jugularis spurius of Luschka, 
petroso-squamosus of Hyrtl, petrosus anterior of Bell). 
This occasional sinus, at the bottom of the temporal fossa, 
describes a curve along the petro-squamous suture, from 
the spinous foramen—connecting with the medidural 
vein and also with the cavernous sinus—to either (or 
both) the emissarium temporale or the petrous portion of 
the lateral sinus (often by perforating the prominent 
petrous ridge). Its physiological interest arises from 
the prominent part which it plays in the foetus. Zuck- 
erkandl (1878) found this sinus 22 times in 280 skulls. 
Knott, 4 times in 44, found what appears to have been a 
continuation of this sinus to the sphenoidal; in 7 of 44 
subjects he found the prepetrosal on both sides, in 19 on 
one side only. 

Caudad, the cavernous empties into the oblique su- 
per- and sub-petrosal sinuses, but principally the former. 
The Superpetrosal Sinus starts from the cavernous, runs 
in the prolonged attached border of the tentorium along 
the dorsal ridge of the petrous bone, and enters the lateral 
sinus against the current at the beginning of its sigmoid 
flexure. It alone offers a direct encranial connection be- 
tween the prebasal and lateral sinuses. The temporal 
sinus (medicerebral or anastomotic vein) and the subcer- 
ebral vein discharge into this in nearly one-half the 
cases, the precerebellar vein more constantly. As a con- 
sequence, its size varies considerably, though it is usu- 
ally small. The vestibular and even tympanic veins of 
the ear pass to the superpetrosal sinus, either directly or 
by a dural vein. In his forty-four subjects, Knott notes 
its absence twice on the right and once on the left. 

The shorter Subpetrosal Sinus runs in the petro-occipital 
groove, from the cavernous sinus to the subpetrosal vein, 
which, by bending before its discharge into the jugular 
vein, secures an unimpeded outlet for this sinus (for con- 
nections, vide infra, Vena Subpetrosa). 


261 


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Occipito-Basilar Plexus.—In the occipital fossa are sev- 
eral sinus canals that vary much in size and distribution. 
The Occipital Sinus, usually bilateral, runs along the cere- 
bellar falx and connects with the lateral sinuses by small 
mouths beside the torcular. Pre-, trans-, and post- 
occipitals have been made out. The so-called circular 
sinus of the foramen magnum is more often incomplete 
dorsad of the hole. The basilar sinuses over the like- 
named process connect with the preceding and with the 
prebasal sinuses. Langer has shown that, like the cav- 
ernous sinus, all of these are the persistent channels of 
what originally, in the foetus, was a vein plexus; and he 
has also corroborated Virchow’s description of their en- 
largement in the aged. 

Parasinual Spaces.—These areolar venous pockets or 
derivative reservoirs (lacunte, recessus lateralis), though 
described with increasing definiteness by a long series 
of observers, find but little mention .in the text-books. 
Their principal development is opposite the middle of 
the longitudinal sinus (bilateral). As numerous minute 
spaces they further occur along nearly the whole length 
of the said sinus, and also (Langer) beneath it in the falx, 
beside the lateral sinuses, on both sides of the tentorial 
sinus, and it is said even about the cavernosi. The di- 
lated intradural termination of the postcerebral and para- 
cerebellar veins has also been thus classed. They all 
occupy the attenuated space between the dural layers 
lateral to the sinuses, and hence are very shallow and of 
irregular outline. They have a lining membrane, also 
many intercrossing fibrous filaments, and are injectable 
from or with the sinuses. In positionand characteristics 
they are intermediary between dural veins and sinuses. 
Where present they receive most if not all the dural 
veins. The larger spaces are traversed by incoming pia 
veins with which they connect by one or more openings. 
They increase in size as life advances, and then have in- 
timate relations with the Pacchionian granulations—so 
much so that they have even been termed Pacchionian 
blood cavities. The circulation in their interior is not 
believed to be very active and the spaces have repeatedly 
been found thrombosed. 

On opening a sinus or the jugular canal blood usually 
flows out inamore or less pulsatory stream showing that 
the ruling interior pressure is positive. In the cases of 
operative perforation of a lateral sinus (Jacoby, Knapp, 
Benton, Guye, Owen, Reeve, von Baracz, and others, 
usually ending in recovery) there is no record of air 
being aspirated. But in one case of opening of the 
longitudinal (Genzmer, 1877) so much air was aspirated 
as to prove quickly fatal, and Francois-Franck (1881) has 
endeavored by experiments to show that aspiration can 
be communicated through the vertebral veins to the 
diploic canals of the occiput. 

Occlusion.—Blocking of any single sinus is not neces- 
sarily dangerous, though occlusion of a cavernous or the 
tentorial is always a serious matter. 

By experimental blocking of the dural sinuses in the 
dog, Ferrari (1888) has shown that a large part of the 
whole sinus system, e.g., all the sinuses of the calvarium, 
may be rendered impermeable without injury to the 
functions of the brain. However, occlusion of the col- 
lective blood efferents from the skull is of course quickly 
fatal, being usually preceded by an epileptic attack. 
But all this and more had been already determined by 
clinical experience in man. 

IV. VENovus OPENINGS THROUGH THE SKULL (EMts- 
‘SARITA, ETC.).—From their number and pathological im- 
portance, and for clearness of description, these passages 
ought to constitute a separate class. Each of the cranial 
bones (except the ethmoid) has a foramen permitting 
direct communication between the dural sinuses and veins 
and the exterior veins; still these are of very unequal 
size, and in part disappear in the adult. There is but 
little topographical correspondence between the position 
of these exits and the area drained through them; nor is 
the area in any case closely definable. They may all act 
as efferent vessels although the ophthalmic veins are 
usually afferent—partially so, says Sesemann, 1869; 


262 


largely so, Gurwitsch, 1883, and Merkel—and certain of 
the others may conduct either way according to circum- 
stances. Only Nos. 2, 6, 7, and 8 are superficial, while 
7, 8, 11, and perhaps 4, belong rather to the dural and 
diploic system. Nearly all the blood normally passes 
out through the two postlacerated foramina with their 
four canals. But any one of the exits and, so far as 
known, any two—or, in case of the smaller emissaria, 
several—may be permanently closed without causing 
serious harm. Both internal jugulars have been tied in 
the same subject (Pilger, 1880) without other evil con- 
sequences than a temporary headache. 

1. Jugular Canal.—In the lateral part of the postlac- 
erated foramen. This, by far the largest of all the exits, 
leads from the sigmoid flexure of the lateral sinus to the 
bulb or gulf of the internal jugular vein. Its path 
through the foramen is often more or less separated from 
the passing nerves, etc., by @ bony septum, thus forming 
a true jugular foramen. Rarely it is very small on one 
side, or even absent (four or five known cases). 

By adding the series of 159 skullsexamined by Dwight 
to the 100 by Riidinger, we have 259. In 1738 of these 
the right jugular foramen was larger than the left (7.e., 
about two-thirds), in 65 the reverse (one-quarter), and 
in 21 the two were equal (one-twelfth). This harmonizes 
with what was said above (swb Torcular). 

2. Emissarium Mastoidewm, of most importance in 
fetal life. It arises directly from the lateral sinus, and 
empties usually into the occipital vein (extracranial), 
sometimes into the postauricular, or even directly into 
the external jugular. In the 16 perfect skulls ex- 
amined by Green (American Journal of Otology, vol. iii.), 
it was absent on both sides in 1, and on one side in 1. It 
was always just behind the posterior limit of the mastoid 
process. The external opening was opposite the meatus 
(at about the middle of the perpendicular height of the 
mastoid) in 20, above this in 2, below in 6, and directly 
on the base of the skull in 1. Its diameter measured 5 
mm. in 1, 4mm. in 4, 3 mm. in 10, 2 mm. in 10, and 0.5 
mm. in 4, 

3. Emissarium Postcondyloideum (postjugular vein), 
passing from the lateral sinus near its termination to the 
upper cervical or vertebral veins. In 44 skulls, Knott 
found this on both sides in cnly 138, on the right in 21, 
and on the left in 10. In Dwight’s series of 142 skulls, 
with unequal jugular foramina, the postcondyloid fora- 
men was larger on the same side as the larger jugular in 
58, on the other side in 37, and equal or absent in 52 (this 
foramen being wholly for the transit of the emissary). 

4. Emissarium Precondyloideum, connecting with the 
occipital sinus or its basal prolongation, taking up a 
diploic vein, and passing in part to the prepetrosal vein, 
in part to the plexus about the vertebral. As plexus 
venosus hypoglossi, Luschka described a cluster of veins 
about the hypoglossal bundles as they unite in the inner 
portion of the foramen, from which two veins passed 
down the canal. Trolard says that externally the pre- 
condyloid foramen presents a deep cavity in which is 
lodged a true venous confluens. Ventrad its wall is hid- 
den by the external part of the atlo-occipital ligament. 
He says that this confluens receives five veins: (1) Ven. 
trad and mesad, the medilacerate; (2) latero-ventrad, a 
connection with the subpetrosal vein; (8) dorsad, a pre- 
condyloid vein; (4) latero-dorsad, an inconstant vertebral 
vein (passing between atlas and occiput, behind the in- 
ternal jugular, sometimes in a bony canal); (5) a little 
vein on the preatlo-occipital ligament, communicating 
across with the intraspinal sinuses. 

Dwight, in the same series of 142 skulls, found the 
precondyloid foramen larger on the same side as the 
jugular in 16, on the other side in 11, the two sides equal 
in 115. “There does not appear to be any definite rela- 
tion between their size and that of the postcondyloids.” 

5. Small uncertain veins through the foramen magnum 
or beside the vertebral arteries, connecting some mar- 
ginal sinus or vein with the vertebral and spinal vessels. 
The fine veins in the spinal cord also connect with intra- 
substantial ones above. 





EXPLANATION OF 
PLATE XVIIL | | | 








EXPLANATION OF PLATE A VALI: 


Fie. 1.—Sinus Cavernosi et Intercavernosi—Sinus Circularis of Ridley. 
Inferior aspect of a corrosion preparation from a child, with afferents and efferents (some- 


what enlarged, and also arbitrary as to execution of smaller vessels). From Langer’s “ Der 
Sinus cavernosus der harten Hirnhaut,” Sitzbr. d. k. Akad., 1885, Vienna (Fig. 5). 
V.o., Vena ophthalmica superior et inferior. 


S.z.c., Sinus intercavernosi. ; 
#, Emissary veins passing through the oval foramen to the pterygoid plexus. 


S.p.z., Sinus petrosus inferior. 
L, Space for the dorsum ephippii. 
Fig. 2.—Fine anastomotic network between three arterial twigs in the pia of the parietal region. 
(Lucas, Paris Thesis, 1879.) 
Fig. 3.—Lobule of a choroidal villus; one portion bare of epithelium. Sinuous vascular loop. En- 
largement, 500 diameters. (From Luschka.) 
a, Portion covered by epithelium. 
b, Fibrillary connective tissue. 
c, Structureless connecting substance extending well beyond the capillaries. 


Fic. 4.—Very perfectly injected vessels of a choroidal villus. Two hilus vessels, a vein, and an 
artery. Loops, vascular nets, etc. Enlargement, 50 diameters. (From Luschka’s “ Die Ader- 


geflechte des menschlichen Gehirns,” 1855, Taf. ii., Fig. 2.) 


ae Dees 


OF THE 


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Brain-Vessels (Vide Explanation at End of Article). 





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Brain, 
Brain. 








6. Hmissarium Occipitale, a small mesal conduit from 
the torcular through the occipital protuberance to the 
external veins of the occiput. It is often, but not always 
sinuous, and takes up an azygoid diploic trunk. Knott 
found it as a small but traceable vein in 6 of his 44 
cases. In most of the others there was a small vein 
piercing one of the bone plates and anastomosing with 
the diploé veins. 

7. Hmissarium Parietale.—In 100 skulls Gruber found 
the parietal foramen on both sides in 29, on the right in 
19, on the left in 12; average distance from angle of oc- 
cipital squama, 3-5 cm.; distance from sagittal suture, 
2-17mm. Their size varies ordinarily from 4 to 1 mm. 
They do not terminate internally directly in the long 
‘sinus, but in the parasinual spaces or dural veins. 

8. Diploie Connections.—Innumerable small openings 
through the inner plate of the skull connect the dural 
veins and spaces with the diploé canals. These are 
largest and most numerous along the longitudinal sinus 
(corrosion preparation). 

9. Orbital Connections.—(a) The ophthalmic vein is, 
next to the jugular, the largest and most constant of all 
the passages. It empties largely into the cavernous sinus 
(through the orbital fissure, where it bears a constant 
constriction), but has free anastomosis with the prefacial 
vein at the inner canthus. Allen says that formerly the 
trunk of the facial was opened at this point to relieve 
cerebral congestion. (0) The central retinal vein has full 
anastomoses with the ophthalmic, but goes as arule to 
the cavernous sinus, or frequently to a fine venous plexus 
around the optic nerve, and then by several veinules in 
part to the subophthalmic vein, in part to the said sinus. 
(c) The smaller subophthalmic vein or veins connect 
doubly with the larger into which, or oftener into the 
sinus cavernosus, they discharge (always afferent, say 
Sesemannand H. Meyer). Peripherally, they anastomose 
with facial and even pterygoid veins. (d) The oph- 
thalmo-dural vein of Hyrtl] (1859) is practically included 
under the more or less constant connection of the medi- 
cerebral vein and the sphenoid sinus. Occasionally this 
sinus or vein has a small anastomosis, through the lateral 
part of the orbital foramen, with the ophthalmic or other 
orbital vein. Evidently, the vena aberrans of Verga 
(1856) should be classed here. As a passage from the 
ophthalmic vein or cavernous sinus to the lateral sinus, 
Knott mentions one case (on right); or between ophthal- 
mic vein and superpetrosal sinus, three instances (on 
left). 

10. The Hinissary of the Foramen Rotundum from the 
cavernous sinus, and accompanying the superior maxil- 
lary nerve as described by Nuhn, was twice seen by 
Knott (on right). 

11. The medidural vein discharges largely through the 
oval, or spinous, foramen. Nubn described a pair of 
veins which, after traversing the oval foramen, formed a 
plexus about the inferior maxillary nerve and terminated 
in the infratemporal veins. Knott found these veins on 
both sides in 18; two veins on right and one on left in 6, 
the reverse in 4; a single vein on each side in 11; no vein 
on one side in 5. Luschka and Trolard describe a vein, 
from the cavernous sinus, that receives dural veins from 
the anterior petrous surface and departs through the oval 
foramen; in this case the medidural emerges through the 
spinous foramen. 

12. Plexus s. Sinus Caroticus.—Bell (1827) mentions a 
vena sodalis arteria carotidis, as an emissary from a petrous 
sinus, descending through the carotid canal. Rektorzik 
(1858) seems to have rediscovered this. A prolongation 
of the cavernous sinus into the carotid canal constitutes 
the sinus caroticus. This breaks up into a plexus of 
small veins about the artery, converging to one or more 
small trunks below, that may pass to the internal jugular. 
It may connect with 11 and 18. Knott was always able 
to find this communication, though the vessels varied 
much in size and number. 

13. Vena Medilacerata.—Englisch is credited with 
having described (1863) a constant communication, out- 
side the skull, between the cavernous sinus and the sub- 





petrosal vein. As inferior petro-occipital sinus, Trolard 
independently described the same. “On the exterior 
base of the cranium a small vein occupies a groove ex- 
tending between the two lacerated foramina. Its direc- 
tion is latero-caudad. Itinosculates with cavernous sinus 
or carotid plexus, and with the precondyloid confluens ” 
(vide supra, sub 4).. Knott found this in 14 out of 33 
cases. 

14. Vena Subpetrosa, from the subpetrosal sinus, through 
the premedian portion of the foramen postlacerum, to 
the jugular vein. Here it is separated—not rarely by 
bony lamina, thus forming the foramen anomalum of 
Gruber, 1869—by three nerve trunks from the jugular 
canal. From numerous investigations Gruber found that 
only rarely did this vein pass quite through the foramen 
before entering the jugular, and that then it first con- 
nected with the termination of the lateral sinus. How- 
ever, in 8 out of 22 times Knott found that the vena sub- 
petrosa ended at about the level of the lower margin of 
the jugular foramen, in 9 a little above, and in 5 a little 
below. It connects also with the precondyloid vein or 
confluens, and commonly receives the internal auditory 
veins. 

To these may be added the following, of rare occur- 
rence in the adult: 

15. Emissarium Temporale (foramen jugulare spurium). 
This is held to be a relic of the primary jugular vein. 
When present, it proceeds from the prepetrosal sinus, 
perforates the temporal bone beneath the root of the 
zygomatic arch, emerges just behind the glenoid fossa at 
the edge of the porus acusticus externus, and ends in the 
external jugular system. 

16. Horamen Caecum, in fetal life a communication be- 
tween the longitudinal sinus and the veins of the frontal 
sinus, ethmoid bone, and nose. Rarely, if ever, observed 
in the adult. 

17. The very rare pathological venous blood tumors of 
the cranium (vide Mastin, Jowrnal of the American Medical 
Association, 1886), arterio-venous aneurisms of the scalp, 
etc., occasionally communicate on the one hand with ex- 
ternal veins of the head, on the other through openings 
in the bone usually with the long sinus. 

18. Possibly a couple should be added from Hédon. 
Small rami accompany the olfactory bundles through the 
cribriform plate of the ethmoid, of course connecting 
above with the vein of the olfactory bulb. “A vein leaves 
the aqueduct of Fallopius by the stylomastoid foramen 
to anastomose with the external jugular or post-auricu- 
lar (Sperino). It joins, according to Blandin, a small 
dural ramus traversing the hiatus of Fallopius.” 

LyMPHATIC SYSTEM IN THE Brain.—There are no 
lymphatic glands in the cranial cavity ; nor does the brain 
possess a system of independent lymphatics. Within the 
brain substance all the larger lymph passages accom- 
pany the blood-vessels as cylindrical enveloping spaces. 
These are at least twofold: (a@) Adventitial spaces between 
media and adventitia, which latter are not closely bound 
together in the vessels of the central nervous system as 
in the remainder of the body: (0) perivascular spaces of 
His and Robin, connecting with the subpial or so-called 
epicerebral space. Their cxistence in normal tissues has 
been repeatedly disputed, and unquestionably their size 
is artificially much increased by the usual methods of 
preparation. The latest investigators, Rossbach and 
Sehrwald, assert very positively the real existence of 
these spaces. They worked by Golgi’s method, claiming 
that this marks the lymph, and thus the lymph spaces, 
rather than the ganglion cell and its processes. 

The beginning of the lymph passages is to be sought 
in the very narrow spaces surrounding the ganglion cells 
—pericellular spaces (Obersteiner). To each of these latter 
spaces run, according to Rossbach and Sehrwald, many 
fine canals (rootlets), often coming a long distance through 
the albalis, and starting about vessels and from glial 
lymph spaces. These surround the protoplasmic cell 
processes. The efferents from these cell spaces pass along 
the apex process, branch, and empty into perivascular 
and superficial glial spaces, or directly into the epicere- 


263 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





bral space. The lymph system of each ganglion cell 
has no direct anastomoses with that about any other such 
cell. They also describe a lymphatic plexus about the 
glia cells (periglial space), especially in the external 
cortical layer, and in the first subcortical albalis. These 
are often intermediary between the pericellular spaces 
and the perivascular spaces, into which latter and the 
epicerebral space they empty. 

The results of Rossbach and Sehrwald, regarding 
lymphatics in the brain substance, are evidently dis- 
credited by Frommann (Centbl. f. med. Wiss., 1888, pp. 
881, 882). As regards the hypophysis, Pisenti and Viola 
(zbid., 1890, pp. 451, 452) believe that certain structures 
observed by them represent lymph spaces. A. cortical 
lymph-connective system has been studied by Bevan 
Lewis. 

The lymphatics of the choroid plexus in the paraccele 
unite (Arnold) to one trunk following Galen’s vein. In 
the ependyma lymphatic networks have occasionally 
been observed. 

The lymph passages collect in the pia to larger trunks, 
follow the course of the veins, and pass out, in part 
through the jugular foramen to superjugular glands, in 
part through the carotid canal to the deep cervical glands, 
in part beside the vertebral vessels to the infrajugular 
glands. 

Little evidence of lymphatics in the myel is found by 
Kadyi. The perivascular spaces of His occur, but are 
likely of artificial origin. From the results of one injec- 
tion he figures a network of voluminous canals running 
longitudinally beside the central canal, and that possibly 
represent a lymphatic system. 

SeRovus CAVITIES, CEREBRO-SPINAL FLUID, ETC.—Be- 
tween dura and arachnoidea is the subdural space. In 
the normal condition this contains only a capillary layer 
of fluid. The dura has a system of lymphatics accom- 
panying the blood capillaries, within their adventitia. 
Besides, in the endothelium of the dura independent lym- 
phatic plexi and stomata have been described, presenting 
a communication with the subdural space, and conduct- 
ing off the subdural fluid. Through the oval and spinous 
foramina pass (Arnold) lymphatics to the deep facial 
glands, probably coming from the dura. 

The interstices of the pia, ¢.e., the somewhat broken 
room between arachnoid and pia proper, constitute the 
subarachnoidal space (cavum subarachnoidale). This is 
the retainer of the cerebro-spinal (cephalo-rachidian) fluid. 
Although this fluid can pass back and forth between the 
corresponding cephalic and spinal spaces, it is no longer 
held that there is a continuous ebb and flow from one to 
the other at each respiratory movement and even pulsa- 
tion. This space is exceedingly attenuated wherever the 
brain lies close to the skull, as over the convexity. At 
other points it forms lacuna-like pockets, termed by Key 
and Retzius cisterne. Among these may be mentioned: 
Cisterna magna (cerebello-oblongata), where the arachnoid 
spreads across from the caudad border of the cerebellum 
to the oblongata; cisterne frontis (laterales et media) ; 
cisterna Sylwii; and over the optic lobes the cisterna 
ambiens. The celes connect with these cavities (the 
ceelian fluid comes from the choroid plexuses—vide Plate 
XVIIL., Figs. 3 and 4); the metepiccele with the cisterna 
magna through the foramen Magendii and the aper- 
ture laterales; the paraccele with the diaccele per the 
foramen of Munro; and the diaceele with the metepiccele 
through the aqueduct. There is no canalis Bichati, for- 
merly supposed to connect the paraccele with the sub- 
dural space. Hence, while the ccelian and subarachnoid 
cavities are united, neither has any direct connection 
with the subdural space. An indirect connection may be 
offered by the nasal lymph net, as this may be injected 
from the subdural as well as subarachnoidal space, by 
way of perineural lymph passages about outgoing nerves. 
Another assumed indirect connection is by Pacchionian 
bodies and the sinuses. The experiments of Key and 
Retzius, confirmed by Kollmann (1880), seemed to show 
that the perforations of the dura—opposite venous spaces 
—by these bodies furnish one of the principal discharge 


264 


paths for both-subarachnoidal and subdural spaces. 
Probably, however, their injections produced artificial 
openings, not existing intra vitam. Certainly they do 
not usually attain any development until long after youth 
has passed. Further reasons in opposition are given by 
Adamkiewicz in his polemic (Eulenburg’s “ Real-Ency- 
clopidie,” 1886, art. “Gehirndruck”) against Bergmann’s 
theory of brain compression, and in favor of his own 
somewhat novel views. Material injected into the sub- 
arachnoidal space in animals traverses the supercer- 
vical and submaxillary glands. In man it can pass out 
in the optic sheath to the bulb, in the sheath of the facial 
and the acoustic as far as the internal auditory meatus— 
whence fracture of the petrous with tearing of the nerve 
sheath leads to oozing out of cerebro-spinal fluid—and 
finally to the lymphatics in the nasal mucous membrane, 
the supposed path of meningeal infection from nasal 
sources. 

The writer has recently shown that during the whole 
of fetal life in the human subject, there exist efferent 
passages for the cerebro-spinal fluid along the larger 
nerve trunks from the spinal cord, notably those from 
the lumbar enlargement. After birth, however, these 
promptly close up. In the lower animals they are more 
persistent. 

The subarachnoidal cisternze protect the large basal 
vessels from compression, and in like manner the peri- 
cellular spaces shield the enclosed cell and its process 
from shock and pressure. Further, the perivascular 
channels protect the brain substance (His) in a more gen- 
eral way. William Browning. 


LITERATURE (MODERN). 


General. 


Dwight : Anatomy of the Head, Boston, 1876. 

Langer: Blutgefasse der Knocken des Schadels und der harten Hirn- 
haut, Vienna, 1877. 

Kadyi, H.: Ueber die Blutgefasse des menschlichen Riickenmarkes, 
Lemberg, 1889, pp. 152. 

Browning: The Normal and Pathological Circulation in the Central 
Nervous System, Philadelphia, 1897. 


Arteries. 


Heubner : Luetische Erkrankungen des Gehirns, etc., Leipsic, 1874. 

Duret: Recherches anat. sur la circulation de l’encéphale. Arch. de 
Physiologie, 1874. 

Ibid.: Various previous articles ; also Gaz. médic., 1877, No. 4. 

Lucas, E.: Essai historique, critique, et experimental sur la circula- 
tion artérielle du cerveau. Thése de Paris, 1879. 

Wilder : American Neurological Association, 1885. Reported in Jour- 
nal of Mental and Nervous Diseases, July, 1885, pp. 348, 349. 

Windle: The Circle of Willis. Reports of British Medical Association 


for 1887. New York Medical Journal, ii., 1888. 
Done i Des ruptures de l’artere méningée moyenne, Paris, 
890, p. 115. 


Adamkiewicz, A.: Die Arterien des verlingerten Markes vom Ueber- 
gang bis zur Briicke, Vienna, 1890. [Reprint.] 

Kolisko, A.: Ueber die Beziehung der Art. choroidea anterior zum 
hintern Schenkel der innern Kapsel des Gehirns, Vienna, 1891, p. 56. 


Veins. 

Rosenthal: De intimis cerebri venis, in Acta Acad. Leopold. Carol., 
vol. xii., Bonn, 1824. 

Labbé: Note sur la circulation veineuse du ceryeau. Arch. de Phys- 
iologie, 1879. 

Browning: The Veins of the Brain and its Envelopes, Brooklyn, 1884. 
(This work has been freely used in preparing the present article.) 
Hédon : Note sur la circulation veineuse de l’encéphale. Journal de 

Médecine de, Bordeaux, June 3, 1888. 

Hédon, E.: Etude anatomique sur la circulation veineuse de l’en- 
céphale, Paris, 1888, pp. 96. 

Browning, William: The Arrangement of the Supracerebral Veins in 
Man, as Bearing on Hill’s Theory of a Developmental Rotation of 
the Brain. Journal of Nervous and Mental Disease, November, 1891. 

Svijachenitioff, Grigor: [Anatomy of Veins of Posterior Part of Head, 


of Neck, and Base of Skull], St. Petersburg, 1889. (Treats of extra- 
cranial veins, emissaries, etc.) 


Sinuses. 


Trolard : Recherches sur l’anatomie du systéme veineux du crane et 
de V’encéphale. Arch. Gén. de Méd., 1870. 

Riidinger: Beitrige zur Anatomie des Gehérorgans, und der venésen 
Blutbahnen der Schadelhéhle, Munich, 1877. 

Knott, J. F.: Cerebral Sinuses and their Variations. Trans. Lond. In- 
ternational Med. Congr., 1881. 

Browning: Spaces Beside the Dural Sinuses, etc. 
of the Medical Sciences, October, 1882. 

Langer: Der Sinus Cavernosus der harten Hirnhaut. 
d. Wien. Akad., May, 1885. 


American Journal 


Sitzungsbericht 


REFERENCE HANDBOOK 
OF THE 
MEDICAL SCIENCES. PLATE XIX. 





Representation (in the two lower pictures) of the condition known as *‘Choked Disk,” as seen with the 
ophthalmoscope. For purposes of comparison, the appearance of the normal fundus oculi is shown in the 
upper picture.—( From Haab—Aitlas of Ophthalmoscopy.) 


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Brain, 
Brain, 





Lymphatics. 


Many articles by Arnold (1888), Hyrtl (1860), His (1865), Robin, 
Schwalbe, Obersteiner (1870), Riedel, Arndt, Krause, etc. 

Key and Retzius: Studien in der Anat. des Nervensystems, ete., 1876. 

Rossbach and Sehrwald: Uber die Lymphwege des Gehirns. Centbl. 
f. med. Wiss., 1888, Nos. 25 and 26. 


BRAIN, COMPRESSION OF.—Notwithstanding the 
unhappy use of a word that does not describe the subtile 
condition it is meant to express, the term compression is 
a convenient one that seems justified by the necessities of 
analysisand study. It is generally used ina pathological 
sense to describe a complexity of symptoms arising from 
a particular state of the brain characterized mainly by 
disorder of the circulation within the cranium, and mani- 
fested by more or less derangement of the three great 
faculties of the nervous system. 

As a principle used to account for the phenomena of 
brain disease, and as a complication that is often present 
after various lesions of the brain and its membranes, the 
special and differential diagnosis of compression is of 
grave importance, and includes a wide range of cerebral 
pathology. The prevailing opinions of writers on this 
subject are somewhat misleading, since compression, in 
its true sense of occupation of less space, is a condition 
of the brain which in most cases seems to be assumed 
rather than demonstrated to exist, and it is rare to find a 
case of compression in which there are not present the 
symptoms both of concussion and laceration of the brain. 

Errotocy.—The squeezing of its constituent parts or 
the diminution of volume that is,supposed to interfere 
with the functions of the brain may be effected by press- 
ure from without the encephalon, or by tension within 
its proper substance. ‘The condition arises from a great 
variety of causes, most common of which are cerebral 
tumor, hemorrhage, and inflammatory foci. Hyper- 
trophy of the brain, simple congestion, hydrocephalus, 
and effusion from various causes may result in compres- 
sion. The effusion may take place quickly or slowly. 
Some experiments, however, point to the fact that the 
symptoms of compression are not to be attributed to 
augmentation of tension of the cephalo-rachidian liquid. 

Other causes are foreign bodies, loose splinters, or 
larger portions of depressed bone, and, in fact, any in- 
jury of the head, whether simple contusion, scalp wound, 
or fracture of the skull. Whatever be the cause of com- 
pression, it should be borne in mind that the most char- 
acteristic symptoms are brought about by sudden action, 
for compression established slowly upon the brains of 
animals by the injection of a liquid causes no apprecia- 
ble symptom, unless the quantity injected be unusually 
large; and it should be further remembered that, in the 
human subject, appreciable symptoms of compression 
are not always induced by such causes as sanguineous 
extravasation into the cranium and the cerebral ventricles, 
nor by the pressure of a foreign body, a tumor, or a 
fracture. 

Symproms.—Loss of consciousness and paralysis, which 
vary according to the seat and extent of the compression, 
are symptomatic of the condition, no matter whether the 
compression be sudden, like that following a wound or 
some mechanical injury of the skull and its contents, or 
whether it be slow, as that following enlargement of the 
brain from extravasation of blood, lymph, pus, serum, or 
tumors. Paralysis, excepting that of one or the other eye, 
is always on the side opposite to that which is the seat of 
injury. Thesymptoms may come onalmost immediately 
after any injury of the brain that disorganizes its sub- 
stance; but there are other cases in which compression 
takes place slowly and after a certain lapse of time. The 
initial symptoms that characterize this period are mainly 
subjective and those of congestion, as vertigo, head- 
ache, confusion of ideas, nausea, and, on rare occasions, 
vomiting. Then follows a lethargic sleep and more or 
less paralysis, and the patient cannot be aroused by any 
stimulus. The face is suffused and dusky, it wears an 
expression of well-pronounced stupor, and the eyelids 
are usually closed and immovable; respiration is slow, 
labored, and stertorous, something like the act of snor- 


ing, and thé peculiar blowing movements of the lips 
in expiration have been compared to the act of smoking 
a pipe. Deglutitionisimpossible, and the tendon reflexes 
are abolished. As the intracranial trouble increases the 
pulse becomes slow and labored. It may be hard and 
frequent, or small and intermittent. Sometimes it is 
very irregular, and the symptoms may resemble those of 
anemia of the brain and medulla, brought about by ex- 
perimental means. Paralysis of the sphincters is gener- 
ally present, with involuntary evacuations; or the patient 
may have torpidity of the bowels and obstinate con- 
stipation. Retention of urine, often present from pa- 
ralysis of the bladder, is followed by incontinence as the 
result of overflow from distention. The skin may be 
cool or it may be hot and perspiring, and the tempera- 
ture, though generally normal, may reach as high as 
106° F. One or both of the pupils may be contracted or 
dilated, or they may rest immobile and unresponsive to 
the action of light. Thesymptoms of optic neuritis may 
also be present, and sometimes nystagmus is noted. Pa- 
ralysis both of motion and of sensation, in one or both ex- 
tremities, may exist in case the compression is exercised 
on the hemispheres, and convulsive movements and 
twitching of the limbs may occur on the paralyzed side 
or on the opposite side. Death occurs from arrest of 
respiration. (See Coma and Asphyzia.) 

Driaenosis.—These pathognomonic symptoms, which 
are chiefly owing to effusion under the dura or to fracture 
of the inner table of the skull with resulting secondary 
anemia, are not always met with, nor do such injuries 
as those inflicted by nails and arrow-heads driven into the 
skull, and even by missiles lodged in the brain, always 
produce the symptoms of compression. Sometimes the 
brain may be compressed without any disturbance of its 
functions. Pressure from an abscess, causing a hollow 
in the brain as large as a man’s fist, has been known to 
cause no symptom of compression. Itis, moreover, doubt- 
ful whether depressed fracture be a frequent cause of 
compression, since the injury is always complicated by 
laceration, the symptoms of which are often mistaken 
for those of compression; and it is often difficult and al- 
Ways embarrassing to determine, after an injury of the 
head, whether we have to deal with a contusion of the 
brain, a simple concussion, or the more problematical 
symptoms of cerebral compression. One state so often 
merges into the other that the attempt to establish a clear 
basis for a sure diagnosis of the respective conditions 
seems hopelessly confused and intricate. Roughly speak- 
ing, the most characteristic symptom of concussion is 
somnolence and intensity of the evil from the outset; 
contusion manifests itself by agitation, delirium, convul- 
sions, contractions, and the delay of febrile symptoms; 
while the most salient symptom of compression is paraly- 
sis, except in the case of effusion of blood into the convex- 
ity of the hemispheres or into the ventricles, when con- 
tracture or tonic muscular spasm of extended duration is 
the more prominent phenomenon. Without being a sure 
sign, paralysis constitutes at least a valuable element in 
the diagnosis of a condition that has no single confirmative 
sign. If there be an unequivocal sign of cerebral com- 
pression in the majority of cases following injuries of the 
head, it is, perhaps, that furnished by obstruction of the 
venous circulation, in consequence of which the blood of 
the eye is not returned into the cavernous sinus, when we 
find with the ophthalmoscope papillary or peripapillary 
congestion, a general or partial serous infiltration of the 
papilla, and astrong dilatation with tortuosity of the ret- 
inal veins. (These appearances are shown in the accom- 
panying colored plate.) In concussion the fundus of the 
eye retains its normal state; in compression there is al- 
ways serous peripapillary infiltration, dilatation, tortuos- 
ity, and sometimes thrombosis of the veins’of the retina. 
The intraocular changes herewith portrayed are not al- 
ways pathognomonic, but they lend to the diagnosis an 
additional source of correctness. As arule, when the eye- 
grounds show arrest of the retino-choroidal circulation, 
we have an indication of the arrest of cardiac circulation 
and of the nervous functions. 





265 


Brain. 
Brain. 





ParHnoLoey.—According to many observers, the gen- 
eral sy mptoms of compression are owing to cortical 
anemia, and the general impairment of cerebral function 
is owing to disturbance in the capillary circulation, which 
prevents the normal interchange between the plood and 
the tissues, and results in phy siological death of the af- 
fected portion of the brain. In compression, the blood 
may be extravasated upon the surface of the brain, the 
effusion taking place between the skull and the dura, 
and in the cavity of the arachnoid, or in the intervening 
spaces that separate the membranes from the brain, or it 
may be effused into the ventricular cavities, or into the 
substance proper-of the brain. The volume of an ex- 
travasation between the dura and the bone is sometimes 
very large; but, as a rule, effusions of this kind are al- 
ways much larger at the v ault of the cranium than at its 
base. Sanguinary effusions between the dura and the 
pone, according to the summarized opinions of writers 
on the subject, generally coagulate into a firm clot that 
may either be absorbed or undergo organization and be- 
come adherent to both the bone and the dura, This clot 
never becomes encysted as do clots in the cavity of the 
arachnoid, but may undergo ossification. It is also sus- 
ceptible of other changes. Thus, for example, it may 
lead to necrosis of the neighboring bones of the skull, 
which may be perforated by an abscess having as its 
foyer the sanguineous effusion. 

Blood extravasated between the layers of the arachnoid, 
especially on that part which covers the cerebrum, is of 
common occurrence in the severest head injuries, and 
forms at the convexity of the hemisphere a thin, evenly 
spread layer. It clots rapidly, loses its coloring matter, 
undergoes organization, assuming the form of a false 
membrane or of a membranous cyst, and may be absorbed 
and take on a secreting action like other cysts. 

Effusions between the visceral layer of the arachnoid 
and.the pia are less common than those in the cavity of 
the arachnoid, and are generally associated with some in- 
jury of the brain itself. They spread extensively into the 
spaces usually occupied by the cerebro-spinal fluid, and 
do not become encysted as in other situations. 

Traumatic effusions into the brain substance may occur 
inany situation. They are generally associated with lacer- 
ation or other severe injury of the brain, and are for the 
most part fatal. Should recovery take place, the blood clot 
undergoes changes similar to those observed in the organi- 
zation of an ordinary clot from cerebral hemorrhage. 

All effusions of blood between the dura and the brain 
are susceptible of being reabsorbed, of being encysted in 
a false membrane, and of giving place to encephalitis, 
meningitis, and other grave symptoms that come emi- 
nently within the province of surgery ; in fact, it is chiefly 
from this point of view that compression has been treated 
by the great masters. 

Clinical and experimental facts show that in compres- 
sion from injury of the occipital region death results not 
from failure of the heart, as often surmised, but from 
failure of the respiration. The symptoms are not me- 
chanical but depend on trouble of circulation inthe bulb, 
and have their point of departure in the cortex of the 
hemispheres including the vaso-motor centre. 

In place of attributing many of the troubles grouped 
under the subtile heading of compression to pressure ex- 
erted upon the brain, it would be better to attribute them 
to congestion, to contusion, to laceration of the cerebral 
substance, and to interference with the function of the 
respiratory centre, which puts us in a position to doubt 
whether the effects of compression upon the brain are 
not susceptible of further and more convincing proof. 

Procnosis.—The integrity of the brain is not compro- 
mised by mere compression itself, nor is the condition a 
very fatal one. Its gravity depends on consecutive in- 
flammation, secondary ansmia, and the effect on the 
respiratory centre. Sometimes the symptoms disappear 
spontaneously and gradually without interference. 

The TREATMENT of compression raises many questions 
of operative interference, which are discussed elsewhere 
under their respective headings. The whole end of treat- 


266 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ment is to restore interrupted respiration and prevent 
cerebral inflammation. In endeavoring to do this, artifi- 
cial respiration and heat to the head by irrigation appear 
most commendable. Irving C. Rosse. 


BRAIN, CONCUSSION OF THE.—(Concussion of the 
cord is analogous to concussion of the brain.) The term 
“concussion of the brain” comes down to us from the 
earliest ages; it was used by Hippocrates, Galen, and Cel- 
sus; its modern significance was given it by Boirel, but 
it was Littré who first studied the subject post mortem, 
in 1705, 

The subject of concussion of the brain, or commotio 
cerebri, has received much attention from various work- 
ers, especially in the last fifty years. The theories con- 
cerning it have varied widely, even to the extent of 
contradiction. The general cause of this condition—trau- 
matism—and the characteristic symptoms of the same— 
sudden unconsciousness, feebleness of heart and respira- 
tion—are well known; but what occurs in the cells af- 
fected is as yet undiscovered. 

Verneuil, the eminent French surgeon and writer, 
after much observation and experience on this subject, 
formulates the following definition: “It is a series of 
phenomena occurring more or less suddenly which result 
from a mechanical shaking (jarring movement) of the 
anatomical cells, tissues, and organs, characterized by 
temporary excitation or depression of the properties, 
offices, or uses of the parts which are shaken; and as a 
result there are caused anatomical changes similar to 
those which are normally seen in the successive phases of 
functional activity and functional repose.” 

According to Pick, this term was first used because 
there was thought to be a shock and molecular disturb- 
ance to the cerebral tissues with no visible lesions or 
lacerations. This cannot hold, since the autopsy almost 
invariably discloses macroscopic lesions. However, these 
lesions are not necessarily the cause of the insensibility. 
It has been shown by William Savory that the state of 
unconsciousness and insensibility passes away, while the 
lesions remain. In many cases the extent of the lesion is 
not sufficient to produce the existing symptoms, and, 
again, the lesions may be present when there is no insen- 
sibility. 

There are three grades: mild, severe, and fatal. 

In explanation of the mildest grade the following has 
been offered: The cerebral cortex, owing to’a momen- 
tary deprivation of nutrition, following lowered blood 
pressure and fall of temperature, ceases for the time being 
to function, and so follow loss of memory and uncon- 
sciousness. 

In the more severe type the molecular disturbance is 
more violent and is naturally followed by graver symp- 
toms. Mental functions are temporarily suspended, the 
condition of the patient somewhat resembles sleep, al- 
though the eyes are often in motion unnaturally with 
closed lids; or if at rest, they are not upturned and di- 
vergent as in normal individuals. This may be termed 
“the sleep of concussion.” There isnosnoring. Indeed, 
there may be disturbances of the cardio-pulmonary func- 
tions or paralyses of different parts of the body from 
localized lesions of the brain. 

In the fatal form, death may follow at once or after a 
few hours. 

ErroLocy AND PatTHoLocy.—The gross cause of cere- 
bral concussion is, beyond doubt, some form of trauma- 
tism either applied directly to the head or indirectly 
transmitted, as in the case of a fall upon the feet—when 
the shock is transmitted through the spine,—or in that 
of a blow or a fall upon the chin. But the changes pro- 
duced in the brain substance and the subsequent results 
have been the subjects of much argument. 

Treves groups the theories of concussion under three 
heads: 

1. Molecular disturbances. 

2. Multiple hemorrhages. 

3. Vascular disturbances. 

In the molecular form of disturbances the brain sub- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





stance is thrown into vibrations by the violence trans- 
mitted to it. The old idea that obtained, viz., that there 
were no macroscopical lesions, has been entirely over- 
thrown by modern workers, for, as has been noted, in all 
fatal cases which come to autopsy macroscopical lesions 
consisting of hemorrhages or lacerations are almost in- 
variably discovered. Not infrequently, however, these 
hemorrhages are too insignificant to be the cause of death 
or even of the symptoms of concussion. That cerebral 
anemia exists is hardly disputed. The cause of this ane- 
mia has offered a field for discussion. 

Duret describes “the cone of depression and the cone 
of bulging,” meaning by the first the point which re- 
ceives the injury and by the second the area just oppo- 
site. The force of the injury imparts to the cerebro- 
spinal fluid an impetus which drives it from the lateral 
ventricles into the third ventricle through the aqueduct 
of Sylvius into the fourth, and the latter, receiving more 
fluid than it loses, becomes distended. This distention 
causes a stimulation of the restiform bodies resulting 
in cerebral anemia. Duret also believes that the small 
hemorrhages are due to the blood-vessels losing the sup- 
port of the cerebro-spinal fluid. 

Anzemia may exist by displacement of blood following 
the indentation of the skull. According to Fischer the 
loss of vascular tone may result from the nervous shock 
of the injury and may cause permanent vascular degen- 
eration. Emotion is probably followed by a loss of vas- 
cular tone. The results of shock are sometimes similar. 
Possibly this mechanical vibration causes both physical 
and chemical changes in the nerve cell. 

Phelps believes that the stimulation of the restiform 
bodies resulting in efferent reflex action causes direct 
capillary contraction. 

After the cortical centres have received a shock there 
is instituted an instability of cerebral nutrition due prob- 
ably to increased sensitiveness of the vaso-motor centres 
and a liability to anemia or hyperzemia from very slight 
causes. Oftentimes individuals after head injuries are 
unable to undergo severe labor or exposure to the sun or 
the effects of alcohol. These facts were clearly recog- 
nized in the late Civil War, for men who had suffered in- 
juries of the head were relegated to the invalid corps. 

Symproms.—The most characteristic symptoms of this 
condition are sudden unconsciousness, loss of memory for 
events just preceding or during the injury, muscular 
weakness, dulled sensibilities, general prostration, vomit- 
ing, and changes in the circulatory system, as illustrated 
by the respiration and the pulse. 

These symptoms vary in their intensity and duration 
in accordance with the severity of the injury sustained. 
They may be very slight, consisting only of momentary 
unconsciousness, pallor, and mild interference with respi- 
ration; or they may be so severe as to be followed by death 
in afew moments. Treves notes three stages: 

1. Stage of collapse. 

2. Stage of reaction. 

3. Stage of convalescence. 

This is a convenient and comprehensive classification. 

The clinical picture of the mildest grade is illustrated 
by what is familiarly known as the state of being 
“stunned.” In this condition the patient hears strange 
noises, there are visual disturbances, dizziness, general 
weakness, inability to stand or to use the arms; the eyes 
lose their natural expression, the eyelids close. The pulse 
is always weak; sometimes it is slow, at other times it is 
rapid—more generally the former; and it is probable that 
immediately after the injury it is always slow. Respira- 
tion is disturbed, irregular, and now and then of a sigh- 
ing character. The paralysis which occurs is generally 
only temporary as well as functional, for these phenomena 
disappear with returning consciousness. 

In cases of well-marked concussion the superficial re- 
flexes and knee-jerks are not pronounced, neither are the 
cranial reflexes. In slight cases these are sluggish. 

A common symptom is delirium. This may be violent 
or mild, the nocturnal form being most characteristic in 
cases of cerebral traumatism. 








Brain, 
Brain, 


In the more severe cases the symptoms are more accent- 
uated. The unconsciousness may amount to coma, the 
patient being incapable of being aroused; he cannot even 
swallow. There are successive attacks of vomiting; the 
pulse is irregular, small, and generally very slow. Res- 
piration can scarcely be detected. The skin is cold. 
The pupils are. equal and more or less dilated, their 
reaction to light varying with the extent of the injury. 
There is incontinence of rectum and bladder, for although 
the sphincters of these organs are relaxed the organs 
themselves are not paralyzed. The temperature is the 
same on both sides of the body; rectal temperature is in- 
variably subnormal, even falling to 95° F. 

In the stage of reaction there is a general improvement 
in the bodily functions. The temperature rises, the skin 
becomes warm, circulation improves, respiration is 
stronger, and the pulse gradually becomes normal. This 
stage is ushered in by vomiting. Consciousness comes 
back by degrees, and with returning consciousness head- 
ache oftensupe:venes. The loss of memory noted in this 
stage may refer only to events just preceding the re- 
ceipt of the injury, or it may also include those which oc- 
curred at the time of injury. The loss of memory may 
continue for some time after consciousness is fully re- 
gained. During this stage the patient may die with 
symptoms of encephalitis or of spreading edema. Effu- 
sion of blood may often cause death in injury to the head 
with or without any marked external injury. Effusions 
may occur upon the surface of the brain after superficial 
lacerations of its substance. 

The duration of the stage of convalescence may be 
from a few days to weeks or even months. When re- 
covery is prolonged it is fair to assume that laceration 
has taken place. Such an hypothesis would also ac- 
count for those cases in which complete recovery never 
takes place and in which mental disturbances persist. 

DraGnosts.—Concussion of the brain should be differ- 
entiated from opium poisoning, alcoholic coma, com- 
pression, and contusion. From opium poisoning it should 
be distinguished by the narrow pupils and stertorous 
breathing, which serve as diagnostic differences. It is 
often of medico-legal importance to diagnose this state 
from alcoholic coma. While in the latter the odor of 
alcohol might at first sight seem conclusive, it must not 
be forgotten that the brain lesion may also be present, 
having been received after the alcohol had been taken; 
also that alcohol in some form may have been given after 
the receipt of the injury. At all events, when a perfectly 
clear history pointing unmistakably to alcoholism cannot 
be obtained, give the patient the benefit of the doubt 
and treat with a view to the existence of the possible 
brain lesion, opium of course having been excluded. 

Bourneville differentiates apoplexy and non-traumatic 
hemorrhages from concussion by the temperature, which 
is subnormal] in the former, later becoming normal when 
recovery is to take place, but rising to an extreme degree 
in cases that terminate fatally; whereas in traumatic 
lesions the temperature rises at once while the results are 
uncertain. 

The history will also throw much light on the diagnosis. 
Between concussion and compression the following table 
will be found to contain the points of differentiation: 


Concussion. 


Onset of symptoms immediately 
after injury received. 

Onset sudden. Immediate uncon- 
sciousness. 


Muscular system generally re- 
laxed, no definite paralysis. 

Pulse always weak, generally 
slow, sometimes rapid, and ir- 
regular. 

Respirations slow and shallow, 
may be sighing. 


There is incontinence of urine. 
The pupils are equal, dilated, and 
react to light. 


The surface temperature is equal 
on the two sides. 


Compression. 


Onset of symptoms some time after 
receipt of injury. 

Headache and drowsiness, grad- 
ually increasing to unconscious- 
ness. 

Definite paralysis, local or gen- 
eral. 

Early slow, becoming rapid as the 
condition advances. 


Early respiration is regular and 
slow, later becoming irregular, 
resembling Cheyne-Stokes. 

Retention and overflow of urine. 

Pupils are irregular till the last 
stage, then are dilated and do 
not react to light. 

neansaaarbe teh is generally irregu- 
ar. 


267 


Brain. 
Brain, 


Proenosts.—The prognosis must always be guarded. 
In slight cases recovery is generally to be expected. 
Unfavorable signs are coma, very slow pulse, convul- 
sions, and paralysis. Signs of compression and of lacera- 
tions in the stage of reaction modify the prognosis. 

TREATMENT.—The treatment must vary with the stage 
at which the case is seen. If an external wound exists it 
must be treated, as in ordinary cases, according to its 
character. General directions for the stage of collapse 
are to regulate the depression of the circulatory and 
respiratory systems by means of warmth applied to the 
body; stimulants may be administered by the mouth if 
the patient can swallow; per rectum, or hypodermatically. 
Alcohol is contraindicated unless stimulation is indicated. 
The stimulants that may be used are ether, musk, strych- 
nine, atropine, sparteine, nitroglycerin, camphor; coun- 
ter-irritants such as sinapisms may be applied over the 
precordium and epigastrium or to the calves of the legs. 
If the patient continues to be unable to swallow he may 
be fed through a stomach tube or per rectum. Black 
coffee enemata are also useful. é 

In the stage of reaction stimulants should be withheld, 
the diet should be light, and the bowels should be kept 
open by purgatives and enemata. Darkness and quiet 
are essential. When recovery is delayed shaving the 
head and the application of cold by Leiter’s bags are to 
be commended; calomel and salines are beneficial. 

In the stage of convalescence the patient should not be 
permitted to work and should be shielded from all men- 
tal excitement. Fresh air, rest, and light diet are es- 
sential. 

Chloral hydrate and potassium bromide are indicated 
in cases of irritation. Potassium bromide aids in pre- 
venting inflammation. There must be no constriction at 
the neck; the head must be kept low; the scalp should 
be shaved and examined with care, for in fractures of the 
skull there are often no symptoms of a concussion for 
days or even weeks. 

“ Railway spine” or spinal concussion, formerly used to 
describe the results of concussion, is a misnomer. 

Traumatic neurasthenia may result; this is similar to 
the condition following injuries to the spine when health, 
on account of organic disease or of overstrained nerves, is 
at a low ebb at the time of the injury. Traumatic in- 
flammation of the brain or of its membranes may result. 
Abscesses may also follow. 

Cerebral irritation is a condition sometimes following 
concussion. Its symptoms are probably owing to bruis- 
ing of the frontal lobes. The patient lies on the side 
with the limbs curled up and is unconscious. He is rest- 
less and very irritable; the eyelids are closed; the pulse 
is slow—from 40 to 50; there is an absence of heat in the 
regions of the head and spinal cord; and generally there 
is incontinence of feces and urine. 

This condition may continue for as long a time as three 
weeks. The patient then extends the extremities and as- 
sumes the supine position. ‘The temperature becomes nor- 
mal, the pulse more rapid, and recovery may supervene. 
On the other hand, the mind may be permanently affected. 
There is absence of memory during the illness. 

The findings at the autopsy table have been substan- 
tiated by the animal experiments performed by Koch, 
Fiehlene, Wittkowski, Albert, Goltz, and others. 

Emma E. Walker. 


BRAIN, DEVELOPMENT OF THE.—The develop- 
ment of the brain is bound up with that of the nervous 
system at large. While in the lower animals the nerve 
cells appear scattered or grouped in various parts of the 
body, and such scattered ganglion cells are found in even 
the highest animals, yet it is characteristic of the central 
nervous system as found in vertebrates that the nervous 
structures are collected into a common aggregate which 
contains only such admixture of other than nervous 
tissue as may serve to protect, support, and insulate the 
latter. It is obvious that the ordinary vegetative func- 
tions of life and many adaptive processes may be satis- 
factorily performed without a nervous system as such, 


268 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





as may be seen in the higher plants. The development 
of a central system, then, is an indication of preparation 
for higher functions than those of nutrition and metabol- 
ism or even of complex adjustment to the environment. 

Harly Stages.—After the egg has been differentiated 
into an animal and a vegetative pole and after the vegeta- 
tive cells (by a process of invagination or substitute for 
it) have acquired an internal position, the cells remain- 
ing at the periphery (ectoderm or epiblast layer) repre- 
sent the rudiments from which are to spring all the cells 
and specific organs not only of the central nervous system 
but of the sensory apparatus which forms the avenue 
from the external world to the central system. The 
ectoderm also contains, of course, the forerunners of the 
cells of the epidermis at large. 

In general, the rudiments of the central nervous system 
collect in a broad longitudinal band extending along the 
dorsum of the embryo, while the rudiments of the sense 
organs exhibit a tendency to be arranged in one or more 
series along either side of the central band or medullary 
plate (Fig. 822).* In lower, especially aquatic, forms this 
lateral sensory band is evident in late life as the series of 
lateral-line organs, and it is plain that some or all of the 





Fic. 822 (Nos. | to 4).—Transverse Sections through the Neural Plate 
and Neural Tube of an Embryo Bird. chd, Notochord; hy, ento- 
derm; mf, neural folds; mg, neural groove ; mp, neural plate; ne, 
neural canal; nt, neural tube; so, somatopleure; sp, splanchno- 
pleure. (Mihalkovics and Balfour.) In No. 4 the rudiment of the 
spinal ganglia is represented but not lettered. 


organs of special sense obey the same law of serial 
arrangement, the ear in particular betraying relation- 
ships to the lateral-line system. (Compare Vol. I., p. 627.) 

The Newral Plate and Tube.—The neural or medullary 
plate is supported from below by a band of cells derived 
from the original. entoderm which separates from the 
latter to form a solid rod (perhaps theoretically a tube at 
one stage), called the chorda dorsalis. The medullary 
plate grows more rapidly than the adjacent ectodermal 
tissue, and thus forms a raised border on either side with 
a groove in the median dorsal line. This medullary 
groove is continuous behind with the lip of the blastopore 
or opening left after the invagination of the entoderm. 
As the lateral margins of the medullary groove rise 
higher above the surface (both nervous and epidermal 
portions participating in the growth), the groove is trans- 
formed into a tube. The concrescence of the lips of the 
fold begins at a point corresponding with the site of the 
future midbrain. In the vicinity of the blastopore the 
groove may remain open for some time, and there is formed 
a direct communication with the primitive digestive tract 
through what is known as the canalis neurentericus, a 





*These and several of the following cuts are introduced without 
change from the article by Professor H. F. Osborn in the former edition. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


communication that is disturbed only by the final closing 
of the blastopore. At the cephalic extremity also the 
closing of the tube is long delayed, and there is left an 
opening called 
the neuropore 
communicating 
with the exteri- 
or at the front of 
the head. 

In bony fishes 
and other verte- 
brates whose 
eggs have much 
yolk, the tube 
may be formed 
first aS an ap- 
parently solid 
cord of cells, but 
the final result 
is the same. 

At the cepha- 
lic extremity of 
the digestive 
tract, which at 
this stage ends 
in a blind sac 
separated from 
the pharyngeal 
invagination by the portion of the ectoderm known as 
the septum of Remak, is a region of fusion called the 
area reuniens. Here the cephalic end of the chorda, 
the base of the brain 
tube, and the angle of 
the enteric cavity tend to 
adhere temporarily. On 
the cephalic side of the 
septum the ectoderm 
gives rise to (an appar- 
ently single) median in- 
vagination which ex- 
tends dorsally to meet a 
similar outgrowth of the 
infundibular region of 
the brain, combining 
with the latter to form 
the hypophysis or pitu- 
itary body. On the op- 
posite side of the sep- 
tum a somewhat similar 
outgrowth from the 
cephalic dorsal angle of 
the digestive tract forms 
the so-called Seessel’s sac, which in some cases seems to 
connect with the cephalic end of the chorda. In birds at 
least this sac is distinct from the chorda which subse- 





Fig. 823.—-Median Section of Brain of Bird Em- 
bryo, to Show Hypophysis and Pharyngeal Sac. 





Fig. 824.—Later Stage of Hypophysis. 





Fia. 825.—Illustration Showing the Relation between Chordal Sac, 
Alimentary Canal, and Brain Flexure in Opossum. (From Selenka.) 


quently degenerates and leaves a convoluted thread-like 
vestige behind it that is closely connected with the site 


Brain, 
Brain. 





of origin of Seessel’s sac. The latter, after the breaking 
through of the septum, comes, in birds, to lie in connec- 
tion with the base of the hypophysis (Fig. 828). 

This region seems to mark the morphological front of 
the head, and the medullary tube is often open at front, 
forming a neuropore (Fig. 826). Gradually the tube ex- 


tends cephalically, and the base and roof unite along a 
line a part of which becomes that part of the base of the 





Fie. 826.—Brain of Torpedo, to Show the Neuropore, 7.p. 


brain occupied by the postoptic and preoptic recesses, 
the remaining part being the lamina terminalis (Fig. 826). 
The portion of the brain developed cephalad of the area 
reuniens, 7.¢., in front of the cephalic end of the chorda, is 
called the prechordal as distinguished from the remain- 
ing, or epichordal part of the brain, and is morphologi- 
cally different from the latter. In early stages of the de- 
velopment of the brain tube it appears segmented, and 
many attempts have been made to prove that these seg- 
ments, or neuromeres, have a morphological significance 
and that they correspond with the segments discoverable 
in other and especially the mesodermal tissues. It has 
also been supposed that evidence of this primitive seg- 





Fig. 827 (Nos. 8 to 14).—Horizontal Sections of the Forebrain (8 and 9, 
of abird; 10to 14, of arabbit). (K6lliker, Mihalkovics, L6we.) cal, 
Corpus callosum; chd, choroid plexus; fmr, foramen of Monro ; 
frx, fornix; hms, cerebral vesicle ; hemisphere; inf, infundibu- 
lum; msc, mesencephalon; stm, stem; str, corpora striata; trm, 
lamina terminalis ; thm, optic thalami; ve, ventriculus communis ; 
vtr, fifth ventricle; v’, lateral ventricle ; v3, third ventricle. Other 
letters as above. 


mentation could be seen in the arrangement of the roots 
of the cranial nerves. On the whole, however, it must 
be admitted that, while it is not difficult to detect the 
segmental arrangement in the epichordal part of the 
brain, the prechordal portion either was not derived from 


269 


REFERENCE HANDBOOK OF THE MEDICAL. SCIENCES. 








FIG. 828 (Nos. 15 to 19).—Vertical Sections of the Brain (15 to 18, of the 


rabbit; 19, of the bird). 


(Mihalkovics.) 


cbl, Cerebellum ; chd4, 


tela vasculosa ; chd3, choroid plexus of third ventricle ; epc, epen- 
cephalon ; hph, hypophysis; it, iter; psc?, prosencephalon ; psc}, 
diencephalon ; pns, pons Varolii; smr, sulcus of Monro; v4, fourth 


ventricle. 


a segmented rudiment, or, if so, it has suffered such 


complete alteration as to 


Lam. berm: 
StSERZ» Ee 
Optv, 





Wf-b. 


Fig. 829.—Dorsal View of Chick 
of Fifty-Eight Hours. (After 
Mihalkovies.) Lam. term., 
Lamina terminalis ; F’-b., fore- 
brain; Opt. v., optic vesicle ; 
M-b., midbrain ; H., heart. 


prevent the identification of 
the neuromeres.* 

In all vertebrates the por- 
tion of the medullary tube 
destined to become brain is 
divided at an early stage into 
three embryonic vesicles, the 
forebrain, midbrain, and hind- 
brain respectively (Figs. 827 
and 829). Inall higher verte- 
brates the midbrain is the site 
of a very important flexure 
which is formed at an early 
embryonic stage and causes 
the forebrain to assume a ven- 
tral position with reference to 
the remainder of the brain. 
The division into three lobes 
homologous with the vesicles 
may take place in some cases 
before the closing of the tube, 
but this may be looked upon 
as an instance of retardation 
in the development of the 


tube and is of no morphological significance. 
Embryonic Brain Zones.—After the closing of the 





F1G. 830 (Nos. 30 and 31).—Transverse Sections through the Forebrain 
of a Rabbit, Showing the Development of the Optic Vesicles and 


Rudimentary Parts of the Eye. 


(K6lliker.) 1, Lens; hph, hypoph- 


ysis ; opt!, primary optic vesicle ; opt?, secondary optic vesicle. 


medullary tube the dorsal and ventral median portions 
are thinner than the lateral walls and have been called 


* Locy and his school identify eleven neuromeres in the brain, five 
of them being cephalad of the cerebellum. 


270 





by His basal plate and roof plate respectively, though 
they are rather lines or zones than plates. On either side 





Fig. 831.—Figure of Hu- 
man Embryonic Brain. 
(From His.) A, Optic 
vesicle ; H, prosenceph- 
alon; Z, diencephalon ; 
M, mesencephalon; T, 
isthmus; Tr, infundib- ze 
ulum; Pm,mammillare; Br,pons; Hh, 
cerebellum ; Rf, roof of fourth ventricle ; 
Gb, auditory vesicle; VV, medulla; Nk, 
cervical flexure. 





Fic. 832.—Youngest 
Stage of Ichthy- 
ophis. J, Infundib- 
ulum; <Abl, optic 
vesicle; Zh, dien- 
cephalon ; Mh, mes- 
encephalon; Rh, 
metencephalon. 


the walls are divided into a dorsal and a ventral zone, 
called respectively fundamental and alar zones or plates. 





Fig. 833.—An Older Em- 
bryo of Ichthyophis. 
Ep, Epiphysis ; Ast, op- 
tic peduncle; Sb, mes- 
encephalic flexure: Bb, 
pons flexure. 





Fie. 834.—Embryo 
of a Still Later 
Stage. 


The fundamental plate is the site for the development of 
the motor cells and is the zone of origin for the ventral 





Fig. 835 (Nos. 20 to 23).—Lateral Views of the Brain (20, of a bird; 21, 
22, of abuman embryo; 23, of a pig). (Mihalkovies.) frt, Fron- 
tal lobe ; ocp, occipital lobe ; olf, olfactory lobe; prt, parietal lobe ; 
qgm, corpora quadrigemina; obl, medulla oblongata ; prt, parieta) 
lobe ; res, recessus lateralis ; slv, Sylvian fissure ; spn, spinal cord ; 
tmp, temporal lobe. Other letters as above. 


or motor nerve roots, while the alar plate includes the 
zone of the sensory roots. 

That part of the base of the brain tube which is adjacent 
to the area reuniens forms an expansion in a ventral, cau- 
dal, and cephalic direction, giving rise to the fundus basi 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





laris with a cephalic ex- 
tension, the recessus 
opticus, and a caudal 
prolongation, the reces- 
sus infundibuli. The 
recessus opticus is di- 
vided into the preoptic 
and the postoptic divi- 
sion by thechiasm. At 
the apex of the infun- 
dibulum is the place of 
the pituitary, while the 
tuber cinereum with its 
olfactory connections 
develops behind the in- 
fundibulum. In am- 
phibia the infundibu- 


caudad to form the 
saccus vasculosus. In 
fishes the so-called lobi 
inferiores appear. be- 
hind the infundibu- 
lum, but these have no 
relation to either the 
infundibulum or the 
cinerea, aS has been 
supposed, but are diverticles from the walls of the pes. 
Ltoof of the Brain.—The dorsal walls of the brain nat- 





Fig. 836 (Nos. 26 and 27) .—-Lateral Views 
of the Brain, with the Lateral Ven- 


tricles Exposed. (Mihalkovics.) 
amm, Cornu ammonis; tm, stem. 
Other letters as above. 











as 


mcpkeong so! 












PLR: 







Wp 
gam 


SNR aa55c0sex 


WA 
Ceo a 





Fic. 837.—Median Section of Embryo of Acipenser Sturio, Forty-Five 
Hours After Fertilization. 


urally develop more rapidly than the base. The roof of 
the hindbrain for a large part of its length fails to de- 
velop nervous elements, but 
remains membranous ~ and 
forms the velum medullare 
posterius or kilos. This mem- 
brane becomes associated with 
a rich plexus of blood-vessels, 
and together these penetrate 
the cavity of the hindbrain 
(fourth ventricle), and fur- 
nish the vascular supply to 
that region. The triangular 
form of the velum, where its 
sides converge to the point 
where the solid parietes meet, 
has given rise to the term 
calamus for this locus. Ceph- 
alically the latero-dorsal walls of the hind- 
brain thicken and are reinforced by out- 
growths of ventricular epithelium to form 









Ss 


lum is produced: 





a paired body which becomes apparently single by 
the concrescence of the two halves. This is the cere- 
bellum. In amphibia the cerebellum remains obso- 
lescent and its development varies greatly in the differ- 
ent groups; but in general it can be seen that the 
relative development of this organ is commensurate 
with the necessities for motor coordination. In birds, 
for example, it is highly developed, while the brain as a 
whole remains upon a rather low plain of development. 
Immediately cephalad of the cerebellum is the velum 
medullare anterius or valvula in which the fibres of the 
fourth nerve ultimately decussate and from which there 
is developed in many fishes a remarkable invagination 
into the cavity of the midbrain known as the volvula. 
The roof of the midbrain becomes thickened laterally 
and divides into a cephalic and a caudal portion. The 
larger or tectal portion in lower vertebrates forms two 
hemispherical projections connected by the Sylvian com- 
missure and receiving the fibres from the optic brachia or 
extensions of the optic nerves. The caudal portion hasa 
solid structure, and is composed of a mass of nerve cells 















Fig. 840.—Similar Section of Larva, Four Weeks Old. 


Description of Figs. 839 and 840.—c, Cerebellum; ca, precommissura; cc, commis~ 
sura cerebelli ; cd. chorda dorsalis; ch, chiasm and commissura postoptice ; ep, 
postcommissura ; cs, supracommissura ; de, commissura debilis; e, cerebrum; en, 
entoderm; ep}, paraphysis; ep?, epiphysis; h, hypencephalon = infundibular re- 
gion; hf, sucking disc ; hy, hypophysis; hz, heart; kn, cartilage ; lo, lobus olfac- 
torius impar.; M, mesencephalon; m, mouth; NV, metencephalon ; p, preepineal 


ew ra roof of diencephalon (parencephalon) ; pd, plica dorsalis; pv, plica ventralis; r, 
median olfactory plate; ro, recessus opticus ; si, sinus postopticus ; t, commissura 


Fig. 8388.—Similar Section of Embryo, Sixty-Four 
Hours After Fertilization. 


terminalis ; tp, tuberculum posterius ; v, prosencephalon ; vt, velum transversum of 
the forebrain. 


271 


Brain, 
Brain, 





embedded in astroma. This nucleus tends to drop below 
the surface, and it is probable that in it are found the re- 
flex connections for the optic apparatus. 

In mammals the roof of the midbrain is occupied by 
two pairs of eminences, together constituting the corpora 





Fia. 841.—Lateral View of the Brain of Adult Petromyzon. Hpiph, 
Epiphysis ; hem, hemisphere ; optic lobe, optic lobes. 


quadrigemina, and the representatives of the tectum seem 
to be scattered among several adjacent parts of the mid- 
brain walls. This isaregion especially in need of study. 


inf olf. 
'@ 





Fig. 842.—Longitudinal Perpendicular Section of the Brain of Ammo- 
coetes, for comparison with the brain of Amphioxus. ch, Chorda; 
olf, olfactory sac; inf, infundibulum. 


Immediately cephalad of the tectum is the posteommis- 
sure in which decussate part of the fibres of the dorsal 
longitudinal fasciculus. The roof of the forebrain is 
divided into a 
cephalic and 
a caudal portion 
by the evagina- 
ion: of the epi- 
physis. The 
latter always 
arises just cau- 
dad of the su- 
pracommissure, 
but varies in 
form and rela- 
tions in the dif- 
ferent groups. 
In many lizards 
it gives rise to 
the parietal or- 
gan, or “pineal 
eye.” In snakes 
it becomes high- 
ly vascularized 
and glandular, 
- while in mam- 
mals it appears 
to undergo ret- 
rograde meta- 
morphosis. 
Near the supra- 
commmissure, 
in the roof of the 
first vesicle, 
there develop 
clusters of cells 
forming the ha- 
benule. These 
nuclei are asym- 
metrically de- 
veloped and 
sustain some re- 
lation to the pin- 
eal. From them or a group of cells closely associated 
arises Meynert’s bundle (fasciculus retroflexus). Another 
mass of cells, called the subhabenular nucleus, arises in 
the deeper walls nearer the ventricle. 
Cephalad of the supracommissure the roof tends to be 
membranous and gives rise to various outgrowths in 
different groups (the paraphyses) and to an ingrowing 


272 


W1i-b- 





Fic. 843.—Human Embryo 4 Mm. Long. M-b., 
Midbrain, flexure already developed; O-v., 
optic vesicles ; I’-b., forebrain ; Aw., auditory 
vesicle ; H., heart; C., pharyngeal clefts. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








as 
Fia. 844.—Human Embryo Older than Fig. 843. M-b., Midbrain; Med., 


medulla oblongata; C-f., cervical (or nuchal) flexure; E., eye; F-b., 
forebrain; Olf., olfactory pit. 


velum which with its vascular associates gives rise to the 
choroid plexus. Through this portion of the roof, con- 





Fig. 845.—Similar View of an Earlier Embryo. ch, Chorda dorsalis. 
Other letters as above. 


necting the two sides, there pass, first, the hippocampus 
commissure or fornix, and, in higher vertebrates at least, 





Fig. 846.—Embryo (Older than Fig. 843) Seen as Transparent. 
M-b., Midbrain; Hem., hemispheres; Olf, olfactory pit; Cb, 
cerebellum; Med., medulla; H, heart; IV. ven., space occupied 
by ola] ventricle; EH, auditory vesicle. The cranial nerves are 
numbered. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





the corpus callosum. The lamina terminalis contains the 
_ precommissure. 

Such, in brief, is the course of development of the brain 
stem, but we may pass to the consideration of the several 
portions separately. 

- The Forebrain.—At an early stage the lateral walls 
of the forebrain evaginate on either side to form the 





Fig. 847.—The Brain of a Human Embryo 20 mm. Long. 


primary optic vesicles, which give rise in time to the 
retina and the choroid coat of the eye (Figs. 829 and 
830). For some time the brain vesicle remains in com- 
munication with the optic vesicles through the hollow 
stalks of these outgrowths, and in the amphibia the optic 
stalks remain hollow though clothed exteriorly with the 
fibres of the optic nerve. 

Their connection with the brain is near the base ceph- 
alad of the infundibulum. Cephalad of the points of 
origin of the eyes a second pair of evaginations form 


lobus 
vlfaccorius £14 





Fic. 848.—Diagrammatic Median Section of the Brain of a Human 
Embryo. 


the rudiments of the hemispheres. These spheroidal 
pouches, separated from each other by the lamina termi- 
nalis, rapidly increase in size and soon outstrip all other 
parts of the brain. The communication between the 
ventricles of the hemispheres and the remnant of the fore- 
brain vesicle is at first direct through the portx, but at a 
later period the two porte come to open into a median 


Vou. IL—18 


recess narrowed off from the first vesicle and called the 
aula (see Fig. 860). What remains after the development 
of the eye vesicles and hemispheres is the thalamus or 
diencephalon, while the hemispheres collectively con- 
stitute the prosencephalon. (Another usage embraces 
the thalamus and hemispheres under the term prosen- 
cephalon and applies the term telencephalon to the hemi- 
spheres. ) 

At first the walls of the medullary tube are apparently 
nearly homogeneous, but after the separation of the vari- 
ous outgrowths the rate of development proceeds very 
differently in various parts. Thus, in the walls of the 
hemispheres certain areas develop with great rapidity 
while others are retarded. In the basilateral walls of 
the hemispheres especially there develop masses of cells 





Fig. 849 (Nos. 39 to 43).—Development of the Fissures on the Upper 
Surface of the Hemispheres. No. 39, at sixteen weeks; No. 40, at 
twenty weeks ; No. 41, at twenty-three weeks ; No. 42, at the middle 
of the seventh month ; No. 43, at the close of the seventh month. 
(Ecker.) c, Sulcus centralis ; cm, calloso-marginalis ; f1, s. frontalis 
superior; f*, s. frontalis inferior; f%, s. praecentralis; #1, gyrus 
frontalis superior; F*, g. frontalis medialis; F'%, g. frontalis infe- 
rior ; gp, g. postcentralis ; gpr, g. preecentralis ; ip, g. intraparietalis ; 
tp!, g. intrap. posterior; P1, g. parietalis superior ; P?, g. par. infe- 
rior; po, s. parieto-occipitalis ; 8, fissura Sylvii. 


which give rise to projections into the ventricles (Figs. 
829 and 830). In this way a distinction is produced be- 
tween the axial lobes of the cerebrum and the mantle 
portion. From the axial lobes arise in mammals the cor- 
pora striata through which pass the bundles of fibres 
from the cortex to lower centres and from the cord and 
lower parts of the brain to the cortex (see Fig. 859). . 
Elsewhere in the cerebrum the development tends to 
cause the cells to collect on the peripheral aspect, and 
thus is formed the cortex cerebri, the most important 
portion of the brain from a psychical point of view, 
though from the physiological standpoint it may seem 
rather an epiphenomenon or afterthought. ’ 
Fisswres of the Cerebrum.—As a result of the rapid and 
unequal growth of the hemispheres they are at first 
bodily flexed about a horizontal axis afforded by the line 
of attachment to the axial portion of the brain. The 


273 


Brain, 
Brain, 


first result of this flexure is the formation of the Sylvian 
flexure and fossa. This is one of the most important 
landmarks in the brain, giving rise to a depressed region 
of cortex (the insula) covered by flaps (the opercula) and 





Fic. 850 (Nos. 44 to 47).—The Development of the Conyolutions on the 
Sides of the Hemispheres. No. 44, at sixteen weeks; No. 45, at 
twenty weeks ; No. 46, at twenty-three weeks; No. 47, at the close of 
the seventh month. S!, Anterior branch of the Sylvian fissure; 7, 
g. temporalis superior; J?, g. temporalis inferior; t}, temporalis 
superior. (Ecker.) 


marked in the adult brain by the fissure of Sylvius. 
Here is located (on the left) the motor speech centre 
(Broca’s region). On the dorsal surface,extending from 
the dorsal margin obliquely toward the fissure of Sylvius, 
is the compensating fissure of Rolando (sulcus centralis), 
the convolutions adjacent to which contain the most im- 
portant centres for voluntary motion. By means of 
these landmarks the “lobes” of conventional anatomy 
are indicated at anearly period. Instead of going farther 
into details as to the sequence of development of the 
fissures and convolutions we venture to quote from Dr. 
J. D. Cunningham,* who, in the “ Memoirs of the Irish 
Academy of Science” bearing his name, gives an ex- 
tended account of the comparative development of the 
surface anatomy of the cerebral hemispheres. We con- 
dense from this work the following statements: 

Complete Fissures (“'Total-Falten”).—The transitory 
fissures which appear in an early period of the develop- 
ment of the hemispheres are distinguished by the fact 
that they are a result of a series of deep infoldings of the 
thin cerebral wall and form shelf-like projections into 
the ventricles. 

Under normal conditions none of the fissures which 
appear on the lateral aspects of the hemispheres persist 
in the adult, though in the ape two at least are persist- 
ent. Upon the mesal aspect, on the contrary, the cho- 
roid, a portion of the arcuate, and sometimes the parieto- 
occipital with part of the calcarine fissures persist. The 
choroid and arcuate appear as early as the fifth week. 
The choroid fissure occupies the lowest limit of the mesal 





*‘* Contribution to the Surface Anatomy of the Cerebral Hemi- 
spheres,” J. D. Cunningham, Cunningham Memoirs of Royal Irish 
Academy, vii. 


274 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


wall, reaching the porta, cephalad, and extending caudad 
nearly to the extremity of the temporal lobe. Though 
not at first occupied by blood-vessels, and therefore not 
formed by them, its walls do not develop into nervous 
tissue but remain epithelial and are occupied by this pre- 
plexus. The fissura arcuata (Ammonsfurche of Mihalko-- 
vics) makes its appearance on the mesal face of the hemi- 
sphere at a higher level than the choroid fissure, and 
while it extends, like the preceding, into the temporal 
lobe, it also passes cephalad into the frontal region. That 
portion of the hemisphere which lies between the two 
fissures mentioned is termed the arcus marginals, in con- 
nection with which are formed the callosum, the gyrus 
dentatus, and the fornix. 

The caudal part of the fissure arcuata is retained in 
adults as the hippocampal fissure, and gives rise to the 
elevation in the floor of the descending cornu known as 
the hippocampus major. 

The remainder of the complete fissures are transitory. 
The mesal wall of the hemispheres being thicker than 
the outer, the transitory fissures there first appear. They 
may appear as early as the eighth week, and reach a 
high degree of development only after the tenth week. 
Their maximum development is reached between the 
periods when the fornix and callosum appear, 7.¢., near 
the beginning of the fifth month. 

On the mesal aspect of the hemispheres the transitory 
fissures, which vary in number, radiate from the arcuate 
fissure toward the free border of the hemisphere, and 


Touma 
ow My’ 
S$ it 
a Q Kal ) 
\ 





“FIG. 851 (Nos. 48 to 51).—The Convolutions on the Inner Surfaces of the 


Hemispheres. No. 48, at sixteen weeks; No. 49, at twenty weeks; 
No. 50, at twenty-three weeks; No. 51, at the end of the eighth 
month. cl, Fissura calcarina: f*,s. olfactorius; gf, g. fornicatus ; 
gh, g. hippocampi; gu, g. uncinatus; h, s. hippocampi; t%, s. tem- 
poralis inferior ; t4, s. occipito-temporalis inferior; 7, g. occipito- 
temporalis lateralis; 7°, g. occipito-temporalis medialis. 


others, lying between them, but not connecting with the 
arcuate fissure, appear near the margin. The usual 
number on each hemisphere appears to be eight. 

The primitive fissures which bound the cuneus are the 
precursors of the calcarine and parieto-occipital fissures. 
As the wall of the cerebral vesicle thickens, and the 
hemisphere elongates, the stellate fissures become de- 
tached from the arcuate fissure and gradually disappear. 

Upon the outer aspect the arrangement of the fissures 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 





is also radial, with the Sylvian fossa as the centre, but 
these fissures usualiy do rot reach the fossa. There is 
frequently an additional fissure occupying the place of 
the future Sylvian. In some cases the precursor of the 
calcarine is carried horizontally around the occipital pole, 
appearing on the lateral surface as an external calcarine 
fissure. 

It is regarded as probable that under abnormal condi- 
tions, as when the callosum fails to develop, the transi- 
tory fissures may persist to a certain extent. The fact 
emphasized by Sir William Turner, that in Macropus, 
where the callosum is rudimentary, the radiating fissures 
resemble those of an immature human brain, is at least 
suggestive that the development of the callosum has 
some effect on the disappearance of these fissures. 

Dr. Cunningham fully agrees with His and Kolliker 
that the occipital lobe is due to a general growth and not 
a local outpouching of the hemisphere; its peculiar form 
is due to the transformations produced by axial flexures 
—especially the pons flexure. This backward thrusting 
of the posterior part of the hemisphere is chiefly re- 
sponsible for the preservation of the precursory calcarine 
and parieto-occipital fissures. The temporary fissures 
are in all probability peculiar to primates, and appear 
prior to the appearance of a distinct occipital lobe. 

The parieto-occipital and calcarine fissures form upon 
the mesal aspect of a posterior part of the adult hemi- 
sphere a >— shaped figure. The stem is directed 
obliquely ventrad and intersects the gyrus fornicatus. 
The parieto-occipital fissure forms the more direct con- 
tinuation of the stem, and continues on the ectal surface 
as the external parieto-occipital fissure. The calcarine 
branch passes toward the occipital pole. The stem is 
called the anterior calcarine fissure. The apex of the cu- 
neus gives off two deep annectant gyri—the gyrus cunei 
and anterior cuneo-lingual gyrus. The gyrus cunei forms 
a barrier between the parieto-occipital fissure and the stem, 
while the gyrus cuneo-lingualis anterior separates the 
stem and the posterior part of the calcarine fissure. 

The calcar (hippocampus minor) is formed wholly by 
the stem or anterior calcarine fissure. 

In apes the calcarine fissure -is deep and much more 
stable than the parieto-occipital. In the chimpanzee the 
gyrus cuneus is on the surface (a condition found in 3.9 
per cent. of human brains), while in the orang and gib- 
bon the cunei may be on the surface or at the bottom of 
the fissure. The gyrus cunei is never absent. Cunning- 
ham believes that the whole calcarine fissure of anthro- 
poids corresponds to the “stem” of the human calcarine; 
or rather, the whole length of the precursor of the human 
calcarine is the equivalent of the ape calcarine. The 
posterior calcarine of man is of later origin and takes the 
place of an abolished portion of the original fissure. The 
cuneus of the ape does not have the same morphological 
value as that of man. Only the cephalic part is present 
in the ape; the caudal part is absent or blended with the 
gyrus lingualis. In the ape the entire length of the cal- 
carine fissure is on the tentorial face of the hemisphere. 

The posterior calcarine fissure is distinct from the 
“stem” in origin, the latter being a “complete fissure ” 
and having unbroken continuity of existence with the 
fore-part precursor. 

T he Occipital and Parietal Indices are the distances along 
the mesal margin of the hemisphere intercepted by the 
intersection of the external parieto- -occipital fissure and 
the fissure of Rolando respectively; in the first case the 
measurement being taken from the occipital pole, in the 
second from the parieto-occipital intersection, and both 
these distances being given in terms of hundredths of the 
entire length along the dorsal margin of the hemisphere. 

For the human brain the following averages are given: 





3 T0656 MONS saree vues risteteie OY index, abe peh ea A index, 28.5, 

to 7% months.. oe 18.6: 24.7. 
6: to 844 months.. na 20.7 ; Pe 24.1 
Full-time foetuses.. eS 20.8 ; bie 25.7 
Mirstl2 MONS ..cns a ecerciet eee %y 22.3 5 PS 25.6 
AAD VORIR. co tiece seve sais ieleerers sts a 23.2; x 24.2 
WN foe GR (el he emma nee eneers My 20.8 ; ‘a 27.4 
PA CHUTIES sesistisucits oraleidiaisietre alete etecaiite 3 21.25 ve 25.5 


Brain. 
For apes the following table is given: 
OVATI Osa dernetstessteie tierce qanmersreare oO. index, 23.23 P. index, 21.3. 
OHIMPANZESeaciceciee as ai sieisiee ets 24.2 ; 19.9. 
Fiamiadr yas). cecctcntse aeaemaratiese i 29.5 ; 20.5. 
Gynlocepnalusiieecne cece concen eee ONT ss ihe 22, 6. 
MAnNGaby cc ienitiencsaedon cence: i 30.5 ; ry 24.1, 
MaCAQle:.aaeoneousiiere cence hy 31.0; = 19.0. 
Cercopithecusst..cdacsae vs ace en's ‘i 32.9 3 hy 19.0 
COD UB eerccatelal terse nlectereceisrenstanners Ms 33.1; ny 20.6 


The low parietal index and high occipital index are in- 
structive features. In low apes there is an enormous in- 
crease in the occipital portion of the border; whereas in 
the high apes the amount of increase is smaller. The 
relative shortness of the parietal border in high apes is 
due to the relative increase of the occipital and frontal 
borders. In low apes the reduction of the parietal por- 
tion is entirely due to the great size of the occipital lobe. 

The following summary is reproduced verbatim: 

1. At an early period in the development of the cere- 
bral hemisphere a series of deep infoldings of its thin 
walls make their appearance. On_the exterior of each 
hemisphere these show in the form of sharply cut linear 
fissures. 

2. Certain of these fissures, are permanent; the great 
majority are transitory. 

3. The transitory fissures, with two exceptions, have 
disappeared by the time the corpus callosum is fully 
formed. 

4. A deficiency of the corpus callosum is associated 
with a persistence of the temporary fissures. 

5. The temporary fissures indicate an important stage 
in the growth of the cerebrum, and are apparently asso- 
ciated with the mapping out of the occipital lobe. 

6. A quadrupedal pause in the growth of the cerebrum 
brings the skull capsule into antagonism with the growth 
of the hemispheres, and, in consequence, the wall of the 
cerebrum is thrown into folds. These folds disappear as 
the occipital lobe assumes shape, owing to the expansion 
of the cranial cavity, and a restoration of growth har- 
mony between skull and brain. 

7. Consequently it is only in Primates, which alone 
possess well-developed occipital lobes, that tr ansitory in- 
foldings of the cerebral walls in all pr ‘obability exist. 

8. The two transitory fissures which do not disappear 
before the full development of the corpus callosum are: 
(a) the external calcarine, and (’) the external perpen- 
dicular fissure of Bischoff. In point of fact the latter 
fissure does not appear until after the full development 
of the corpus callosum. 

9. The external calcarine fissure produces an infolding 
of the outer wall of the posterior horn of the lateral ven- 
tricle, which presents the same direction, and lies imme- 
diately opposite to the true calcarine infolding, or the 
calcar avis. 

10. The fissure corresponding to this in apes is, as a 
rule, permanent, and in some species its anterior end 
forms in the adult a bulging on the outer wall of the 
ventricle. 

11. The external calcarine fissure disappears before the 
sixth month of foetal life in man. 

12. The external calcarine fissure is present on the outer 
surface of the fcetal cerebrum from the beginning of the 
fifth month to the end of the sixth month. 

13. It is a complete fissure and corresponds to the 
“ Affenspalte ” on the ape’s brain. 

14. The “ Affenspalte ” on the ape’s brain is also a com- 
plete fissure, and presents a well-marked bulging on the 
outer wall of the posterior horn of the ventricle; but, 
unlike the external perpendicular fissure of the human 
foetus, it is permanent. 

15. Certain fissures, therefore, which are complete and 
temporary in the human brain, are complete and perma- 
nent in the ape’s brain. 

16. The complete permanent fissures in the human are: 
(a) the fore part of the calcarine; (0) the hinder part 
of the fissura arcuata; (¢) in many cases the parieto-oc- 
cipital; and (d) in some cases the midcollateral. The 
Sylvian fissure is not a complete fissure. 


275 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





17. Of the fissura arcuata the hinder part alone is pre- 
served as the fissura hippocampi. The fore part, which 
is generally supposed to be retained as the callosal fissure, 
is in reality obliterated. 

18. Synchronous with the appearance of the radial 
transitory fissures on the mesal face of the hemisphere 
two fissures appear, which lie in series with the former 
and occupy the ground afterward held by the parieto- 
occipital and calcarine fissures. These may be termed 
the precursors of these fissures. 

19. The precursor of the parieto-occipital fissure some- 
times shows an unbroken continuity of existence with 
the parieto-occipital fissure of the adult brain. In other 
cases it is obliterated, and its place is afterward taken by 
a secondary sulcus, which attains, however, a very great 
depth. 

30. In the adult brain the parieto-occipital fissure, even 
in its complete form, does not form any eminence on the 
inner wall of the posterior horn of the ventricle, because 
it does not extend downward as far as the cavity. Above 
its lower end the hemisphere is solid. 

21. The posterior end of the calcarine precursor is in 
every case obliterated, and the anterior part retained. 
The extent of the part obliterated varies considerably in 
different brains. 

22. The anterior preserved portion of the calcarine fis- 
sure forms the “stem ” of the >— shaped fissural ar- 
rangement on this part of the hemisphere, and its hinder 
part corresponds to the calcar avis. 

28. In the place of the hinder portion of the calcarine 
precursor, which is obliterated, a secondary furrow ap- 
pears. This may be termed the posterior calcarine sulcus. 

24. The posterior calcarine sulcus is formed in two 
pieces which run together and also form the “stem.” In 
this way the entire length of what in anatomical lan- 
guage is called the calcarine fissure is formed. 

25. The posterior calcarine sulcus is not a complete 
fissure. 

26. In the ape the entire length of the calcarine fissure 
is represented by that portion of the fissure which in man 
is termed the “stem,” and by that alone. The posterior 
calcarine sulcus does not exist in any form in the apes. 

27. The cuneus, therefore, has a different morphologi- 
cal value in the apesand inman. In connection with 
this compare the abnormal human hemispheres. These 
exhibit certain conditions which approximate to those 
present in the apes. 

The Fossa and Fisswra Sylvit.—The sign of the Sylvian 
depression appears at the end of the second month of 
development. Dr. Cunningham summarizes his investi- 
gation as follows: 

“1. As growth proceeds the outline of the Sylvian fossa 
changes considerably. At first nearly circular, it elon- 
gates in a vertical direction and then backward on itself, 
and assumes a triangular outline. 

“2. The high prominent mantle border or rim which 
surrounds the depression is divided by intervening angles 
into four sections, viz.: the temporal (postoperculum), 
or lower; the fronto-parietal (operculum), or upper; 
the frontal (preoperculum), which is formed by an open- 
ing out and flattening of the primitive single anterior 
angle; and an orbital (suboperculum), or front portion. 

“3. Each of these portions of the bounding rim acts 
as an independent line of growth, and consequently, in 
course of time, four opercula grow over the Sylvian area 
so as to enclose it. The temporal and fronto-parietal 
opercula appear first; the frontal and orbital do not de- 
velop until a much later period. 

“4. The so-called three limbs of the fissure of Sylvius 
are formed by the meeting over the Sylvian area of the 
contiguous lips of the four opercula; the posterior hori- 
zontal limb intervenes between the fronto-parietal and 
the temporal opercula; the anterior ascending limb be- 
tween the frontal and fronto-parietal opercula; the an- 
terior horizontal limb between the frontal and the orbital 
opercula. 

“5. The frontal operculum is therefore the same as 
the ‘cap de Broca,’ and it shows great variations in its 


276 


length, It may be absent altogether, and then the two 
anterior limbs of the Sylvian fissure are fused into one. 
When the frontal operculum is reduced in length we 
have the Y-condition of the two anterior Sylvian rami. 

“6. The Sylvian fossa once mapped out on the surface 
of the hemisphere, it extends very rapidly. The growth 
is not proportionate with that of the hemisphere, it is 
much more rapid. 

“7. During intrauterine life the anterior end of the 
insula maintains a very nearly fixed position with refer- 
ence to the anterior end of the cerebrum, while the pos- 
terior end of the cerebrum moves rapidly toward the 
occipital pole. After birth the posterior end of the in- 
sula is fixed, while the anterior end, as growth advances, 
oscillates slightly—at first approaching and then retreat- 
ing from the anterior end of the cerebrum. 

“8. An anterior limb of the Sylvian fissures can be 
determined only by the following tests: (a) it must cut 
right through the entire thickness of the operculum and 
reach the furrow surrounding the island of Reil; (0) it 
must lie in front of the precentral sulcus. 

“9. A single anterior limb of the Sylvian was present 
in 30 per cent. of the hemispheres examined; the two 
anterior limbs, quite distinct and separate, were present 
in 37.5 per cent.; the Y-shaped condition of the two 
limbs was present in 31.5 per cent. 

“10. The two orbital limbs of the Sylvian fissure can- 
not be regarded as belonging to the same category of the 
true anterior limbs. They are not developed as primitive 
deficiencies in the orbital operculum. 

“11. The posterior insula is not connected with the ex- 
tremity of the temporal lobe, as Erbstaller has asserted, 
but with the limbic lobe. 

“12. On the surface of the foetal insula there appear 
three radial furrows which correspond in every respect 
with the three ‘Primiirfurchen’ on the outer surface of 
the mantle (viz., the fissure of Rolando, the inferior pre- 
central sulcus, and the vertical limb of the intraparietal 
sulcus). The radial furrows on the insula clearly belong 
to the same fissural system and intermediate links be- 
tween the three radial fissures on the outer surface of the 
hemisphere, and the three radial fissures on the insula 
may exist in the form of secondary sulci, cutting the 
margin of the fronto-parietal operculum. 

“13. The fissure of Rolando is clearly the proper 
boundary of the frontal lobe. Above, it is separated only 
from the calloso-marginal fissure, which bounds the lobe 
internally, by a narrow but superficial gyrus; below, the 
inferior transverse furrow of Erbstaller acts as an inter- 
mediate link between it and the sulcus centralis insule. 
The sulcus centralis insule and the calloso-marginal - 
sulcus are brought into close relationship at the anterior 
perforated spot on the base of the brain. An almost 
continuous fissural system, therefore, marks out the lim- 
its of the frontal portion of the cerebrum. 

“14. The temporal pole is formed entirely by the for- 
ward growth of the fore part of the temporal operculum. 

“15. In the adult brain the insula is proportionately 
longer in the male than in the female. At all periods of 
growth it would seem that the insula is relatively longer 
on the left side. than on the right side. In the negro 
brain it would appear that the insula.is relatively shorter 
than in the European brain. 

“16. In the anthropoid ape the so-called anterior limb 
of the Sylvian fissure is not homologous with either of 
the anterior limbs in man. 

“17. In the chimpanzee and orang there are only two 
opercula, viz., the fronto-parietal and the temporal. 
The frontal and orbital opercula of the human brain are 
entirely absent in the anthropoid cerebrum. 

“18. Restricting the term insula to that part of the 
hemisphere surface which is concealed from view by 
opercula, the extent of this area in the ape is very much 
less than in man. The central index is 18.2 in the chim- 
panzee and 21.5 in the orang; in man the central -index 
is 29.6. In the lower apes the central index is higher 
than in the anthropoids. 

“19. In man the field of the insula shows marked 


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Brain, 
Brain, 





changes with reference to the cranial wall during intra- 
uterine life. More and more of its area comes to lie 
under cover of the parietal bone, and relatively less 
under cover of the frontal bone, as development pro- 
ceeds. In the aduit the coronal line cuts the insula in 
such a manner that thirteen per cent. of its length lies in 
front of it and eighty-seven per cent. behind it. 

“20. In the chimpanzee and the low apes no part of 
the insula lies in front of the coronal line; in the orang 
the upper and anterior corner of the insula projects 
slightly in front of this line. 

“21. In the human infant and young child, as well as 
in the ape, the point at which the stem of the Sylvian 
fissure reaches the outer surface of the hemisphere is 
situated relatively farther back than in the human adult. 

“22. The Sylvian fissure is relatively longer in the left 
hemisphere than in the right, and in the ape than in 
AO.) 

“28. In the Cebus (Figs. 853 and 854) the Sylvian fissure 
lies above the level of the squamous suture; in the ma- 
caque, homadryas, and orang, it lies immediately sub- 
jacent to the fore part of the suture; in Cynocephalus 
anubis and the chimpanzee the fissure is situated in its 
fore part below the level of the front part of the suture. 

“29. The relative depth of the parietal and temporal 
lobes in the lower apes resembles that in the human child; 
in the anthropoid ape the relative parietal depth of the 
hemisphere exceeds that in the human adult.” 

The Fissure of Rolando.—Cunningham found that in 
sixty per cent. of the brains examined the upper end of 





Fig. 852.—Left Cerebral Hemisphere of a Chacma Baboon. p, Various 
parts of the intraparietal system of furrows ; p1, sulcus postcentralis 
inferior ; p?, two parts of the sulcus postcentralis superior ; %, ra- 
mus horizontalis; i.p., sulcus postcentralis transversus ; 0, occipital 
operculum. 


the fissure of Rolando turned over the mesal border of 
the hemisphere; in nineteen per cent. its ventral end was 
connected by a shallow transverse sulcus with the Syl- 
vian fissure. The fissure of Rolando appears in two 
parts; the lower two-thirds appears before, and inde- 
pendently of, the upper third. The relative position of 
the fissure of Rolando is remarkably constant. The 
upper fronto-Rolandic index is 53.8, the lower 43.3. In 
anthropoids the upper end of the fissure of Rolando is 
placed relatively farther back than inman. The aver- 
age Rolandic angle in the human brain is 71.7. The 
average relative length of the fissure of Rolando is 39.3. 

The Intraparietal Suleus.—“1. The entire sulcus, 
single and continuous in some of the lower apes (e.g., 
Cebus), becomes broken up in the human brain into a 
group of furrows which present different relations to 
each other in different cases. 

“2. Three of the elements of the sulcus in the human 
brain, viz., the sulcus postcentralis inferior, the ramus 
horizontalis, and the ramus occipitalis, are disrupted 
portions of the original fissure; one, the sulcus postcen- 
tralis superior, is a superadded element (Fig. 859). 

“3. In the development of the sulcus in the human 
foetal brain, all the four segments of the sulcus have, as 
a rule, an independent origin, although, as Pansch has 
shown, the sulcus postcentralis inferior and the sulcus 
horizontalis very frequently appear as one continuous 
furrow. 

“4. The sulcus postcentralis inferior usually appears 


first; then the ramus horizontalis and ramus occipitalis; 
and last of all the sulcus postcentralis superior. 

“5. In Cebus there is no sulcus postcentralis superior; 
it is present, however, in most of the old-world apes, 
é.g., the baboon, macaque, 


gibbon, chimpanzee, orang, 
and gorilla (Fig. 858). 

“6. In the chimpanzee and 
orang there is reason to be- 
lieve that this segment of the 
postcentral sulcus consists of 
two elements, one placed 
above the other (Figs. 856 
and 857). 

“7. Eberstaller’s third and 
lower segment of the post- 
central sulcus (viz., the sul- 
cus postcentralis transversus) 


is not only present in man, © 


but also in the majority of 
the old-world apes. 

“8. In the apes the intra- 
parietal sulcus is deeper than 
the fissure of Rolando; the 
opposite is the case in man. 
This would seem to indi- 
cate that the morphological 
value of the sulci is different 
in man and the apes. The 
phylogeny and ontogeny of 
these furrows are in apparent 
variance with each other. 





Fic. 853.—Cerebrum of Cebus 


Albifrons. f, Sulcus frontalis 
inferior ; ~.c., sulcus postcen- 
tralis inferior; 7, fissure of 
Rolando ; s, Sylvian fissure ; p, 
intraparietal sulcus; 3, ra- 
mus horizontalis; p*, ramus 
occipitalis ; st, furrow corre- 
sponding to sulcus transversus 
occipitalis of Ecker; p.0., pa- 
rieto-occipital fissure; an., 
first annectant gyrus; a.f., 
ape cleft. 





The fissure of Rolando appears first on the develop- 
ing cerebrum of the human fcetus, yet it is the intra- 
parietal sulcus which first makes its appearance in the 
evolution of the primate cerebrum... . 

“11. In man there appears to be a general tendency 

toward a union of the two originally distinct postcentral 

elements of the sulcus, 

and a divorce from the 

lower of those of the 

ramus horizontalis. ... 

“13. The ramus oc- 

cipitalis was connected 

with the ramus hori- 

> zontalis in 63.7 per 

cent. of the adult hu- 

man hemispheres ex- 
amined. 

“14, The union be- 
tween these two ele- 
ments of the sulcus, as 
Ecker and Wilder have 
shown, is much more 
common on the left side than on the right. 

“The sulcus transversus of Ecker is not the homologue 
of the ‘ Affenspalte’ in the apes, but merely a terminal 
bifurcation of the ramus occipitalis.” 

The Sulcus Precentralis.—“1. The sulcus precentralis 
inferior in the human 
brain is composed of a 
vertical and a horizon- 
tallimb. The latter is 
carried forward into 
the middle of the front- 
al convolution. 

“2. This furrow is 
the earliest to appear 
on the outer surface of 
the frontal lobe of the 
foetal brain. In some 
cases it is seen in the 
fifth- month cerebrum 
in the form of a long, 
deep, vertical sulcus, which subsequently undergoes a 
retrograde development before its adult condition is 
reached. In many cases, in its early condition, it pre- 
sents a form in every respect comparable with that ob- 


; oT 


Fig. 854.—The Outer Surface of the 
Cerebrum of Cebus Albifrons. 1, Fis- 
sure of Rolando; p.c.i., sulcus pre- 
centralis inferior ; h, ramus horizon- 
talis; /?, inferior frontal sulcus. 





Fie. 855.—Another View of the Same. 
p.c.s., Sulcus preecentralis inferior (?) ; 
€.0., a Slight trace of the sulcus fronto- 
orbitalis. Other letters as in Fig. 854. 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





served in the cerebrum of the low ape (Cebus). Fre- 
quently it is developed in several pieces. 

“3. The sulcus precentralis superior is closely con- 
nected with the basal part of the first frontal furrow. It 
is usually developed along with it. It consists of two 
pieces—an upper and a lower—which may be partially 
or completely separated from each other, as well as from 
the basal part of the first frontal furrow by an annectant 

yrus. 

“4. Two additional furrows belonging to the precen- 
tral system are occasionally present, viz., the sulcus 
precentralis medius and the sulcus preecentralis margi- 
nalis. 

“5. The sulcus preecentralis medius may arise in two 
different ways: (a) It may be formed by the ramus hori- 
zontalis of the inferior precentral sulcus divorced from 
the vertical stem and assuming a very oblique or an al- 
most vertical position; (>) it may consist of a new ele- 
ment placed between the superior and inferior precen- 
tral furrows, but showing a 
closer connection with the 
LOMMET ea 

“12. The superior frontal 
gyrus and the middle frontal 
gyrus are each partially sub- 
divided into two tiers or sub- 
divisions by furrows which 
may be respectively termed 
the sulcus frontalis mesialis 
and the sulcus frontalis me- 
dius. 

“13. Both of these furrows 








“28. About the seventh month of feetal life the in- 
ferior precentral sulcus of the human brain attains a 
position which it retains unaltered throughout all the 
subsequent changes of growth; previous to this it is 
placed relatively farther back 
on the surface of the hemi- 
sphere. 

“29. At first it is placed 
in front of the coronal suture. 
The sutural line, however, 
moves forward so that the 
sulcus ultimately comes to lie 
behind it. 

“30. In the ape cerebrum 
the inferior precentral sulcus 
lies relatively much farther 
forward than in the cerebrum 
of man. It may be placed 
subjacent to, or in front of, 
the coronal line.” 

The Hippocampus. — The 
median part of the mantle, 
that portion which adjoins 
the opposite hemisphere and 
the thalamus, is very early 
separated from the rest of the 
cortex by a total fissure con- 
sisting of the hippocampal 





Fic. 857.—Right Hemisphere of 
a Male Orang, Six Years Old. 


fissure, the fissura calcarina, 
and ‘the (temporary) fissura 
parieto-occipitalis. The por- 
tion so separated is the gyrus 


r, Fissure of Rolando; 1, sul- 
cus postcentralis inferior; »?, 
two parts of. sulcus postcen- 
tralis superior; p°, ramus 
horizontalis; ~*, ramus oc- 





Fig. 856.—Cerebral Hemisphere 
of Young Female Chimpanzee, 
as seen from above. The oper- 
culum on each side has been 
removed. 7, Fissure of Ro- 
lando; p!, sulcus postcentralis 
inferior; p?, two portions of 
sulcus postcentralis superior ; 
p, ramus horizontalis; p4, 
ramus occipitalis ; b, terminal 
bifurcation of the intraparie- 
tal sulcus ; p.0., parieto-occip- 
ital fissure; a.7., first parieto- 
occipital annectant gyrus; a, 
deep annectant gyrus in the 
course of the intraparietal sul- 
cus; €, secondary sulcus in the 
superior parietal lobule ; a.f., 
bottom of the ‘ape-cleft”’; 0, 
cut surface of occipital oper- 
culum ; t?, parallel sulcus. 


have secured a firm footing 
in the human brain, but only 
one (viz., the frontalis me- 
dius) has established itself 
upon the brain of the chim- 
panzee (Fig. 856). . . . 

“17. The sulcus frontalis 
mesialis is absent or poorly 
developed in the brain of the 
NESTON ees 

“20. The sulcus preecen- 
tralis inferior and the inferior 
frontal sulcus are the fur- 
rows which are most firmly 
impressed upon the brain of 
theapes. In Cebus they alone 
are present; in Calithrix there 
are also traces of the sulcus 
preecentralis superior and sul- 
cus fronto-orbitalis; in the 
baboon there are, in addition, 
a rudimentary sulcus fron- 
talis superior, and perhaps (?) 
traces of a sulcus frontalis 
medius (Figs. 852 and 8538). 

“21. Inthe chimpanzee and 


the gorilla the sulcus frontalis medius is often present in 
a form precisely similar to that seen in the human brain; 
in the orang the condition of this sulcus is doubtful; in 
the gibbon the sulcus frontalis medius is absent. 

“22. In the chimpanzee, therefore, the same convolu- 
tion ties may be seen as in man, with this exception: the 
superior frontalis is never split into two by a sulcus 
frontalis mesialis. 

“23. The inferior fronta] convolution of apes is very 
different from that in man. 

“24 The frontal and orbital Sylvian opercula are 
completely absent in the apes. 

“25. Consequently, a portion of the island of Reil is 
uncovered and exposed on the surface of the cerebrum. 

“26. The sulcus fronto-orbitalis of apes corresponds to 
the anterior limiting sulcus of the island of Reil in man. 

“27. There are no anterior limbs of the Sylvian fissure 
in the anthropoid apes. The so-called anterior limb of 
the Sylvian fissure corresponds to the anterior free border 
of the fronto-parietal operculum. 


278 


cipitalis; a.n., first parieto- 
occipital annectant gyrus; 
_p.0., parieto-occipital fissure ; 
a.f., bottom of *“‘ape-cleft’’; 
o, cut surface of occipital 
operculum ; 8s, fissure of Syl- 
vius; t}, parallel sulcus. 


marginalis, and from it there 
develops caudally the curi- 
ous structure known as the 
hippocampus or Ammons- 
horn. The hippocampus is 
enrolled like a scroll and its 
mesal margin is rolled by an inverse curve into the space 
left by the loosely rolled fornicate portion. This portion 
of the cortex has been shown to be related to the function 
of smell, and to it are traced various bundles from the 
olfactory tuber. From it aiso rise fibres which cross in 
the hippocampal commissure or decussate in the fornix 


LLY 
ees a 





Fig. 858.—Right Cerebral Hemisphere of a Male Orangoutang, Six 
Years Old. f1, Sulcus frontalis superior ; £2, sulcus frontalis infe- 
rior ; f.m., sulcus frontalis medius ; ¢.0., sulcus fronto-orbitalis ; p.c., 
sulcus preecentralis inferior; p.c.s., sulcus preecentralis superior ; 
p.c.i., Sulcus przecentralis inferior ; 7, fissure of Rolando ; 1, suleus 
postcentralis inferior ; p?, sulcus postcentralis superior ; 3, sulcus 
horizontalis intraparietalis ; ¢.c., external calcarine fissure ; t1, par- 
allel sulcus; t?, second temporal suleus; H1, H?, H8, transverse 
temporal gyri of Heschl; R, insula; A}, first annectant gyrus; S?, 
anterior free border of the fronto-parietal operculum ; O, anterior 
edge of the occipital operculum. 


body and thence descend by the columns of the fornix 
to the thalamus. Some of the fibres pass to the tuber 
cinereum and enter the mammillary bodies. 

The Olfactory Region.—From a part of the hemispheres 
near the cephalic end of the gyrus marginalis, in lower 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain. 
Brain, 





animals at the cephalic extremity of the brain, while in 
higher mammals the point is. ventrally folded, there 
arises a protuberance called the olfactory lobe. Still 
cephalad the ventricle is produced to form a dilatation 
of the wall—the olfactory tuber. The actual means by 
which the tuber is formed may be discovered by watch- 
ing the early stages of development. At a very early 
period the front of the hemispheres comes into actual 





¥iac. 859.—Outer Surface of a Cerebral Hemispheve in the Early Part of 
the Seventh Month. t}, Parallel sulcus; .c.i., inferior frontal; f1, 
sulcus frontalis primus; .c.s., sulcus preecentralis superior ; 1, fis- 
sure of Rolando; p, intraparietal sulcus; p1, sulcus postcentralis 
inferior ; p*, ramus horizontalis of the intraparietal sulcus; 4, ra- 
mus occipitalis ; e.p., fissura perpendicularis externa. 


contact with the depressions of the skin forming the 
olfactory fossa (Figs. 863 and 864). In this fossa there de- 
velop the ganglion cells of the olfactory from the proximal 
end of which the olfactory fibres make their way into the 
hemispheres. In this way the hemispheres are connected 


reer 





Fig. 860.—Horizontal Section of Guinea-Pig Head. Dc., Diacele; St., 
striatum; Aw., aula; L.t., lamina terminalis; P., plexus; H., bip- 
pocampus; a. and p., proliferating areas; 2., inner capsule. 


with the epithelium and the connection is retained from 
this time on. In some cases, as in certain fishes, the growth 
of the head causes the brain to be withdrawn a long dis- 
tance from the olfactory fosse, and the tuber is drawn 
out into an almost thread-like stalk which has often been 
mistaken for the olfactory nerve. In other cases the 
tuber has refused to be separated from the brain, and the 
frbres connecting with the olfactory epithelium have been 
extended and have been usually called the olfactory 
nerve, though here again incorrectly, for in a strict sense 
there is no olfactory nerve and this bundle should be 
called the root. In the tuber two portions can be dis- 
tinguished, the unaltered protrusion of the brain called 
the pes, and a slipper-like enlargement covering the pes, 








called the pero. Inthe latter isdeveloped what is known 


as the glomerule zone, in which the final branches of the 
olfactory root fibres mingle with the arborizations of the 





Fic. 861.—Two Horizontal Sections of Brain of Young Opossum, to 
Show Hippocampus and Fimbria. 


special mitral cells of the pero. Fibres from the latter 
pass backward to the region of the hippocampus. 

The Diencephaion and Mesencephalon—The external 
characters of the thalamus have already been mentioned 
in sufficient detail. Within there develop a number of 
clusters of cells which are better known in lower animals 
than in man, but in all cases the exact function remains 
problematical. It seems certain that the several tracts 
from organs of special sense here find rendezvous and 
from these temporary stations extend to the cortical 
areas. From the cerebellum fibres enter the nucleus 
ruber. From the geniculate nuclei the optic radiations 





Fig. 862.—Hinder Portion of Cerebral Hemisphere of Full-Term Foetus, 
Showing Conditions Approximating to Those of Anthropoid Apes. 1, 
Upper end of fissure of Rolando ; ¢.m., calloso-marginal sulcus ; p.0., 
parieto-occipital fissure ; cuwn., cuneus ; ¢, gyrus cunei; p.c., praecu- 
neus; g.f., gyrus fornicatus ; ¢.c., callosum ; c.f, collateral fissure ; 
OC, posterior secondary calcarine fissure; S, “stem” of calcarine 
fissure. 


pass to the occipital cortex. The rapid growth of the 
roof of the mesencephalon, as well as the curvature of the 
base due to the midbrain flexure, tends to fill the mid- 
brain vesicle, and in mammals the narrow iter alone re- 


279 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





mains. The basal or pes portion develops the several 
centres for visual co-ordination, while the dorsal longi- 
tudinal fasciculus lies immediately beneath the iter. 
Ventrally the fibres passing in both directions connecting 
the prosencephalon with the medulla oblongata form a 
thick mass on the ex- 
ternal aspect of the 
pes, called the crusta, 
through which the 
fibres of the third nerve 
find exit. 










Fig. 864.—Epithelium of 
Olfactory Pitin Prolif- 
eration. 


Fig. 863.—Section through Head of Gar- 
ter-Snake Embryo. a, Midbrain; b, 
olfactory pit; c, infundibulum. 


The Medulla Oblongata and the Cerebellum.—Reference 
has already been made to the relation of the cerebellum to 
the medulla, and also to the fact that this massive organ is 
built up partly from proliferations from the lateral walls of 
the fourth ventricle and partly from the concrescence of 
masses proliferated at the cephalic margin of the tela. In 
some mammals, at least, the writer has described a process 
of actual eversion of a sac from the lateral walls of the 
fourth ventricle in the region of the future cornucopia 
to give rise to superficial proliferating areas to supply 


Figs. 865 AND 866.—Horizontal Sections through the Head of Embryo Guinea-Pig. 
860 from the same series farther dorsad.) Fig. 865 passes through the level of the eyes and infundib- 
ulum. The extension of the ventricle of the optic recess into the stalks of the optic nerves is 





shown at O.r. 


the cornucopiz is shown; Fs., frontal sinuses. 


280 








G.g., Gasser’s ganglion; L., lens; Op.l., optic lobes, roof of mesencephalon ; 
r.l., lateral recess of fourth ventricle extending upward within a fold of the rhomboidal lip to 
cover the lateral aspects of the cerebellum, as atx. Fig. 866 passes at a somewhat lower level, and 
shows the extension of the lateral recess near the tip of the cerebellum. At L.r. the beginning of 


the surface when cut off from the direct replenishment 
from the ventricles by the intrusion of the white matter. 
(Of. Figs. 865-868.) In an entirely similar way Professor 





Fig. 867.—Transverse Section of the Medulla and Cerebellum of Mouse 
Embryo. P.z., Superficial proliferating zone derived from the epi- 
thelium of everted lateral recess; L.r., lateral recess; Pl., plexus; 
c., cornucopia; VITI., root of eighth nerve; IV., fourth ventricle. 


His explains the origin of the olives by the eversion of 
the walls of the fourth ventricle at a lower level and the 
final envelopment of the proliferating epithelium in the 
parietes of the medulla. 

The margin of the cellular portion of the roof of the 
fourth ventricle constitutes the rhomboidal lip (“ Rauten- 
lippe” of His), which has been shown by many independent 
observers to have a most important function as a pro- 
liferating organ for both the medulla and the cerebellum. 

In man there is a greater development of nervous 
matter in the roof of the fourth ventricle and the walls 
of the lateral recess than in lower mammals. In all 
mammals there is a caudal as well as two lateral protru- 
sions of the membranous walls (tela). The lateral pro- 
trusions form the lateral recesses just mentioned, while 
the caudal projection in man becomes perforate, forming 

the foramen of Magendie or 
metapore. This pore is char- 
acteristic of anthropoids, but 
is absent in lower mammals. 

Even as early as the end of 
the third week the forebrain 

‘forms almost a right angle 
with the medulla, and during 
the fourth and fifth weeks 
the pons flexure increases till 
the base of the mesencepha- 
lon is separated from that 
of the medulla only by the 
narrow and deep “saddle 
cleft.” From the dorsal ex- 
tremity of this cleft arises the 
fossa Tarini. The pons flex- 
ure gives opportunity for the 
development of the cerebel- 
lum by providing a place for 
it. The flexure finds recipro- 
cal expression in the choroid 
fold or inward loop of the 
tela. 

The cerebellum is divided 
into a median vermis, and, 
on either side, a pileum, para- 
flocculus, and flocculus. The 
regions which form the pilea 
are first developed and the 
vermis is last toappear. The 
first sulci also appear on the 
lateral parts and not on the 


(Compare also Fig. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





vermis. At about the middle of the third month four 
or five transverse convolutions appear on the vermis. 
By the fifth month the definitive form of the cerebellum 
is clearly defined. By this time the prepeduncles con- 
nect with the midbrain, and the valvula is formed by the 





Fig. 868.—Portion of Similar Section to Show the Double Proliferating 
Zone with Fibre Layer Between, at a, b, c. 


thinning of the dorsal walls cephalad of the vermis. As 
early as the third month the restiform bodies connect 
with the lateral lobes to form the postpedunculi. In the 
fourth month the medipedunculus and pons become 
obvious. : 

The formation of the pons by the decussating fibres of 
the medipeduncle of the cerebellum greatly modifies the 
cephalic part of the organ and leaves an isthmus region 
between the cephalic border of the pons and the mesen- 
cephalon which otherwise would perhaps hardly rise to 
the value of a recognized portion of the brain. At 
different levels in the medulla the sensory and the motor 
bundles connecting the cord with the upper parts of the 
brain decussate, and by this means the simplicity of 
structure seen in the cord is entirely destroyed in the 
myelencephalon. Added to this is the remarkable dif- 
ferentiation of the centres of the several cranial nerves 
(q. v.), Which also obscures the original uniformity of 
arrangement. The effect of the increased emphasis laid 
upon a particular sense is well illustrated in fishes, in 
which, for example, huge excrescences arise on the me- 
dulla in the region of one or other of the cranial roots, 
almost equal to the cerebellum in size. 

Several authors have observed even in human brains 
serially arranged eminences in the floor of the fourth 
ventricle, but whether they indicate neuromeres in the 

) sense in which that term is now used in morphology, and 
what their fate may be in the adult, remain points of dis- 
pute. At the end of the second month there may be 
recognized in sections of the medulla four somewhat dis- 
tinct regions: (1) the region of the motor nuclei; (2) the 
substantia reticularis; (8) the region of the lateral nuclei 
and the substantia gelatinosa, and (4) the region of the 
olives. To these in later stages are added a vast number 
of tracts and scattered nuclei which may best be studied 
in the adult brain. 

The various regions of the brain developed in the 
manner above described have been given a great variety 
of names, and there has as yet been no general agreement 
as to the connotation of many names in common use. 
The system proposed by Professor His is given below 


because of its completeness, though it will require to be 
modified in detail to adapt it to more general usage. 


ne pele oblongata, Myelencephalon I. ) Bhouben: ) 
1. Fons , | .e \ 
II. Cerebellum t Metencephalon II. f gE 
III. Isthmus rhombencephali ITI. J a sats 


IV,. Pedunculi cerebri 
IV. Corpora quadrigemina + fesencephalon IV. 
V,. Pars mammillaris hypothalami } Enceph- 
Ve. Thalamus ] haan | Dienceph- f 
Vs. Metathalamus he Pate alon V. 
V,. Epithalamus eat 
VI,. Pars optica hypothalami 
ee td ee | Heri 

3» Rhinencephalon peta 
VIy. Pallium : ( spheerium J 


Prosen- 
| cephalon 
Telenceph- 
alon VI. 





The term epencepahalon is often applied to the cere- 
bellum, but, in spite of its great size in man, it is only an 
extension of the lateral walls of the medulla. It has 
been proposed to use oblongata as the brief substitute 
for the full form, “medulla oblongata,” but the substan- 
tive seems the more natural part of the binomial, as the 
objection that medulla is ambiguous is of no practical 
moment. 

Prosencephalon has been generally used as synonymous 
with telencephalon as applied by His, and by using met- 
encephalon instead of rhombencephalon we have a series 
of terms, founded on a sound embryological basis, which 
may be considered correlative and which are easily ap- 
plied, viz., meten-, mesen-, dien-, and prosen-cephalon. 

Closely related to the prenatal changes above described 
are their postnatal consequences. There is no sharp line 
to be drawn between the phenomena of growth before 
birth and those which continue in after life. Changes in 
proportion during the adolescent period affect the relation 
between head and body and between brain and the re- 
mainder of the central nervous system. Brain develop- 
ment proceeds in advance of that of the body at large, 
though in cases of defective development of the brain the 
body may attain a considerable degree of perfection, as 
has been shown by Lenowa. In a feetus of twenty-one 
weeks, according to Bischoff, the percentage weight of 
the brain to body is 18.5, in new-born male children 15.8, 
in new-born female children 12.2, at sixteen years of age 
the percentage is 3.9, inadult males it is 1.9, and in adult 
females 2.1. At birth the weight is nearly alike in the 
two sexes, but the absolute weight is, of course, influenced 
by the size of the body. During the first year, and to 
a somewhat less extent for the three following years, the 





Fic. 869.—Longitudinal Section of Cerebellum of Early Mouse Em- 
bryo. Mes., Mesocele or iter; V., valvula; R.l., rhomboidal lip, 
and proliferating area derived from it; Pl., plexus; Ch.f., choroid- 
eal fold; IV., fourth ventricle: Med., medulla base. 


growth is very rapid. By the seventh year the enceph- 
alon has nearly attained its full weight. Afterabout the 
fiftieth year a gradual loss of weight becomes apparent. 
The continuous and unequal demands made upon vari- 
ous parts of the brain operate to stimulate growth, waste, 
and repair to an unequal degree in different parts. In 
this connection it is important to note that there are laid 


281 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





up in store in certain parts of the brain nascent or latent 
cells (granules) which may interpolate themselves among 
the depleted cells of older growth. 

Education in its broadest sense includes all changes in 
the brain due to reactions of the organ upon afferent 
stimuli.. It is usual to state that all the elements (cells, 
etc.) of the brain are preformed in it at birth. If this 
were so, then education would consist in the progressive 
modification of these cclls and the perfection of a wide 
range of intercommunications between them. Leaving 
out of the account the possibility of the proliferation of 
new cells from a germinative epithelium, there can be 
no doubt that the latent cells above mentioned are called 
into activity by exercise, and increased brain power and 
a more extended range of activity are thereby secured. 
It would apparently follow that activity of mind would 
hasten the period of senility and brain decline; but as the 
reverse is the case, it may be assumed that proliferation 
or an analogous process really takes place. 

C. L. Herrick. 


BRAIN DISEASES: DIAGNOSIS OF LOCAL LE- 
SIONS.—Hisrory.—Although it was known in the first 
century that each hemisphere of the brain is in func- 
tional relation with the opposite half of the body, the 
facts upon which the prevailing theory of the localiza- 
tion of different functions in separate parts is based were 
not discovered until 1822. At that time Thomas Hood, 
in England, and Bouillaud, in France, noticed that dis- 
turbances of speech were caused by disease in the frontal 
lobes of the brain. M. Dax (1836) was the first to limit 
the area governing speech to the left frontal lobe, and 
Broca (1861) located it more exactly in the left third 
frontal convolution. The discussion of aphasia in the 
Academy of Medicine in Paris in 1864 awakened general 
interest and led to further investigation. Until that time 
scientific men, rejecting the unwarrantable conclusions 
of Gall and the phrenologists, had believed the teachings 
of Flourens, that the brain acts as a whole, its various 
parts not possessing various powers. The pathological 
evidence against this position collected by Broca, and 
strengthened during 1864-67 by facts observed by Hugh- 
lings Jackson and Meynert, received confirmation in 1870 
from a new series of physiological experiments made by 
Fritsch and Hitzig in Berlin. These investigators found 
that in animals the anterior portion of the convexity of 
the brain is métor; that its irritation by electricity causes 
coordinated motions in the limbs of the opposite side, 
and that its destruction causes paralysis. Ferrier (1873- 
76), Nothnagel (1877), Munk (1881), and Luciani (1884) 
have confirmed these results, and have shown further 
that the posterior portion of the convexity is sensory, its 
destruction being attended by impairment of the powers 
of perception through the various senses. Goltz, though 
opposing a strict limitation of functions to definite re- 
gions, admits that the results of destruction of various 
parts are different, and he has noticed that extensive in- 
jury to the anterior portion changes the character of an 
animal from kind to vicious, while injury to the posterior 
portion has the opposite effect. The conclusions of phys- 
iologists differ regarding the results of experiments, but 
do not overthrow the theory of localization as applied to 
man; for a mass of pathological evidence has been col- 
lected during the past ten years which will bear but one 
interpretation. Charcot and his pupils in France, Noth- 
nagel, Exner, and Wernicke in Germany, H. Jackson and 
Ferrier in England, and others, have gathered, classified, 
and analyzed a very large number of cases of brain dis- 
ease of limited extent, which were accompanied by defi- 
nite symptoms, and have established a causal relation 
between lesions of certain portions of the brain and dis- 
turbances of certain functions, both motor and sensory. 
It has also been discovered that deficient development of 
an organ is accompanied by deficient development of that 
part of the brain which is in functional relation with that 
organ, and vice versa (von Gudden). 

Further, the researches of Flechsig (1877-84) have 
proven that an anatomical connection exists between cer- 


282 





tain organs and certain parts of the brain by means of 
tracts, which can be distinguished from one another by 
peculiarities in the time and process of their development. 
To these same tracts are limited the secondary changes 
which ensue when the active organ at one extremity of 
the tract is destroyed. 

All these various kinds of evidence combine to establish 
the conclusion that definite parts of the brain possess 
distinct functions, and although there remain numerous 
functions whose location is unknown, and many parts of 
the brain whose function is undetermined, a sufficient 
number of facts is available to warrant in many cases of 
cerebral disease a localization of the lesion. 

GENERAL CONSIDERATIONS.—Since the different parts 
of the brain preside over different functions, the symp- 
toms present in any lesion will depend as much upon its 
situation as upon its nature. Certain general symptoms, 
such as headache, vertigo, convulsions, coma, or optic 
neuritis, occur in many forms of disease, and being indi- 
cations of disturbances of nutrition, or of increased intra- 
cranial pressure, do not indicate the position of the dis- 
ease. Other symptoms, however, such as disturbances 
of motion, of sensation, of sensory perception, of memory, 
or of speech, are known as local symptoms, since each is 
present only when a certain part of the brain is involved. 
It is from these that the localization of a lesion can be 
determined. Local symptoms must, however, be inter- 
preted with caution, and the direct effect of the lesion 
must be distinguished from its indirect effect. For ex- 
ample, immediately after a cerebral hemorrhage, attended 
with headache, vertigo, or coma, and possibly general 
convulsions and vomiting, the local symptoms of hemi- 
plegia, hemianzesthesia, and aphasia may be present, and 
may lead to the suspicion of a very extensive lesion. 
After a few days, however, there may remain only a 
partial hemiplegia, all other symptoms having subsided. 
In such a case the hemiplegia is the only direct local 
symptom; the indirect local symptoms—aphasia and 
hemianzesthesia—being incidental to the pressure on, or 
to disturbance of, circulation in parts adjacent to the 
actual seat of disease. It is only when a lesion is single, 
its effects stationary and of some duration, that a diagno- 
sis of its position is to be made. 

In diagnosticating the position of a lesion it is necessary 
to distinguish disease in the cortex from disease within 
the hemisphere. The functions of these parts are differ- 
ent. The gray cortex receives and initiates impulses. 
The white: matter within the hemisphere transmits the 
impulses. The impulses sent along white tracts to the 
cortex become conscious perceptions only when they 
reach their destination in the gray matter. Theimpulses 
passing along the white tracts from the cortex have been 
started in the gray matter as conscious volitions by effort. 
Thus sensation or motion may be suspended either by 
disease in the cortex or by disease in the tracts within the 
hemisphere. The cortex hasanother function. A sensa- 
tion once perceived, or a motion once acquired, leaves 
behind it a trace, whose nature is unknown, which shows 
itself in a disposition in the cells of the cortex to react 
more promptly to a similar impulse than to a dissimilar 
one. This is the physical basis of memory. Since simi- 
lar impulses always enter by the same sensory organ, and 
since each organ is connected with its own region of the 
cortex, it follows that the various memories are distrib-, 
uted in various regions. But these memories are often 
associated in consciousness, and this association is secured 
by means of white fibres which pass between and connect 
the various regions. It becomes evident, therefore, that 
diseases of memory may afford an important clue to the 
location of a lesion; and that the distinction between a 
disease of the gray cortex involving a loss of a certain 
kind of memory, and one of the white tracts within the 
hemisphere interfering with the proper association of 
ideas must not be overlooked. No part of the gray mat- 
ter can act vicariously for another part. Each tract con- 
veys its own impulses. 

Draenosis.—I. CoRTEX CEREBRI.—1. Lesions involv- 
ing the frontal lobes upon the base may destroy the olfac- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





tory bulb or tract and produce anosmia on the side of the 
lesion. Lesions in the other convolutions of the frontal 
lobes, excepting those in the posterior part of the third 
convolution of the left side, present no distinctive local 
symptoms. Some disturbance of mental action, mani- 
fested by an inability to concentrate the attention, to 
think connectedly, and to control the emotions, or even 
by a condition of imbegility, may be caused by disease in 
this region. 

These convolutions are often defective in idiots, and 
their comparative development in animals determines the 
mental power of the individual. But disease in this 
region in man does not cause a loss of any particular 
mental faculty, and for the higher powers of mind no 
location can be determined. Normal mental action im- 
plies the integrity of the entire brain. When general 
symptoms of cerebral disease are present, but no local 
symptoms can be found, the possibility of disease in the 
frontal convolutions is to be considered, and the occur- 
rence of the mental disturbance mentioned affords a pre- 
sumption in favor of this location. 

Lesions in the posterior part of the third frontal con- 
volution on the left side in right-handed, and on the right 
side in left-handed persons give rise to ataxic or motor 





Fic. 870.—Diagram of the Fissures and Convolutions of the Convexity 
of the Left Hemisphere of the Brain, with the areas presiding over 
various functions. ‘The speech areas are shown on this hemisphere. 
The motor area is more extensive on the left than on the right hemi- 
sphere. 


aphasia (Fig. 870). In this area are located the memo- 
ries of the combination of motor acts necessary to the 
pronunciation of words, memories which have been ac- 
quired by practice. If these memories are blotted out, 
the ability to initiate the impulse required to produce a 
given sound is lost, and speechlessness results. When 
this convolution alone is affected the patient can under- 
stand what is said to him, and may be able to write, but 
cannot talk (see Aphasia). 

2. Lesions of the anterior and posterior central convo- 
lutions and of the paracentral lobule produce disturbances 
of motion (Fig. 870). The motor tracts which connect these 
convolutions of each hemisphere with the body decussate 
partially in the medulla, and the degree of the decussa- 
tion differs in different individuals. In the large major- 
ity of persons the tracts which cross to the opposite side 
are so much larger than those which go to the same side 
that the symptoms of cerebral disease are noticed only on 
the side of the body opposite to the side of the lesion. 
In all cases, however, except in those in which the decus- 
sation is complete (one in sixty), the side which is appar- 
ently normal is slightly affected. The disturbances of 
motion may be in the form of spasms and convulsions, 
or in the form of paralysis. Lesions irritating the motor 
region give rise to the former; those which destroy the 
cortex to the latter. The lower third of the anterior cen- 
tral convolution is in functional relation with the muscles 
of the face and tongue (Fig. 870). The middle third of 
both central convolutions governs the arm (Fig. 870), the 
motions of the shoulder, elbow, and hand lying from 
before backward and from above downward in the order 





named. The upper portion of both convolutions and the 
paracentral lobules contain the motor centres for the body 
and leg, the motions of the hip, knee, and foot lying 
from before backward and from above downward in the 
order named. The area related to the movement of the 
eyes is located by Landouzy and Exner in the inferior 
parietal lobule. As these areas for each part are distinct, 
cortical lesions of limited extent may affect one alone, or 
two adjacent areas; but it is only lesions of very great 
extent which can destroy them all. Monospasms, or 
monoplegia, are, therefore, prominent symptoms in dis- 
ease of the motor region. An irritation beginning in one 
area may extend to adjacent areas, in which case a con- 
vulsion may commence in one part and then involve 
other parts. The relative position of the areas, then, de- 
termines the order of progress of the convulsion, face, 
arm, and leg being successively affected, or vice versa ; 
and face and leg never being involved together without 
affection of the arm. When the entire side is involved 
the convulsion may become general. The seat of the 
initial irritation mav. therefore, be indicated by the order 
in which the spasms extend. After such a spasm there 
remains a paresis in the muscles affected, those last and 
least involved recovering first (see Hpilepsy). If the irri- 
tating lesion becomes a destroying lesion the monospasm 
is succeeded by monoplegia, and from the part of the 
body affected the area in the motor region which is de- 
stroyed can be determined. In cortical disease it is seldom 
that the lesion involves a single area without encroach- 
ing upon adjacent areas; hence, associated monoplegise 
of face and arm, or arm and leg, are more frequently met 
with than paralysis of one part alone. But even in these 
cases the disturbance of motion usually begins or is more 
marked in one part, rather than in both equally, and the 
order of extent of paralysis may indicate the direction in 
which the disease is progressing, and the place from 
which it started. 

In paralysis from cortical lesion there is a loss or marked 
impairment of the muscular sense, and there may be 
some disturbance of general sensation. <A loss of motor 
memories, ¢.g., the motions involved in writing, playing 
an instrument, using a tool, occurs in cortical disease, and 
may indicate that the seat of the lesion is in the area of 
the arm. The limits of the region receiving impulses 
which awaken the perception of touch, temperature, and 
pain are not fully determined. It is thought, however, 
that the motor and sensory regions coincide, while it is 
probable that the sensory region extends beyond the 
motor and includes the parietal lobules which lie poste- 
rior to the motor area. Ferrier, however, teaches that 
the gyrus hippocampus is the region in which these sensa- 
tions arereceived. Lesions affecting the posterior central 
convolution give rise to combined motor and sensory 
symptoms, the sensory areas lying in the same order as 
the motor areas, face, arm, and leg in the lower, middle, 
and upper thirds respectively. Lesions in the motor area 
anterior to the fissure of Rolando usually produce paraly- 
sis without anzsthesia. Lesions in the parietal lobules 
may produce anesthesia but do not cause paralysis. 

Each sensory area is in functional relation with the op- 
posite limb to a much greater degree than with the limb 
of the same side. Monoanzsthesia may therefore occur 
from cortical lesion. The loss of sensation is rarely total, 
as it is probable that the decussation of sensory impulses 
is rarely complete. The degree of impairment of sensa- 
tion is to be ascertained only by comparison of the 
affected limb with the other three. If the sensory area 
is not destroyed but is only irritated, subjective sensa- 
tions in the limb whose area is affected occur, and such 
monoparesthesiz are valuable indications of cortical 
lesion, when disease in other parts is excluded. 

Monospasm and monoplegia, monoparesthesia or 
monoanesthesia, are therefore the chief symptoms of 
cortical disease in the sensorimotor area. The two 
former indicate an affection lying anterior to the parietal 
lobules. The two latter may occur when these also are 
involved. No other local symptoms of disease in the 
parietal lobules are known, the disturbances of speech or 


283. 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








of sight which occur occasionally when the supramarginal 
gyrus is involved being due to a coincident lesion of the 
tracts passing beneath it. 

3. Lesions of the three occipital convolutions and of 
the cuneus produce disturbances of vision (Fig. 871, D). 
Each occipital lobe is in anatomical connection with the 
like-named half of each retina, and hence a lesion of one 
occipital lobe produces an affection of vision in the oppo- 
site half of both visual fields. Irritation of the cortex 
of this region may cause hallucinations of vision, and if 
the irritation is in one lobe the subjective sights will ap- 
pear upon the opposite side of the median line, and will 
move with the eyes of the patient. Destruction of the 
cortex will produce bilateral homonymous hemianopsia, 
z.e., blindness in the opposite half of both eyes, and may 
also cause a loss of visual memories; the patient will fail 
to recognize familiar objects, and cannot recall scenes 
and faces formerly known. If the lesion is in the left 
occipital lobe near to its junction with the inferior parie- 
tal lobule (see Fig. 870), written and printed language 
also may no longer be recognized, and the patient, there- 
fore, may lose the power of reading while speech re- 
mains. It is not yet possible to affirm the functional 
relation between various parts of the visual area in the 
occipital convolutions and various parts of the retinal 
surfaces, although a few cases indicate that such a rela- 
tion may exist. The relation of the angular gyrus, 
which lies anterior to the occipital lobe, to vision is un- 
determined. While it was formerly supposed to be the 
centre of the visual area by Ferrier, this view has been 
opposed by German authorities, who hold that the dis- 
turbances of vision which have occurred occasionally 
when it was diseased have been due to a lesion of the 
visual tract which lies beneath it and which passes to the 
occipital lobe (see Hemianopsia). 

4. Lesions of the first and second temporal convolu- 
tions produce disturbances of hearing, but whether each 
lobe is related to the opposite ear alone, or to both ears, 
is undetermined (Fig. 871, E). Irritation of these convo- 











Fic. 871.—The Projection Tracts Joining the Cortex with Lower Nerve 
Centres. Sagittal section showing the arrangement of tracts in the 
internal capsule. A, Tract from the frontal lobe to the pons, thence 
to the cerebellar hemisphere of the opposite side; B, motor tract 
from the central convolutions to the facial nucleus in the pons and 
to the spinal cord; its decussation is indicated at K ; C, sensory 
tract from posterior columns of the cord, through the posterior part 
of the medulla, pons, crus, and capsule to the parietal lobe; D, 
visual tract from the optic thalamus (O.T.) to the occipital lobe ; E, 
auditory tract from the internal geniculate body (to which a tract 
passes from the VIII. nerve nucleus [J]) to the temporal lobe; F, 
superior cerebellar peduncle; G, middle cerebellar peduncle; H, 
inferior cerebellar peduncle; CN, caudate nucleus; C.Q., corpora 
quadrigemina; Vt., fourth ventricle. The numerals refer to the 
cranial nerves. 


lutions may cause hallucinations of hearing, and destruc- 
tion of them may cause deafness. If the lesion is upon 
the left side and involves the first convolution, the symp- 
tom produced is word-deafness, or loss of memory of the 


284 


sound of words, with consequent inability to recognize . 
the meaning of spoken language or to recall the words 
necessary to speech. This is also known as sensory or 
amnesic aphasia. It can be distinguished from motor or 
ataxic aphasia by the inability of the patient to under- 
stand what is said to him (see Aphasia). 

5. Lesions at the apex of the temporo-sphenoidal lobe 
may produce disturbances of taste and smell, but further 
investigations are needed to establish the localization of 
these functions. 

6. Lesions of theisland of Reil have caused disturbance 
of motion in the face and arm of the opposite side, and 
also have caused aphasia when the left island was in- 
volved. It is not certain, however, to what extent these 
symptoms were dependent upon the affection of adjacent 
convolutions, of tracts beneath the island, or of the basal 
ganglia (Figs. 872 and 873). The associating tract which 
joins the sensory with the motor speech centres lies just 
under the convolutions of the island of Reil and destruc- 
tion of this tract would cause paraphasia. Lesions of the 
island of Reil would be especially liable to affect the cir- 
culation in the motor area, since the branches of the mid- 
dle cerebral arteries pass over it. While, therefore, it 
can be stated that hemiplegia and aphasia may be pro- 
duced by lesions here, it is probable that they would be 
indirect and not direct local symptoms. The function of 
the island of Reil is unknown. 

The facts which have been stated regarding cortical 
lesions are based: upon autopsies and are independent of 
any physiological considerations regarding the functions 
of the various parts, although they agree with the results 
of experiment on animals. It is evident that disease 
which affects an extensive region of the cortex may pro- 
duce a number of symptoms arising from the implication 
of several areas at the same time. Such widespread dis- 
ease is usually attended by general symptoms, marked 
mental disturbance, loss of memory, and lack of self- 
control, as well as by the local symptoms. 

II. CEREBRAL TRActTs.—1. The white matter of the 
brain consists of fibres of two varieties: association fibres 
which join the different convolutions and functional 
regions with one another, and projection fibres which join 
the different convolutions with the basal ganglia and 
with the gray matter of the pons, medulla oblongata, and 
spinal cord. ‘These fibres are so interlaced in the centrum 
ovale that neither can be injured without affecting the 
other. An interference with the passage of impulses 
through association fibres produces symptoms of a men- 
tal character. Anexample of this has been cited in de- 
scribing lesions of the island of Reil, viz., paraphasia. 
The patient suffering from this disease can recall the de- 
sired words, and is able to initiate the motions necessary 
to speech; but the associating tract between the memory 
of a definite word and the memory of its motion being 
broken, he does not speak the desired word but replaces 
it by another. Thus, in a case known to the writer, 
whenever the patient spoke she said, “Ah, dear me, I 
don’t know,” much to her own annoyance, as she under- 
stood what was said to her and knew what she ought to 
say in reply. The forms of paraphasia are numerous, 
but are all to be. referred to lesion of association fibres. 
It is very probable that many defects of memory, and 
much of the apparent stupidity in brain diseases, is to be 
ascribed to a failure of function in these fibres by which 
ideas are associated. Nothing more definite can be stated 
regarding their injury, and the mental symptoms, aside 
from paraphasia, do not indicate the location of the dis- 
ease. 

2. Lesions of projection fibres produce well-marked 
local symptoms. It is by means of these fibres that all 
parts of the body are joined to connecting parts of the 
brain, so that in imagination a map of the body can be 
projected upon the cortex of the brain. An interference 
with any separate bundle of fibres will therefore produce 
symptoms in the organ with which it is joined, and there- 
fore will cause effects somewhat similar to those produced 
by a lesion of the corresponding part of the cortex. It 
is necessary to consider the lesions of the various tracts, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





as they produce different symptoms. The projection 
fibres passing inward and downward from the extensive 
cortical surface of each hemisphere converge, and are 





Fia. 872.—The Motor Tract. 
nucleus; O.T., optic thalamus; N.C., caudate nucleus; C, crus; P, 


S, Fissure of Sylvius; N.L., lenticular 


pons; M, medulla; O, olivary body. ‘The tracts for face, arm, and 
leg gather in the capsule and pass together to the lower pons, where 
the face fibres cross to the opposite VII. nerve nucleus, while the 
others pass on to the lower medulla where they partially decussate, 
to enter the lateral columns of the cord; the non-decussating fibres 
pass to the anterior median columns. The effect of a lesion sit- 
uated at three points in the tract is shown on the left side of the 
figure. 


finally collected into a compact tract which lies between 
the basal ganglia and is known as the internal capsule. 
Many fibres pass into the basal ganglia, but as their 
function is only conjectured, the effect of their destruc- 
tion is unknown. Others pass between the ganglia, 
through the capsule, and issuing from its basal portion 
enter the crus cerebri, and traversing it go down to the 
pons, medulla, and cord. 

Since the fibres passing through the capsule are gath- 
ered from distant and widely separated regions of the 
cortex, a small focus of disease in the capsule may pro- 
duce as serious and widespread symptoms as disease of 
great extent in the cortex. Extensive disease in the cortex, 
or in the centrum ovale, produces considerable mental im- 
pairment, but this is not true of capsular disease. Hence 
in any case in which the symptoms are extensive, but the 
mind unimpaired, the probability is in favor of a small 
lesion in the brain tracts rather than of a large lesion in 
the cortex. The brain tracts in the capsule may be in- 
jured either directly, by lesions in their course, or indi- 
rectly, by lesions in the basal ganglia in whose vicinity 
they pass. In both cases the initial symptoms will be 
the same if the disease begins suddenly ; but in the latter 
case recovery may follow, while in the former the symp- 
toms may increase in number, owing to secondary degen- 
erations following a lesion of a tract. If the disease is a 
slowly progressive one (e.g., tumor), general symptoms 
may precede local symptoms, and indirect local symp- 
toms will be succeeded by direct local symptoms. 

The internal capsule is divided into two halves, an an- 
terior and a posterior division, by the projection of the 
apex of the lenticular nucleus, which lies on its outer 
side. Through the anterior division pass the projection 


Brain, 
Brain, 





fibres from the frontal lobes (Fig. 871, A), and the fibres 
which join the anterior parts of the cortex with the basal 
ganglia. Nothing is known as to the exact function of 
either of these bundles of fibres, and no symptoms of 
their injury can be stated. Extensive lesions may occur 
in the white matter of the frontal lobes, affecting both 
association and projection tracts without producing any 
symptoms, although in many such cases the symptoms 
present in cortical lesions of the frontal lobes do occur. 
Through the posterior division of the internal capsule 
pass several important tracts. These are (1) the motor 
tract from the lower third of the central convolutions, 
which curves over the lenticular nucleus and passes down 
in the anterior part of the posterior division of the cap- 
sule, enters the second quarter of the crus, thence passes 
into the median part of the ventral half of the pons, and 
turning downward ends in the facial and hypoglossal 
nuclei (Fig. 874, #a.); (2) the motor tract from the other 
thirds of the central region (Fig. 871, B), which is known 
as the pyramidal tract, since its fibres, after passing 
through the third quarter of the crus and the ventral 
portion of the pons, make up the pyramid of the medulla 
(Fig. 874, W.); (8) the tract conveying general sensations 
from the entire body (Figs. 871, C, 874), which lies just 
behind the pyramidal tract, and having come from the 
tegmentum of the crus, and passed through the posterior 
third of the capsule, radiates toward the parietal convo- 
lutions (Fig. 874, S.); (4) the visual tract (Fig. 874, D), 
whose fibres, issuing from the pulvinar of the thalamus, 
pass upward and turn backward in the capsule on their 
way to the occipital lobe (Fig. 874, O.); (5) the auditory 
tract, which passes through the lower posterior segment 
of the capsule on its way from the auditory nucleus to 
the temporal lobe (Fig. 871, E). Lesions of the internal 
capsule which affect one or more of these tracts cause 
distinct local symptoms. Lesions in the motor tract pro- 
duce paralysis, whose distribution will depend upon the 
extent to which the tract isinvolved. Usually the entire 
tract is affected and hemiplegia results; but occasionally 
the facial and hypoglossal muscles are only slightly 
affected. In all cases the upper branch of either facial 
nerve escapes, since its cortical centres are bilateral. In 
lesions of the pyramidal tract the arm and leg of the op- 
posite side are always paralyzed together. Lesions lying 
in the sensory tract cause hemianzesthesia, which is rarely 
absolute, but usually in the form of great impairment of 
sensation on the opposite side from the lesion. Lesions 
lying still farther back may affect the visual tract and 
cause blindness in the opposite half of both eyes. It is 





Fig. 873.—The Association Fibres in the Centrum Ovale. A, Between 
adjacent convolutions ; B, between frontal and occipital lobes; C, 
between frontal and temporal lobes, the cingulum; D, between 
temporal and frontal lobes—lesion of this tract causes paraphasia ; 
E, between occipital and temporal lobes—lesion of this tract causes 
word-blindness ; C.N., caudate nucleus ; O.T., optic thalamus. 


possible that lesions in the lower part of the capsule may 
produce loss of hearing in the opposite ear. Whether 
taste and smell are ever affected by capsule lesions is un- 
determined. 

It is evident that an extensive lesion in the capsule may 


285 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





involve two or more of these tracts; and hemiplegia, 
with hemianzesthesia and hemianopsia, could not be pro- 
duced by a single lesion lying in any other part. The 
initial effects of a 

= hemorrhage or 
thrombosis, which in- 
volves the internal 
capsule, may be ex- 
tensive, as several 
tracts may be affect- 
ed. If but one, how- 
ever, is really de- 
stroyed, the affection 
of the others will be 
temporary, and the 
symptoms will de- 
crease in extent and 
severity until they 
are limited to the af- 
fected tract. It is 
only after the tem- 
porary -effects have 
subsided that the dis- 
ease can be located 
accurately. On the 
other hand, a slowly 
progressing lesion, 
tumor, or abscess 
may involve one 
tract after another in 
succession, and the 
progress of the case 


will determine the 
localization of the 
lesion. 


3. Aphasia may be 
due to a lesion in the 
tract which joins the 
third frontal convo- 
lution with the facial 
and hypoglossal nu- 





Fic. 874.—Horizontal Section through the 
Brain. (After Striimpell.) NVC, nu- 
cleus caudatus; F’, fornix; JC, ante- 
rior half of internal capsule ; OT’, optic 
thalamus; Fa, facial tract; M, motor 


tract ; ve ene ee hes veer chip clei in the pons. 
in posterior half of internal capsule ; af ate s 

IR, island of Reil ; NL, nucleus lentic- Two courses have 
ularis; EC, external capsule; V,lateral been described as 


ventricle, posterior cornu. taken by this tract. 
One corresponds to 
the course of the fibres from the face area of the motor re- 
gion through the internal capsule, already detailed. The 
other is as follows: The aphasic tract passes inward from 
the frontal region, turns backward, crossing at right 
angles the motor tract, and going along the upper border 
of the lenticular nucleus, in the external capsule, to its 
posterior limit, it curves over the nucleus and enters the 
internal capsule near the sensory tract, then crosses this 
tract to the second quarter of the crus, and so reaches the 
pons. Lesions in the course of either of these tracts have 
produced aphasia when in the left hemisphere. Such an 
aphasia resembles ataxic or motor aphasia, and is not to 
be distinguished from it. It is more liable to be associ- 
ated with agraphia than when the lesion is in the frontal 
convolution, as association fibres are likely to be destroyed 
when the lesion is in the centrum ovale. 

4. Lesions of the cortex and of the tracts as they are col- 
lected in the capsule having been considered, it is evident 
that lesions of the centrum ovale, through which the 
tracts pass on their way from one to the other, will pro- 
duce similar effects to those in either part, according as 
it lies nearer one or the other. The association fibres 
which pass through the centrum ovale are shown in Fig. 
873. Any interference with them will produce defects in 
the association of concepts and ideas, and hence be shown 
by mental defects, especially defects of memory. Lesions 
of the centrum ovale have no distinctive symptoms by 
which they can be differentiated from lesions in the cortex 
or capsule, unless the affection of association fibres as well 
as of projection fibres adds distinct mental symptoms. If 
the lesion is so situated as not to affect any of the projec- 
tion tracts it will not produce any local symptoms. 


286 





III: Lestons or THE BASAL GANGLIA are very frequent. 
and give rise to many symptoms. These symptoms are, 
however, to be ascribed to a coincident affection of the 
tracts just mentioned, which pass through the internal 
capsule between the ganglia (Figs. 874 and 875), and 
hence the local symptoms of lesions in the lenticular or 
caudate nucleus and optic thalamus are those of lesions 
of the internal capsule opposite those bodies, viz., in its 
posterior division. If the symptoms are permanent, the 
capsule is probably injured. If the symptoms pass 
away, the capsule was incidentally affected. And the 
effects of the lesion may entirely subside while the lesion 
remains, if it is limited to either of these ganglia. It is 
therefore evident that we cannot locate a lesion in the 
ganglia from any direct. local symptoms; for, as we are 
ignorant of the function of the ganglia, we do not know 
what is the effect of their destruction. The hemichorea 
and hemiathetosis which occasionally remain after lesions 
of the thalamus are to be regarded as symptoms of irri- 
tation constantly exerted upon the motor tract passing 
near it. There are few facts to support the assertions 
that the optic thalamus is a sensory ganglion, except that 
lesions of the pulvinar cause hemianopsia. The basal 
ganglia, doubtless, have important reflex functions, and 
comparative anatomy indicates that some functional rela- 
tion exists between the lenticular nucleus and the arm; 
between the caudate nucleus and the lez; between the 
thalamus and the organs of sensation. The effects of a 
lesion limited to any one of these ganglia, and producing 
no influence upon adjacent parts, are, however, beyond 
detection. As a matter of fact, seventy per cent. of the 
cases of hemiplegia are due to a lesion in the basal gan- 
glia and affecting the internal capsule; and from the 
symptoms and nature of the disease its location there 
can usually be affirmed. The diagnosis is, however, made 
from the capsular symptoms, as already detailed. 

IV. Lestons oF THE EXTERNAL CAPSULE AND OF THE 
CLAUSTRUM cannot yet be located (Figs. 872 and 874). 
If on the left side, they usually produce paraphasia like 
the lesions of the island of Reil. 

V. LESIONS OF THE CORPORA QUADRIGEMINA are very 
rare. If the anterior pair is involved, blindness, loss of 
pupil reflex, strabismus, and nystagmus may be pro- 
duced. If the posterior pair is involved disturbances of 
coordination may be marked. As both pairs are usually 
affected together, the combination of these symptoms 
may aid a diagnosis. Blindness is such a common symp- 
tom of cerebral disease that it is only when it is not due 
to choked disc, optic atrophy, or neuritis, and when it 
is not of the nature of hemianopsia, that itis to be thought 
a local symptom of quadrigeminal lesion. <A defective 
agtion of the same branches of the oculo-motor nerves on. 
both sides is rather more characteristic of quadrigeminal 
disease than the total affection of one nerve. Cases are 
yet too few to warrant more accurate statements. 

VI. Lesions oF THE TEGMENTUM OF THE CRURA 
CEREBRI, which lies beneath the corpora quadrigemina. 
Since the sensory tracts pass through this region, anes- 
thesia may be produced by such a lesion, and the prox- 
imity of the corpora quadrigemina would give rise to 
indirect local symptoms of their affection. Lesions of the 
red nucleus cause the symptom of incoordination which 
occurs when the posterior pair of the corpora quadri- 
gemina are involved. They also cause paralysis of the 
third nerve, which passes through this nucleus. Lesions 
of the foot of the crus cerebri, in which the motor tract 
passes, cause hemiplegia of the opposite side. As the third 
nerve issues through the foot of the crus, a lesion here 
causes a paralysis of this nerve on the side of the lesion. 
Hence hemiplegia of one side, with third-nerve paralysis 
of the other side, indicates a lesion of the foot of the crus 
cerebri on the side of the third-nerve paralysis. Lesions 
on the base which press upon this part will produce the 


same combination of symptoms. 


VII. Lesions oF THE CEREBELLUM, if located. in the 
hemispheres and not in the median or vermiform lobe, 
and if of such a nature as not to exert pressure on sur- 
rounding parts, may not produce any symptoms. If 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the lesion is in the vermiform lobe, disturbances of co- 
ordination known as cerebellar ataxia occur, which con- 
sist in an inability to walk without staggering like a 
drunken man. The ataxia exists only while the patient 
is in an upright position; it rarely affects the motions of 
the arms, and when it does it never interferes with the 
fine adjustments, but only with extensive movements in 
space, ¢.7., grasping objects at a distance. These pa- 
tients can stand with eyes closed without swaying. In 
these respects the ataxia differs from that of posterior 
sclerosis. A second characteristic symptom of cerebellar 
disease located in the vermiform lobe is vertigo. This 
may be very severe, but as it may occur without ataxia, 
and ataxia may be present without vertigo (though rarely), 
the two are not to be considered asinterdependent. Ver- 
tigo is increased by rising to an erect position, but may 
persist when the patient is in bed. It decreases some- 
what when the patient has remained fixed in any position 
for some time; but is always increased when he closes 
his eyes. The vertigo is usually an early symptom of 
cerebellar disease. It is more constant and persistent in 
cases in which the intracranial pressure is increased. It 
may gradually pass off in other cases. Cerebellar vertigo 
does not differ from vertigo in Méniére’s disease, and is 
probably due to an affection of the terminal fibres of the 
eighth nerve, from the semicircular canals or their nuclei. 
The vertigo of Méniére’s disease is, however, usually ac- 
companied by deafness. Ataxia and vertigo together 
afford strong presumption of disease in the vermiform 
lobe, although neither alone is sufficient for a diagnosis. 
The indirect local symptoms of cerebellar disease may 
be numerous. They are due to an affection of the tracts 
and nerve nuclei in the pons and medulla (see Fig. 871). 
Various forms of paralysis and anesthesia, vaso-motor 
disturbances, obstinate vomiting of a projectile character, 
general symptoms of intracranial disease, e.g., headache, 
optic neuritis, are usually present with tumors, abscesses, 
or hemorrhages in the cerebellum, especially if they are 
in the median lobe. The combination of cerebellar ataxia 
and vertigo with these and other symptoms of pons dis- 
ease (See Section IX.) affords clear evidence of disease in 
the cerebellum. € 
Lesions of the cerebellum have no apparent effect upon 
the mental powers when they occur in adults. <A defi- 
cient development of the cerebellum is, however, a fre- 
quent cause of congenital idiocy. When one cerebellar 
hemisphere fails to develop, the opposite olivary body in 
the medulla and the opposite hemisphere of the cerebrum 
usually present an atrophic appearance. 
Lesions of the middle peduncles of the cerebellum, the 
crura cerebelli ad pontem, produce characteristic symp- 
‘toms. These consist in a tendency on the part of the 
patient to assume a forced position, to turn toward or 
fall toward one side in walking, or even to revolve con- 
stantly about one axis of his body. The forced move- 
ments may be made by the eyes (conjugate deviation in 
one direction), by the head, or by the entire body. Ina 
case seen by the writer, in which the autopsy showed a 
tuberculous tumor in the left middle peduncle and in the 
vermiform lobe, in addition to ataxia, vertigo, vomiting, 
and headache, the patient lay constantly on his left side, 
and when he turned upon his back or toward the right 
side the vertigo became so excessive that he was obliged 
to resume at once his former position. In walking, this 
patient showed a tendency to fail toward the right side, 
and found it impossible to turn around toward the right. 
Such patients may lose their balance in moving in one 
direction, e.g., forward or backward, and in attempting to 
regain it they may be obliged to hasten their movements. 
This has been interpreted wrongly as a tendency to com- 
pulsory walking in one direction, e.g., backward. It is 
really due to the vertigo. Lesions of the other peduncles 
of the cerebellum do not produce any known character- 
istic symptoms aside from those of cerebellar disease. 
VIII. Lestons UPON THE BASE OF THE BRAIN, tumors, 
chronic meningitis, may produce local symptoms by af- 
fecting the parts lying near them. Thus, all the cranial 
nerves may be involved either separately or in various 





Brain, 
Brain, 





combinations, and the nerve first or most severely af- 
fected may indicate where the lesion began. If sucha 
lesion affects the optic nerve of one side, the optic chiasm, 
or the optic tract, blindness, either in the form of amau 
rosis of one eye or in that of hemianopsia of some variety, 
will be produced. If the lesion affects the crus cerebri or 
pons, the symptoms of lesion of this part (wide swpra and 
Section IX.) may be present in addition to cranial-nerve 
paralysis. In all cases progressive bulbar paralysis is to 
be excluded before the diagnosis is made. The local 
symptoms of lesion of those parts of the cortex which lie 
on the base of the skull are undetermined, but a tumor of 
some extent which invades the left Sylvian region may 
cause aphasia from pressure upon the island of Reil. The 
variety of symptoms possible in basal disease can be de- 
termined by the study of the organs upon the base of 
the brain (see Brain), and any unusual combination of 
symptoms in intracranial diseases, especially if of syphi- 
litic origin, should lead to a question as to the possibility 
of a lesion in this locality. 

IX. Loca LEstons In THE Pons VAROLIL AND ME: 
DULLA OBLONGATA.—The pons Varolii and medulla ob 





Fia. 875.—The Base of the Brain and the Cranial Nerves. Pons and 
Medulla. J to XII, The cranial nerves; 7h, optic thalamus; h, 
pituitary body ; tc, tuber cinereum ; a, corpora albicantia ; P, pes 
pedunculi ; 7, internal, and e, external, geniculate body; PV, pons 
Varolii ; pa, anterior pyramid of medulla; 0, olive ; d, decussation of 
anterior pyramids; ca, anterior column of spinal cord; el, lateral 
column of spinal cord ; Ce, cerebellum ; jl, flocculus of cerebellum. 


longata lie upon the base of the brain, between the cere- 
brum and its crura above, the spinal cord below, and the 
cerebellum behind. Through them pass important tracts 
which join these organs with one another, and by means 
of which motor, sensory, vaso-motor, and trophic im- 
pulses are sent from the brain to the body, and from the 
body to the brain. Diseases in the pons and medulla 
cause symptoms of wide extent and serious nature, by 
interfering with the transmission of these impulses. The 
pons and medulla are not, however, merely organs of 


287 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





transmission. They contain centres of great importance, 
and preside over numerous functions. In them are 
located the nuclei of origin of the cranial nerves from the 
fifth to the twelfth inclusive, and through them the 
cranial nerves pass outward from these nuclei to the sur- 
face. In them are also situated complex automatic cen- 
tres, which preside over the acts of combined movement 
of the eyeballs, deglutition, articulation, respiration, and 
cardiac inhibition, and which regulate the tone of the en- 
tire vaso-motor system, and the secretion of saliva, per- 
spiration, and urine. Disease in the pons and medulla, 
by affecting these various centres, produces important 
symptoms, and the complexity of those symptoms is evi- 
dent from the number of normal functions which will be 
interfered with in any case of extensive lesion. These 
functions and their affections must be considered sepa- 
rately. 

ik "rhe Tracts Passing through the Pons and Medulla. 
—These may be studied by the aid of a schematic draw- 
ing (Fig. 880), and by comparing a number of sections 
made at different levels through the pons and medulla 
(Figs. 877 to 888). 

(1) Tracts Connecting the Cerebrumand Cerebellum (Fig. 
876, A).—From the frontal lobe of each cerebral hemi- 
sphere tracts pass downward through the corona ra- 
diata, enter the anterior division of the internal cap- 
sule, and issue upon the base of the brain in the inner 





Fic. 876.—The Projection Tracts Joininy the Cortex with Lower Nerve 
Centres. Sagittal section showing the arrangement of tracts in the 
internal capsule. A, Tract from the frontal lobe to the pons, thence 
to the cerebellar hemisphere of the opposite side; B, motor tract 
from the central conyolutions to the facial nucleus in the pons and 
to the spinal cord; its decussation is indicated at K; C, sensory 
tract from posterior columns of the cord, through the posterior part 
of the medulla, pons, crus, and capsule to the parietal lobe; D, 
visual tract from the optic thalamus (O.T.) to the occipital lobe ; E, 
auditory tract from the internal geniculate body (to which a tract 
passes from the VIII. nerve nucleus [J]) to the temporal lobe; F, 
superior cerebellar peduncle; G, middle cerebellar peduncle; H, 
inferior cerebellar peduncle; CN, caudate nucleus; C.Q., corpora 
quadrigemina; Vt., fourth ventricle. The numerals refer to the 
cranial nerves. 


third of the pes pedunculi (Fig. 877, p). From the 
parietal, occipital, and temporal lobes of each hemisphere 
tracts pass downward through the corona radiata, enter 
the posterior division of the internal capsule, and issue 
upon the base of the brain in the outer third of the pes 
pedunculi (Fig. 877, p). A section through the crura 
cerebri at the level of the anterior corpora quadrigemina 
(Fig. 877), shows the pes pedunculi (p-+ p’) separated 
from the tegmentum by the substantia nigra (s7). 

The outer and inner thirds of each pes (exclusive of 
the median fasciculus p') are made up of these tracts from 
the cerebral lobes. After passing through the pes these 
tracts enter the pons Varolii, where they are split up into 
small bundles by the transverse fibres of the pons. Sec- 
tions through the pons Varolii at various levels (Figs. 
878 to 883) show that the basal half of the pons con- 


288 


sists of longitudinal and transverse bundles of fibres 
interlaced, and that considerable masses of gray matter, 
consisting of large polygonal cells, lie between the fibres. 
It is in these gray masses that the longitudinal bundles 





Fig. 877.—Section through the Crura Cerebri. (Wernicke, X 2.) , 
Pes pedunculi; »,, median fasciculus; sn, substantia nigra; cgi, 
corpus geniculatum internum ; gp, corpus quadrigeminum posterior ; 
l, lemniscus ; rk, red nucleus of tegmentum through which pass fibres 
of oculomotor nerve, IIT, from its nucleus in the gray matter below 
the aqueduct of Sylvius, to its exit between the crura; ep, fibres in 
the formatio reticularis which have come from the posterior com- 
missure ; hi, posterior longitudinal bundle; V, descending root of 
the trigeminal nerve ; vh. upper part of the decussation of the supe- 
rior peduncles of the cerebellum, which end in the rk; r, raphé; al, 
lenticular loop. 


under consideration from the cerebral lobes terminate. 
Hence, in the sections through the lower portion of the 
pons (Figs. 882 and 883), fewer longitudinal bundles 
are seen than in the upper sections. From the masses of 
gray matter in the pons, the transverse fibres originate 
and pass laterally to the cerebellum. The majority of 
the fibres from one-half of the pons pass to the opposite 
hemisphere of the cerebellum, and thus cross the median 
line, where they interlace with those of the other side. 
The gray masses of the pons are thus interposed ina con- 
tinuous tract between the cerebrum and the cerebellum; 





Fig. 878.—Section through the Pons. (Wernicke, X 2.) sts and stc, 
Superficial and deep transverse bundles of fibres intersecting the 
longitudinal bundles, and terminating in the masses of gray matter 
of the basal portion ; »,, median fasciculus of the pes; 1, lemniscus ; 
l,, lower lemniscus; rk, red nucleus of tegmentum; cs, superior 
peduncle of cerebellum, some fibres of which are decussating in the 
raphé; ep, fibres in formatio reticularis, which have come from the 
posterior commissure ; hl, posterior iongitudinal bundle; Vd, de- 
scending root of the fifth nerve; JV, fourth nerve decussating in the 
valve of Vieussens. 


each cerebral hemisphere being connected with both cere- 
bellar hemispheres, but to a far greater extent with the op- 
posite hemisphere than with the one upon the same side. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain. 
Brain, 





Lesions of the frontal, parietal, and occipital lobes, if 
extensive, are followed by degeneration in the tracts from 
these lobes to the masses of gray matter in the pons. 





Fic. 879.—Section through the Pons. (Wernicke, xX 2.) sts, ste, stp, 
Superficial and deep transverse bundles of the pons, intersecting the 
longitudinal bundles, and terminating in the mass of gray matter of 
the basal portion ; », pyramidal (motor) tract from the middle third 
of the pes; p1, median fasciculus of the pes, here seen to join the 
lemniscus, /; V, fifth nerve root; em, middle peduncle of cerebel- 
lum; cs, superior peduncle of the cerebellum with cb, valve of 
Vieussens ; rk, hl, cp; V, as in Fig. 878; lc, locus ceruleus. 


Congenital absence of the cerebral cortex (Porencephalie) 
results in congenital absence of these tracts. Absence or 
atrophy of the cerebellum is attended by absence or atro- 
phy of the transverse fibres of the pons, which join the 
cerebellar hemisphere with the gray masses of the pons. 
Congenital deficiency of one cerebral hemisphere is occa- 
sionally attended by atrophy of the opposite cerebellar 
hemisphere, and vice versa. The function of the tract 
from the cerebrum to the cerebellum is doubtless to 
maintain a communication between these organs. But 
the exact function is unknown, and lesions 
in the course of these tracts in the pons 
do not produce any known 
symptoms. 

(2) The Motor Tracts.— 
These enter the upper bor- 
der of the pons from the 
middle third of each pes 
pedunculi (Fig. 877), hav- 
ing come from the cen- 
tral convolutions through 
the corona radiata and an- 
terior part of the posterior 

division of the in- 

ternal capsule (Fig. 

876, 2). Each mo- 
Vilnerve. tor tract, at its en- 
; trance into the pons, 
contains fibres whose des- 
tination is to the motor 
centres for the face, arm, 
and leg of the opposite 
side. But the centres of 
the facial nerve lie in the 
pons Varolii (Figs. 882 
and 883). In its pass- 
age through the pons, 
therefore, the facial divi- 
sion of the motor tract 
leaves the remainder and 
crosses the median line. 
This crossing is made by 
way of the raphé, fibres 
leaving the longitudinal bundles in the ventral half of 
the pons, turning dorsad, entering the raphé, decussating 
with similar fibres from the opposite side, and then turn- 
ing laterad to reach the facial nucleus (see Figs. 882 
and 883). From the facial nucleus the facial nerve 


Vou. Il.—19 





Fig. 880.—The Motor Tract in Pons 
and Medulla. Lesion at A causes 
hemiplegia of side opposite to le- 
sion; lesion at B causes alternat- 
ing paralysis; lesion at C causes 
paralysis of tongue on side of le- 
sion and of extremities of opposite 
side ; lesion at D causes paralysis 
of extremities of opposite side ; le- 
sion at EH causes paralysis of ex- 
tremities of both sides. 


passes outward to the side of the pons, having first 
passed inward and curved around the abducens nucleus 
in the so-called knee of the facial nerve. The accom- 
panying diagram indicates the course of the motor 
tract in the pons and medulla. Asaresult of the divi- 
sion of the motor tract of one side, lesions in the pons 
produce different forms of paralysis, according to their 
location. A lesion in the motor tract in the upper third 
of the pens causes hemiplegia of the side opposite to the 
lesion (Fig. 880, lesion at A). <A lesion in the middle 
or lower third of the pons causes alternating paralysis, 
v.e., paralysis of the face on the side of the lesion, with 
paralysis of the arm and leg on the opposite side (Fig. 
880, lesion at B). In the first case (hemiplegia) the 
upper branch of the facial nerve is not affected, the pa- 
tient can close his eye on the paralyzed side, and the 
facial muscles contract to the faradic electric current. 
In the second case (alternating paralysis) all branches of 
the facial nerve are involved, the eye remains open, and 
the reaction of degeneration develops soon after the lesion 
occurs. In this case it is usual to find a paralysis of the 
abducens nerve on the same side as the facial paralysis, 
in which case the eyeball will be turned in. 

The motor fibres to the tongue take a similar course to 
those to the face, but leave the motor tract at a point in 
the lower third of the pons. Having reached the hypo- 
glossal nucleus in the medulla they end, but the hypo- 
glossal nerve passes outward, lying in close proximity 
to the motor tract in the medulla, as shown in the dia- 
gram. A lesion in the lower third of the pons or in the 
medulla may thus cause paralysis of one side of the 
tongue and of the opposite arm and leg (Fig. 880, lesion 
at (). In the medulla the motor tracts pass in the an- 
terior pyramids (see Fig. 875, pa), and before entering 





Fic. 881.—Section through the Pons. (Wernicke, X 2.) sts, stp, Su- 
perficial and deep transverse pons fibres from the cerebellum through 
cm, the middle cerebellar peduncle ; :p, the pyramidal (motor) tract ; 
l, lemniscus; mf, formatio reticularis; hl, posterior longitudinal 
bundle; Vm, motor nucleus and root of the trigeminal nerve; Vs, 
sensory root of the trigeminal nerve; Vc, cerebellar root of the tri- 
geminal nerve; Vd, descending root of the trigeminal nerve (see 
Figs. 879, 880, and 881) ; Vd-++, crossed descending root of trigem- 
inal nerve; Vdr, fibres from the raphé to the trigeminal root; sg, 
substantia gelatinosa of V root. 


the spinal cord undergo partial decussation. A lesion in 
one pyramid will cause paralysis of the opposite arm 
and leg (Fig. 880, lesion at D); but as the two pyra- 
mids lie side by side, lesions of the medulla, by affecting 
both at once, may produce paralysis of both arms and 
legs; and this is especially the case if the lesion lies so 
near the spinal cord as to involve the decussation (Fig. 
880, lesion at /). 

The various forms of paralysis produced when both 
sides of the pons are involved at once can be ascertained 
by reference to the diagram. 

In all these affections of the motor tract a condition of 
spastic rigidity may follow the paralysis, and an increase 
of tendon reflexes is usually observed. In a few cases of 
pons lesion, however, the tendon reflexes have been lost. 


289 


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Brain. 





The electric condition of the paralyzed muscles in the 
limbs is normal from the outset, and no rapid atrophy 
occurs. 

The situation of the pyramidal tract is seen in all the 
figures at p. In the upper part of the pons (Figs. 878 





Fig. 883. 


Figs. 882 AND 883.—Sections through Pons. (Wernicke, X 2.) sts, 
Superficial transverse pons fibres from cerebellum through em, mid- 
dle cerebellar peduncle ; , pyramidal tract; l, lemniscus ; m/f, for- 
matio reticularis ; VJ, abducens nucleus from which abducens nerve 
passes forward, lying near p; VII, facial nucleus lying deep in mf, 
sending its fibres backward toward the floor of the ventricle (Fig. 
882), where they turn upward (Fig. 883), and then curve outward, 
thus forming a bend or knee around the VI nucleus; Va, ascend- 
ing root of trigeminal nerve ; ci, inferior cerebellar peduncle ; VIII, 
auditory root; 8c, external auditory nucleus; ct, corpora trape- 
zoides ; os, superior olive. 


and 879) its fibres are seen to be split up into small 
bundles by the transverse pons fibres. 


In the middle of 






Fia. 884.—Section through Medulla. (Wernicke, X 4.) , Pyramid ; 
1, lemniscus or interolivary tract; 0, olive; mf, formatio reticularis ; 
Va, ascending root of trigeminal nerve ; 8, auditory root; 8e, exter- 
nal auditory nucleus ; 8i, internal auditory nucleus ; mk, upper end 
of hypoglossal nucleus ; ci, inferior peduncle of cerebellum. 


290 


REFERENCE HANDBOOK OF THE MEDIUAL SCIENCES. 


the pons, however (Fig. 881), they have collected to- 
gether, and in the lower part of the pons (Figs. 882 and 
883) they form a compact tract which continues down- 
ward in the anterior pyramid of the medulla (Figs. 884 
to 887, p). At the lowest level of the medulla (Fig. 
887) the pyramidal fibres decussate, and thus pass into- 
the lateral columns of the spinal cord. About one-fifth 
of the pyramidal fibres do not, however, take part in the: 
decussation, and these continue downward in the anterior 
median columns of the spinal cord. The ratio of decus- 
sating to non-decussating fibres was found by Flechsig: 
to vary greatly, and in one case in sixty no decussation 
occurs.- The relative sizes of one lateral pyramidal tract. 
and of the opposite anterior median column of the spinal 
cord depend wholly upon the extent of the decussation 
of the pyramids in the medulla. 

(8) The Tract of Muscular Sense.—This is called the- 
lemniscus or fillet in the pons, and the interolivary tract. 
in the medulla. As it conveys sensations upward we 
trace it in that direction. It arises from the nuclei gra- 
cilis and cuneatus on the dorsal surface of the medulla, 
in which the columns of Goll and Burdach of the spinal 
cord end (Figs. 887 and 888, ft and fe). It then crosses. 
the median line, decussating with its fellow of the op- 
posite side in the upper decussation of the medulla. 
(sensory decussation of Meynert; pinniform decussation 
of Spitzka) (Fig. 887, 7, ff). The fibres after decussat- 
ing turn upward, enter the interolivary tract, and pass 
onward through'the medulla beyond the upper level of 
the olives into the pons (Figs. 884 and 885, 7). Here 
this tract broadens out, becoming almost ribbon-like in 
its appearance, and hence has been called the fillet. In 
the pons the fillet lies behind the deep transverse bundles. 
of the pons, and just in front of the formatio reticularis. 
(see Figs. 878 to 883, 7). 

As it passes up it receives additional fibres from the- 
superior olive (Fig. 884, 0, s), but these leave it again 
at the level of the posterior corpora quadrigemina (Fig. 
878, 7), while the main part of the fillet passes onward 
in the outer part of the tegmentum of the crus cerebri. 
(Fig. 876, 7), and thence into the posterior part of the: 
internal capsule, whence it radiates to the parietal cortex 
of the brain. 

Sensations of muscular sense being transmitted by this: 
tract, a lesion in it causes ataxia in the limbs of the op- 
posite side. A unilateral ataxia may indicate a lesion in 
the course of the fillet. 

(4) The Sensory Tract, which transmits sensations of 
touch, temperature, and pain through the medulla and 
pons, is in the formatio reticularis. This portion of the- 
medulla and pons lies just be- 
neath the gray matter of the floor 
of the fourth ventricle, behind 
the tracts hitherto described. It. 
is made up of nerve fibres pass- 
ing in three directions: (@) trans- 
versely, the commissural fibres: 
of the cranial nerve nuclei; (0) 
from the nuclei ventrad, the fibres. 
of the cranial nerve roots and 
arciform fibres; (¢) longitudi- 
nally, the sensory tract. The 
longitudinal fibres can be traced 
from the gray matter and vari- 
ous columns of the spinal cord,. 
through the formatio reticularis to its upper level . 
in the tegmentum of the crus, whence they issue- 
to enter the posterior part of the internal capsule. 
In the medulla the formatio reticularis of each 
side is divided into two parts by the line of exit of 
the nerve roots of the twelfth (see Fig. 885). The- 
inner part, near the median line, contains the continuation. 
of the anterior and antero-lateral columns of the spinal 
cord, and the interolivary tract or lemniscus already de-- 
scribed. The outer part contains the sensory tract now” 
under consideration. Inthe inner two-thirds of this outer: 


, part the fibres pass which convey impressions of touch, 


temperature, and pain from the opposite half of the trunk. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





and limbs. In the outer third of this part is found a col- 
umn of peculiar structure resembling the substantia ge- 
latinosa of the posterior horn of the spinal cord, and in 





Fig. 885.—Section through Medulla. (Wernicke, x 4.) p, Pyramid ; 
1, lemniscus or interolivary tract; ci, fibres from the olive which 
cross the raphé and pass outward and backward to enter the infe- 
rior cerebellar peduncle, er; mf, formatio reticularis, in which Xa, 
the deep nucleus of the vagus (nucleus ambiguus), lies; Va, ascend- 
ing root of trigeminal nerve ; 12, hypoglossal nucleus and root ; Xf, 
respiratory bundle around which, in the floor of the ventricle, the 
vagus nucleus lies, and below which the vagus root issues; 8¢ and 
8i, auditory nuclei; hi, nucleus cuneatus, from which fibres pass 
outward and enter cr. 


this column terminate the fibres of the sensory part of 
the trigeminal nerve (Figs. 884 and 885, Va), which turn 
downward after entering the pons Varolii, and terminate 
at different levels in 
the pons and medulla 
(see Fig. 886). Thus 
the outer portion of the 
formatio reticularis 
contains the sensory 
tract from the face of 
the same side. It is 
evident from the dia- 
gram that a_ lesion 
which involves one- 
half of the formatio 
reticularis in the pons 
and medulla will pro- 
duce an _ alternating 
anesthesia, z.e., loss of 
sensation on one side 
of the body and on 
the other side of the 
face and head (lesion 
at B, Fig. 886). Al- 
ternating anesthesia is 
as characteristic a 
symptom of lesions of 
the formatio reticularis 
of the pons and me- 
dulla, as alternating 
paralysis is of lesions 
in the motor tract of 
the pons. In the up- 





Fig. 886.—The Course of the Sensory 
Tractin Ponsand Medulla. A, Lesion 
in tegmentum of crus cerebri, or upper 
quarter . pons, peeing coe yl 
thesia of the opposite side; B, lesion 
in formatio reticularis of pons or me- Per part of the pons 
dulla, producing alternating aneesthe- the sensory tract from 
sia. the face crosses the 

median line, and hence 

a lesion in the formatio reticularis in the upper third 

of the pons, or in the crus cerebri, will produce a uni- 

lateral anesthesia (lesion at A, Fig. 886; see Fig. 

881, Vdr, Vd+). A lesion involving both halves of 





the formatio reticularis will produce bilateral sensory 


symptoms. 
It is evident that a lesion of any extent, either in the 
pons or in the medulla, will inevitably destroy one or 


more of these four tracts, and consequently will produce 


serious symptoms of wide extent and of con- 
siderable diversity. 

2. The Centres Lying in the Pons and Me- 
dulla.—The cranial-nerve nuclei lying in the 





Fig. 887.—Section through Medulla, Level of Sensory Decussation. 
(Wernicke, X 4.) ft, Nucleus gracilis; fe, nucleus cuneatus, from 
which fibres curve around the central gray, and then decussate and 
turn upward (cephalad) in the interolivary tract, l-ft; Va, ascend- 
ing root of the trigeminal nerve; ci, inferior peduncle of cerebel- 
lum, of which ks, direct cerebellar column of the cord, is a part; Xf, 
respiratory bundle ; XJ, medullary nucleus of spinal accessory nerve 
and its root; 12, hypoglossal nucleus and root ; mf, formatio reticu- 
laris ; oi, olive. 


pons and medulla must be briefly enumerated, since 
lesions affect them. They are located either in the gray 
matter of the floor of the fourth ventricle, or below 
this in the formatio reticularis. 

Figs. 889 and 890 show the relative position of the 
cranial-nerve nuclei in the pons and medulla from the 
fifth to the twelfth, inclusive. 

The third and fourth nerve nuclei and roots, together 





Fig. 888.—Section through Medulla, Level of Motor Decussation. hi, 
Posterior columns of spinal cord; /t, nucleus gracilis in column of 
Goll; fe, nucleus cuneatus in column of Burdach; tr, tubercle of 
Rolando, where posterior horn of spinal cord merges into Va, as- 
cending root of V; ks, direct cerebellar column; p, pyramid decus- 
sating to reach lateral column; cad, anterior cornu of cord; ale, 
antero-lateral column of cord. 


291 


Brain. 
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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





with the effect of lesions in them, will be discussed in 
the article on Ophthalmoplegia. 

The cranial nerves from the fifth to the twelfth may be 
considered in two categories: first, the motor nerves; 
second, the sensory nerves. 

(1) The Motor Nerves are the motor branch of the tri- 
geminal which supplies the muscles of mastication, the 
abducens, the facial, the motor portion of the glosso- 
pharyngeal and of the vagus, the spinal accessory, and 
the hypoglossal. 

Lesions which irritate the tracts from the cortical cen- 
tres to these nuclei, or lesions in their vicinity which 
cause irritation, may produce spasm of the muscles sup- 
plied by them. Thus spasm of the jaw (trismus), with 
grinding of the teeth, nystagmus, conjugate lateral de- 
viation of the eyes, spasm of the face, spasm of the 





Fig. 889.—Diagram Showing the Position of the Cranial Nerve Nuclei 
upon the Floor of the Fourth Ventricle (Erb). v to xii, Nuclei; V to 
XII, cranial nerves; v, median of V; v’, motor nucleus of v’’, as- 
cending root of V; viii, inner nucleus of VIII; viii’, outer nu- 
cleus; viii/’, viii’’’, lateral nuclei of VIII; 27, middle cerebel- 
lar peduncle ; 3, inferior cerebellar peduncle ; 2, superior cerebellar 
peduncle ; 4, eminenter teres ; 5, striae acusticz ; 6, ala cinerea. 


throat and larynx, and spasm of the tongue may occur 
from lesions of an irritating nature. Such are small 
hemorrhages, small areas of softening, or small tumors 
in the pons or medulla. Such lesions must lie in or 
near the floor of the fourth ventricle, or in the course 
of the nerve roots, to produce these spasms. A 
review of recent literature shows that they are to 
be regarded as rare symptoms. If such spasms 
occur alone, without other symptoms, it is difficult 


Fic. 890.—Longitudinal Section Showing the Relative Position of the Cranial Nerve 


Nuclei (Edinger). 


to determine the nature of the lesion, or to decide that the 
spasm is not functional. If they occur in connection with 
other symptoms of pons or medullary lesion, they are val- 
uable as evidence of the exact position of the disease. 


292 







Lesions which interrupt the tracts from the cortical cen- 
tres to the motor-nerve nuclei, which destroy those nuclei, 
or which interfere with the conduction of impulses along 





Fig. 891.—The Innervation of the Muscles of the Eye. (After Hun- 
nius, *‘ Zur Symptomatologie der Briickenerkrankungen.’’) P, Pons 
Varolii ; III, oculomotor nuclei, with R.i., nerve to left internal rec- 
tus, and R.i.’, to right internal rectus ; VI, abducens nuclei, with R.e., 
nerve to left external rectus, and R.e.’, to right external rectus ; tract 
from cortex to VI conveys voluntary impulses of conjugate deviation 
of the eyes; tract from VI to III unites the action of one external 
rectus with the opposite internal rectus ; C, centre for convergence 
of the eyes which is independent of VI and is actually in connection 
with the cortex by independent tracts not shown; A, situation of a 
lesion in the cerebrum producing loss of voluntary conjugate devia- 
tion of the eyes to the right; B, situation of a lesion in the pons 
producing loss of voluntary conjugate deviation of the eyes to the 
left; C, situation of lesion in the pons in the posterior longitudinal 
bundle, causing paralysis of conjugate motion to the right; D, situa- 
tion of a lesion in the pons in the posterior longitudinal bundle, and 
involving the VI nucleus, causing loss of conjugate motion to the 
left, with permanent deviation of the eyes to the right. 


the nerve root and nerve trunk, will produce paralysis. 
Paralysis of the muscles of mastication is the rarest form 
of paralysis. Paralysis of the external rectus muscle, or 
of the facial muscles and tongue, is very common. Par- 
alysis of deglutition or of the vagus is occasionally met 
with. Itiseasy to determine in any case whether the par- 
alysis is due to lesion of the central tracts, or to lesion of 
thenerve nuclei. Inthe first case atrophy does not follow 
the paralysis, and there is no change in the electric re- 
action in the muscles. In the second case atrophy occurs 
soon after paralysis, and is accompanied by a reaction of 
degeneration. But the latter symptoms 
are common to lesion of the nerve root 
and trunk as well as to lesion of the nu- 
cleus; hence other symptoms are neces- 
sary to establish a diagnosis of a lesion 
in the nucleus. When paralysis of the 
muscles supplied by one cranial nerve 
occurs alone, the probability is in favor 
of a peripheral nerve lesion, e.g., a men- 
ingitis or tumor on the base of the brain; 
and a central lesion can be thought prob- 
able only when an implication of other 
muscles in the domain of other nuclei 
ensues. 

Paralysis of the external rectus is so 
common that it requires some attention. 
It is usually due to a lesion on the base 
of the brain outside of the pons, involv- 
ing the sixth nerve. It may be due also 
to lesionin the pons between the nucleus of the sixth nerve 
and the exit of the root (see Fig. 882). In both cases there 
will be a permanent deviation of the eye inward and an in- 
ability to turn it outward, with contraction of the pupil. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brai n, 
Brain, 





But abducens paralysis may also be due to a lesion of the 
abducens nucleus in the pons. In such cases there is the 
added symptom of inability to perform conjugate move- 
ment of both eyes toward the side of the lesion, and a 
permanent deviation of both eyes to the opposite side. 
But this deviation does not prevent the voluntary act of 
convergence of both eyes to anear point. Lastly, ab- 
ducens paralysis may be due to lesions in the crus, or 
between the crus and the cortex, in the course of the 
tract conveying voluntary impulses from the cortex to 
the sixth-nerve nucleus. Such lesions will interfere with 
voluntary conjugate movement of both eyes to one side, 
viz., toward the side whose abducens is paralyzed. But 
since such a lesion may lie in the pons after the decussa- 
tion of this tract, or in the cerebrum before its decussa- 
tion, it cannot be said that the deviation is uniformly 
either toward or away from the lesion. In this case there 
is no permanent deviation of the eyes to either side; for 
the abducens nucleus being uninjured, it maintains the 
tone of the external rectus muscle, and during rest the 
eyes are found directed forward. If a lesion in the course 
of the central tract is of an irritative nature, however, it 
may cause forced motions of the eyes by sending im- 
pulses to the sixth nucleus. Under these circumstances 
there will be conjugate deviation of both eyes toward the 
side of the abducens paralysis.' The act of conjugate 
movement may also be interfered with, without paralysis 
of the abducens nerve. That act is governed by the sixth 
nerve nucleus, or by a special nucleus in its immediate 
vicinity as yet undetermined. It involves an innervation 
of one external rectus muscle and of the opposite internal 
rectus muscle. But the internal rectus muscle derives its 
innervation from the third nerve. A crossed connection 
must therefore be maintained between the abducens of 
one side and the oculo-motorius of the other side. This 
connection is maintained by means of the posterior longi- 
tudinal fasciculus (Figs. 877 to 888, h?). A lesion in the 
pons in the course of this bundle will interfere with the 
act of conjugate movement without paralyzing either 
abducens or oculo-motor nerve alone. In none of the 
cases mentioned is voluntary convergence of the eyes to 
a point suspended. These conditions may be understood 
by reference to Fig. 891. 

A very extreme contraction of the pupils is mentioned 
as a symptom in cases of sudden lesion of the pons. It 
has not been explained. 

Paralysis of the facial muscles is very common, but is 
usually due to lesions in the nerve outside of the pons. 
The symptoms which are produced when the facial nerve 
root or its nucleus is invaded in the pons, resemble 
those of Bell’s palsy; for all the facial muscles are 
affected, and an atrophy with reaction of degeneration 
ensues. The situation of the lesion in the pons can be 
determined only when other symptoms of pons disease, 
such as alternating paralysis (Fig. 880), are present. 

Paralysis of the motor portion of the glosso-pharyngeal 
nerve, with dysphagia or difficulty of swallowing, is a 
not infrequent symptom of pons disease. It occurs after 
sudden lesions, such as hemorrhage or embolism, also as 
the result of tumors, and most frequently of all in pro- 
gressive bulbar paralysis. 

Paralysis of the motor and vaso-motor mechanisms, 
governed by the vagus nerve, is a constant symptom of 
disease in the lower part of the pons and in the medulla. 
Arrest of respiration and heart action, from lesion of this 
nucleus, is the cause of sudden death, which so fre- 
quently attends sudden lesions in the medulla and pons. 
When the lesion is, however, of a slowly progressive 
nature (tumor, sclerosis about a hemorrhage), symptoms 
of irritation may occur from gradual invasion of the 
pneumogastric centres. Projectile vomiting; slow or 
very rapid, or intermittent, irregular pulse; dyspnea; 
loss of voice; polyuria and glycosuria, are symptoms 
which have been ascribed to such lesions. The two last- 
named symptoms have been associated with tumors in 
the lower part of the medulla? and upper part of the 
spinal cord, which have involved the fibres from the 
vaso-motor centre on their way downward to their exit 








from the cord at the eighth cervical segment. The intra- 
medullary nucleus of the spinal accessory nerve is so 
closely adjacent to that of the vagus that they are usu. 
ally involved together, when difficulty of respiration and 
articulation ensues. When the spinal portion of the 
nerve is affected, spasms of the neck occur; but this 
symptom is characteristic of meningeal affections, and 
has not been observed in central lesions. 

An affection of the hypoglossal nerves or their nuclei 
is very frequently observed in medullary disease, partly 
because the nerves pass through the middle of the 
medulla, and partly because their nuclei are large. If 
the lesion produces irritation of one nucleus, fibrillary 
twitchings and spasm in one-half of the tongue may be 
caused. It is more usual to find paralysis than spasm, 
in which case the tongue, when protruded, will deviate 
toward the paralyzed side, and will, therefore, point 
toward the lesion. But when the tongue is affected by 
disease in the medulla, it is not unusual for both halves 
to be involved, and then it is found that the power of 
protruding it is suspended, and motions in the mouth are 
also difficult. Hence talking, chewing, and swallowing 
are interfered with. An electric examination in these 
cases will demonstrate the reaction of degeneration in the 
intrinsic muscles of the tongue, and prove that the lesion 
is medullary, and not cerebral. Anarthria or dysarthria, 
7.e., imperfect articulation, is, according to Nothnagel, 
a frequent and important symptom of medullary disease. 

(2) The Sensory Nerves of the pons and medulla are the 
trigeminal, the auditory, and the glosso-pharyngeal. 
Lesions which affect the trigeminal nerve and produce 
anesthesia of the face have already been considered, 
Trophic disturbance of the eyeball has not yet been ob- 
served in cases of lesion of the trigeminal root or nucleus. 
The auditory nerve is occasionally affected in diseases 
of the pons and medulla. Two sets of symptoms are 
then produced: one referable to the implication of the 
fibres conveying auditory impressions, the other due to 
the irritation or destruction of fibres concerned in the 
sense of equilibrium. Deafness has been observed in 
pons disease on the side of the lesion,* and is probably 
due to destruction of the auditory fibres passing inward 
to the inner auditory nucleus on the floor of the fourth 
ventricle, or to an implication of that nucleus (see Fig. 
884). The central course of the auditory tract is be- 
lieved to be as follows: From the inner and outer audi- 
tory nuclei fibres cross the median line in the corpus 
trapezoides (Fig. 883, ct) to the opposite superior olive, 
thence turn upward with the lemniscus, pass beneath the 
posterior corpora quadrigemina in the lower lemniscus 
(Fig. 877, /'), and thus reach the internal geniculate body, 
from which a tract passes outward through the lower pos- 
terior part of the internal capsule and corona radiata to 
the temporal lobe of the brain (Figs. 876, 884). The 
course of this tract has been traced by anatomists, and 
has not yet been confirmed by pathological observation. 
Lesions at any part of it should produce deafness in one 
ear. Disturbance of equilibrium may occur from lesions 
in the lateral portion of the pons, if such lesions interrupt 
the part of the auditory nerve conveying such sensations 
to the cerebellum. This part of the auditory nerve passes 
either directly into the cerebellum through the inferior 
peduncle, or terminates in the external auditory nucleus, 
which is connected by fibres with the cerebellum (Figs. 
882, 883, e, c71), Vertigo, which isa frequent symptom of 
pons lesion, and rotatory movements of the body toward 
one side, which is an occasional symptom of pons dis- 
ease when the lesion involves the lateral portion of the 
pons, and the inferior and middle cerebellar peduncles, 
are probably due to an involvement of this portion of 
the auditory nerve in the lesion. The rotatory move- 
ment is probably due to a voluntary attempt to correct a 
subjective sense of motion. The patient really suffers 
from vertigo, and thinks that he is turning or falling 


* It is recorded in five cases in twenty-six. In other cases it may 
have been present, but was not recorded (Starr: ‘‘The Sensory Tract 
in the Central Nervous System,” Jour. of Ment. and Nervous Disease, 
July, 1884) 


293 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





toward one side; he therefore tries to prevent this falling 
by turning toward the other side. The symptom may be 
so serious that such rotatory movements are constantly 
kept up until the patient dies of exhaustion. The pa- 
tient turns toward the side opposite the lesion (?). 

The sensory portion of the glosso-pharyngeal nerve 
receives the sensations of taste,* and in two cases in which 
its nucleus has been involved a loss of taste has occurred. 
This symptom is so rarely elicited that it is not known 
whether lesions elsewhere in the pons or medulla will 
produce it. 

The Vaso-Motor Centre.—Lesions in the upper half of 
the medulla produce marked vaso-motor symptoms.? 
They consist of a general vaso-motor paralysis with 
flushing of the surface and sensation of heat, and of ab- 
normal sweating. The vaso-motor centre is bilateral, and 
each centre controls the circulation on the same side of 
the body. Lesions in its area are so likely to cause sud- 
den death that but few cases can be found in which it 
was affected (eight cases in my collection). But the 
symptoms of a vaso-motor character are to be looked for 
in any case of medullary lesion, and when such symp- 
toms are limited to one lateral half of the body, and are 
associated with other symptoms of bulbar disease, they 
are valuable as signs of the situation of the lesion. 

There are a few general symptoms that have been 
not infrequently observed in pons disease which require 
mention. General convulsions are the most constant of 
these. The majority of sudden lesions (hemorrhage, 
embolism) in the pons are ushered in by general convul- 
sions, followed by coma. Nothnagel established the fact 
that in animals irritation of the pons produces general 
convulsions, and hence authors have spoken of a convul- 
sive centre in the pons. It is hardly warrantable to 
hypothecate such a centre. Butitis probable that lesions 
in the pons are capable of producing general convulsions 
by irritating the motor tracts which pass through it. 
This is borne out by the fact that when the lesion isa 
tumor or a sclerosis, 7.¢., a gradually increasing lesion, 
convulsions do not occur. Headache, disturbance of 
vision, vertigo, and psychical changes have been fre- 
quently observed in connection with diseases of the pons 
and medulla, but they are to be ascribed to changes in 
the circulation or internal cranial pressure, and not to 
any special local lesion. 

It is evident from this review that the symptoms of 
lesions of the pons and medulla are very numerous, very 
complex, and very various, in accordance with their 
extent and the manner of their occurrence. The symp- 
toms in bulbar paralysis are very different from those of 
softening from embolism. And as almost every case so 
far recorded has differed from every other in important 
particulars, it is necessary to study carefully and fully 
all the symptoms occurring in any case of central lesion. 
If the cranial nerves are involved, or if there is present 
alternating paralysis or anesthesia, the possibility of 
pons or medullary disease must be considered, and an 
investigation of the various symptoms here detailed 
should not be neglected. M. Allen Starr. 


1 See Report of Clinical Society, Lancet, March 18th, 1887. 

2 Archiv fiir Psychiatrie, xiii., S. 658 u. S. 671. 

3 ©. L. Dana: Jour. Nery. and Ment. Dis., xiii., 65, 1886. 

4M. A. Starr: The Sensory Tract in the Central Nervous System. 
Jour. Nery. and Ment. Disease, xi., July, 1884; also, Vaso-Motor Neu- 
roses, Pepper’s System of Medicine, vol. v. 


BRAIN: EMBOLISM AND THROMBOSIS.—Emporism. 
— Htiology.—Cerebral embolism is almost always the re- 
sult of an endocarditis, either acute or chronic, of the left 
side of the heart. In acute ulcerative endocarditis the 
emboliare usually very small, and lodge in the capillaries. 
This form of the disease will not be discussed in this 
article. 

The embolus consists generally of small, soft particles 
of fibrin which have been detached by the current of 
blood from the vegetations on the valves of the heart. 
But the embolus may also be composed of calcified par- 
ticles, or of pieces of the valves which have been sepa- 





294 





rated by the ulcerative process from the main part of the 
valve. Less frequently the embolus is detached from a 
cardiac thrombus, situated often in the left auricular ap- 
pendix, or near the apex of the left ventricle. 

In rare instances the embolus is derived from the right 
side of the heart, and such cases have been explained 
either by the patency of the foramen ovale, or by the 
transmission of the embolus through one of the pulmo- 
nary veins, which are said to constitute a direct communi- 
cation between the right and left sides of the heart. 
Cohnheim reports a case of embolism of the middle cere- 
bral artery owing to thrombosis of the veins of the lower 
limb. In this case the foramen ovale readily admitted 
three fingers. So far as we are acquainted with thé 
literature of the subject, this is the only case of the kind 
on record. 

Myocarditis may also give rise, though very rarely, to 
cerebral embolism by causing rupture of the endocardium, 
and the consequent admixture of the products of inflam- 
mation with the blood. This is also true of gummatous 
or other growths in the substance of the heart, which 
proliferate through the endocardium. 

Another source of embolism is found in atheromatous 
degeneration and calcification of the inner coats of the 
aorta, with subsequent deposit of fibrin, and in aneurism 
of the same vessel. Embolism may result also from 
thrombosis of one of the arteries in the circle of Willis, a 
portion of the thrombus becoming detached and giving 
rise to an embolus in one of the more peripheral vessels 
in the brain. 

Cerebral embolism may also result from gangrenous 
or other processes in the lungs, which have caused ulcera- 
tion and finally perforation of a vein, and thus permit 
the entrance of the gangrenous or other material into the 
blood. This mode of development has been referred to 
previously in the discussion of abscess of the brain. 

Tumors may give rise to embolism in the same way. 
Another equally rare cause of embolism is the existence of 
wounds, phlegmonous inflammations involving the sub- 
cutaneous adipose tissue, and complicated fractures of 
the bones in which inflammatory processes are set up in 
the medulla of those organs. 

Von Dusch maintains that many of the cases of sudden 
death in pleurisy during aspiration, or while the pleura 
is being washed out, are due to the formation of thrombi 
in the pulmonary veins. He believes that the develop- 
ment of paralysis, which is observed sometimes under 
such circumstances, may be explained by the secondary 
occurrence of cerebral embolism. Indeed, in one in- 
stance of this kind, the cerebral emboli were discovered 
at the post-mortem examination. Finally, mention 
should be made of the capillary pigment emboli of the 
brain, seen occasionally in severe forms of intermittent 
and remittent fever. These emboli may be so numerous 
as to give the brain a chocolate color. Allthe cases of 
the kind which have come under our observation have 
originated in Central or South America. 

In our experience cerebral embolism occurs much more 
frequently in males than in females, but, according to 
Gowers, it is more frequent in women, owing, as he 
claims, to the greater frequency of mitral stenosis in 
females. . 

Pathological Anatomy.—Cerebral emboli (with the ex- 
ception of the capillary emboli, which will not be dis- 
cussed in this article) are usually single, and, in the ma- 
jority of cases, are situated in the left middle cerebral 
artery. This predilection is explained by the fact that 
the current of blood from the aorta passes by a straighter 
course into the left carotid than into the right carotid, and 
that, furthermore, the left middle cerebral artery is the 
direct continuation of the carotid. It has been claimed 
by Gelpke, on the basis of statistics, that the left middle 
cerebral presents only a slight preponderance over the 
right middle cerebral in this respect, but this is probably 
owing to the fact that, on account of the usual situation 
of the embolus in the vessel on the left side of the brain, 
the history of such cases is not generally reported. 

In a certain proportion of cases the emboli are situated 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





in other vessels, and even two or more may be present at 
the same time. 

The following is a brief résumé, according to Duret, of 
the distribution of the blood-vessels to the brain. These 
vessels may be divided into two classes: First, those 
which are given off at the base of the brain and at once 
enter the organ to supply the parts situated above (basal 
ganglia, etc.); and secondly, the continuations of these 
vessels which supply the cortex. We shall first describe 
the former. 

The anterior cerebral and anterior communicating 
arteries send off a number of small branches which sup- 
ply the anterior part of the corpus striatum. 

The posterior cerebral artery sends branches to the 
walls of the third ventricle, the optic thalamus (mainly 
the posterior portion), the tegmentum of the crus cerebri, 
and the corpora quadrigemina. 

The middle cerebral artery (the most important artery 
of the brain) gives off a number of branches before it 
supplies the cortex: (1) The internal striate arteries to the 
first and second divisions of the lenticular nucleus and 
the internal or white capsule; (2) the lenticulo-striate 
arteries which supply the anterior part of the third. divi- 
sion of the lenticular nucleus and of the internal capsule, 
and also pass to the corpus striatum; (3) the lenticulo- 
optic arteries which pass to the posterior part of the third 
division of the lenticular nucleus and the anterior portion 
of the optic thalamus. 

Following is the cortical distribution of these vessels: 

The anterior cerebral artery supplies the convolutions 
on the inferior surface of the frontal lobe, the first and 
second frontal convolutions, the paracentral lobule, and 
the precuneus. 

The posterior cerebral artery supplies the gyrus unci- 
natus and hippocampus, the inferior surface of the tem- 
poro-sphenoidal lobe, and the occipital convolutions. 

The middle cerebral breaks up into five branches: (1) 
To the third frontal (Broca’s) convolution; (2) to the as- 
cending frontal convolution; (8) to the ascending parietal 
convolution; (4) to the inferior parietal and superior tem- 
poro-sphenoidal convolutions; (5) to the first and second 
temporo-sphenoidal convolutions. 

The pons Varolii and medulla oblongata are supplied 
in the following manner: 

The basilar artery gives off vertical branches, which 
supply the nuclei of origin of the nerves and the epen- 
dyma of the fourth ventricle. The nuclei are also sup- 
plied by small vessels, which enter with the roots of the 
nerves. 

The inferior cerebellar artery supplies the lateral parts 
of the medulla and the inferior cerebellar peduncle. The 
remaining portions of the pons and medulla, and the 
cerebellum, are supplied by the transverse and cerebellar 
arteries. 

The vessels which enter the substance of the brain from 
the base are terminal arteries, 7.e., there is no anastomosis 
between the distribution of one vessel and the adjacent 
ones. A certain amount of anastomosis exists between 
the vessels which ramify in the pia mater, but this is 
very often insufficient to compensate for the anemia pro- 
duced by the plugging of one of these arteries. 

When a terminal artery is completely obstructed by 
an embolus, the supply of arterial blood to the distribu- 
tion of the vessel is shut off. According to Cohnheim, 
the reflux of blood from the corresponding vein will 
gorge the capillaries with blood. Litten believes that 
the filling of the capillaries is due to the influx of blood 
from the capillaries of adjacent regions. If the blood 
pressure is too feeble, however, this feature is not ob- 
served. 

Asa result of the cessation of circulation in the terri- 
tory supplied by the obstructed vessel, the nutrition of 
the capillaries and veins becomes impaired, and they 
therefore permit the escape of red blood globules. Then 
the tissues which have been deprived of blood undergo 
simple fatty degeneration, and an infarction is produced. 
Finally, absorption occurs, leaving a cyst containing clear 
fluid. 











If a reflux of blood into the vessels does not take place, 
the infarction has a yellowish or whitish color from the 
beginning, but in other respects the course is the same as 
that just described. The retrogressive changes (necrobi- 
osis) probably begin at the end of thirty-six or forty- 
eight hours. Some authorities think that these changes 
begin at the end of two or three hours. , 

Unlike what takes place in embolism of other organs 
of the body, embolism of the brain does not often produce 
a hemorrhagic infarction, but almost always results in a 
patch of yellow or white softening. The reason for this 
difference is not very clear. 

When the embolus is lodged fn one of the vessels sup- 
plying the cortex, the effect produced varies according 
to the size of the vessel and the extent to which it anas- 
tomoses with surrounding ones. Infarctions in this 
region are usually of small size, though they occasion- 
ally attain much larger dimensions than those situated 
within the brain, particularly if a large branch of the 
middle cerebral artery has been occluded. The color of 
the infarction is yellow or brown, and the external sur- 
face is often extremely hard. It diminishes in extent 
toward the interior, and sometimes involves only the 
gray matter of the convolutions. On the other hand, 
the white matter below the convolutions may alone be 
affected, while the cortex escapes. The pia mater above 
the lesion is usually infiltrated with fluid, and is readily 
detached from the surface. 

In old cases in which the motor regions have been in- 
volved, either within the brain or in the cortex, descend- 
ing degeneration of the pyramidal tracts occurs as it does 
in cerebral hemorrhage. Moreover, I have occasionally 
seen atrophy of the unaffected parts of the hemisphere 
after extensive lesions of this kind, though not to so 
marked an extent as that which I have described as oc- 
curring in cerebral hemorrhage. 

Clinical History.—From the nature of the disease, the 
symptoms of cerebral embolism always begin suddenly. 
The attack may or may not begin with a disturbance of 
consciousness, and, as in cerebral hemorrhage, this may 
vary from a passing vertigo or feeling of confusion to 
complete and profound uaconsciousness. General or uni- 
lateral convulsions also constitute a not infrequent 
accompaniment of the attack. The symptoms during 
the stage of unconsciousness differ in no respect from 
the corresponding ones of cerebral hemorrhage, but they 
are not apt to be so prolonged, and, moreover, there are 
no characteristic phenomena connected with the bodily 
temperature. There is usually a slight rise of tempera- 
ture soon after the development of the seizure, but after- 
ward it varies irregularly from time to time. In fatal 
cases the temperature usually rises steadily until death. 

As the embolus is situated commonly in one of the 
arteries of the left side of the brain (usually the middle 
cerebral), right hemiplegia usually results, and in a con- 
siderable proportion of cases is associated with aphasia. 
In fact, the sudden occurrence of right hemiplegia and 
aphasia, without previous head symptoms, is prima facie 
evidence that we have to deal with an attack of embolism 
of the left middle cerebral artery. 

The character of the aphasia differs greatly in individ- 
ual cases according to the situation of the lesion, and all 
the different varieties of aphasia may thus be produced 
(vide the article on Aphasia, in Vol. I.). In some cases, 
indeed, aphasia is the only symptom produced, and may 
remain permanent without being followed by any other 
symptom. Ina case which came under my observation 
it was associated with epileptiform convulsions, which 
recurred at irregular intervals. 

At other times the aphasia is a temporary symptom 
which soon disappears, but is followed later by an apo- 
plectiform attack, attended with hemiplegia, which then 
runs the usual course. 

The duration of the hemiplegia varies within very 
wide limits. If recovery does not take place within a 
few weeks, the paralysis will probably persist for the 
remainder of life. Unlike the hemiplegia of cerebral 
hemorrhage, the paralysis is not so apt to undergo slow 


295 


Brain. 
Brain, 





but progressive improvement. Recovery takes place 
either rapidly or not at all in the large majority of cases. 

The further course of the disease can be distinguished 
in no respect from that of cerebral hemorrhage. As we 
have stated in our discussion of the latter subject, even 
a post-mortem examination may fail to distinguish in old 
cases between the remains of a clot and an embolic proc- 
ess, inasmuch as the embolus itself may gradually have 
been absorbed and the original brain lesion replaced by a 
cyst or cicatrix. 

For the changes in the symptomatology due to the 
varying location of the embolus, we must again refer 
the reader to the article by Dr. Starr, on Brain Diseases : 
Diagnosis of Local Lesions. 

But we will here describe a very peculiar group of 
symptoms, apparently of bulbar origin, which has been 
observed in a number of instances in which the lesion 
was situated in another part of the brain. The clinical 
history of this form of disease is well shown by the fol- 
lowing case reported by Berger: 

“A man, aged sixty-one, suffering from small, con- 
tracted kidneys. In 1883 dysarthria and dysphagia de- 
veloped suddenly without any violent apoplectiform 
symptoms. At the end of two days right hemiparesis 
and salivation were observed. Striking improvement 
after local faradization. About a year later an attack 
of tonic rigidity of the body, followed by an exacerba- 
tion of the disturbances of speech and deglutition, and 
also of the right hemiparesis. Paralysis of the orbicula- 
ris oris, particularly on the right side, and of the muscles 
of the tongue and deglutition. Inconstant condition of 
the glosso-labio-pharyngeal paralysis; no progressive 
course. No atrophy; normal electrical irritability of the 
paralyzed muscles.” 

Quite a number of autopsies have shown that symp- 
toms of this character may be due to a bilateral or even 
unilateral lesion of the cerebral hemispheres in any posi- 
tion which interferes with conduction from the cortex to 
the centres of articulation and deglutition in the medulla 
oblongata, though the latter may be entirely intact. <A 
case of this description, in which I was fortunate enough 
to obtain an autopsy, was seen by me only a few days 
ago. In this instance a spot of softening was situated in 
the anterior third of the posterior half of the right in- 
ternal capsule, and also involved slightly the anterior 
part of the optic thalamus. 

Diagnosis.—The diagnosis of cerebral embolism has 
been considered in part in the discussion of cerebral 
hemorrhage, so that very little need now be said on the 
subject. 

One combination of symptoms, viz., the sudden occur- 
rence of right hemiplegia and aphasia in a patient who 
has previously presented no cerebral symptoms, is ex- 
tremely characteristic of embolism of the left middle 
cerebral artery. This group of symptoms is observed 
with comparative rarity as the result of any other lesion, 
though, of course, a hemorrhage occurring in the internal 
capsule may give rise to the same symptoms. In the 
latter event, however, the disturbance of consciousness 
is usually more severe than in the former, and, in addi- 
tion, the onset of the disease is generally not so sudden. 

The development, during an apoplectiform attack, of 
an embolism of the central artery of the retina is very 
significant of a similar affection of one of the cerebral 
vessels. Symptoms indicative of the formation of infarc- 
tions in the spleen, kidneys, and lungs may also aid us 
in coming to a conclusion. 

Youthful age and the presence of valvular disease of 
the heart also point to embolism rather than hemorrhage. 
In very young children and infants, however, cerebral 
embolism is much rarer than hemorrhage. 

If aphasia occurs as the sole symptom the diagnosis 
must be made from the attendant circumstances, such as 
the existence of cardiac disease, the occurrence of pre- 
vious attacks of a clearer nature, the age of the patient, 
and the subsequent history of the disease. 

Berger states that the pseudo-bulbar symptoms men- 
tioned in the preceding section are distinguished from 


296 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


glosso-labio-pharyngeal paralysis by the following differ- 
ential features: 

1. Sudden apoplectiform development of the symp- 
toms, which present no tendency to progression. 

2. The presence of other cerebral disturbances. 

3. The absence of atrophy of the paralyzed muscles, 
even after the disease has lasted a considerable time. 

4. The absence of the reaction of degeneration. 

5. The intact reflex irritability of the paralyzed mus- 
cles. 

6. The absence of signs of progressive muscular 
atrophy. 

Prognosis.—This depends mainly upon the situation 
and character of the artery—whether terminal or not— 
in which the embolus has lodged, and upon its complete 
or incomplete occlusion. The latter factor is of com- 
paratively slight importance, since incompletely occlud- 
ing emboli usually are converted into completely oc- 
cluding ones from the secondary deposit of a thrombus. 
As a matter of course, the occlusion of one of the ves- 
sels supplying the pons or medulla may prove rapidly 
fatal. 

If improvement occurs it usually takes place within 
one or two weeks. Otherwise the symptoms remain 
stationary or are complicated at a later period with 
secondary contractures, etc., as in cerebral hemorrhage. 
According to our experience, there is less danger of 
mental impairment than in cerebral hemorrhage. Re- 
lapses may occur at any time from the continuance of 
the primary cause. Death occurs much less frequently 
than in hemorrhage of the brain, unless the embolus 
lodges in the basilar artery. 

CEREBRAL THROMBOsSIS.—Ltiology.—Thrombosis of 
the cerebral arteries is generally the result of atheroma- 
tous degeneration of the vessels. In such cases the cur- 
rent of blood is also usually slowed on account of weak- 
ness of the heart’s action, and coagulation, therefore, 
takes place upon the roughened parts of the inner coat 
of the vessel. The deposit of coagulated blood gradually 
increases in extent until, as a rule, the lumen is entirely 
occluded. In rare instances, however, a parietal throm- 
bus forms, leaving part of the lumen free for the passage 
of blood. 

As we have stated previously, it is quite common to 
find, also, that a secondary thrombus is deposited upon 
a cerebral embolus, whatever the origin of the latter may 
have been. 

A syphilitic affection of the walls of the vessels may 
lead to thrombosis in the same way that atheroma does, 
but the syphilitic vascular lesions have been discussed 
under a separate heading (see Brain: Syphilis). 

As atheroma of the vessels is usually one of the acci- 
dents of advancing age, so thrombosis is also most fre- 
quent after middle life. 

Another variety of cerebral thrombus is that known as 
the marasmic thrombus. This develops in intact vessels 
as the result of simple retardation of the current of blood 
(perhaps associated with a change in its chemical con- 
stitution), and is observed usually after protracted, ex- 
hausting diseases or severe attacks of an acute infectious 
disease. . This variety is also observed in childhood, from 
similar causes. : 

Another form of thrombosis is the result of direct 
compression of the vessel, either from a mass of sur- 
rounding exudation, particularly in tuberculous menin- 
gitis, from the growth of a tuberculous new formation 
through the wall of the vessel, or from the pressure of a 
tumor of the brain. In such cases, however, the clinical 
history of the thrombus is usually lost in that of the 
primary disease. 

Clinical History.—Cerebral thrombosis is frequently 
preceded by prodromal symptoms, which vary greatly 
in character and duration, lasting at times for many 
months. These symptoms are due probably to the im- 
paired nutrition of the brain, on account of the slowly 
increasing diminution of the elasticity and calibre of the 
affected vessel. 

Dizziness is one of the most common prodromal mani- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





festations; it may be constant or intermittent, and is 
often aggravated by any sudden change in position. 
Violent headache is more infrequent, and is usually dif- 
fused over the entire head. The patient grows moody 
and morose, the memory is weakened, and impairment 
of speech may also be noticed. Sometimes intercurrent 
attacks occur, in which the individual partly loses con- 
sciousness, experiences numbness in an arm or leg, and, 
perhaps, has a slight loss of power in these parts. 

In addition to the cases of mental weakness, Monakow 
describes a form of more decided psychical disturbance. 
This may assume the shape of senile mania or melan- 
cholia or the delusions of persecution. In the latter 
event, the patient believes himself ill-treated by his 
family and friends, threatens lawsuits in order to defend 
his rights, etc. 

Others exhibit increased excitement, with vivid hallu- 
cinations and occasionally, as in ordinary acute mania, 
sing aloud, gesticulate violently, and exhibit complete 
confusion of ideas; destructiveness may also be mani- 
fested. This condition rapidly gives place, however, to 
a quiet dementia. 

Melancholic conditions are rarer. They are character- 

ized by mental confusion and depressive excitement; 
delusions of a religious tinge are sometimes noticed, and 
there may be a tendency to suicide. This condition also 
terminates quickly in dementia. 
_ After a longer or shorter duration of the prodromal 
stage, the symptoms proper of the thrombosis usually 
develop with great rapidity. Sometimes, indeed, the 
attack is as sudden as one caused by embolism or hemor- 
rhage, and if no previous symptoms have been observed, 
it may be impossible to make a differential diagnosis. 
The symptoms of the attack itself can usually be dis- 
tinguished in no respect from those of cerebral hemor- 
rhage, but there is some difference to be noted in the 
subsequent history. Recovery from the paralysis which 
has been produced is extremely exceptional. On the 
contrary, the impairment of motion grows more marked 
with time. This feature is explained in part by another 
peculiarity of the affection, viz., that very commonly 
the mental power becomes steadily impaired after the 
attack of paralysis. If several seizures occur (as is not 
infrequently the case), the patient gradually sinks into 
a condition in which he forgets almost everything, and 
even fails to attend to the wants of nature; his speech is 
thick and indistinct, ete. 

The symptoms due to thrombosis of the basilar artery 
are so peculiar that they merit separate consideration. 

The symptoms develop suddenly or gradually, accord- 
ing to the mode of development of the thrombus.. 

Sometimes merely a severe apoplectic attack is pro- 
duced, accompanied often by contraction of the pupils 
and irregular breathing, the attack proving fatal in a 
period varying from a few hours to several days. 

But usually very characteristic phenomena are devel- 
oped. If hemiplegia is present (and this is usually the 
case), it is generally of the so-called “alternate” type 
(Gubler). In this form of hemiplegia the body is para- 
lyzed on one side and the face on the opposite side (the 
paralysis of the facial nerve involves the occipito-frontalis 
and orbicularis palpebrarum, and is therefore similar to 
peripheral facial paralysis). In addition, there is an- 
other very rare form of alternate hemiplegia, in which 
the face and body are paralyzed on the same side, the 
motor oculicommunison the opposite side. Leyden pro- 
poses to call the former variety inferior alternate hemi- 
plegia, the latter variety superior alternate hemiplegia. 

In addition, disturbances of speech and deglutition are 
frequently produced, the former more commonly than 
the latter. The difficulty of speech is shown by the 
thick, muffled articulation, and is due to paresis of the 
muscles of articulation; in other words, it does not pre- 
sent the characteristics of any of the forms of aphasia. 
The tongue is usually moved with difficulty. The 
bodily temperature is apt to rise very high in these cases 
shortly before death, and Eichhorst has reported a case 
in which the temperature reached 108° F., 


——— 


Despite the gravity of the lesion, some patients make 


~a tolerably complete recovery, and again become able to 


walk about, until a further extension of the disease pro- 
duces a second and fatal attack. 

Diagnosis.—As we have on several occasions remarked, 
the symptoms of an apoplectic seizure due to cerebral 
hemorrhage, embolism, and thrombosis may be identical. 
But the attendant circumstances are often of such a nature 
that we shall be enabled to distinguish cerebral throm- 
bosis from the two other affections mentioned. 

When the prodromal stage is very long and the attack 
itself develops slowly, the recognition of thrombosis is 
usually quite easy. But when these conditions do not 
hold, the diagnosis depends chiefly upon the age of the 
patient, the condition of the blood-vessels (particularly 
the radial and temporal arteries), and the subsequent 
history of the case. 

Furthermore, it is characteristic of this disease that it 
is very often attended by a gradual, pronounced failure 
of the mental powers, so that the patients finally sink 
into a demented condition. 

In a considerable proportion of cases, however, it is 
impossible to make a positive diagnosis between cerebral 
hemorrhage and thrombosis. 

Prognosis.—The prognosis, as regards complete recov- 
ery, is extremely unfavorable, not so much on account 
of the severity of the lesion itself, but from the fact that 
the vital powers are usually at such a low ebb that 
restoration of function in the affected parts is impossi- 
ble. 

Sometimes a considerable interval elapses between the 
individual attacks, but the disease is always progressive, 
and unless carried off by an intercurrent disease, the pa- 
tient gradually sinks into a condition of imbecility, finally 
gets up bed-sores, etc. 

Treatment.—During attacks of cerebral embolism or 
thrombosis very little can be done beyond keeping the 
patient perfectly quiet. When indicated by the pulse, 
stimulants should be administered to rouse the failing 
action of the heart. 

After the primary attack has passed over, the treat- 
ment of the residua of embolism will be essentially the 
same as that advised concerning cerebral hemorrhage. 

After thrombosis, the paralysis and other symptoms 
do not yield to treatment, and little can be done beyond 
keeping up the general nutrition of the patient. 

Leopold Putzel. 


BRAIN: FUNCTIONS OF CEREBRAL CORTEX.— 
It is now conceded that the physiological processes un- 
derlying sensation and perception, emotional expression, 
language, voluntary movement, memory, the association 
of ideas and intellection are to be sought within the en- 
cephalon. It is admitted, also, that the structures which 
are thus prerequisite to every manifestation of mental 
life are the neurones of the cortex of the cerebral hemi- 
spheres. Exner’s statement that a “physiology of the 
cerebral cortex in the sense in which there is a phys: 
iology of the muscle, etc., scarcely exists at the pres: 
ent time” is doubtless as true now as it was two 
decades ago. And yet the functions of the cerebral 
cortex, both of its entirety and also of differentiated por 
tions, are at the present day in large measure ascertained 
and comprehended. 

A bare recital of the facts of cerebral localization con 
duces only to confusion. It would be difficult to point 
to another department of science in which facts as facts 
have so little significance. Before a fact or reputed fact 
can be comprehended and made to serve as the basis for 
conclusions concerning the nature and localization of the 
cerebral functions, it must not only be critically examined 
on its own merits; it must also be connected with a great 
multitude of other complicated phenomena and inter- 
preted in relation to general theories of mental and neural 
activity. The comprehension of the functions of the 
cerebral cortex is mainly the result of psychological in- 
terpretation and analysis. 

Six different methods of investigation or lines of in- 


297 


Brain, 
Brain, 





quiry have contributed all the facts upon which the con- 
clusions that constitute the science of cortical neurology 
are based. Each has certain advantages not possessed 
by others, and each has its limitations. The first of these 
methods is the method of biological comparison, — Al- 
though this is the oldest method, it is certainly the least 
important. Even the ancients had noted the greater 
size of the human brain in comparison with that of the 
lower animals, as well as the more complicated structure 
of its convolutions; in consequence, some taught that 
the superior intelligence of man was to be accounted for 
by the greater size of his brain, and that the brain was 
peculiarly the seat of intelligence. It has been customary, 
also, to compare the size of the frontal lobes in the more 
intelligent races with that of the same structures in the 
less intelligent races and in the lower animals. But this 
method alone would lead to the conclusion that the occip- 
ital and perhaps the temporal lobes were also the seat 
of higher psychical processes. Attempts have been 
made to draw positive conclusions from examination of 
the relative size, weight, thickness, and surface area of 
the cerebral convolutions in normal and degenerate indi- 
viduals or classes of men. This method furnishes only 
presumptive evidence that relative excess of cortical sub- 
stance is associated with higher grades of intelligence. 
The second method is that of experimental extirpation. 
This method was the first to give convincing evidence of 
diversity in the localization of functions within the cere- 
bro-spinal nervous system. Observations on the brain- 
less frog revealed the significant difference between 
those functions which could be carried on by the spinal 
cord alone and those which required the spinal cord and 
brain. The distinction between a reflex and a conscious 
reaction was thus no longer a matter of definition, for 
the brainless frog was shown to be a simpler, more me- 
chanical, and less intelligent frog than the intact frog. 
The differentiation between sensory and motor paths of 
conduction, first demonstrated by Bell through section- 
ing of the ventral and dorsal nerve roots, next revealed 
the possibilities of artificial interference or extirpation. 
Increased refinement of procedure has made possible the 
destruction of small or large portions of the cerebrum 
for the purpose of observing the resultant effect upon 
the behavior of the animal after recovery. The interpre- 
tation of the results of small or large ablations is beset 
with many difficulties. It is therefore not surprising that 
different observers have obtained widely divergent re- 
sults. If the effect of experimental extirpation be re- 
stricted to paralysis of a group of muscles or to some 
disorder of motility, and if these disturbances persist 
long after the operation, the inference is relatively direct. 
But after ablations that affect sensation only, the exact 
amount and character of the sensory disturbance is some- 
times difficult to ascertain, because these experiments are 
necessarily restricted to the lower animals, and the loss 
of sensation must be inferred from disorders of movement 
functionally related to the sense in question. Moreover, 
it is not easy even with the most approved method to 
limit the area destroyed. Inflammations ensue, degen- 
erations take place, cicatrices and abscesses may form. 
Post-mortem examination will not always serve con- 
vincingly to distinguish areas that have been rendered 
functionless from those that were still active at the time 
of death. Many of the phenomena of motor and sensory 
disturbance are evanescent, while others are so minute 
as to escape all but the most careful observation. Par- 
alyses which slowly recover may be explained either by 
assuming an identity of function for different portions 
of the cortex or by a substitution of function on the part 


of cells that have learned to perform an unwonted task. — 


To distinguish between a simple loss of sensation and 
those losses which have been variously described as soul- 
blindness, soul-deafness, etc., is a matter of extreme diffi- 
culty. The exact nature of the details of the psychical 
life of the lower animals is wholly conjectural; anatom- 
ical homologies between the human brain and the brains 
of lower animals are of doubtful significance, and it may 
be questioned whether anatomically identical parts of the 


298 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


brains of man and the lower animals perform similar 
functions. It is, therefore, not surprising that the func- 
tions of the frontal lobes were first unassailably established 
by this method only within the last decade through the 
painstaking experiments of Bianchi. 

The pathological method, which may also be called the 
method of natural extirpation, has peculiar advantages. 
The subjects of such experiments of nature are human 
beings, who may be carefully studied and questioned. 
The post-mortem location of cerebral lesions has been of 
the greatest service in furnishing early and convincing 
evidence of cortical areas of specific function in the hu- 
man brain. The existence and location of a speech centre 
was demonstrated by Broca from pathological findings 
as early as 1861 and was suggested by Bouillaud even 
in 1825. The evidence furnished by the pathological 
method is, however, often equivocal and even contradic- 
tory. The morbid anatomy of the brain is vague and 
indecisive compared with the definiteness of many estab- 
lished forms of mental disease. Conflicting evidence is 
to be expected. Cerebral lesions are seldom circum- 
scribed; tumors or hemorrhages at any one point often 
produce associated and secondary functional disturbances 
which may obscure the exact relations of cause and effect. 
It is also very seldom that bilaterally symmetrical lesions 
occur; and yet these are in some cases the only cause of 
the complete and persistent loss of function. Moreover, 
observers have not until recently determined and reported 
the ante-mortem condition of the patient with sufficient 
regard for essential details. .To this lack of careful ob- 
servation chiefly is ascribable the tenacity of the belief 
in the existence of so-called “ silent areas.” 

The method of irritation (chiefly electrical irritation) 
has contributed materially to the exact localization of 
cortical centres for the various bodily movements. By 
this method very small areas are incited to functional ac- 
tivity either by the electric current or by mechanical or 
chemical irritation. An objection to the localization of 
centres in the cortex by direct stimulation of the gray 
matter of the cerebral hemispheres has been found in the 
fact of electrical diffusion through the substance of the 
brain, whereby even weak currents may act upon areas 
remote from the electrode. Even the separation of the 
mass of a particular area by section from adjacent parts 
will not eliminate the diffusion of the current through 
the blood or along the nerves of the normal pathway of 
projection. Although it had been established that a 
current will produce similar movements whether applied 
to the gray matter of the cortex or to the fibres immedi- 
ately below, Franck and Pitres and Carville found that 
when applied to the cortex the current may be weaker 
and that the movements follow the application of the 
stimulus at an appreciably greater interval. These re- 
sults demonstrate the participation of the gray matter of 
the cortex in the production of the movements. The 
epoch-making investigations of Fritsch and Hitzig ad- 
vanced conclusive evidence that movements of greater 
co-ordination can be produced by the application of cur- 
rents to restricted areas of the Rolandic cortex than by 
stimulation elsewhere. The method of irritation has 
been employed chiefly on the lower animals, but occasion- 
ally also upon man. 

The histogenetic method, more familiarly known as the 
embryological or myelinization method, which is the 
outgrowth of modern improvements in histological tech- 
nique, has, in the hands especially of Meynert, Edinger, 
and Flechsig, contributed results o* great value. This 
method seeks to establish the anatomical relations of 
conduction pathways and cerebral centres at ontogenetic 
periods before the number and complexity of interlacing 
fibres defy the analysis of the microscope. The projec- 
tion and other fibres of the cerebral cortex take on their 
myelin sheaths at different periods of foetal and infantile 
life; before their myelinization they are believed to be 
functionless. The maturity of the cortical areas to 
which these fibre tracts belong may be inferred, according 
to Flechsig, from the successive development of the tracts 
themselves. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The last method to receive mention is the histo-degener- 
ative method. Secondary degeneration of nerve fibres 
and tracts invariably follows artificial extirpation and 
natural lesions. This degeneration is at first always in 
the direction of the functional conductivity of the tract; 
but later degeneration is also observed in the contrary 
direction toward the centre of neural emission. The 
study of the course of such degenerations has supplied 
much new evidence pointing to the anatomical and phys- 
iological connection of cortical areas with lower centres. 
The histological methods may be expected to supply in 
the future the more valuable contributions toward the 
comprehension of the interrelations of the neuronal ele- 
ments of the various parts of the cerebral cortex. 

These various methods have contributed within the 
present century a mass of material evidence, the several 
details of which are often self-contradictory, but from 
which a consistent consensus of opinion can be gathered 
by critical sifting and weighing of opposing contentions. 
The present article attempts to present only the general 
tendencies of the results and to outline the more signifi- 
cat conclusions. The over-emphasis of conflicting de- 
tails and of erroneous interpretations of results has often 
caused the localization of specific cerebral functions to 
appear more doubtful than it really is. The psycho- 
logical and metaphysical theories, which have helped to 
form the opinions of physiologists and other investi- 
gators, have contributed not a little to this confusion. 
Physiologists, in revolt against the dogmatism of meta- 
physical speculation, have frequently sought to frame 
conclusions in such manner as to avoid entanglement 
with psychological theory. The result, unexpected by 
them, has often been to warp or pervert their conclu- 
sions by primitive psychological points of view, which 
had long before been discarded even by traditional psy- 
chology. The controversy of Pfliiger with Lotze is a 
notable illustration of this tendency of the physiologi- 
cal mind to assail certain doubtless unjustifiable psycho- 
logical theorizing, and yet, in the effort, reverting to a 
speculative attitude that the history of the development of 
the anatomy and physiology of the nervous system shows 
to have been a distinguishing characteristic of the science 
only at its earliest beginnings and to have long since 
been set aside. Speculative views on the nature of the 
human soul or mind and on its relation to the body and 
objects of nature have always determined the trend of 
conclusions respecting the specific functions of the cere- 
bral cortex; for the reason, as has been before maintained, 
that these conclusions are necessarily psycho-physio- 
logical inferences. 

Until the time of Descartes all interpretations of phys- 
jological functioning were based upon crude psycho- 
physiological theories which were the outgrowth of a 
notion variously described as animism, vitalism, and an- 
thropomorphism. Briefly, animism identifies conscious- 
ness, life, and movement. The soul may be identified 
with the breath, because with the cessation of breathing 
the life and soul of the organism cease to exist or at least 
leave the body. Other observers, their attention at- 
tracted to the movement of the heart as the most sig- 
nificant bodily function, assumed this organ to be the 
seat of lifeand consciousness. Thus Aristotle considered 
the brain the coldest and most bloodless of the organs, 
its chief purpose being to temper the excessive heat of 
the heart, the true organ of the mind. Though the soul, 
as the vital principle of the entire organism, may be con- 
nected more particularly with some one organ of the 
body, nevertheless every organ, and indeed every object 
of nature, according to the animistic doctrine, functions 
through its endowment with a conscious vitalizing prin- 
ciple. Every physiological process and certainly every 
bodily movement is, from this point of view, the work of 
a rational and intelligent, though not always conscious 
or reflective spirit or soul. The animistic hypothesis is 
one that appears throughout the history of the organic 
sciences in many different guises. It is the progenitor 
of the doctrine of animal or vital spirits, and at almost 
all periods has inspired theories of psycho-physiological 





Brain, 
Brain. 


generalization such, e.g., as that advocated by Pfliiger as 
late as the middle of this century. 

It must not, therefore, be supposed because Pythag- 
oras maintained the brain to be the seat of the mind 
and intellect and Hippocrates speaks of the brain as the 
index and messenger of the intellect that they had arrived 
at these conclusions from a careful observation of facts. 
These are rather lucky guesses which subsequent research 
substantiated. Doubtless a few had observed the effect 
of concussion of the brain and had even referred idiocy to 
brain deficiency. It is stated that Hippocrates com- 
mented upon the loss of mental function following dis- 
ease and injury of the brain, and that Polybos claimed 
the brain to be a centre for the nerves and the organ of 
the mind. Erasistratus is said to have taught that sen- 
sory nerves arise from the brain membranes and motor 
nerves from the cerebral substance. Herophilus, accord- 
ing to Celsus, maintained that vital forces resided in and 
circulated from the ventricles of the brain, and Galen 
stated definitely that the seat of the soul and intellect is in 
the brain and that the animal spirits have their origin in 
the ventricles of the brain and pass thence to the heart 
through the arteries. The Christian writers adopted 
Galen’s view and conferred on it a theologic sanction 
which made correction difficult. As late as the thirteenth 
century Gordon, professor of médicine in Montpellier, 
placed common sensation and the reception of impressions 
in the anterior cornua of the lateral ventricles, imagination 
and intellection in the posterior, judgment in the third 
ventricle, and memory in the fourth. Rhazes (1554) lo- 
calizes imagination in the second lateral ventricle, reason 
in the middle ventricle, and memory in the posterior. 
Willis (1622-1675) considered the brain substance as 
the dynamic source or storehouse of the animal spirits. 
He placed memory and will on the convoluted surface of 
the cerebrum, and associated imagination with the corpus 
callosum, sense perception with the corpus striatum, im- 
pulse and emotion with the basal parts about the crura, 
vision with the thalamus, and involuntary acts with the 
cerebellum. These somewhat suggestive attempts to 
state the psycho-physiological functions of the brain 
were rendered futile and bereft of all inspiration to ex- 
perimental discovery by the persistent belief in the doc- 
trine of animal spirits. When some anatomists of the 
seventeenth century attacked vital spirits resident in the 
ventricles (Alexander Benedictis as early as 1527 was so 
bold as to doubt that the spirits existed at all), they were 
regarded as revolutionary by the great majority of the 
seventeenth and eighteenth century medical writers. 
The vital spirits, however, were gradually losing their 
psychical attributes and were at this time generally de- 
fined as like to “little flames” or in a still more material 
way as those “ very subtle particles ” (Willis). Moreover, 
anatomical investigations were indicating the nerves 
rather than the arteries as the conductors of these animal 
spirits. 

Descartes (1596-1650) first presented a psycho-physio- 
logical theory which contained possibilities for future 
advance. With him began a new era in physiological 
speculation. His chief contributions were (1) a consist- 
ent theory of a sensorimotor mechanism; (2) a clear dis- 
tinction between the automatic or reflex functions of the 
cerebro-spinal system and its conscious functions; (3) a 
description of the sensorimotor arc as composed of 
afferent and efferent nerves and of a central system capa- 
ble of reflecting sensory impulses from the brain to motor 
nerves mechanically and unconsciously, or even in spite 
of the will. Although it cannot be claimed .that Des- 
cartes discovered spinal reflexes, for he considered the 
brain as the centre for both conscious and reflex move- 
ments, he nevertheless was far ahead of his time in justly 
appreciating the reflex capacity of the central nervous 
mechanism. He made the error of assuming that there 
must be a single point in the brain at which sensory 
impulses are transformed into sensations and the will 
exercises its determining influence upon the body. Even 
those who scorn this philosopher’s attempt to find the 
seat of the soul in the pineal gland are not seldom guilty 


299 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of a similar assumption, although they may perhaps as- 
sign it a different location. 

After the time of Descartes various observers soon 
began to report reflex phenomena, but it was not until a 
century had passed that Whytt (1714-1766), in an essay 
on “ Vital and Other Involuntary Motions of Animals,” 
reported the now classical experiment of Hales. <A de- 
capitated frog was shown to be capable of reflex move- 
ment for thirty hours after decapitation. When a needle 
was thrust down the spinal marrow, the animal was 
strongly convulsed and immediately afterward became 
motionless. Whytt concludes that the immediate cause 
of the contraction of the muscles of animals, or at least a 
necessary condition, is a certain power or influence lodged 
in the brain, spinal marrow, and nerves. Of this power 
he says: “If in compliance with custom I shall at any 
time give it the name of animal or vital spirits I desire it 
to be understood to be without any view of ascertaining 
its particular nature or manner of acting.” Whytt de- 
monstrated the special structures with which reflex func- 
tioning is connected. He believed, however, that no 
motion could take place in the body unattended by some 
degree of consciousness, thus rejecting the mechanical 
theory of Descartes and substituting a diffusion of con- 
sciousness wherever nerves are found. 

Whytt’s definition of the “ power of nerves” was fixed 
for science by Haller (1708-1777), who maintained the 
existence of a similar power inherent in living muscle. 
This he called irritability or “ vis in situ,” which he con- 
sidered to be independent of the sensibility of nerves. 
He also used the term “vis nervosa,” but nevertheless 
takes for granted the existence of animal spirits and even 
debates what manner of fluid it may be. 

The development of the concept of a force of gravity 
and the exploitation of the famous vibration theory of 
Newton made possible a detailed development of the 
mechanical theory of nervous reaction suggested by 
Descartes. Thus David Hartley (1649), the well-known 
psychologist, endeavored to explain the functions of the 
brain in connection with the association of ideas and 
sensations on a basis of the vibrations of the ether, a 
subtle fluid of the nerves. Indeed, Newton had himself, in 
the “ Principia,” advanced the opinion that all sensations 
and movements are excited by the vibrations of a very 
subtle spirit propagated through the solid capillamenta 
of the nerves from the organs of sense to the brain and 
from the brain to the muscles. 

Unzer (1727-1799), taking up Whytt’s results and 
point of view, distinguished more clearly between the 
sensory impulse which travels from the periphery to the 
brain, and the material idea, as he calls it, into which it 
is transformed in the brain, giving rise to an image in 
the soul. The sensory impulse on reaching the brain is 
reflected or turned back, giving rise to motion with con- 
ciousness. If it is reflected or turned back before reach- 
ing the brain it gives rise to motion without conscious- 
ness. Unzer, however, thought that the spinal ganglia 
were the structures in which this reflection took place. 

Prochaska’s work on reflex action (1749-1820) re- 
mained for fifty years an object of commendation. He 
was looked upon by Longet as the investigator who first 
made reflexes a distinct class of action. He clearly 
posited a vis nervosa as the cause latent in the nervous 
pulp, capable of producing certain effects when acted 
upon byastimulus. “External impressions made on sen- 
sitive nerves are propagated with great velocity through- 
out their entire length to their origin. From this place, 
they are reflected according to a certain law and pass into 
certain and corresponding motor nerves by which again, 
being very quickly propagated to muscles, they excite 
certain and determinate movements. This place in which, 
as a centre, nerves of sense and motion meet and com- 
municate, and in which the impressions of sensitive nerves 
are reflected into motor nerves, is called by a term already 
received by most physiologists, the ‘sensorium com- 
mune.’” Prochaska even brought his central mechanism 
into line with biological conceptions of instinct, in main- 
taining that the law under which reflection takes place is 


500 


“the preservation of the individual.” Many physiolo- 
gists had followed Newton in establishing a vibration 
theory for the nervous system; Prochaska, in turn, was in- 
fluenced by Galvani’s discoveries to look upon electricit 
as the physical condition for the manifestation of vis 
nervosa. Neither Prochaska nor Unzer made any lasting 
contribution to our knowledge of the localization of di- 
verse centres of reflex and conscious reactions. 

Unzer had presented certain views on the localization 
of cerebral functions, and Prochaska in 1784 published in 
Vienna a work on the nervous system in which he de- 
veloped a scheme of cerebral localization which estab- 
lishes him as the immediate predecessor of Gall. Owing 
to the unproductiveness of the phrenologists and because 
of the dogmatism with which the system was asserted, 
it is customary to look upon Gall as having no place 
whatever in the development of the science of neurology. 
The excesses of phrenology are to be attributed to Spurz- 
heim, Combe, and their followers. Their noisy advocacy 
of what they considered a philosophical system gave to 
it great popularity until the middle of this century, and 
its attendant ill-repute in scientific circles. Gall, it is 
true, embraces within his system the views of the physi- 
ognomists, who had remained somewhat outside the pale 
of science; but he is nevertheless a legitimate successor 
of the cerebrationists of his time. The advanced posi- 
tion which he held and the discussion to which it gave 
rise were a distinct impulse to the development of ex- 
perimental workin neurology. Indeed, Gall and Spurz- 
heim were among the first to give public demonstrations 
of the anatomy of the human brain, as also they were 
among the first to advocate that the cerebral cortex is 
the only organ of the mind. It is true that Gall and his 
followers contributed nothing to our knowledge of the 
localization of functions in the cerebral cortex, but they 
nevertheless pointed the way; those who followed, em- 
ploying more legitimate scientific methods, initiated the 
discoveries that have led to the present status of the sci- 
ence. Gall’s methods hark back to preceding modes of 
thought and demonstration, and hence he is the last 
significant figure of a line of speculators and investigators 
that began with Descartes. After him, the presumption 
has always been in favor of specialization of function, 
and of restricting the psychical functions of the nervous 
system at least to the cerebrum. His chief errors flowed 
from the acceptance of a psychological system, which 
viewed the mind as made up of separate faculties, and 
from his readiness to use insufficient evidence to arrive 
at far-reaching conclusions. Thus he placed the faculty 
of language behind the eyes, because he observed the 
protruding eyes of some of his school-fellows noted for 
their facility in language. The protrusion of the eyes 
and the various bumps upon the skull were to him in- 
dices of the growth of the convolutions immediately 
beneath. Gall recognized twenty-six different faculties 
or organs, and selected their place by examining the heads 
of friends, of inmates of jails and lunatic asylums, and 
of other persons who happened to be conspicuous for 
some special faculty or mental trait. These twenty-six 
organs were marked upon the skull by round enclosures 
with vacant interspaces. The common phrenological 
charts wherein the skull-cap is portrayed divided into 
oblate and coterminous areas are the production of Spurz- 
heim and Combe, who increased the number of faculties 
to thirty-five and neatly filled out the entire area with an 
equivalent number of organs. 

When Bell, in 1811, published the results of sec- 
tioning the anterior and posterior roots of the spinal 
nerves, he gave to the world the first satisfactory demon- 
stration of the specificity of the function of motor and 
sensory nerves. He thereby initiated the era of experi- 
mental investigation and laid the foundation of modern 
nerve physiology. Simple as were the facts observed by 
Bell and clear as was the evidence, the embodiment of 
his results, known as Bell’s law, was not accepted with- 
out challenge. On the one hand, he was accused of dissect- 
ing the brain to find the seat of the soul. It was probably 
for this reason that he privately published his conclu- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





sions in a communication entitled “Idea of the New An- 
atomy of the Brain, Submitted for the Observation of His 
Friends.” On the other hand, it was argued against Bell’s 
law that the mechanical juxtaposition of fibres of specifi- 
cally different function was as unscientific as the system 
of phrenology. As late as 1831 Lange and Beck main- 
tained that Bell’s law was as speculative as Gall’s locali- 
zation of cerebral functions. The labors of Magendie, 
Bellingeri, Panizza, and Van Deen confirmed Bell’s con- 
clusions. Miiller’s “ Physiologie” (1834) established Bell’s 
law in Germany, contributing to the facts of functional 
specificity by the galvanic irritation of both roots of 
the spinal nerves of the frog. Longet, in 1841, demon- 
strated Bell’s law on higher animals. 

Before the relation of the sensory and motor roots to 
the gray matter of the cord and cerebrum could be estab- 
lished, some intelligible hypothesis was necessary to ex- 
plain the function of the cord in transferring a sensory 
stimulus toa motornerve. Marshall Hall’s “ Memoirs on 
the Nervous System” (1887) elaborated a mechanical 
theory of reflex action. He maintained that the cord is 
composed of two parts very closely connected with each 
other; the first part is a bundle of nerves mediating sen- 
sation and volition, the central organ for these fibres be- 
ing in the brain; the second part is the true spinal cord, 
generally though not invariably connected with the first 
part and distinguished by excito-motor nerves. He thus 
assumed the existence of two separate systems of nerves, 
an excito-motor system and a sensori-volitional system, 
both perhaps enclosed within the same nerve sheath. 
With the function of the excito-motor system nothing 
psychical was associated; he stoutly affirmed that brain- 
less reflexes were unattended by sensation or by any 
other rudimentary form of consciousness even in the least 
degree. Theexcito-motor force he identified with Haller’s 
vis nervosa, Miller’s motor power, and Flourens’ ex- 
citability. Kiirschner, who translated Hall’s work into 
German, maintained that sensory nerves ran in the pos- 
terior column and motor nerves in the anterior column. 
He distinguished single movements of flexion and exten- 
sion that are produced in the cord from the coordinate 
movement of limbs produced in the cerebellum and cere- 
brum. 

Many observations were made to determine the truth 
of Hall’s statement that brainless animals never moved 
spontaneously. Volkmann, in Miiller’s Archiv for 1838, 
justly maintains that whether the cord has obscure sen- 
sations is not manifest, for experiments prove only that 
the part of the body furnished with a brain does not feel 
the irritation of that part which has been severed from 
itsconnection. He inclines to the view that the behavior 
of animals with cord and oblongata is not purely reflex, 
but rather of such character that it is impossible to deny 
the co-operation of a psychic principle, the degree of 
consciousness in such case being dreamlike, and marked 
by the presence of obtuse sensations and even obscure 
conceptions that help to determine the mdvements. 
Miller, on the other hand, maintained that if the sensory 
stimulus can pass on to the sensorium commune in the 
brain, it becomes a conscious sensation, but in case of 
section of the spinal cord it produces centripetal action 
in the cord only. In both cases reflex movements may 
result, but in one instance they are attended by conscious 
sensation, in the other not. 

The last opponent to the theory of non-conscious spinal 
reflexes and of the localization of all psychical functions 
within the cerebrum was Pfliiger (1853), who contributed 
so largely to our knowledge of reflexes and yet vitiated 
his conclusions with primitive metaphysical considera- 
tions. Consciousness for him is motion and exists wher- 
ever central nerve substance is found. It is divisible in 
all animals with its material substratum; hence the well- 
known theory of a spinal-cord soul. Reflex action is the 
operation of a neuro-psychic mechanism by means of 
which the peripheral sensory fibre, by whatever cause 
excited, causes through mediation of the spinal cord the 
ordinary state of excitation in motor nerves. The brain 
is not the only organ of sensation; the functions of the 


Brain, 
Brain, 


sensorium are extended throughout the cerebro-spinal 
system. 

A consistent theory of the central neural mechanism 
was finally contributed in an acceptable form by Lotze 
in the article on “Instinct” in Wagner’s “ Handworter- 
buch der Physiologie.” He suggests that the reflexes, and 
probably the lower instincts also, are purely mechani- 
cal. These elementary reactions, he explains, are due 
to purely physical connections which have been estab- 
lished by nature, and which the mind can neither invent 
nor construct. After the mind learns these elementary 
movements, it may weave them into richer and more 
complicated patterns, just as letters may be combined 
by the mind into sentences. Physical changes set up in 
the peripheral ends of sensory nerves are therefore con- 
ducted unaltered in character to the brain. Here occur 
all those processes by which physical excitation is trans- 
muted into the psychic forms of sensation, feeling, etc. 
The reflexes of Pfliiger’s decapitated frog are due not to 
sensation or intelligence present in the cord, but to the 
after-effects of these, for the motor states of the mind are 
transformed into nervous impulses in the brain alone, 
whence they are propagated through the efferent nerves 
to the muscles. By practice and training a secondary 
character which survives decapitation is imparted to sub- 
ordinate centres. Lotze’s mechanism is thus constituted 
of inherited and acquired habits. With Lotze’s explan- 
ation of the neural basis of reflex, instinctive, and con- 
scious reactions, the restriction of strictly psychical func- 
tions, at least, to the encephalon may be considered to 
have been at last decisively established. 

Meanwhile, the evidence of the specificity of parts of 
the encephalon was being advanced by experimental 
physiologists in the first instance and by pathologists in 
thenext. Flourens, in 1821, published his “ Experimental 
Researches on the Character and Functions of the Ner- 
vous System”; a second edition in 1842 reported addi- 
tional experiments. Longet and Vulpian, in 1866, and 
Goltz, in 1869, contributed experimental evidence. Flour- 
ens was the first to employ extensive ablations of various 
portions of the encephalic nervous system. He was thus 
able to locate a centre for the coordination of respiratory 
movements near the angle of the calamus scriptorius and 
to show that the medulla oblongata contained centies for 
movement of the face and for some forms of emotional 
expression. Vulpian demonstrated that a young rat de- 
prived of all the encephalon above the medulla oblongata 
can yet move its limbs and emit a cry of pain when its 
toes are pinched. On destruction of the oblongata the 
cry ceases, but the reflex movements continue. More- 
over, he correctly interpreted the cry as no real sign of 
pain, but only a reflex contraction of the laryngeal and 
expiratory muscles. The investigations of Flourens in 
1828, and later of Goltz, proved that the semicircular 
canals are the peripheral organs of equilibration, and 
located the central organ of equilibration in the cerebel- 
lum. These demonstrations were made on pigeons, cats, 
dogs, andmoles. Inall cases, partial ablation of the cere- 
bellum induced disturbances of gait and station, rang- 
ing from slight swaying or reeling to an apparently com- 
plete loss of station and locomotion. Similar experiments 
performed on the cerebral hemispheres seemed to show an- 
nihilation of perception, ideation, volition, and intelli- 
gence in general, but large tracts of the brain cortex could, 
according to Flourens, be removed without causing any 
apparent mental disturbance. The ablation of single 
areas produced a similar result. These results led Flour- 
ens to the formulation of the dictum of the equivalence of 
all parts of the cerebral hemispheres, each portion being 
capable of performing all the functions of the whole. 
Flourens believed, however, that sensation proper was de- 
stroyed by removal of the cerebral hemispheres. Vulpian, 
on the other hand, maintained that sensation continued, 
but was crude and obscure in comparison with the distinct 
sensation or perception of the cerebral hemispheres. Lon- 
get ascribed the crude sensation to the midbrain. Goltz 
does not decide the question, but ascribes to the midbrain 
an adaptive faculty and terms the reactive functions of 


B01 


Brain. 
Brain, 





these centres, “responsive” movements. Ferrier accepted 
this distinction and suggested three groups of reactive 
functions: the kentro-kinetic or excito-motor function of 
the spinal cord; the eesthetico-kinetic function of the mid 
brain and cerebellum; and the noetico-kinetic function 
of the cerebral hemispheres. In this way, he endeavors 
to avoid the use of the term sensation in connection with 
the complicated movements of the midbrain, defining the 
esthetico-kinetic reaction as one unaccompanied by con- 
sciousness. The various investigations of this initial 
period of physiological experimentation tended, when 
the results were analyzed and judiciously interpreted, to 
restrict all conscious functioning to the cortex of the 
cerebral hemispheres. 

Flourens’ researches had been indeed epoch-making, 
so far as they concerned the establishment of the specific 
capacities of the portions of the nervous system below 
the cerebral hemispheres. So thoroughgoing were his 
methods, so painstaking his researches, and so full of in- 
sight his conclusions, that the doctrine of the equiva- 
lence of all portions of the cerebral hemispheres long 
held sway, even against sound pathological evidence, 
and according to Ferrier became in consequence answer- 
able for many erroneous notions in cerebral physiology 
and pathology. Schiff went so far in advocacy of Flour- 
ens’ conclusions that he set aside the testimony of pathol- 
ogists, which made for the specificity of parts of the 
cerebral hemispheres, as the opinions of “mere practical 
physicians.” Those who localized specific areas over 
the cerebral convolutions were also often slightingly re- 
ferred to as phrenologists. 

And yet sound pathological evidence had steadily been 
accumulating which pointed to this specialization of 
cerebral function. Bouillaud, in 1825, from experiments 
on animals and from the facts of clinical research, was 
led to maintain that lesion of the anterior lobes was more 
particularly responsible for loss of speech, and that 
special motor centres are situated in the cerebrum, the 
destruction of which is responsible for paralysis. Limited 
lesions of the cerebral hemispheres, he reports, give rise 
to limited paralysis which would not be the case if the 
cerebral hemispheres did not contain a multiplicity of 
differentiated centres for the conduction of motor im- 
pulses. With prophetic insight he remarks: “Iam well 
aware that the preceding propositions appear at variance 
with the results of experiments upon animals. It is cer- 
tain that after ablation of the cerebral hemispheres an 
animal may walk, run, move its jaws, eyes, eyelids, etc. ; 
and it is not less certain that an alteration of the cerebral 
hemisphere in man gives rise to paralysis, more or less 
complete, of voluntary motion on the opposite side of 
the body. Can we refute the one set of facts by the 
other? No, certainly not, for facts equally positive are 
not susceptible of refutation. A time will come when 
new light will dispel the apparent contradiction which 
exists between them.” 

The credit of having first indicated the motor function 
of certain regions of the cortex, and of giving a rational 
explanation of the phenomena of unilateral cerebral con- 
vulsions, belongs to Hughlings Jackson. Experimental 
physiology had apparently demonstrated that neither 
electricity nor any other customary stimulus of nerves 
and nerve centres was capable of exciting movement 
when applied. directly to the surface of the brain. It 
was, therefore, inferred that centres below the cerebral 
hemispheres were alone capable of initiating movements, 
and that the cerebral convolutions exercised restrictedly 
a psychical function. Against this view, Jackson con- 
tended that the cortex did not transmit an “influence ” to 
some distant motor region, but was itself motor and 
capable of motor discharge by irritation. 

A much more dramatic discovery added force to the 
arguments of those who opposed the finality of the con- 
clusions of the experimental physiologists. This was a 
contribution to the pathology of the cerebral hemispheres 
presented by Broca in 1861 and followed by corroborative 
evidence presented in a second contribution in 1865. In 
these clinico-pathological observations, Broca demon- 


802 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


strated that the cause of the disorder of speech known as 
aphasia, which had previously been syraptomatically in 

vestigated by Lordat as early as 1820, Bouillaud (1825), 

Jackson (1829), Dax (1886), and others, was a lesion of the 
posterior third of the inferior frontal convolution, An- 
alysis of the two cases first reported by Broca showed the 
lesion to be in the left cerebral hemisphere, which he at 
first regarded as accidental. Reports of similar cases by 
Voissan (1862), Broca (1864), and Seguin (1867), who had 
collected two hundred and seventy-two cases of right 
hemiplegia with aphasia, led to the conclusion that the: 
speech centre was located in the inferior frontal convolu- 
tion of the left hemisphere only. Broca himself, an an- 
thropologist of note, offered, as an explanation, the fact 
that the great majority of humanity are right-handed, in 
consequence of which the left hemisphere contains the: 
centres for the exquisitely coordinated movements which 
subserve speech, as well as those for the finer adjustments. 
of movements executed by the more motile hand. Bas- 
tian (1869) was the first to recognize the relationship of 
defective auditory perception to speech production. 

Ogle (1871) distinguished aphasia from agraphia. Broad-. 
bent first pointed out in 1872 the condition which is known 
as “ word-blindness.” The investigations of Wernicke, 
which began in 1874, furnished the basis for the concep- 
tion of sensory aphasia, and for the recognition of three 
varieties of aphasia: visual, auditory, and motor. He 
showed that a lesion of the first temporal convolution pro- 
duced auditory aphasia, and maintained that the most 
typical aphasia Gan occur with lesion of other parts of the: 
brain than Broca’s convolution. Contributions of im- 
portance, leading on to a better understanding of aphasia, 
were made by Trousseau and Hughlings Jackson, Fi- 
nally, Kussmaul, in 1877, in the article on Aphasia in 
“ Ziemssen’s Encyclopedia,” introduced the terms “ word- 
deafness ” and “ word-blindness,” and fixed the concept of 
aphasia in a form which it retained substantially until the 
time of Déjerine. 

About this time Fritsch and Hitzig, in 1870, changed 
entirely the attitude of experimental physiologists by 
their discovery that the application of the galvanic cur- 
rent to the cerebral surface of the brain of dogs gave rise 
to movements on the opposite side of the body. The re- 
sult of these investigations was to show that certain por- 
tions of the convexity of the cerebrum are motor, while 
other portions are non-motor. The original experiments 
located five motor areas in 
the cerebrum of the dog: 
a centre for the muscles. 
of the neck in the middle 
of the prefrontal gyrus. 
at the place where its sur- 
face falls off steep, a cen- 
tre for the extensor and 
adductor of the fore limb- 
at the outermost end of 
the postfrontal gyrus in 
the region near the end of 
the frontal fissure; a cen- 
tre for the bending and 
rotation of the same limb- 
a little farther back; a 
centre for the hind limb. 
in the postfrontal gyrus, 
but toward the median 
line of the hemisphere and. 
back of the preceding two. 
centres; and a facial cen- 
tre in the middle part of 
the gyrus lying above the: 
fissure of Sylvius (see Fig. 892). Points lying between 
these, when stimulated, produced contractions of the 
muscles of the back, tail, and abdomen, but circum- 
scribed areas for these muscles could not be ascertained. 
The motor areas lie, therefore, to the front and the non- 
motor areas behind. By using weak currents, the move- 
ments are localized to definite groups of muscles of the 
opposite side of the body, while stronger currents ap- 





Fig. 892.—Cortical Areas in the Dog. 
(After Fritsch and Hitzig.) 4, 
Muscles of the neck ; +", extension 
and adduction of the fore-limb; 
+, flexion and rotation of fore- 
limb, #F, hind-limb; 0’, facial 
area. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





plied to the same or closely adjoining areas stimulate 
other muscles or even muscles of the same side. When 
the left cortical centre for the fore limb was excised, there 
followed a clumsiness of: the right fore limb, the right 
foot (but never the left) easily slipping. Although no 
movement was quite destroyed, the right foot was ad- 





Fig. 893.—Cortical Areas in Monkey. (Ferrier.) 1. Forward move- 
ment of leg; 2, the same, and toward middle line of body; 3, the 
same, with movement of the tail; 4, retraction and adduction of 
arm; 5, extension of arm; a, Db, c, d, movements of fingers; 6, 
fiexion and supination of arm; 7, lifting and retraction of angle of 
mouth ; lifting of upper and sinking of lower lip; 9, opening of 
mouth, with protruding of tongue; LO, the same, with retraction of 
tongue ; 11, retraction of angle of mouth and turning of head away 
from stimulated side ; 12, opening of eyes, dilatation of pupils, head 
and eyes turned away from stimulated side; 18, turning eyes away 
from stimulated side and down; 13’, the same, and up; 14, the 
same, and same movement of head, expansion of pupils, pricking of 
opposite ear; 15, lifting of lips and corner of nostril on stimulated 
side. 


ducted somewhat weakly and was often planted on the 
back instead of on the sole. Sensibility of the skin was 
not noticeably changed. These and later experiments 
substantiated the conclusion of the investigators that cer- 
tain motor functions, probably all, are to be assigned to 
circumscribed areas of the cortex. 

Ferrier, in 1878, and later in 1876 reported the discovery 
of numerous centres of electrical irritation on the cere- 
bral hemispheres of the monkey. These were found, as 
reference to Fig. 893 will show, to lie close together about 
the Rolandic fissure in the central convolutions. Even 
after it had become generally accepted that the effect of 
these weak currents was not due to the conduction of 
the electrical stimulus to lower motor areas, but was the 
effect of the direct stimulation of gray matter in the cor- 
tex, which was thus proved to exercise a determining 
influence over the pathways of motor conduction, it still 
remained a matter of doubt as to the degree to which the 
specialized functions of muscle groups may be localized 
in the cerebral cortex. Some experimenters claim that 
minute areas, at first excitable, after a time cease to be so. 
Others report that a displacement of the excitable points 
may take place. Exner distinguishes between absolute 
and relative motor fields, the former being those wherein 
lesions are always followed by impaired motion, the latter 
being suchas sometimes give rise to impaired motion and 
sometimes not. Panneth found that a number of minute 
areas or spots could be detected as lying in a larger ex- 
citable zone. 

Although the investigations of Fritsch and Hitzig de- 
monstrated the connection of the Rolandic convolutions 
with voluntary movements, the interpretation of their 
functioning remained uncertain for some time. Even at 
the present day, it is possible to find charts of the distri- 
bution of functions over the cerebral hemispheres, based 
upon the erroneous interpretation of Hitzig’s results. 
Ferrier was above all others responsible for drawing a 
sharp line of demarcation between the purely motor cen- 
tres and the sensory centres. According to this view the 
Rolandic convolutions are centres for the emission of 
motor stimuli only, their excitation perhaps giving rise 
to no consciousness whatever. The so-called motor areas 
are supposed to receive directly no afferent sensory stim- 
uli, but to be physiologically stimulated from other por- 
tions of the cortex. Ferrier accordingly located tactile 
sensibility in the limbic lobe, particularly in the hippo- 
campal convolution. He denied that such sensibility 

















Brain, 
Brain, 





was interfered with by ablation of parts of the motor con- 
volutions. A better understanding is chiefly due to Munk, 
though in second degree to the labors of Goltz and to the 
criticisms of Bastian, 

Munk made a much more extensive series of extirpa- 
tions of areas in the brains of dogs and monkeys than 
previous investigators had done. These led him to the 
conclusion that the occipital lobes are connected with the 
sense of sight, the temporal lobes with that of hearing. 
On removal of the area A, (Fig. 894) in a dog’s brain on 
both sides, and examining the animal some days after the 
operation, he observed a peculiar disturbance of the sense 
of sight, without injury to any other sensory or motor 
function. The dog moves with perfect freedom without 
striking any obstacle, and when such are put around 
him, he eludes them by crawling under or jumping over 
them. But the sight of dogs or men, whom he had be- 
fore greeted joyfully, now leaves him perfectly cold. 
However hunger and thirst may cause him to move 
about, he no longer seeks the accustomed place for his 
food, and will even pass it by as long as he does not 
smell it. <A light held to his eye no longer causes him to 
blink, nor does the sight of the whip, which formerly 
drove him into the corner, produce any effect upon him. 
He had been trained to give his paw when a hand was 
held out, now he will not give it unless ordered to. “By 
the extirpation, the dog has become psychically blind, 
z.e., he has lost the sight-presentations which he pos- 
sessed, his memory pictures of former sight perceptions, 
so that he neither knows nor recognizes anything he 
sees.” But the dog does see, and gradually forms a new 
store of sight memories. Munk further states that no 
matter how long the dog is kept alive, he never regains 
any of his former sight-memories, except by renewal of 
the experience. Complete removal of both sight areas, 
he asserts, causes total and permanent “cortical blind- 
ness”; if only one side be destroyed, hemiopia results. 

In the same manner extirpation of a limited area in 
each temporal lobe produced what Munk calls “ psychic 
deafness,” a condition much like the so-called “ word- 
deafness” in the human subject. The dog hears per- 
fectly, but no longer understands words to which he 
had before been trained. Gradually, however, the dog- 








AA, sight area; 
B, hearing; ©, feeling of hind limb; D, of fore limb; E, of the 
head; F, of protecting apparatus of eye; G, of the ear; H, of the 
neck; J, of the trunk. 


Fic. 894.—Cortical Areas inthe Dog. (After Munk.) 


learns how to hear. In the so-called motor zone the re- 
sults are no less striking. In opposition to his predeces- 
sors, Munk maintains that the motor disturbances are 
always accompanied by sensory disturbances, which 
consist in the loss of the most complex feelings, the sense 
of position, of pressure, muscular sense, etc. He con- 
cludes that the paralysis is the result of the loss of motor 


303. 


Brain, 
Brain, 





memories, and calls the motor zone the “area of feeling.” 
Within this area (Fig. 894) are seven subareas, those for 
the fore and hind limbs, head, eyes, ears, neck, and body. 
The rapidity of restitution of function, when one of these 











o's PROTRACTION 


€ i 
° 
. 3 
. ee 
a ane 


° 
° f ® 

PLATYSMA 

> pe 2 Ley 


& 






Z) 









ry . * “ay 
e sc Li 
‘MOUTH AND 
2 LARYNX 
Ay 


Fig. 895.—The Distribution of Motor Areas Over the External Surface of the Cerebral Hemi- 
(After Horsley and Schafer, from Barker.) 


spheres of the Monkey’s Brain. 


areas is removed, depends upon the extent of the lesion; 
if it is all removed the defect isa permanent one. In the 
monkey’s brain Munk obtained essentially the same re- 
sults. 

A summary of the results of Beevor, Horsley, and 
Schiifer (1887-1894) will serve best to indicate the pres- 
ent status of knowledge as to the exact representation of 
different movements over the Rolandic convolutions of 
the monkey and orangoutang, which stand nearest to 
man in biological relationship. The anterior central 
gyrus, they find, is much more concerned in the motor 
function than is the posterior central 
gyrus. They conclude that within 
the area of motor representation for 
the limbs, the regions for the larger 
joints are generally at the upper part 
of the area, while those of the smaller 
joints and more differentiated move- 
ments are at the lower part. Move- 
ments of extension are represented 
in the upper part, while those of 
flexion are in the lower. There ap- 
peared to be no absolute line separat- 
ing the area of one movement from 
that of another, each movement hav- 
ing a centre of maximal functional 
representation gradually shading off 
into the surrounding cortex. They 
distinguished a primary result of elec- 
trical stimulation from the subse- 
quent epileptoid march of the move- 
ments as the electrical stimulus 
became diffused through the cortex. 
Their general scheme of motor rep- 
resentation is diagrammatically sum- 
marized in Figs. 895 and 896. The 
results from ablations of areas of 
the cortex were quite in accord with 
their findings by the physiological 
method. Suggestive is the report 
that muscular movements of each in- 
dividual segment are much more fully represented in 
the cortex of the ourang than in that of the monkey. 
It seems a general law that the higher the animal the 
more definite is the area of representation not only of 


304 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


individual segments, but of individual movements be- 
longing to one segment. This would suggest a still 
more specific motor representation in the human brain. 
The subdivisions of the motor area in man have been 
ascertained from a large number of 
carefully reported cases and autopsies, 
and from the electrical excitation of 
circumscribed areas of the cortex dur- 
ing its exposure for cerebral opera- 
tions. The exactness with which 
such localizations can be determined 
is remarkable. In 1888 Keen extir- 
pated the focal representation of the 
wrist in the right cerebral hemisphere 
which he had fixed in relation to the 
areas for the movements of the el- 
bows, shoulder, and face. After op- 
eration the left hand was found to 
be paralyzed as regards all move- 
ments of the fingers and wrist. The 
elbow was weak, but the shoulder 
and face were entirely unaffected. 
The distribution of specific motor 
areas over the cortex of the human 
cerebrum is presented in Figs. 897 
and 898. The following summary is 
based upon those of Mills and Gor- 
dinier, omitting details which in 
some cases are still doubtful. As 
shown in the diagrams, the specific 
leg area occupies the upper third of 
the two Rolandic convolutions, the 
arm area the middle third, and the 
face area the lower third. The trunk muscles are repre- 
sented on the median surface of these two convolutions, 
the paracentral lobule. The leg area extends over the 
posterior part of the paracentral lobule and the upper 
anterior part of the superior parietal lobule; it occu- 
pies a greater antero-posterior surface than does the 
area of the arm or face. The movements of the thigh, 
knee, leg, foot, and toes are ranged in order from the 
front backward. The arm area is subdivided from 


above downward into centres for the movement of 
the shoulder, elbow, hand, and fingers. 


The move- 





Fig. 896.—The Distribution of Motor Areas Over the Median Surface of the Cerebral Hemi- 
spheres of the Monkey’s Brain. 


(After Horsley and Schafer, from Barker.) 


ments of the shoulder are also represented in. the an- 
terior part of the paracentral lobule. The subdivi- 
sions of the face area contain from above downward 
the movements of the orbicularis palpebrarum and oc- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cipito-frontalis, the mouth, lips, tongue, pharynx, and 
larynx. The platysmal movements, according to Mills, 
are probably represented in the posterior part, and the 
larynx and pharynx in the anterior part. Movements 
of the head and eyes are probably represented in the 
posterior part of the first and second convolutions ad- 


Rinesthetic and 
General Somatic Sensation 


Kineesthetic 
iting ? 





Fic. 897.—The Distribution of Sensory and Association Areas Over the 
External Surface of the Cerebral Hemispheres. The diagram shows: 
1, The area of kinesthetic and general somatic sensation, occupy- 
ing the central convolutions and portions of adjacent convolu- 
tions. (This is usually called the motor area. It is both an emissive 
or motor and a receptive or sensory area. The localization of the sub- 
divided sensorimotor areas is indicated in the diagram.) 2, the area 
of auditory sensation, occupying the middle portion of the superior 
conyolution and adjacent portions of the transverse convolutions of 
the temporal lobe; 3, the area of association of the first order, occu- 
pying the occipital lobe, the second and third temporal convolutions, 
a portion of the superior temporal convolution, the insula, and the 
posterior parietal convolutions ; 4, the area of association of the sec- 
ond order, or the zone of language, occupying the angular gyrus, 
the upper portion of the superior temporal convolution, the posterior 
third of the inferior frontal convolution (restricted to a single hemi- 
sphere, most frequently the left); 5, the area of association of the 
third order, the area of apperception, occupying the prefrontal re- 

, ions of the frontal lobes. 


jacent to the ascending frontal and on the median surface 
of the first frontal convolution. Those movements of 
the body which are always bilaterally innervated appear 
to have bilateral representation, so that an injury of one 
hemisphere, ¢.g., of the laryngeal centte, fails to produce 
paralysis. Those movements, on the other hand, which 
may take piace on one side of the body only, are repre- 
sented in the assigned area of the opposite hemisphere 
only. 

To Munk, in the opinion of the writer, belongs the 
credit of offering a satisfactory interpretation of the re- 
lation between the motor and sensory functions of the 
cortex and between psychical disturbance and the loss of 
simple sensation. From this point on, I shall merely sum- 
marize the views of different authorities with respect to 
various cortical functions, considering first in order the 
sensory areas, and next the areas of higher psychical ac- 
tivity. The excitable motor area is a “feeling sphere,” 
according to Munk, because it receives afferent stimula- 
tions which excite the cortical cells to give rise to sensa- 
tions and ideas of bodily movement. Cortical stimula- 
tion, otherwise than through the afferent tracts, may 
awaken memories or ideas of such movements. Fritsch 
.and Hitzig. had indeed referred to the Rolandic convolu- 
tions as the area of the muscular sense. For a long time, 
however, sensations of the muscle sense were understood 
to be due to the efferent stimulus of the cells in that 
region. This notion gave rise to the theory of an “in- 
nervation feeling” or “sense,” a theory which Wundt 
did not entirely give up until the appearance of the third 
edition of the “ Physiologische Psychologie” in 1887. It 
is now accepted that the activity of purely motor cells 
of efferent conduction in the Rolandic region (probably 
the large pyramidal cells) is unaccompanied by con- 
sciousness; that sensations or feelings of bodily movement 
are primarily due to the activity of sensory cells of the 
same region which receive stimulation from the sensory 


Vou. II1.—20 


Brain, 
Brain, 


conduction paths comprising the median fillet and pos- 
terior columns of the cord. Bastian made the valuable 
proposition to call these areas “kinesthetic” areas or 
areas of “kineesthetic sensation.” Goltz’s results were 
in many ways contradictory of both Munk’s and Ferrier’s, 
but this contradiction is to a great extent limited to de- 
tails, and in the main his work is confirmatory of the 
trend of the results as indicated in this paper. Although 
he contended that it is not possible permanently to para- 
lyze any muscle, he distinguishes between fine and 
coarse adaptations, and shows that although a dog’s paw 
is not paralyzed as an organ of locomotion by the de- 
struction of the cortex, it yet remains permanently par- 
aheee for all those actions in which it is employed asa 
hand. 

The testimony of experimental physiologists, includ- 
ing in addition to those mentioned above Luciani, Hors- 
ley, and Mott, points unequivocally to the so-called 
motor area and immediately adjacent convolutions as the 
centre of kinesthetic sensation and of touch, pressure, 
heat, cold, and pain sensation as well. For this reason 
the convolutions of motor function are designated in 
Figs. 897 and 898 as areas of kinesthetic and general 
somatic sensation. Confirmatory are also the pathologi- 
cal findings of Gowers, Westphal, Seguin, Dana, and 
Starr. Dana’s twenty-five cases, four of his own with 
twenty-one others, all prove that lesions of the central 
convolution are attended by partial or complete loss of 
tactile, temperature, pain, and muscular senses in the 
limbs of the opposite side of the body. Starr, after 
thirty cases of cerebral operations consisting of excisions 
of parts of the motor area, thinks that it is clearly de- 
termined that the tactile centres are situated in the Ro- 
landic area, especially in the postcentral gyrus. Redlich, 
from an analysis of twenty cases of lesions confined to 
the parietal lobe, states positively that these lobes are 
the centres for muscle sense. Nothnagel, Luciani, Sep- 
pelli, and Flechsig long ago asserted that the parietal 
lobes were concerned in the reception of muscle sense 
impressions and possibly of the other forms of general 
sensation. Many pathologists whose opinions justly 
carry great weight are opponents of the view here repre- 
sented. Among these, Mills is most worthy of mention 
as still contending for the restrictedly motorial function 
of the excitable areas of the Rolandic convolution and 


K incesthetic and 


General Somatic Sensation 





Fig. 898.—The Distribution of Sensory and Association Areas Over 
the Median Surface of the Cerebral Hemispheres. The diagram 
presents: 1, The area of kingesthetic and general somatic sensation, 
occupying portions of the parietal and frontal lobes; 2, the areas of 
visual sensation in the convolutions adjacent to the calcarine fissure ; 
8, the areas of olfactory and gustatory sensation in the uncinate 
gyrus and adjacent cortex; 4, the area of association of the third 
order, or area of apperception, in the prefrontal convolutions of the 
frontal lobes. The portions of the parietal and temporal lobes to 
which no special function is assigned in the diagram are association 
areas of the first order. 


for a distinct representation of cutaneous and muscular 


sensations in the adjacent postero-parietal convolutions, 
precuneus and gyrus fornicatus. In support of this view 


305 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





he maintains that innumerable cases have been reported 
of lesions of the motor cortex without impairment of 
sensibility. He also cites his own experience with that 
of others which shows that surgical excision of the Ro- 
landic cortex is not necessarily followed by any sensory 
impairment. 

The results of histological investigation of the struc- 
tural elements of the cortex in the main confirm the view 
that the functions of the Rolandic cortex are only in part 
motor. At least four layers of the cortex are distin- 
guished—a superficial layer rich in small cells and tan- 
gential fibres, a layer of small and a layer of large pyram- 
idal cells, and a deeper layer of polygonal cells which 
are supposed to give rise to short and long associational 
neuraxones. Only the pyramidal cells, perhaps only the 
very large pyramidal cells, are supposed to give rise to 
the projection neuraxones of efferent or cortico-fugal 
conduction—7.e., those fibres which pass in groups func- 
tionally related through the internal capsule to the crura 
cerebri, to terminate about the motor cells of the cranial 
nerves of the same, but chiefly of the opposite side, or to 
continue on through the pyramids and, a portion crossed 
and a portion uncrossed, to terminate about the motor 
cells in the anterior horn of the cord, partly on the same 
and partly on the opposite side. The path of these pro- 
jection neurones has been made out by the stimulation 
methods of Beevor and Horsley, Burdon Sanderson, 
Franck, and Pitres, and by the studies of resultant de- 
generation, first initiated by Tiirck in 1851, and subse- 
quently extended by Bouchard, Charcot, Pierret, Noth- 
nagel, von Monakow, Marchi, Hoche. The excision of 
limited areas of the motor cortex gives rise to secondary de- 
generations also; these have been studied by von Gudden, 
von Monakow, Franck, Pitres, Moueli, Marchi, Algeri, 
Muratoff, Mellus and Langley, and Sherrington. The true 
motor cells are so situated that they may be stimulated 
to activity by the constituent cells of the proximate cor- 
tex, by associational and commissural neuraxones from 
remote parts of the cortex, or by the neuraxones of affer- 
ent conduction which terminate, perhaps, in all four lay- 
ers of the cortex. Cajal has presented a scheme of inter- 
cortical relation, and has constructed an elaborate theory 
of the neuronal mechanism of association, ideation, and 
attention. Problematic as this scheme remains, it indi- 
cates a new line of speculation as to cerebral functions, 
based on a discrimination of the various sensory, motor, 
and associational cells of a given part of the cortex, and 
promises much fora future better understanding of the 
specific psycho-physiological activities of the nervous 
system. 

Edinger from embryological researches, and von Mona- 
kow from the study of secondary degeneration, report 
that the sensory fibres of the fillet or lemniscus terminate 
in the cortex of the postcentral convolution and parietal 
lobe. The afferent neuraxone terminations in the Rolandic 
convolutions are in functional connection with the nuclei 
of the mid- and hind-brain, particularly with those path- 
ways of conduction which mediate common sensation. 
This area, therefore, is physiologically a sensory or recep- 
tive centre for cortico-petal stimuli of all sense tracts ex- 
cept the four sense tracts of special sensation, as well as 
the motor or emissive centre of the most important tracts 
of motor innervation. 

The most extensive experiments dealing with the sen- 
sory fibres leading to this part of the cortex are those 
of Flechsig. He divides these cortico-petal fibres—which 
pass together through the internal capsule and which are 
the indirect continuations of the dorsal roots of the cere- 
bral and spinal nerves—into three groups or systems, 
distinguished by the fact that they put on their myelin 
sheath at different periods. The first group becomes 
medullated at the beginning of the ninth foetal month. 
It occupies the posterior part of the internal capsule 
and, in its upper half, the area immediately behind 
the fibres of the pyramidal tract. These fibres are dis- 
tributed exclusively to the cortex of the two central gyri, 
which are thus the first regions of the cortex to become 
connected by means of medullated fibres with the sen- 


306 


sory apparatus of the body (see Figs. 900 and 901). The 
second group receives its myelin about a month later 
than the first group. These fibres are distributed to the 
central gyri, the lobulus paracentralis, and the foot of the 
superior frontal gyrus. Another portion is distributed 
to the gyrus fornicatus along its whole length. The 
posterior bundles run toward Ammon’s horn, and still 
another bundle enters into the uncus and arrives at the 
subiculum cornu Ammonis. The whole of the limbic 
lobe is thus connected with the lateral nucleus of the 
thalamus. The third system is also joined with the lat- 
eral nucleus of the thalamus and one part runs directly to 
the foot of the third convolution, another portion through 
the pars frontalis of the internal capsule into the frontal 
lobe almost as far as the pole, part of the fibres reaching 
the middle portion of the gyrus fornicatus, another part 
the anterior half of the superior frontal gyri, while single 
fibres go to the middle of the frontal gyri. Edinger and 
von Monakow also distinguish from the cortico-fugal 
pyramidal tract a fronto-cerebro-cortico-pontal tract. 
These fibres, according to Flechsig, arise in those regions 
of the cerebral cortex which correspond to the distribu- 
tion of the third group of sensory fibres, 7.¢., the feet of 
the three frontal gyri and possibly also the middle por- 
tion of the gyrus fornicatus. They terminate in the 
nuclei of the ponsand are concerned with the movements 
of bilaterally innervated muscles, such as those of the 
eyes, neck, and trunk. The motor impulses concerned in 
the speech movements may also, he believes, be carried by 
these fibres, though according to Barker there is a good 
deal of evidence that the speech path is separate and dis- 
tinct. 

Results indicating the cortical localization of the area 
of vision have from the first been consistent in prescrib- 
ing its limits to the occipital lobes and adjacent parieto- 
temporal convolutions. The location within these limits 
has been differently assigned; thus Hitzig to gyri in the 
posterior lobes of the dog, while Ferrier has persistently 
contended for the angular gyrus. Munk’s careful and 
critical investigations prepared the way for an undete 
standing of the relation of the different parts of the 
visual area. He distinguished between psychical blind- 
ness and the simple Joss of vision proper, and found 
different areas giving rise to these diverse conditions. 
He interpreted the area of simple or primary vision to be 
the cortical projection field of the retina, whereas ad- 
jacent areas added those memory images which made 
visual impressions intelligible. Despite conflicting evi- 
dence, it is fairly well established that the primary visual 
areas of the cerebral hemispheres are situated in the 
neighborhood of the cuneus, and that the calearine fissure 
bears about the same relation to visual stimulation as the 
Rolandic fissure does to somesthetic stimuli. This state- 
ment refers, however, only to retinal stimulations, which 
constitute in reality only a very smal] part of those sen- 
sory stimuli which are essential for the maintenance of 
complete vision. Henschen proposes for this area the 
name of calcarine retina, and suggests, from an examina- 
tion of clinico-pathological evidence, that the upper lip of 
the calcarine fissure of one hemisphere is the projection 
field of the lower quadrants of the visual fields of the 
homonymous halves of both retinee, and that the lower 
lip has a corresponding connection with the upper visual 
fields. Henschen also assigned the cortical representa- 
tion of the central portion of the retina to the anterior 
part of the calearine fissure and of the peripheral por- 
tions of the retina to the posterior part. The macula 
seems from many results to have a separate and distinct 
representation and to be represented for each eye in both 
cortices, whereas the symmetrical halves of each retina 
are represented in the hemisphere of the same side only. 

Cajal has shown that the fibres of the macula retained 
their individuality as far as the basal ganglia. It is de- 
nied, however, by von Monakow and others, that there is 
a distinct cortical area for the macula. He believes that 
it is represented in perhaps all portions of the occipital 
lobe constituting the visual area, even in the posterior 
part of the angular gyrus Examination of the results 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


of pathological findings indicates the possibility of much 
individual variation both at the centres and along the 
conduction pathways. There can be little doubt that 
the cuneus (see Fig. 898, page 305) is the cortical centre of 
primary visual sensation, and that regions which ontogen- 
ically acquire the associational capacity of complex visual 
perception involving the visual memories of past expe- 
rience, spread out over the convex surface of the occipi- 
tal lobes and perhaps to adjacent lobes, certainly to the 
angular gyrus (see Fig. 
897). Kinzesthetic stim- 
uli from the muscles of 
the eyes are important 
elements in visual per- 
ception; whether these 
are conducted to the 
visual area also does not 
appear; it is probable, 
however, that sensations 
of eye movements are as- 
sociated in this area with 
the light sensations due 
to retinal stimulation. 
This conclusion seems 
the more necessary since, 
according to Ramon y 
Cajal, Engleman, von 
Monakow, von Gehuch- 
ten, K6élliker, and Held, 
the centrifugal fibres 
start in the axis-cylinder 
processes of the pyram- 
idal cells of the cortex 
and arborize in the su- 
perficial gray matter of 
the anterior corpora 
quadrigemina. Proc- 
cesses from these gan- 
glia terminate in the 
nervous feltwork of the 
retina and are in func- 
tional connection with 
the motor nuclei of the 
ocular and other nerves 
supplying the facial 
muscles. The connec- 
tion of the cortex with 
these subcortical ganglia 
suggests that the oculo- 
motor functions of the 
occipital lobe are exer- 
cised centrifugally via 
the optic radiation, as 
maintained by Munk and 
Sherrington (see Fig. 
899). Thus through Pde 
these centrifugal neu- 
rones the retina, the oc- 
ular reflexes, and facial 
instinctive movements 
may be under the influ- 


“a 
fi 


f 
: 
“ai H 
AN: a 
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at 
H ‘i 
















Nopticus. 


Moe 


Gatum faterate 






Optic radiations. 


_ Stratum pigmenti retine. 
$ é , 


-« Radiatio occipito-thalamica,. 


\\ Lobus occipitalis (cortex) 
Fourth layer. \ We 


Dendrazxone. ” \) 


Fig. 899.—Diagram of the Visual Conduction Paths. 
Barker.) a, b,c, Rods and cones of the retina; d, e, bipolar cells; f, large 
multipolar ganglion cells, giving rise toaxones of the optic nerve; g, centrif- 
ugal axone of a neurone, the cell body of which is situated in the anterior 


Brain, 
Brain, 


obstacles, etc., the retinal reflex of contraction of the 
pupils to light, and perhaps even of acquired visual re- 
flexes, such as the flight from a whip, etc. The expres- 
sion of the emotions of involuntary origin appears to 
have its origin in the thalamus. The loss of the emo- 
tional involuntary reflex, at all events, may follow upon 
a lesion of this subcortical ganglion. 

As in the case of cortical visual representation, the 
localization of the sense of audition has been restricted 
by almost all observers 
to a region of well-de- 
fined limits, in this case 
to the convolutions of 
the temporal lobe. Fer- 
rier’s results point to the 
superior temporo-sphe- 
noidal convolution on 
each side, because elec- 
trical excitation of this 
area on either side in- 
variably produced in the 
monkey retraction of the 
opposite ear associated 
with opening of the eyes 
and dilatation of the 
pupils; these movements 
Ferrier regarded as a 
significant index of au- 
ditory perception. 
Munk distinguished an 
area of greater intensity 
from adjacent regions of 
less intensity, both in 
N. oculo-motorius. the temporal lobes. Lu- 
ae ciani considers the audi- 

5 tory sphere to extend 
g) over the whole cortical 

area of the temporal 


Rods and cones; 


Membrana limitans externa. 


External nuclear layer, 
External molecular layer. 
Internal nuclear lauers 
Internal molecular layer. 
Layer of ganglion cells. 


Layer of nerve fibres., 


‘ae 
‘Membrana limitans interna, 


Colliculus superior. , 
a 


lobe. Pathological evi- 

5 ero dence has with equal de- 

; 7 cisiveness pointed to the 

temporal lobe. Bastian, 

‘Dendrazone. Wernicke, Friedliinder, 


Shaw, and Mills leave no 
room for doubt that the 
centres for hearing are 
situated in the superior 
temporal gyrus of each 
side. Each car seems to 
be represented in both 
lobes, as both superior 
temporal gyri in man 
must be destroyed in 
order that total deafness 
shall ensue. The re- 
searches of Flechsig, von 
Monakow, Held, von 
Kolliker, Ramon y Cajal, 
and Florence Sabin have 
shown the anatomical 
relations of the cochlear 


Third cortical layer (giant 
pyramidal cells). 


(After von Monakow, from 


ence of the occipital corpora quarigemina (colliculus superior), its terminal dendritic processes branch of the auditory 
cortex. Of the basal being situated in the retina; h, Golgi cell of type LJ, in the lateral geniculate nerve, Which alone is 
nuclei, 7.¢., thalamus, Lat Eee neurone connecting the paper ee Raia te the atl gee concerned in hearing 

. lobe, its axone running in the optic radiation of Gratiolet. The centripe . a pec treese 4 BES 
external geniculate ang centrifugal courses of the visual impulses are indicated by the arrows. with the various basal 


body, anterior corpora 
quadrigemina, connect- 
ed with the visual function, the external geniculate 
body alone seems to be in direct relation to retinal stim- 
uli. Lesion of this ganglion inevitably causes hemi- 
anopsia, and its destruction is followed by atrophy of the 
inferior portion of the bundle of Gratiolet. The pulvi- 
nar of the thalamus, on the other hand, may atrophy 
without producing hemianopsia if the geniculate body be 
intact. Lesion of the pulvinar and anterior corpora 
quadrigemina may, nevertheless, produce important 
modifications of vision. These ganglia appear to be 
centres of visual reflexes, such as winking, avoiding of 


nuclei, the chief of which 
are the trapezoid nu- 
cleus, the superior olive, the posterior corpora quadri- 
gemina, the median geniculate nucleus, and the nucleus 
lemnisci lateralis. The fibre tracts connecting these va- 
rious nuclei furnish an anatomical basis for more than 
one pathway of partial decussation. These fibres are 
also connected with the anterior corpora quadrigemina 
and with the motor nuclei of the cranial nerves, thus con- 
stituting a basal organ for automatic movements of the 
head, and perhaps of the trunk, in response to auditory 
stimulation. It is not deemed advisable to present the 
several parts of the complicated pathway of afferent 


307 


Brain. 
Brain, 





conduction, as these have been made out by various in- 
vestigators. It will suffice to mention that the collected 
fibres from these various nuclei pass as the lateral fillet, 
according to Flechsig in two separate bundles, to the 
internal capsule, and go transversely through the same in 
two separate bundles to the transverse gyri of the tem- 
poral lobe. The one bundle ascends near the external 
capsule and arrives from behind and above into the audi- 
tory sense area. The other runs for some distance along 
with the occipito-thalamic radiations, and passes around 
the fossa Sylvii from behind and below into the temporal 
lobe itself, close by the second and third temporal gyri, 
to reach the transverse temporal gyrus. The exact ex- 
tent of the sense region, according to Flechsig, corresponds 
to the two transverse gyri of the temporal lobe, particu- 
larly the anterior and that portion of the superior tem- 
poral immediately adjacent (see Figs. 900 and 901, on 
pages 308 and 309). ‘ 

The giant pyramidal cells, which are believed to give 
origin to the cortico-fugal projection tracts, seem to be 
absent in this region. Flechsig nevertheless maintains 
that the temporo-cortico-cerebro-pontal path begins here. 
The axones of this bundle of fibres, usually but mistakenly 
called Tiirck’s bundle, pass down, through the anterior 
portion of the occipital part of the internal capsule, to 
the lateral region of the base of the cerebral peduncles; 
thence they go into the pons, terminating perhaps in the 
nuclei of that region. Flechsig is inclined to think that 
this temporal path represents a mode of connection, by 
way of the brachium pontis, of one cerebral with the op- 
posite cerebellar hemisphere. The fibres are medullated 
at a later period than the fibres of the pyramidal tract; 
Von Monakow and Déjerine also report on this tract 
Déjerine believes, however, that the bundle arises from 
the whole temporal lobe, but chiefly the median and 
inferior convolutions. Whatever the origin, course, and 


termination of this tract may be, there can be little 





fia. 900.—The Sense Areas and Association Areas on the External Surface of the Right Cerebral 
(From Flechsig.) The closely dotted areas about the central fissure, on the middle 
part of the superior temporal convolution, and in the posterior part of the occipital lobe, indicate 
respectively the primary areas of general somatic sensation, of auditory and of visual sensation. 
The regions not marked with the dots are: 1, The posterior association areas in the parietal, 
occipital, and temporal lobes ; 2, the middle association area in the insula; 3, the anterior association 
As the thickly dotted regions shade off into the unmarked regions, so the 
primary sense areas are continued into adjacent portions of the association areas, presenting a 


Hemisphere. 


area in the frontal lobe. 


gradual transition from the simpler to the more complex functions. 


doubt as to its existence. The evidence seems to point 
to the middle part of the superior temporal convolution 
as the primary cortical auditory area (see Fig. 897, page 
805), while the areas for more complex auditory percep- 


308 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tions are located in the upper part of the second and third 
convolutions toward the angular gyrus, and perhaps ex- 
tend downward over the fourth and fifth temporal con- 
volutions also, a region in which Mills places a centre for 
the hearing of words—the so-called “naming” or “idea” 
centre. 

The vestibular branch of the auditory nerve is con- 
nected with nuclei which are in anatomical relation with 
the cerebellum and with the median fillet; thus stimuli 
from this branch may pass to the somesthetic area of the 
cerebral hemispheres. 

Ferrier located the sense of taste and smell in the sub- 
iculum and in neighboring portions of the lower temporal 
convolution. | Munk localized smell in the gyrus hippo- 
campus. According to Andriezen, the cortical regions 


which receive the olfactory projection fibres are (1) the 


region of the genu of the gyrus fornicatus; (2) the septum 
lucidum; (8) the inferior extremities of the hippocampal 
and uncinate gyri. Hill looks upon the fornix as one of 
the conduction paths, and this is certainly in accord with 
the relation of that structure to the terminal cortical areas 
just named. Cases have been reported by Ogle, Jack- 
son, Hamilton, Worcester, and others, in which impair- 
ment or loss of smell was associated with lesions of the 
gyrus uncinatus or its immediate vicinity. According 
to Flechsig, the olfactory conduction path in the fore- 
brain is the first path connected with the special sense 
organs to become medullated. Turner grouped the re- 
gions especially-connected with the sense of smell in 1865 
under the term rhinencephalon. His and Edinger con- 
sider this separation of the parts concerned with smell 
to be in accord with the facts of embryological and phy- 
logenetical development. The rhinencephalon is rich 
in neurones connecting it with the basal ganglia; these 
lower centres are therefore so situated as to be able to re- 
spond reflexly or anatomically to all forms of general or 
special sensory stimulation. The gyrus hippocampus, 
especially the uncus, appears 
to be established as the corti- 
cal sensory area for olfactory 
stimulation. The _ cortical 
area for the sense of taste is 
probably located adjacent to 
the area for that of smell, per- 
haps occupying in part a por- 
tion of the fourth temporal 
convolution. Turner (1897) 
in reviewing the subject finds 
disagreement among investi- 
gators as to the peripheral 
gustatory neurones and al- 
most complete ignorance as to 
the central neurones. Bech- 
terew has presented a scheme 
of taste conduction paths. 
Peripherally these involve the 
fifth and ninth nerves in the 
region of the fourth ventricle, 
where 
with the motor nuclei of the 
fifth, seventh, and ninth 
nerves. The limited knowl- 
edge pointing to a definite 
location of taste sensation is 
in accord with the relative 
unimportance of this sensa- 
tion and with its close asso- 
ciation to the sensations of 
smell, of touch, and of tem- 
perature. 

The primary centres of 
sensation occupy only about 
one-third of the superficial 
surface of the cerebral hemi- 
spheres (see Figs. 897, 898, 900, and 901). These physi- 
ologically are higher sensorimotor centres superimposed 
upon the lower basal centres, and enable the organ- 
ism which possesses them to act in response to stimuli 


they are associated — 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 











with more complicated coordination than would be pos- 
sible with the basal and other lower centres alone. In 
Figs. 900 and 901 the central portion of each sensory 
area is indicated by the more numerous dcts which rep- 
resent, according to Flechsig, 
their richer supply of cor- 
tico-petal fibres, while the 
less frequent dots represent 
the portion in which these 
fibres are less numerous. 
The remaining two-thirds of 
the cerebral area, unmarked 
with dots, are not provided 
with projection fibres either 
afferent or efferent. The 
white matter of all these cor- 
tical regions, with the excep- 
tion perhaps of that beneath 
the angular gyrus, becomes 
medullated considerably later 
than that of the sense cen- 
tres, so that even in children 
three months old the former 
are sharply distinguishable 
from the latter by their pov- 
erty of myelin. Flechsig 
finds, however, that medullat- 
ed paths gradually grow out 
from the sense centres into 
these non-medullated regions. : 
Further, between the individ- 
ual gyri of the non-medullat- 
ed regions, bands of associa- 
tion fibres gradually ripen, 
connecting the individual 
gyri with others near them 
and also with gyri at a dis- 
tance. These areas Flechsig 
designates association areas; 
through these alone one sensory area is indirectly con- 
nected with another. The association areas are there- 
fore centres whose cells are superimposed upon those of 
lower primary sensory areas, supplying a mechanism for 
the higher co-ordinations which are most representa- 
tive of the intelligent as well as of the conscious life of 
the organism. He designates as the posterior association 
area that part which includes the precuneus, all the 
parietal gyrus, except the postcentral gyrus, part of the 
gyrus lingualis, the fusiform gyrus, and the middle and 
inferior temporal gyrus, as well as all portions of the oc- 
cipital gyrus not concerned in the visual sense area. 
This association region is therefore situated midway be- 
tween the visual, the somesthetic, and the auditory sense 
areas, and is indeed not remote from the olfactory and 
gustatory areas. The middle association area is consti- 
tuted by the island of Reil, surrounded by the somes- 
thetic area, the auditory area, and the olfactory area, from 
all of which bands of fibres run into it. The prefrontal 
convolutions constitute the anterior association area, 
which is chiefly connected with the somesthetic area and 
the olfactory sense area. 

The facts advanced by Flechsig are admitted in part, 
but contested in part also. Thus von Monakow asserts 
that projection fibres go to nearly all parts of the cortex, 

_ though he, as well as all others, admits that some parts re- 
ceive fewer by far than others, the frontal lobe especially 
receiving few, if any. Some also deny that association 
tracts connect the sensory areas only indirectly through 
the association areas. These tracts have been made out in 
some instances with much precision. The polymorphous 
cells of the fourth layer and of the pyramidal layers are 
admitted to give origin to the fibres that either separately 
or as constituents of well-defined tracts unite in functional 
relationship the cortices of separated convolutions. 

By means of the corpus callosum the gyri in one hemi- 
sphere are connected with those in the opposite hemi- 
sphere. Of short association fibres there are five differ- 
ent bundles that have been made out in the occipital lobes 


sphere. 


in the frontal lobe. 


(From Flechsig.) 








alone. In the frontal lobes, fewer distinct bundles of 
association fibres have been made out, although Déjerine 
has described the source of several. In the temporal 
lobe and insula, similar bundles have been described but 





Fic. 901.—The Sense Areas and Association Areas on the Median Surface of the Left Cerebral Hemi- 
The closely dotted regions in the anterior portion of the parietal and 
posterior portion of the frontal lobes, about the calcarine fissure, and in the hippocampal and 
uncinate gyri, indicate respectively the primary sense areas of general somatic sensation, of visual 
sensation, and of gustatory and olfactory sensation. 
The posterior association area in the precuneus and temporal lobe; 2, the anterior association area 


The regions not marked with dots are: 1, 


no definite tracts have been ascertained. The long associa- 
tion tracts that have been described are, according to Bark- 
er: (1) the cingulum, which belongs to the rhinencepha- 
lon; (2) fasciculus longitudinalis superioris, connecting 
the frontal and occipital lobes; (8) fasciculus longitudi- 
nalis inferioris, uniting the occipital and temporal lobes; it 
is suggested that this may be the bundle connecting the 
visual sense area with the auditory sense area; (4) fasci- 
culus uncinatus, which extends between the uncus and the 
basal portion of the frontal lobe, and which may be an as- 
sociation tract of the rhinencephalon; (5) the tapetum, 
which is held by some to be a portion of the fasciculus 
longitudinalis superioris. According to Déjerine, it arises 
in the whole cortex of the frontal lobe, and, passing through 
the tapetum, its fibres are distributed to the lateral surface 
and inferior border of the lobus occipitalis. 

These results seem to establish a direct connection be- 
tween the various sense centres, as well as the indirect 
connection through the association areas as proposed by 
Flechsig. Whether Flechsig be right or wrong in this, 
whether subsequent research shall substantiate or dis- 
prove the anatomical connections and relationships in- 
dicated by the report of his results of the embryological 
method, it seems to the writer that Flechsig’s psycho- 
physiological interpretation of the functions of the asso- 
ciation areas isin the main incontestibly sound in psy- 
chology, and accordant with the trend of conclusions 
drawn from multifarious experimental and clinical in- 
vestigations. 

It has already been pointed out that most authorities 
distinguish between sensory disturbances and perceptual 
disturbances. Loss of memory and of higher sense per- 
ception have generally been attributed to regions which lie 
from the direction of the auditory, visual and somesthetic 
areas toward theangular gyrus. Itis immaterial whether 
psychical blindness, deafness, etc., are due to a loss of 
memory images or to an ataxia of sense perception. It 
seems clear that the nearer a lesion lies to the calcarine 
fissure, the Rolandic fissure, or the middle part of the 


309 


Brain, 
Brain, 


temporal convolution, the more likely is the injury to 
give rise to a loss of sensation only; and the nearer the 
injury is to the angular gyrus, the more likely is the re- 
sult to be a loss of perception, ideas, and memories con- 
nected with sensory impression. And yet it is difficult, 
both on the physiological and on the psychological side, 
to distinguish a pure sensation from one with an admix- 
ture of memory images. What a sensation would be 
utterly divorced from integral connection with the con- 
sciousness of the individual it is impossible to say. The 
association centres of Flechsig are centres of perceptual 
and ideational integration. Through their activity, in 
conjunction with the functions of the sensory areas, the 
actions of the human being are able to reflect the influ- 
ence of acquired individual experience. 

The posterior association centre (see Fig. 897, page 305, 
and Fig. 900, page 308) is concerned chiefly with the intel- 
lectual processes. Injury to the cells of this centre is 
followed by various forms of psychical blindness, by 
apraxia, agnosia, amnesia, and sometimes a weakening of 
the imagination. The anterior association centre is most 
closely associated in function with the someesthetic area, 
and hence also with the motor regions concerned 
in conduct, so that here in all probability is to 
be sought the anatomical mechanism by means 
of which the memory effects of all conscious 
bodily experiences, especially of acts of will, are 
retained. In injuries to this region, Flechsig 
maintains, interest in the external world is lost 
and the most marked alterations of character, at- 
tention, reflection, and inhibition are manifest. 
There may be symptoms of over-appreciation 
or of great self-depreciation; the speech may 
for a long time remain unaffected, but judgment 
as to what is right and wrong, beautiful and 
hateful, will be impaired, and there may be lack 
of self-command, even when uninfluenced by 
violent emotions, readiness to yield to sexual 
excitement, and finally imbecility. When the 
posterior association centres are mainly involved 
it is knowledge of the external world, rather than 
of his body and personality, that is impaired. 
Ideas regarding the objects of the external world 
are confused, there is a poverty of ideas or an 
inability to express them in words, yet with all 
this the patient may have perfect self-possession 
and a normal regard for himself and his friends. 

These two association centres are not connected 
with each other excepting through the someesthetic area. 
Flechsig, accordingly, seems to assume a more or less 
significant distinction between the intellectual processes 
and those of volition. The centres are bilateral and are 
richly connected by fibres of the corpus callosum, In 
this they are distinguished from the middle association 
centre, the island of Reil, which is very sparsely supplied 
with these commissural fibres. This centre seems to be 
for the one hemisphere only. It is the association cen- 
tre more particularly for the cortical elements concerned 
in the speech function, situated, as it is, in such close 
proximity to the inferior frontal convolution and to the 
temporal convolution; it is therefore in connection with 
the portions of the posterior association centre that are 
_ connected with the visual and auditory speech functions. 
‘These functions are so closely connected with the intel- 
lectual processes that a few words on the most recent 
conclusions as to their nature and localization will assist 
toward a comprehension of the relation of the association 
centres to the rest of the nervous system. 

The history of the study of the symptom complex 
known as aphasia throws an interesting sidelight on the 
localization of cerebral function. Mention has already 
been made of the conclusions of Wernicke, Kussmaul, 
and others. It is quite impossible to enter in this connec- 
tion into an analysis of this very important chapter of 
cerebral localization. Collins’ monograph on the “ Gene- 
sis and Dissolution of the Faculty of Speech” gives a con- 
cise critical résumé of the various views, and sketches a 
theory of speech location essentially in harmony with 






310 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


that of Déjerine, and, in the opinion of the writer, most 
satisfactory from all points of view. By the time of 
Kussmaul the three elements involved in aphasic disturb- 
ance were well recognized—the motor emissive element, 
the visual element, and the auditory element. Charcot 
deserves the credit of emphasizing the fact that so-called 
motor aphasias are generally kinzesthetic aphasias, de- 
pending upon the loss of motor images. He believed 
that there was an articulate speech centre in the inferior 
frontal convolution, and a graphic kinesthetic centre in 
the middle frontal convolution. An individual who de- 
pended in speaking or writing upon kinesthetic images 
originated in these centres, Charcot called a moteur; one 
who depended on the visual elements was a visuel; and 
one who depended on the auditory elements was an 
auditif. The predisposition to belong to one of these 
three types might be inherited or might be acquired by 
education. The centres for the auditory and visual ele- 
ments lay close together in the neighborhood of the angu- 
lar gyrus. Charcot taught that these centres must act 
in harmonious co-operation in order that intellectual ex- 
pression and conception should be complete. These cen- 


| 











Yy 
Ye 


= 
2 


fi 















ee 


Wy 
YY 
ppg 

]/ 
GY 


Fic. 902.—The Zone of Language, According to Déjerine. (From Mills.) The 
zone of language, as indicated by the shaded regions, comprises the portion 
of the third frontal convolution posterior to the ascending branch of the 
fissure of Sylvius and the lower extremity of precentral convolution, the 
upper portions of the first and second temporal convolutions, and the supra- 
marginal and angular convolutions of the parietal and occipital lobes. 


tres were, however, independent, and an injury to one 
might remove certain elements without necessarily inter- 
fering with the others. 

This view was a great improvement upon the complex 
schemes that had been evolved by the Germans, of whom 
Lichtheim showed that no less than fourteen different 
areas might be the seat of a lesion producing aphasia. 
Naming centres, ideational centres, propositionizing cen- 
tres, and the like were thus cast aside. A tendency tow- 
ard an extreme of localization for different phases of the 
faculty of speech was in this way checked. Déjerine 
made a great step in the direction of still greater simplic- 
ity. He established the dependence of sensory agraphia 
upon loss of visual memories in the angular gyrus, which 
causes alteration of internal language, due to loss of visual 
images associated with word-blindness. He maintained 
that writing with the hand was not a specialized func- 
tion but simply the outward expression through the hand 
of visual images of various graphic symbols. This view 
is not accepted by some authorities, notably Mills, Gor- 
dinier, and Bastian, who still maintain the existence of a 
graphic centre. It may appear that in certain individual 
cases the cells in the second frontal convolution may be 
so trained by education that after adult life is reached 
the destruction of these cells may cause an inability 
properly to co-ordinate the muscles of the arm. The 
graphic-motor centre appears nevertheless to be less 
stably established as a specifically differentiated portion 
of the cortex than is the kinesthetic speech centre in the 
left inferior frontal convolution. Déjerine also contended 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 








against the functional independence of the three speech 
centres, mantaining that the language centre is really a 
zone constituted of portions of the temporal, parietal, and 
inferior frontal convolutions of which the three recognized 
speech centres were focal areas of most intense representa- 
tion. The extent of this zone of language, which is 
shown in Fig. 902, is not strictly delimited. Collins 
says: “It varies in individual cases and at different 
periods of life in the same individual; namely, it is sub- 
ject to phylogenetic and to ontogenetic variations as 
well, the latter depending somewhat upon the speech 
acquisition of the individual and on the range and num- 
ber of avenues by which he receives or has schooled him- 
self to receive information from language.” 

An injury to any portion of the zone of language will 
produce disorders of all the elements of speech function. 
This centre is emissive to the cortex of the Rolandic re- 
gion, in which there are separate areas for the movements 
of respiration, vocalization, and lingual and labial action, 
from which proceed the true motor impulses. The cen- 
tre in which are stored visual images is situated in the 
angular gyrus; the auditory centre occupies a position 
in the posterior part of the first temporal convolution 
immediately adjacent to the gyrus; the island of Reil 
may be involved. The speech zone receives and com- 
bines impulses coming into it from the auditory, visual, 
and kineesthetic areas. 

The views of Déjerine are in opposition to the theory 
of a cortical centre as a restricted area performing a cer- 
tain specific psychical function and no other. Very simi- 
lar are the views of Flechsig. The parts of the sensory 
areas which produce simple sensations have been shown 
to fade insensibly into the regions which perform func- 
tions related to more developed perception, and these 
shade off again into areas of ideation and conception, 
whose functioning constitutes a summation of impressions 
from all sense regions. For these areas I believe we 
may accept Flechsig’s boundaries and name of posterior 
association centre. Perception, ideation, imagination, 
memory, thought, reason, etc., are not distinct psychical 
processes, but all are analyzable psychologically into as- 
‘sociations or groups of ideas of more or less remote sen- 
sory origin. As these mental processes are revealed only 
through external expression, the cortical areas in which 
they are represented, of which the angular gyrus is the 
topographical centre, have a motor side also. In the 
‘same manner that the pyramidal tracts from the motor 
areas act ultimately upon the cells of the lower motor 
nuclei to induce more complex co-ordinations than are 
possible when spinal or basal centres act alone, so it is 
the function of the cells of the association area to act in a 
more complicated way upon the Rolandic neurones and 
other projection tracts. A part of this association area, 
Déjerine’s zone of language, is shown to be connected 
with the association of those elements which constitute 
language, a function which has grown in the history of 
the race to have an amazing significance for man’s in- 
tellectual life. Consequently I believe we may separate 
the zone of language (including the posterior third of 
the inferior frontal convolution, doubtfully the posterior 
third of the second frontal, the island of Reil perhaps, 
the angular gyrus, the upper part of the first and per- 
haps second temporal convolutions) from the rest of the 
association zone, aS an area representing higher co-ordi- 
nations peculiarly significant for the processes of thought. 
We may designate the zone of language as a higher asso- 
ciation area, or an association area of the second order. 
This specialized association area has a representation on 
only one side of the brain, whereas we have reason to be- 
lieve that both cortical association areas take part in the 
simpler intellectual processes, although that on the left 
would appear to be somewhat more important. In spe- 
cial cases the right zone may perform language func- 
tions, even in right-handed persons, just as many persons 
learn to write with the left hand if the right has been in- 
jured or removed. 

The prefrontal lobes have been variously designated 
as “silent” or “functionless” areas, as higher psychical 


centres, as centres of inhibition, as apperception centres, 
and as centres of the will and personality. So great is 
the misunderstanding of the nature of the functions of 
these lobes, even at the present time, and so often is posi- 
tive evidence wrongly interpreted and even misquoted, 
that a somewhat extensive presentation of the facts and 
conclusions with respect to their functions is demanded. 

The result of stimulation of these regions is negative, 
hence they are designated as silent areas. Ferrier, how- 
ever, reports movements of the head and eyes, and early 
suggested that these might be movements characteristic 
of attention, which is the basis of intellection, and that 
these lobes might therefore be considered areas of higher 
psychical function. Extirpation of these prefrontal 
regions in dogs and monkeys by Hitzig, Ferrier, Horsley 
and Schifer, and Goltz was accompanied by slight, hardly 
noticeable, mental deterioration. Munk and other ob- 
servers, on the other hand, deny any loss of attention, 
perception, thought, or inhibitory power. Many authori- 
ties report areas for movements of the head and neck and 
of the trunk, and such centres are now assigned to the 
roots of the upper frontal convolution. 

Bianchi (1888-95) contributed the first experimental 
demonstration conclusively pointing to the psychical 
functions of the frontal lobes. His experiments were 
made upon twelve monkeys and six dogs, all of which 
he subjected to very minute observations both before and 
after the operation, these observations extending in some 
cases over a period of years. To determine the bound- 
aries of the prefrontal zone, Bianchi stimulated electric- 
ally all of the frontal region and excised all portions from 
2 or 3mm. in front of the excitable areas for the arm, 
face, jaw, and trunk. No special effort was made to pre- 
serve the olfactory bulb in the monkeys, but it was kept 
intact in the dogs. The results of electrical excitation 
agree with the conclusions of other observers. 

Regions in front of the motor area of head, neck, and 
eyes were found to be unexcitable with a current of 
equal strength. Stimulation of the base of the upper 
frontal convolution produced slight rotation of the head 
to the opposite side and some lateral displacement of the 
trunk at the level of the lumbar region. Excitation of 
the inferior area caused raising of the eyelid together 
with dilatation of the pupil. The results which Bianchi 
obtained from unilateral extirpation may be summarized 
as follows: 

1. During the first weeks were noted rotatory move- 
ments, concavity of the trunk toward the mutilated side, 
and paresis of the opposite arm (obvious in the more deli- 
cate movements). These symptoms disappeared at the 
end of two or three weeks. No oculo-motor disturbances 
were observed. 

2. Tactile sensibility was normal except in one dog 
(diminished in opposite limb) and one monkey (hypervs- 
thesia in opposite ear and face). 

3. In one monkey there was diminution of hearing on 
one side. 

4. Taste and smell appeared normal. 

5. In all cases there were visual disturbances. A piece 
of sugar was not seen with the right eye until it was 
nearly in a line with the visual axis. The left eye ap- 
peared to be normal. 

6. There was no perceptible difference in behavior or 
psychical manifestations of animals mutilated on one side 
only. They were still susceptible of feelings and capable 
of new adaptations. 

When both lobes were removed, there was apt to be a 
weakness of the left limbs and a tendency to rotate 
toward the right; but in some cases, after a time, all move- 
ments were perfectly performed, though in a listless, auto- 
matic fashion. Sensibility was not necessarily disturbed. 
There was a decided lack of interest, the habitual state 
seeming to be one of indifference, and the strongest feel- 
ings manifested were terror and the desire for food. 
Affection for the keeper and for the other animals disap- 
peared. There was a lack of power to make new adapta- 
tions, to defend themselves, and to resist the influence of 
sensory stimuli. For example, the monkeys would pick 


311 


Brain, 
Brain. 





up and eat a piece of plaster as readily as a piece of 
sugar. Even if they spit it out after breaking it up, as 
sometimes happened, they would return to the fragments 
and swallow them, apparently unable to resist the re- 
semblance to sugar. Psychical life seemed to be reduced 
to the existence of actual sensations; there was no change 
or resource, and experience profited nothing. Percep- 
tion seemed to lack some of the factors necessary to the 
formation of a complete judgment. There were crude 
sensations, but no co-ordination of simple presentations 
into representations of higher complexity. 

Bianchi’s conelusions are as follows: Paralysis of the 
trunk muscies does not always occur, and it is in any case 
but temporary. The phenomena observed upon destruc- 
tion of the frontal lobes cannot be explained by the oc- 
currence of a temporary trunk-muscle paralysis. Bianchi 
does not look upon Ferrier’s hypothesis as satisfactory. 
The facts obtained point to more than a simple defect of 
attention correlated with paresis of ocular and cervical 
muscles. 

Bianchi does not accept the view that the frontal lobes 
are distinctively inhibitory centres. On the contrary, he 
justly contends that every part of the nervous system 
becomes under different circumstances an inhibitory 
centre. When some particular area of the brain is ex- 
cited there is an afflux of nervous waves into it, and this 
weakens the aptitude of other regions to fulfil their func- 
tions. If busy with a problem one becomes deaf and 
blind; if auditory or visual centres are strongly excited, 
the flow of ideas is weakened or arrested. Bianchi’s 
final conclusion may be stated thus: In the frontal 
lobes, the incoming and outgoing products of sensory 
and motor areas are co-ordinated and fused with the 
emotional states that accompany perception; this area, 
therefore, determines what has been called the “ psychical 
tone” of the individual. 

From the time of Bouillaud many cases have been re- 
ported of injury to the frontal lobes without sensory or 
motor symptoms and with no apparent diminution of in- 
tellectual capacity. In the light of more recent knowl- 
edge of the effects of lesions in this region of the cerebral 
hemispheres, it isno doubt correct to infer that these cases 
were not carefully observed. Forexample, the American 
Crowbar Case, 1868, in reality a classical instance of con- 
clusive evidence as to the peculiar functions of the pre- 
frontal area, is still frequently misquoted and wrongly 
interpreted in medical literature, despite the critical an- 
alysis of Ferrier and Mills. The subject of this injury 
was a young man, twenty-five yearsof age. At the time 
of his injury, he was engaged in tamping a blasting 
charge in a rock with a pointed iron bar three feet seven 
inches in length, one and one-fourth inches in diameter, 
and weighing thirteen and one-fourth pounds. A pre- 
mature explosion drove the bar clean through the frontal 
region of the skull, entering at the left angle of the jaw 
and passing out ‘near the sagittal suture in the frontal 
region. The patient recovered and lived for twelve and 
a half yearsafterward. Froma post-mortem examination 
of the skull it was clearly seen that the whole lesion was 
situated anterior to the coronal suture,and hence embraced 
only the prefrontal region. The following report, by 
Dr. Harlow, of the patient’s mental condition after re- 
covery from the injury presents a typical picture of 
mental decadence: 

“His contractors, who regarded him as the most effi- 
cient and capable foreman in their employ previous to his 
injury, considered the change in his mind so marked that 
they could not give him his place again. The equilib- 
rium or balance, so to speak, between his intellectual 
faculties and animal propensities seems to have been 
destroyed. He is fitful, irreverent, indulging at times 
in the grossest profanity (which was not previously 
his custom), manifesting but little deference for his fel- 
lows, impatient of restraint or advice when it conflicts 
with his desires, at times pertinaciously obstinate, yet 
capricious and vacillating, devising many plans of future 
operations, which are no sooner arranged than they are 
abandoned in turn for others appearing more feasible. A 


312 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


child in his intellectual capacity and manifestations, he 
had the animal passions of a strong man. Previous to 

his injury, though untrained in the schools, he possessed 

a well-balanced mind, and was looked upon by those 

who knew him as a shrewd, smart business man, very 

energetic: and persistent in executing all his plans of 

operation. In this regard his mind was radically changed, 

so decidedly that his friends and acquaintances said he 

was ‘no longer Gage.’ ” 

Corroborative evidence is contained in many subsequent 
observations. Lepine, in 1877, reported a case of abscess 
of the right frontal lobe in which the patient “was in a 
state of hebetude.” Heseemed to comprehend what was 
said but could scarcely be got to utter a word. Bara- 
buc, 1876, reported a case of atrophy of the frontal con- 
volutions in both hemispheres in which muscular power 
and sensation were unimpaired, but the patient was in a 
state of complete dementia, marching about restlessly the 
whole day, picking up what came in his way, mute and 
quite oblivious of all the wants of nature and requiring to 
be tended like a child. Davidson, 1876, reported a case of 
injury to both frontal lobes in which the only symptoms 
were of a psychical nature. Every action that this pa- 
tient performed left the impression on the mind of the 
observer that it was purely automatic or machine-like. 
Cruveilhier reports a case of complete idiocy from birth 
until the age of fifteen, with atrophy of two-thirds of the 
frontal lobe. Ferrier states that the frequent association 
of idiocy with such defect of the frontal lobes is a gener- 
ally recognized fact. 

Williamson, 1896, presented five cases of gross lesions, 
tumors, and abscesses involving the prefrontal region 
of one or both hemispheres in which were noticed marked 
mental symptoms. He gives the following instructive 
summary of these and forty-five other cases recorded in 
recent medical literature: 


A condition of mental decadence; a dull mental state; loss 
of power of attention; loss of memory ; loss of spontanei- 
ty ; the patient taking no heed of his surroundings ; sleep- 
ing during the greater portion of the day, or being semi- 
comatose. (In two of these it is noted that the patients 
were in a perplexed mental condition, and constantly 
appeared to be searching for something.)............+.. 32 
Loss of memory; mental failure, but patient cheerful...... 6 
Patient suspicious; suffered from delusion, and was oc- 
Casionally VIOlOME = 21.15) 0jsiexeie:e)e efe's 910-01 le vols vitor tea nee 
Patient irritable and vViolent.........0ssseccesevees 1 
Patient generally asleep; irritable when awake... ou eh 
Patient ambitious, excitable; memory lost ..............6. 1 
Slowness of mental processes; patient simple and childish. 1 
nar anxiety ; childishness; hallucinations ; suicidal ten- 
ONCIES se. Fates civiaic viele ao eine pilsle’elale orate waisig/els eth att aetna 





It may be considered as having been demonstrated be- 
yond the possibility of a doubt that injury to one frontal 
lobe probably, and injury to both lobes certainly, will 
cause mental deterioration. The amount and character of 
this deterioration can be ascertained only from a careful 
detailed examination of the antecedent and subsequent 
capacities of the individual. In general, the phenomena 
are slight intellectual degradation, moral and emotional 
perversion, deficiency of attention, and volitional inef- 
ficiency. The functions of these lobes seem peculiarly 
representative of the mental character and general con- 
duct as these have been developed as the result of a life- 
time of education and action. These areas may therefore 
be designated association areas of the third or highest 
order. They exercise no functions which are not per- 
formed by the other association areas in less degree of 
complexity. Wundt calls these areas, centres of apper- 
ception; an appropriate term if we remember that ap- 
perception is a synthesis or organized coordination of 
all the acquired intellectual and other responsive reactions 
of a brain to the environment of the individual pos- 
sessing it. As pointed out by Waller, it is thus a “high- 
level neural synthesis”; similar syntheses of lower level 
being accomplished by other portions of the cerebral 
hemisphere. Hughlings Jackson presented a similar 
view in the suggestion of a hierarchy of neural processes, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





Stripping the individual, who has attained adult life, 
successively of his prefrontal lobes, the association zone 
of language, the other association areas, will successively 
reduce him to a lower grade of human being than he has 
come to be. The cells of the prefrontal lobes may .be 
put to different uses in the brains of different persons. 
Loss of the frontal lobes might leave a Descartes still a 
fairly satisfactory college professor. The loss of these 
lobes and of portions of the other association areas might 
not unfit the college professor to live the normal life of a 
day laborer whose frontal lobes may be put to a strain 
to maintain his lower standard of activities. 

It may be well to summarize the general conclusions 
of this article and to indicate the point of view from 
which these conclusions have been examined. It is 
customary to distinguish between sensory and motor 
functions of the nervous system, as though certain nerve 
elements performed the duty of supplying us with sensa- 
tions, and others contributed an equal service by bring- 
ing about our movements. Waller has emphasized the 
objections to this view, maintaining that no centre is 
exclusively either motor or sensory, but that all centres 
are both sensory and motor. In this, he correctly inter- 
prets the facts, which show that brain centres physio- 
logically perform their functions only when they both 
receive and emit stimuli. It would clear up many psy- 
chological notions, that are often confusedly interwoven 
with reports of the function of various centres, if it were 
kept constantly in mind that no centre, no neurone, and no 
nerve is motor, and on the other hand that no centre, no 
neurone, and no nerve is sensory. 

All manifestations of life and consciousness are pre- 
sented in the movements of the organism. These 
movements are, therefore, the immediate phenomena. 
A movement, even though it may possibly be restricted 
to a single muscle, is yet the summation of the con- 
traction of its individual fibres. The function of any 
nerve fibre is not to produce a movement, but to 
stimulate or irritate a muscle fibre to exercise its in- 
herent function of contracting. Similarly, it is the func- 
tion of an afferent nerve fibre not to convey a sensory 
stimulus, but to innervate the neurone or neurones about 
which its central dendrites terminate. Even the sim- 
plest reflex action is the result of the co-ordination of 
at least two nerve elements which are intercalated be- 
tween the peripheral point of application of a stimulus 
and the muscle fibres to which the motor neurones run. 
A single segment of the spinal cord, through the ana- 
tomical relationship of its neurones, is capable of serving 
as the reflex centre for complicated co-ordinated move- 
ments. The explanation as to why certain definite 
movements are elected to follow in response to a given 
stimulus is partly anatomical and partly physiological. 
In the first case, the answer ultimately reverts to biology 
to explain why neurones should be found so located as 
to be capable of mediating particular movements in re- 
sponse to definite stimuli. If we ascribe the cause to the 
functional habit of the neurones, we again must refer 
the question to biology to give an explanation of the 
inheritance of this congenital function, or to tell how 
neurones acquire during their existence in the organism 
a particular function or habit. When spinal centres 
comprise more than one segment, the problem remains 
the same; more neurones with their axis-cylinder proc- 
esses have been intercalated, and the response of the 
peripheral neurones is now conjointly inspired by a larger 
group of neurones. The movements that result upon 
stimulation of more extensive centres will be characteris- 


tically different from those of segmental origination, but . 


nevertheless these movements will still depend upon the 
interrelations of the neurons in the centres or upon an 
acquired or inherited habit. 

The neurones, which are alone capable of stimulat- 
ing muscle fibres, are located in the anterior horns 
of the cord and in the nuclei of the motor cranial 
nerves. These neurones may therefore be acted upon 
by peripheral neurones of afferent conduction alone, in 
which case they will respond with simple movements; or 


they may be acted upon by other additional central neu- 
rones. These constitute aggregated masses in the medulla 
oblongata, the cerebellum, the various basal ganglia, and 
the cortex of the cerebral hemispheres. As one mass after 
another is added, the peripheral motor neurones become 
the recipients of stimuli from larger and larger groups 
of central neurones, and the co-ordinated movements 
that follow will represent the combined or co-ordinated 
influence of their various cell elements. Thus, in the 
spinal cord, the neurones suflice to bring about simple 
reflexes; by adding the neurones of the cerebellum, more 
complex movements of locomotion are produced; add- 
ing the basal ganglia contributes the anatomical elements 
that render the reflex mechanism sufficiently complex to 
bring about the co-ordinated adjustment 01 the various 
sense organs to stimuli, and also to initiate the instinctive 
movements of the facial parts and body, which are in- 
terpreted as expressions of emotion. But these move- 
ments can all be accomplished without consciousness, 
and are apparently not acquirable in the lifetime of the 
individual. They represent instinctive or inherited 
reactions, simple if relatively few neurones take part in. 
the co-ordination, complex and often apparently purpos- 
ive if a greater number of neurones are involved. When 
to these neurones are added the neurones of the sensory 
areas of the cortex, of the association area, of the zone 
of language, and of the prefrontal lobes, the physiologi- 
cal problem is still merely the question of the anatomical 
connection of these neurones 7nter se and with the periph- 
eral neurones. The evidence and the interpretation of 
what these neurones contribute to the production of com- 
plex bodily movements involve, however, two factors 
not necessary of consideration in connection with the 
functions of centres below the cortex, namely, the rela- 
tion of consciousness to these processes and the develop- 
ment of acquired functions or habits. 

Considered relatively, the functional activities of the 
cortex are largely the result of an ontogenic education, 
whereas those of the lower centres are the result of 
an inheritance of functions acquired in the course of 
organic evolution. But when anatomical and physio- 
logical connections have been established in a given 
adult brain, the physiological problem is then the same 
as before;—namely, “ What additional complexities of 
movements are now possible from this additionally com- 
plex mechanism?” The existence in our minds of cer- 
tain sensations due to the stimulation of particular areas 
may assist in establishing the functional relationships of 
these areas inter se and to lower centres, but the sensa- 
tions themselves can form no part of a physiological ex- 
planation of the responsive movements that take place 
in consequence of such connections. The same principle 
must apply to the association centres as areas of higher 
psychical activity. The polite request “Please get off 
my toe” is as much a motor response of the peripheral 
neurones as the cry of pain. Experience shows that for 
the first reaction, certain cells of the cortex must have 
integral connection with the efferent pathway, which are. 
not necessary for the much simpler movement. The 
psychologist cannot distinguish between perceptions and 
sensations as distinct entities, nor between intellect and 
imagination as diverse processes, nor does he regard the 
will as a faculty exclusive of other manifestations and 
processes of the mind. When it is maintained, therefore, 
that there are areas of higher level than the cortical sen- 
sory areas—first, an association area which is the anatom- 
ical docus for those cells whose functioning is responsible 
for the phases of consciousness distinguished by the 
terms knowledge, conception, imagination, thought; a 
second association area, the zone of language, which is 
the basis of the function of language as an intellectual 
and emotional instrument; and still a third region, the 
prefrontal lobes, which is essential for the preservation 
of high intellectual and moral character and for volitional 
effectiveness—it is not meant that these three centres con- 
tribute each a different mental element to consciousness, 
nor yet that they are the organs of three diverse mental 
faculties. The analysis suggests that a human being, 


313 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





who may manifest, at different times through speech, 
conduct, and bodily movement, intellectual capacity and 
moral character of different grades, must have these three 
areas intact, if he is to continue to evidence the highest 
attainment of which he is individually capable. 

A question, often confusing, is frequently allowed to 
become involved with this psycho-physiological paral- 
lelism of increasing intellectual complexity and increas- 
ing integration of the cells of the central nervous sys- 
tem. On the one hand, the mere addition of neurones 
apparently forms a satisfactory explanation of the in- 
creased complexity of cortical reactions over that of the 
spinal reflexes. The psychical functions of the brain 
might therefore represent the result of a mere phylo- 
genetic increase in nerve tissue, a product of cortical in- 
tegration. On the other hand, in the human being and 
higher o- ganisms, it is a common experience to find 
automatic actions developing from conscious actions, 
even becoming so set in the nervous system as to appear 
ineradicable reflexes. Many facts tend to suggest that 
conscious reaction has always presided over the phylo- 
genetic development of reflex action; that psychical 
function thus preceded reflex function, and both helped 
to determine the course of organic evolution. This view 
was entertained by Cope, the eminent biologist, and is 
exploited as a fundamental philosophical hypothesis by 
Wundt, without doubt the leading psychologist of the 
day. Many difficulties present themselves to the accept- 
ance of either theory. It is not necessary for us to take 
sides on this issue, when considering the localization of 
psychical function over the cortex of the cerebral con- 
volutions; but it is desirable to keep this and similar psy- 
cho-physiological speculations from interfering with an 
acceptance of reported facts and conclusions. 

It is not worth while to enter into a consideration of 
the various theories which have been propounded at dif- 
ferent times to explain the specific nature of the nerve ex- 
citation which passes along the nerve fibres of a pathway 
of conduction. The crudest physical concepts have been 
called upon to do duty by way of explanation; thus the 
cell has been likened to a battery and the fibres to con- 
ducting wires; the nerve stimulus is frequently spoken 
of as a wave of nervous impulse, similar to but not 
identical with the electrical wave, propagated at an ap- 
preciable rate, flowing from nerve fibre to nerve fibre. 
‘Theories of electrical tension, of galvanism, of molecular 
vibrations, and of chemical explosions, are scientific fan- 
cies rather than hypotheses. When the nervous pathway 
was shown to be made up of unitary cellular elements, 
that were contiguous but not continuous, biological 
theory interpreted the conduction of the nerve stimulus 
as a series of ameboid movements. It may be said that 
no hypothesis has yet been formed that offers even the 
hope of becoming a sufficient explanation. 

In addition to the original authorities, mentioned in 
the text, the writer has been much assisted by the critical 
abstracts of the literature to be found in the publications 
of Ferrier, Jackson, Macalister, Collins, Gordinier, and 
Barker, and especially by the “Sketches of the History 
of Reflex Action,” by Hall and Hodge, in the American 
Journal of Psychology, from which have been drawn many 
statements of the established facts of the phenomena of 
reflex action. Lightner Witmer. 


BRAIN, GROWTH OF THE.—The following article 
aims to present a general account of the growth changes 
which occur in the human brain and cord, between the 
time of normal birth and the natural end of life, thus in- 
cluding those found in old age. 

In dealing, as in this case, with data for the most part 
very incomplete, the danger of confusion arises from the 
tendency, on the one hand, to make a general applica- 
tion of special observations, and, on the other, to inter- 
pret the absence of positive as equal to the presence of 
negative evidence. With these words as a preface, how- 
ever, we may spare ourselves the duty of showing in 
special instances the limitations of the observations cited. 

In discussing the changes which occur in the neuraxis 


314 








(brain and spinal cord = central nervous system), the fol- 
lowing outline is employed: 

A. Growth changes in the neuraxis and some of its 
divisions. 

B. Growth changes in the neuraxis—considered as the 
reSultant of changes in the cells which constitute it. 

1. Number of neurones. 

2. Size of neurones. 

3. Changes in the cytoplasm of the cell bodies during 
growth. 

C. Growth of the cerebral cortex. 

A. GROWTH CHANGES IN THE NEURAXIS AND SOME OF 
Its Divistons.—The human encephalon varies widely in 
weight at maturity, even when members of the same 
race and the same social class are alone compared. Dif- 
ferences in the final weight must be looked upon as re- 
sulting from differences in the process of growth. The 
weight of the encephalon at maturity is illustrated by 
ne Be EAL table based on the observations of Dr. 

oyd:! 


TABLE I.—SHOWING IN GRAMS THE WEIGHT OF THE ENCEPHALON 
AND ITS SUBDIVISIONS IN SANE PERSONS. THE RECORDS BEING 
ARRANGED ACCORDING TO SEX, AGE, AND STATURE. (From Mar- 
shall’s tables based on Boyd’s records. ) 












































SANE. 
MALES. FEMALES. 
sla Saas d 
e\/a|é El g|2 
sh eh ee ee ; | 2 | SS aee 
2 2 D D = = ‘D ‘> 2 ™ 
L ro) raf fe ra ra =) oD 
op 5 2 © 
< 8 sa Be el | ac hs 3 Li hee | 
Stature 175 cm. and upward. Stature 163 em. and upward. 
20-40 | 1409 | 12382 149 | 28 23 134 | 1108 | 1265 | 20-40 
41-70 | 1863 | 1192 144 | 27 23 131 | 1055 | 1209 | 41-70 
71-90 | 1380 | 1167 137 | 26 24 130 | 1012 | 1166 | 71-90 
Stature 172-167 cm. Stature 160-155 em. 
20-40 | 1860 | 1188 | 144 | 28 26 137 |°1055 | 1218 | 20-40 
41-70 | 138385 | 1164 144 | 27 26 131 | 1055 | 1212 | 41-70 
71-90 | 1805 | 1135 142 | 28 24 128 969 | 1121 | 71-90 
Stature 164 cm. and under. Stature 152 cm. and under. 
20-40 | 1381 | 1168 188 | 25 24 130 | 1045 | 1199 | 20-40 
41-70 | 1297 | 1128 1389 | 25 25 129 | 1051 | 1205 | 41-70 
71-90 | 1251 | 1095 181 2 25 123 974 | 1122 | 71-90 

















These records were obtained from 2,086 patients of the 
Marylebone Workhouse in London, representing, for the 
most part, the least favored class of persons native to 
Great Britain. For the purpose of weighing, the en- 
cephalon was divided into three portions: (1) The cere- 
brum, including all parts frontal to the midbrain; (2) 
the cerebellum, severed at the peduncles; and (8) the 
stem—the midbrain, pons, and bulb taken together. 

Owing to the fact that these records are based on a 
workhouse population, it is probable that they represent 
brains less well grown and earlier subject to senile 
atrophy than would be the case among the more pros- 
perous members of the community. The general rela- 
tions to which we are about to call attention would, 
however, remain the same. 

On comparing the sexes Table I. shows that the heavier 
brains belong to the males; on comparing those of differ- 
ent stature within each sex, that they belong to the tall 
individuals; and when those of the same sex and stature 
are compared, according to age, to those in the prime of 
life, ¢.e., twenty to forty years of age. Sex and stature, 
then, are conditions which modify the weight which the 
brain will attain at maturity, and after the prime of life 
its weight diminishes. 

Having indicated the weight at maturity under the 
conditions of the race and social class here chosen, we 
have next to determine the weight of the encephalon at 
birth, and the course of the changes by which it reaches 
its full size. 

Vierordt has collected the most complete series of ob- 
servations for the change in brain weight between birth 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 











and twenty-five years of age. 


The data are taken mainly 
from German records. 


They are printed in Table IT. 


TABLE II.—TO SHCW THE INCREASE IN BRAIN WEIGHT WITH AGE. 
ENCEPHALON WEIGHED ENTIRE WITH PIA. (Compiled by Vierorat.) 




















MALES. FEMALES. 
Age. 
Number Brain. Number Brain 
of cases. Grams. of cases. Grams 
0 months 381 38 384 
1 year 945 11 872 
2 years 1025 28 961 
yee: 1108 23 1040 
4 1330 13 1139 
5 1263 19 122 
6 1359 10 1265 
7 1348 8 1296 
8 1377 9 1150 
o 1425 1 1243 
10 1408 4 1284 
11 1360 1 1238 
12 1416 2 1245 
13 1487 3 125 
14 1289 5 1345 
15 1490 8 1238 
16 1435 15 1273 
17 1409 18 1237 
18 1421 21 1325 
19 1397 15 1284 
20 1445 33 1228 
21 1412 31 1320 
22 1348 16 1283 
23 13897 26 18 
24 1424 33 1249 
52/59 1431 33 1224 
424 











When the data in Table II. are cast in the form of. 


a curve representing the increase in weight according to 
age, we obtain the chart given below (Fig. 908). 


Opec eeeee Oo 6S) 10) 120 14° 16-18 20. 22 Years. 


wae a 
COMAPI Se 
_ ASGRE eee 

ese Pf 





Fie. 903.—Curves Showing the Variations in Brain Weight During 
the First Twenty-Five Years of Life. Based on Table II. 


In the records of Vierordt it appears that, except at 
birth and in the fourteenth year, the male has a greater 
brain weight than the female.* 

In both sexes the most rapid increase in weight is dur- 
ing the first year; it continues to be rapid up to the 
fourth or fifth year, and then becomes slow till the seventh 
year, when the weight of the brain found in the adult is 


* During the period of very rapid growth, a slight disparity in the 
average age of the cases compared easily reverses the weight relations 
according to sex. This is the probable cause of greater weight in the 
female at ** birth,” as reported by Vierordt. More careful determina- 
tions by Mies, 1894, and Pfister,4 1897, show the male brain to be 
heavier. e 








nearly attained. From this age on, there is a very slight 
and very slow growth up tomaturity. At the time when 
nearly the final brain weight has been attained—namely, 
the seventh or eighth year—the full difference of 100 
grams or more existing between the two sexes is evi- 
dent. From this, it happens that the rapid growth of 
the brain has occurred while the body is still very im- 
mature, since boys of seven years weigh on the average 
only fifty pounds, and girls but forty- ‘two pounds—this 
in both sexes being about one-third of the adult body 
weight; and that the differences characteristic of sex have 
been established before sexual maturity. The irregular- 
ities of the curve are to be explained as statistical mainly, 
and dependent on the comparative smallness of the num- 
ber of cases available for each year. No significance is 
to be attached to the dip in the male curve at fourteen 
years. The very high averages for the males at twelve 
and fourteen years, and for the females at thirteen years, 
are to be noted, since they occur in other similar series.® 
These “premaxima” are most readily explained by as- 
suming that an overgrowth of the brain during these 
years of beginning adolescence is one source of constitu- 
tional weakness, and hence the children dying at this 
period exhibit heavy brains. There is no reason to sup- 
pose that within the life cycle of the individual, the 
brain attains during these years a greater weight than 
that shown at maturity. 

From the table of final weights (Table I.) as well as 
from that just presented on growth, it is plain that the 
difference in the weight of the encephalon according to 
sex is one exhibited at birth; that it increases during the 
growing period, and is maintained throughout life. In 
the first instance, this difference is most closely asso- 
ciated with the difference in the total body weight of 
the two sexes, and is so correlated in the mammalian 
series. 

Table I. further shows us that the taller persons have 
the heavier brains, and this may probably be extended to 
mean the heavier persons, since when fairly compared, 
the taller are also probably the heavier. In old age in 
both sexes, the brain weight diminishes, as the result of 
shrinkage in the encephalon. There is some reason to 
think that this involutionary process is delayed in the 
more favored social classes. 

It is an important fact that the differences in the 
weight of the encephalon according to sex, age, and 
stature are correlated with only very slight variations 
in the proportional development of the subdivisions of 
the encephalon as here examined. Table III. shows 
the percentage value of these subdivisions for different 
ages at all statures. 


TABLE IIJ.—SHOWING THE PERCENTAGE OF WEIGHT OF THE SUB- 
DIVISIONS OF THE ENCEPHALON, THE RECORDS BEING GROUPED 
ACCORDING TO AGE. BASED ON TABLE I. 





























MALES. FEMALES. 
a a ad Sei ine se 
Se cate Be) ge 
oa fees =| 
a = D 3) = aq 
fat 2 a : a 2 Bi . 
Ape | nef ok todd Na ca Ge 
< BoleSal owl es BES Pecan < 
20-40 100 | 87.52) 10.49} 1.91 “1,96 10.9 | 87.13} 100 | 20-40 
41-70 100 | 87.00} 10.6 | 1.94 2.02 | 10.8 | 87.14) 100 | 41-70 
71-90 100 | 87.83) 10.6 | 1.98 2.11 | 11.16 | 86.4 100 | 71-90 

















Here there is a very slight falling off in the propor- 
tional value of the cerebrum in persons of advanced age. 
In general the value of the male cerebrum is slightly 
in excess. In the next table (IV.), where the comparison 
is made according to stature, there is a regular decrease 
in the value of the male encephalon with diminishing 
stature, and at all statures the male cerebrum is slightly 
in excess of the female. 


315 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





TABLE IV.—SHOWING THE PERCENTAGE OF WEIGHT OF THE SUB- 
DIVISIONS OF THE ENCEPHALON, THE RECORDS BEING GROUPED 
ACCORDING TO STATURE. BASED ON TABLE I. 









































MALES. FEMALES. 
@|s|e ales 
Stature. reall petals eo Are =| 2 | 4 | @| Stature. 
i Die Os eee tes a Deal res 
a] o > | 2 BS o o |s8 
A} oO iS) n io) o oOo |e 
175 cm. and | ay x ye § 163 cm. and 
“upward. 100 ele an 1.90) |1.91 es 86.93 100 | upward. 
172-167 em ....|100/87.2 |10.65}2.08] |2.10)11. 1686.68) 100 160-155 ns 
164 em. andl ” 414 a| | low qa § 152 em. ani 
auiers ¢ |100/87.17/10.6 1.86) |2.09)10.83)87.06)100 heneiandad: 


In Table VY. it is possible to make the comparison of 
the proportional development of the several divisions 
from birth to old age. 


TABLE V.—SHOWING THE PROPORTIONAL WEIGHT OF THE DIVI- 


























SIONS OF THE ENCEPHALON AT DIFFERENT AGES. (Boyd.) 
MALES. FEMALES. 

oe . ool 

° g é ° g 

> =] | bt | 

2g =e |G Eo £|es3 

= = . va U2 a s 
Fe 3 Age. 3 3a d 5 g Age. S &a| 42 
=) 5 ioe g =] &B 2 2 

a o 7a) A es) aR 
45 ‘New born.| 92.4 | 5.8 | 1.60 45 |New born.| 92.1] 6.2 | 1.50 
22 7-14 87.8 | 10.3 | 1.61 18 7- 87.9 | 10.5 | 1.50 
99 30-40 87.3 | 10.6 | 1.98 80 30-40 87.0 | 10.8 | 2.01 
95 70-80 87.0 | 10.7 | 2.09 || 128 70-80 86.9 | 10.9 | 2.15 











We see here that the cerebellum is the portion least 
developed at birth, and that between birth and the seventh- 
year period, the proportions found at maturity are very 
nearly established. In this table, again, the percentage 
value of the cerebrum tends to be slightly greater for the 
male. During the active growing period the reduction 
in the percentage value of the cerebrum is due, of course, 
to the more active growth of the cerebellum and stem, 
while during the involutiopary period—that is, between 
seventy and eighty years, in this table (V.)—the dimi- 
nution in value is due to its more rapid shrinkage, as can 
be seen by examining the absolute weights exhibited in 
Table I. 

As regards the subdivisions of the cerebrum, Fran- 
ceschi® has some observations which are unique. He de- 
termined the weight of the thalamus and striatum for 
each half of the cerebrum, in a number of persons and at 
various ages. During the first five years, the records 
are too few and indefinite to be valuable. Beginning 
with twenty-one years, however, he has the following 
data to present: 


TABLE VI.—GIVING THE WEIGHT OF THE BASAL GANGLIA IN 
THE Two SEXES AT DIFFERENT AGES. WEIGHT IN GRAMS. 
(Franceschi. ) 




















MALES (Basal ganglia). FEMALES (Basal ganglia). 
Number Number 
Age. of ob- Mean weight. Age. of ob- Mean weight. 
servations. servations. 

Right.| Left. Right.| Left. 
21-40 16 41.2 40.8 21-40 20 36.0 36.0 
41-71 38 41.6 42.3 41-70 45 37.7 38.0 
71-87 22 42.4 42.4 71-87 21 37.7 41.0 

















This table shows no regular difference between the 
two halves of the brain. There is, however, a constant 
difference according to sex, these structures being about 
ten per cent. heavier in the male; and very curiously, an 
actual increase in weight in the last age group, when 
according to the other records the total weight of the 


316 


cerebrum is /ess than that found during the prime of life. 
This peculiar relation must be confirmed before it can be 
regarded as significant. 

In connection with the determination of the weight of 
the encephalon as the result of growth there are several 
problems arising frcm the effect of deformation of the 
skull during the growing period, and from the possibility 
of compensatory enlargement of the cranium along one 
or more axes when its normal growth is hindered. The 
winding of the child’s head with a compressing bandage, - 
so as to elongate it in the fronto-occipital axis, has for 
generations been practised about Toulouse, in France. 
The study of the brains of aged persons from this local- 
ity with skulls thus deformed has been made by Ambia- 
let,? his investigation being the most important study 
along this line. As might be expected, the effects 
of this treatment are more pronounced if the deforma- 
tion has been great than if moderate. Ambialet is able 
to show, first, that on the average the total weight of 
the encephalon was diminished, by this treatment, only 
from two to three per cent; further, that the relations 
between the cerebrum and the remainder of the encephalon 
were but slightly modified, the relative value of the cere- 
brum being reduced a fraction of a per cent., and, finally, 
that when the cerebrum is divided into lobes, after the 
method of Broca, the relative weights of these lobes 
are not significantly different from those found in the 
normal brain. Since the skulls in question are very evi- 
dently abnormal in shape, these results indicate that 
compensatory growth has occurred in the enclosed brain. 
This result would agree with those recently obtained from 
the study of crania by Boas,* which he formulates as 
follows: “Among skulls belonging to the same type, a 


. breadth above the average is compensated by a height 


and a length below the average.” This is probably only 
a special case representing a general tendency toward a 
final arrangement of cranial diameters which will result 
in the cranial capacity normal for the individual. The 
effects of bandaging the skull appear to cause a general 
nutritive disturbance rather than one limited by the 
boundaries of the bandage, and the results are not due 
to direct pressure on the enclosed brain. So far as this 
aspect of the problem is concerned, we have the beauti- 
ful researches of von Gudden® on the growth of the 
skull and brain, which show that while these two struct- 
ures may to a slight extent mutually adapt themselves 
to each other, yet the fundamental growth changes in 
the brain are in a high degree independent of merely me- 
chanical conditions. 

In connection with the encephalon, we shall present 
such data as are available on the human spinal cord. 

The weight of the cord at different ages can be best 
shown by a comprehensive tabulation of the results, 
though these are hardly numerous enough to be used 
for the formation of a curve (see Table VIL.). 

It thus appears that the spinal cord increases from an 
average weight of 3.42 gm. at birth to 27 gm. at matu- 
rity—an increase of nearly eightfold (7.8),—gaining in 
weight about twice as much as the encephalon. The 
encephalon has nearly attained its adult weight at the 
seventh year, while the cord (see table) at this time has 
less than two-thirds of its adult weight. So far as this 
table shows, the cord grows more rapidly than does the 
brain at every period succeeding birth. The final enlarge- 
ment of the cord is correlated with the growth of the trunk 
and limbs that occurs during adolescence—a series of 
changes by which the cranial cavity is but slightly af- 
fected. The weight of the cord is therefore closely cor- 
related with the length of the vertebral column. The 
proportion of the weight of the spinal cord to the weight 
of the brain is somewhat greater in men than in women, 
owing probably to the greater growth of the trunk in 
the male. ; 

Since the central nervous system rapidly reaches nearly 
its full size while the remainder of the body is still quite 
small, it follows that the proportion of the weight of the 
entire body represented by it, decreases. 

To show the relative development of the central ner- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 




















Brain, 
TABLE VII.—WEIGHT OF THE HUMAN SPINAL CORD AT DIFFERENT AGES. 
; Bopy. WEIGHT IN GRAMS. 
ewe Grams of 
Observer. Sex and number Age. Tenoth brain for each 
of cases. Weight “Milli. ‘ Brain. Cord. gram of cord. 
Grams. | metres. 
; Wi ed cand deecannoc 10 males, 116. 
MAGS yon 5 eisib's.0'0 21 male and fomaleWBIrth to LL dayscsnjseecs os ||reseresssidensarces ; i ‘ ie f : fe ) Range BR weet 11 females, 113. 
* be 1 iT] BION LOS s nest Ossie aalcie tievslctetsts aie Males ls 
Danielbekof ...| 200 AVCYADO ACER SO' GAYS coke al'aillllie:s aie cisinre-o1'lts afelslele/sce Females 399.2..| 38 0002 Females 104 
WMIGSE sche ts.s +s EPOMBIOA ss sae.03 00 One year six months.......| | 4,856 COBY: Ou wreiviyer stele WM olAecdars obialemter Seres 94 
eres +s URIIOM SMa eee ae a: SUX VORIS Seis eisceicre sen emics ail iors cats w cr wtarets 1,060 .. | Re once TB. BBiis ockenasclettes 73 
Pele thscsse0.s IfOMBIC Rene regret Ten years nine months.....||.......... 1,330 PASO ean eres Nf ess tcp tara ee OC 69 
BaD tere s's.5. 5 cine MMAR aes ead e ale Eighteen years six months..||.......... 1,750 EBAO\ easivnet 27.50 Rieti aroha a ; 
“ “ Slane Oe NT ee eon 10 males, 51. 
SECO NOIEG 13 Brctereisty sieeve) NL UULEY Oats raters stcrsisioihiasinic's/arti| leie ee «ca siais' ole sletierniete.e 6 Seite das Range 24-33.3 gm..| 4 females, 49. 





vous system, as represented by the brain at different ages, 
the percentages below are given from Vierordt: 


TABLE VIII.—PERCENTAGE VALUE OF THE BODY WEIGHT AS REPRE- 
SENTED BY THE ENCEPHALON AT THE AGES NAMED. 


BRAIN WEIGHT. 





Age. 
Male Female 
RECA MEET ORCaCarcloisafo a's «ie sve s\0 side ove eie-e'ee c'erined 12.29 12.81 
NOTIRUEY CHC ema selcieieis aie it's, cc's sn di’via Giese sioe-svsie « 10.50 11.39 
PUM NAN VES torsrate leit cise) bles 0:4 ei8'disielereele.vie\s'siviee:s 7.94 7.98 
PLM Ie RCM cemeteries a aihicisia'sis ie.sav ole ovis ve.sws eo 5.59 5.56 
DME MAREN OREN corel ciecatereie'sa.c)s,scc 4 crereiove e #61. erarvieis 3.62 3.09 
PUDUp ATR WOU GUIS Ol atare seo escie,o Cele: axe ieie'ereiolere s eielaeie.e @ 2.43 2.31 
PEWOHUYsHVO VORTS: i. scccsccccccccncesceccece 2.16 2.23 


This table shows that the proportional value of the 
central nervous system falls off rapidly during the grow- 
ing, period and that the proportional value is greater in 
the female except in the ten, fifteen, and twenty year 
records. This greater proportional value in the female is 
the result of the smaller body weight, and the departure 
from this relation at the periods noted above is a statis- 
tical deviation, due most probably to the fact that during 
adolescent growth the increase in body weight occurs 
earlier in the female than in the male, and hence at these 
times the table compares the sexes at different phases of 
their growth. 

In the growing neuraxis the changes in weight run 
nearly parallel to the changes in volume, but are a trifle 
more rapid, owing to the fact that with advancing age 
the specific gravity of the nerve substance increases and 
the percentage of water decreases. 

Although there are numerous observations on the per- 
centage of water in the human neuraxis at maturity, the 
changes occurring during growth have not been studied. 
To supplement this lack, a series of observations (not 
yet published) made on the white rat by Mr. Polkey and 
myself will be utilized. 

From white rats at different ages the brain and spinal 
cord were removed separately, and the proportion of 
water in them was determined by drying, at about 97° 
C. A study of the results shows that at birth the brain 
contains about 87 per cent. of water and the cord 85 
per cent., whereas in old age the brain contains about 
78 per cent. and the cord 72 per cent. Thus a differ- 
ence in the percentage of water exists between the 
brain and cord at birth, and this difference increases 
steadily throughout life. 

In the case of both portions of the neuraxis, the curve 
representing the diminution in the percentage of water 
can be divided into three parts. The first part covers 
the first eight to ten days after birth. During this time 
the diminution in the percentage of water is slow. The 
second part comprises the next forty days of life. Dur- 
ing this period it is very rapid. The third part is from 
the end of the second period to the termination of life, 
during which there is a very slow but steady diminution 
in the percentage of water. 











The principal change in the central nervous system 
correlated with the proportional loss of water is the for- 
mation of medullary substance, and the two processes 
run very nearly parallel. 

B. GRowtH CHANGES IN THE NEURAXIS CONSIDERED 
AS THE RESULTANT OF CHANGES IN THE CELLS WHICH 
ConstitutTE Ir.—The changes which occur in the cen- 
tral nervous system as a whole are but the resultant of 
all the changes taking place in the cells which compose 
it. An exhaustive list of these components would in- 
volve the cells forming the blood-vessels and the sever- 
al sorts of supporting structures—ependyma, neuro- 
glia, and connective tissue—in addition to the neurones 
proper. Lack of information concerning changes in the 
non-nervous structures will, however, preclude more 
than incidental mention of them, and we can turn our 
attention to the neurones, not, however, forgetting 
that the non-nervous structures are much more impor- 
tant constituents than this treatment of them would in- 
dicate. 

1. Number of the Neurones.—It is first necessary to de- 
termine when the number of nucleated nerve cells (neu- 
rones, actual and potential) is fixed. The absence of 
karyokinetic figures in the human system at the time of 
birth is presumptive evidence that the number of nerve 
cells is not increased after that period. Other observa- 
tions suggest that the production of new nerve cells has 
been completed in man by the end of the third month of 
foetal life, and even if the production of new cells has 
not absolutely ceased at this time, our present evidence 
indicates that it has become very slow. It may be ob- 
served in passing, that in the white rat at birth cell di- 
vision is still very active; but this has little bearing on 
the condition found in man, because the time of birth in 
different mammals does not furnish a base line for com- 
parison, since the maturity of the animal at birth varies 
enormously with the species, and in this instance the 
new-born rat is to be compared with the human fetus 
at least several months before birth. Granted that the 
number of nucleated nerve cells is formed early, we 
have next to inquire what happens to them after they 
have been formed. The studies of His!° and others have 
shown that the first appearance of these elements is in 
the form of a neuroblast, which in some cases develops 
into the complete neurone, while in others it may remain 
undeveloped for years or even throughout life. When 
it does undergo development the order of the changes is 
in general that described by Cajal"! for the cortical neu- 
rones (the pyramidal cells in the cortex of the rabbit). 
First, the formation of the axone, then the dendrites, and 
finally the collaterals; these portions being all well 
marked before the neurone as a whole has attained its 
full size. After this, the medullary sheath appears: 
first on the axone, and later on the collaterals. Never- 
theless, even in those neuroblasts destined to undergo a 
complete development these changes do not occur at the 
same time in all the individuals. The fact that the sum 
of the nucleated cells which furnish both the permanent 
neuroblasts (granules of the authors) and the developed 
neurones is not increased after an early period in the 
foetal development of man is the first important datum. 


317 


Brain. 
Brain, 





The second fact is that a number of these potential neu- 
rones begin to develop shortly after their formation, 
while others delay a longer or shorter time. Thirdly, 
all statements regarding the number of neurones (nerve 
cells) in any part of the nervous system are based on the 
number of fully characterized nerve elements there 
present, and leave unennmerated the potential nerve 
cells in the neuroblast stage. Since the well-charac- 
terized neurones are transformed from the neuroblasts 
only gradually and in series, it follows that during the 
earlier phases of growth the nwmber of neurones will 
increase ; but, as has just been explained, this increase 
is at the expense of neuroblasts already present in the 
locality, and does not depend on the formation of new 
cell elements. 

From this it follows that in a given part of the nervous 
system there exists, after cell multiplication has ceased, 
the paradoxical conditions whereby an increase in the 
number of nerve cells may occur without any increase in 
the total number of neuroblasts and nerve cells taken to- 
gether, since the latter arise by the transformation of the 
former. 

In order to follow this increase in the number of neu- 
rones in the growing animal, it will be advantageous to 
use the following classification of the cell elements. By 
this classification, the neurones constituting the nervous 
system are arranged in three groups. Group I. The 
afferent neurones: Those furnishing the afferent path- 
ways and having their cell bodies located in the spinal 
ganglia or their homologues. In this class the cell body 
lies outside the neuraxis. Group II. The central neu- 
rones—constituting the great mass of the central nervous 
system: All parts of these neurones lie within the wall of 
the original medullary tube, and all the neurones are 
concerned with the distribution cf the impulses within 
these limits. Group III. The efferent neurones—con- 
cerned in distributing the impulses to the organs of 
expression. 
motor element of the ventral horn of the spinal cord, 
with its cell body within the wall of the medullary 
tube and its axone passing either to striped muscle 
tissue or to the peripheral neurones of the sympathetic 
system. To this last group the neurones of the sympa- 
thetic system also belong, but in this case both the cell 
bodies and the axones are found outside of the central 
system. 

Since it is the mass of the central neurones which con- 
stitute the very great proportion of the central nervous 
system, and since this is the group which undergoes the 
greatest variation in the mammalian series, it has seemed 
desirable to separate this group from the other two, and 
this has been done by means of the foregoing classifica- 
tion. The studiesof Birge!? on the number of root fibres 
in frogs of different sizes and of Hardesty '* on the 
growth of these fibres, show that in the afferent and 
efferent groups in the frog new axones are continually 
being formed, and we infer that this new formation fol- 
lows from the development of neuroblasts which have 
remained latent for some time. The growth of the frog 
is so long continued that it is usually said to grow as 
long as it lives—a statement by no means demonstrated. 
The conditions are, however, very different from those 
found in mammals in which the period of growth is 
much more limited and the size of the body is fixed. In 
mammals, the available observations are very few. 
There are no observations on the increase of the neurones 
in the afferent system of the mammal (Group I.) except 
the recent study of the dorsal nerve root (fourth coccy geal 
of the cat) by Dale.'4 Here, the number of medullated 
fibres was found to be the same at different levels of the 
root, thus failing to show in the cat the outgrowing fibres 
revealed by Hardesty in the frog. It appears then that 
the number of dorsal root fibres in this locality is early 
fixed in the cat. Passing next to the efferent neurones, 
the records of Kaiser!® on the “motor cells of the ventral 
horn” in the region of the human spinal cord, comprised 
between the fifth cervical and first thoracic segments, 
inclusive, are as follows: 


318 


The type of the efferent neurone is the - 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








TABLE [X.—SHOWING THE NUMBER OF DEVELOPED CELLS IN THE 
VENTRAL HORN IN THE CERVICAL ENLARGEMENT OF MAN AT DIF- 








FERENT AGES. (Kaiser.) 
Age. Number of nerve cells. 
Foetus, sixteen weeks. 50,500 
Foetus, thirty-two weeks. 118,330 
New-born child. 104,270 
Boy, fifteen years. 211,800 
Male, adult. 221,200 





We assume, of course, in accordance with the explana- 
tion given above, that the additional neurones are derived 
from neuroblasts already present. If the numbers here 
given are interpreted literally, they mean that to the 
ventral roots of these segments there are added during 
the periods given the equivalent number of new fibres. 
Moreover, this addition, according to the table, would go 
on for a long period, and thus we might expect to find 
evidence of outgrowing axones in the ventral roots of 
persons more than fifteen years of age. 

In the case of the ventral root of the fourth coccy- 
geal of a cat, Dale was unable to find any evidence of 
outgrowing fibres; and, furthermore, the studies of Schil- 
ler!® on the oculo-motor nerves of cats of different ages 
showed that at eighteen months the number of fibres pres- 
ent was hardly four per cent. greater than the number 
found at birth, indicating that here, at ‘least, the number 
added between birth and maturity was small. 


TABLE X.—SHOWING THE AVERAGE NUMBER OF FIBRES FOUND IN 
EACH OF THE OCULO-MOTOR NERVES OF CATS, FROM BIRTH TO: 








EIGHTEEN MONTHS OF AGE. (Schiller.) 

Extreme 

Mean js f 
Age of specimen. number of | V@viation in. 

fibro number 

of fibres. 
New born, A, B, C (average of three cases) .. 2,942 2,905-2,980 
One month, D, E (average of two cases) .... 2,961 2,946-2,976 
Four months).Bs;51. son, cbeienicemonmetion tries 3,007 2,995-8,016 
Twelve months, G (mother of A, B, F)....... 3,018 3,002-3,019 
BighteenmMonths, EH sant ecitecctsteetcrsiciee ee 3,085 3,020-3,050 


Using the observations of Schiller to control those of 
Kaiser, it may be argued that the number of efferent neu- 
rones in the cat is early completed. Probably the same 
is true for man; and if it is true for man then the great. 
increase in the number of cell bodies found by Kaiser in 
the ventral horns of the spinal cord is due to the develop- 
ment of central rather than of efferent newrones. 

Until more evidence on these points is available, how- 
ever, further discussion would be useless. 

The total number of neurones found in the brain and 
cord of man is doubtless variable, but for individuals of 
the same race the variability is probably not large. This. 
is concluded from the constancy in the proportional de- 
velopment of the divisions of the encephalon. The 
closest determination of the number of neurones in the 
cerebral cortex of man has been made by Miss Thomp- 
son,!? who employed as a basis the records of Hammar- 
berg.'8 According to this computation, there are in the 
cerebral cortex 9,200,000,000 well-marked nerve cells. 
Using these results as a foundation, and estimating that. 
in the remaining gray matter of the neuraxis the cells. 
have aa average frequency equal to that in the cortex, I 
have computed that the total number of nerve cells in 
the entire central nervous system is 11,200,000,000. 

2. Size of Neurones.—In this connection it is impor- 
tant to remember that on passing down the mammalian: 
series from larger to smaller forms, the nerve-cell bodies. 
diminish much less rapidly in volume than does the en- 
tire animal or its central nervous system. From this it: 
follows necessarily that in the nervous systems of small 
animals, with their small absolute weight and their com- 
paratively large cell bodies, the number of the neurones 
must be far smaller than that found inman. To show 
the average size of the cell bodies in one locality ina 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


series of mammals, the following table from Kaiser is 
quoted: 


TABLE XI.—SHOWING IN A SERIES OF MAMMALS THE MEAN DIAM- 
ETER OF CELLS FROM THE VENTRAL HORNS OF THE CERVICAL EN- 
LARGEMENT. THE MEASUREMENTS FOR THE CHROMOPHOBIC AND 
CHROMOPHILIC CELLS ARE KEPT SEPARATE. (Kaiser.) 


MEAN DIAMETER OF CELLS IN #. 

















Chromophobe Cells. Chromophile Cells. 
1 Plecotus auritus......... 28-53 
2 Talpa Europa ......... 36-54 | 1 Talpa Europea......... 17-40 
2) Erinaceus Europzus.... 25-45 
3 Cercocebus sinicus ...... 33-60 | 3 Cercocebus sinicus....... 238-46 
4 Cuniculus domesticus... 41-61 | 4 Cuniculus domesticus... 32-57.5 
Be HOMO Ac teus .ceee cee 28-59 
1 Bat. 2Mole. 2! Hedgehog. 3Monkey. 4 Rabbit.. 5 Man. 


With this peculiarity of the cell bodies is to be con- 
trasted the behavior of the axones. The calibre of the 
axones is most closely correlated with the volume of the 
cell bodies, and therefore is not more subject to diminu- 
tion than the cell bodies themselves; but, on the other 
hand, the length of the axones necessarily varies with 
the size of the animal. From this it follows that the 
total volume of corresponding neurones is always dimin- 
ished in the smaller animals, and this too despite the 
fact that the diameters of the cell bodies and the axones 
may be but little modified. 

In man a notion of the volume of the average neurone 
at maturity can be obtained by dividing the volume of 
the central nervous system, so far as it is composed of 
neurones, by their estimated number. The volume ob- 
tained is 90,000 u?.* 

The neuroblast, according to His,!° has a volume of 700 
cubic micra. According to this the average neurone would 
have increased only about one hundred and twenty-eight 


times in volume—whereas it can be shown that very © 


many neurones increase more than a thousandfold. 

Since a large number of neurones can be shown to in- 
crease many times more than the average enlargement, it 
follows that there must bea very large number of neuro- 
blasts which develop either slightly or not at all. In 
support of this statement, attention is called to the fact 
that in the cerebral cortex the smallest neurones have 
diameters much smaller than that of the original neuro- 
blasts; while in the cerebellar cortex, the granules with 
a mean diameter of about 7 « appear still more reduced. 
There is at present no satisfactory explanation for these 
cases. 

The only observations on the changes in the volumes 
of growing cell bodies in man are those by Kaiser,!> made 
on the cell bodies of the ventral horns of the cervical en- 
largement of the spinal cord. 


TABLE XII.—SHOWING THE VOLUMES OF THE LARGEST CELL 
BODIES IN THE VENTRAL HORN OF THE CERVICAL CORD OF MAN. 
(Based on Kaiser’s records of the mean diameters.) 








Proportional Time 
volume of A 
hie Age. the cell bodies, | terval. 
1= 700 »3.+ 
UNOS TIS tae Genee Four weeks........ 1 
RMR Saeas anes Twenty weeks ..... Ly 
SEe ree ties aictes' Twenty-four weeks. Bil 36 weeks. 
| Fe opera Twenty-eight weeks 67 
So CGE Oe Thirty-six weeks... 81 
MODE U EYES GI ese a lle die: tne,eirdvenseieise c1ne's 124 
overti{ieen years. |i s.css sessed ss 124 ( 15 years. 
BYLEUIMENELCLULNU cin veysie ood ote staidiets cieieisvercle-tie.cis 48 160 15 years. 








+ The volume 700 «3, in the foetus of four weeks, is taken from His, 
and the figures represent multiples of that volume. 


The proportional volumes given in Table XII. show 
that the rapid enlargement of these cell bodies occurs be- 


* The estimated number of neurones—excluding the spinal and sym- 
pathetic ganglia—is 11,200,000,000._ The volume of the central nervous 
system, composed of neurones = 1,005¢.c. The individual neurone, 
therefore, has the volume given above. 





Brain. 
Brain. 


fore birth. It gives, however, the same values for the 
child at birth and the youth at fifteen years, while in the 
mature man the size is somewhat greater. This is so pe- 
culiar a result that one is inclined to give greater weight 
to the statements of Marinesco,!? who finds the cell bodies 
in question to increase in diameter from their formation 
up to twenty-five or thirty years, and the giant cells of 
the cerebral cortex to enlarge for a still longer time. 

Opposed to Kaiser are also my own observations on 
the white rat, where the growth of the cell- bodies con- 
tinues, though at a diminishing rate, up to maturity. It 
appears from the white rat that the enlargement of the 
cell bodies is an event that takes place early, in the first 
half of the period of rapid growth of the neuraxis (first 
fifty days of life), and that it is mainly accomplished at 
a time when the axones are still increasing in all dimen- 
sions, and when medullation is yet very incomplete. 
The central nervous system in its first embryonic form is 
amass of neuroblasts; in its completed form it is com- 
posed mainly of axones and their medullary sheaths. 
The condition at maturity was brought out by investiga- 
tions of Miss Thompson,!7 on the proportion of the cere- 
bral cortex occupied by the bodiesof the neurones. The 
observations were made on material hardened in alcohol 
and stained with methylene blue (Hammarberg'*). The 
cell bodies, under the conditions chosen, represented only 
1.57 per cent. of the entire volume of the cortex. If we 
should increase this to 3 per cent. and include the den- 
drites with the cell bodies, there would still remain 97 
per cent. of the cortex composed of other substances, 
and in a large measure this 97 per cent. would be repre- 
sented by medullated axones. All the white substance 
of the nervous system is, in even a greater measure, 
composed of the same constituents, so that, taken all to- 
gether, the medullated axones form the great proportion 
of the entire system. For this reason at least, this divi- 
sion of the neurone (the axone) requires special considera- 
tion. There is in the first place no reason to assume that 
the relative size of these structures is exactly the same in 
two brains otherwise comparable. But owing to their 
great preponderance a slight variation in the size of all 
the axones and their sheaths might alter very decidedly 
the gross weight of the encephalon without at the same 
time necessarily adding to its physiological complexity 
(Donaldson ®°), It is easy to see that even among the 
central neurones,—as, for example, the pyramidal cells 
of the cerebral cortex, the axone of which reaches to 
the lumbar enlargement of the spinal cord,—the axone 
with its sheath must be many times the volume of the 
cell body. The medullated axones of the large pyram- 
idal cells are of such a diameter that a length of about 
0.5 mm. of axone is equal in volume to the cell body. 
This gives twenty times the volume of the cell body for 
each centimetre of the medullated axone, and if it ex- 
tended 40 cm. we should have the cell body with (2040) 
800 times its volume as represented by the medullated 
axone. 

In the peripheral nervous system the relative mass of 
the axones is even greater than in the central system. 
Observations on the white rat show that in the case of 
the largest neurones belonging to the mid-lumbar spinal 
ganglia, there is a direct correlation between the increase 
in volume of the growing ganglion cell body and the 
area of the cross section of its axone; the ratios of en- 
largement being similar for both.*? Further, from the 
time when the medullary sheath is formed on the axones 
of these cells up to maturity, this sheath exhibits in cross 
section a simple and constant relation to the enclosed 
axis—viz., the area of the enclosing medullary ring be- 
ing very nearly equal to the area of the enclosed axis. 
This same relation between axis and sheath appears in 
the peripheral system of man, but the relation existing 
in the central nervous system has not yet been deter- 
mined. As to the calibre of the medullated axones in 
the peripheral system, Westphal *! reports in the periph- 
eral nerves of man at birth the smallest fibres, including 
the sheath, 1.2 to 2 ~ in diameter, and the largest 7 
to 8 » with an average diameter for all of 3 to 4 4, while 


319 


Brain, 
Brain, 








in the adult the large fibres are from 10 to 15 » in diame- 
ter. From the third to the sixth week the myelin be- 
comes more abundant and the fibres double in diameter. 
In the eighth month there are still some unmedullated 
portions in the nerves, but these gradually disappear. 

There is no fixed relation between the volwmes of the 
cell bodies and the length of the axones which they pro- 
duce. 

In the frog Dr. Dunn” has shown that the fibres of 
greatest diameter in the sciatic nerve pass to innervate 
the muscles and skin of the thigh, while those going to 
the parts of the frog’s leg below the thigh have a smaller, 
average diameter, as well as being individually of less 
calibre. In this instance, therefore, the fibres of larger 
calibre tend to run the shorter course. 

Looking upon the three groups of neurones as elements 
modified to receive stimulation, and to transmit impulses, 
it is found that the afferent neurones (Group I.) increase 
on the receptive side mainly by the expansion of their 
peripheral axones in the skin and muscles; that the cell 
body is practically devoid of dendrites receiving but few 
stimuli, and that their field of influence is determined by 
the extension of the proximal axone within the central 
system. The central neurones (Group II.) extend their 
receptive side by the multiplication of the dendrites, and 
their discharging side by the extension and ramification 
of their axones; while the efferent neurones (Group III.) 
extend their receptive side by the multiplication of their 
dendrites within the central system, and on their dis- 
charging side influence a greater or less mass of muscle 
or of sympathetic neurones according to the ramifications 
of their axones. 

From this it will be seen that the complexity of the 
central nervous system depends first on the ramification 
of the proximal axones of Group I., second on the rami- 
fications of ‘both the dendrites and axones of Group IL., 
and finally on the ramifications of dendrites alone in 
Group III. It is to this complexity that the growth 
changes in the neurones ultimately contribute, and there 
already exist very suggestive observations by Athias?? 
showing how the growth of the dendrites of the Purkinje 
cells and of the terminals of the “climbing fibres” are 
correlated. During growth the cell bodies may also 
change in shape apparently under mechanical stress. In 
those parts of the spinal cord like the cervical and tho- 
racic regions, where the segments of the cord lengthen 
with the growth of the vertebre, the axes of the mature 
cell bodies tend to be drawn out parallel to the long 
axis of the cord; whereas in the lumbar region of the 
spinal cord, where the segments remain short, the bodies 
of the efferent neurones are more nearly equiaxial. 

As the spinal cord increases in weight, the central 
canal also becomes larger. This involves (in the case of 
the white rat) a large extension of the wall of the canal, 
formed by the ependyma cells. Measurement of the 
ependyma cells shows that the individual elements in- 
crease but very slightly in their diameters, and hence 
the great increase in the wall must be due to the inser- 
tion of new cells. Itseems probable, moreover, that the 
ependyma lining the other cavities of the neuraxis is ex- 
tended by a similar process. 

Neurones tn Old Age.—As a rule the life of the neurone 
is coterminous with that of the individual. There is, 
however, evidence that some neurones die before the in- 
dividual dies, but no evidence shows that new elements 
take the place of those which thus perish. 

Old age in man is accompanied by a loss in the gross 
weight of the encephalon. This has not yet been de- 
monstrated in animals. In the white rat, however, old 
age is correlated with the smallest percentage of water 
found. Systematic studies on the white rat show that 
in old animals (three or more years) the cell bodies in 
every division of the neuraxis are shrunken when com- 
pared with the corresponding elements during the prime 
of life. Casual observations on man suggest the same 
changes, though they are well demonstrated only in the 
spinal cord. Hodge*+ found in a man of ninety-two 
years a diminished number of Purkinje cells in the cere- 


320 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


bellar cortex, and in the spinal ganglia the cell bodies 
and nuclei were shrunken, the nucleoli absent from all 
but a few cells, and the cytoplasm was loaded with pig- 
ment. ‘The coarse changes in old age appear, therefore, 
in the cell bodies and their parts—while the finer changes 
will be brought out when the alterations in the cytoplasm 
with age are described. We should further expect in 
old age a loss of physiological connections between the 
separate neurones, but this has not been demonstrated. 
Changes in the Cytoplasm of the Cell Bodies during 
Growth.—The studies of Marinesco!® and Biervliet ** 
show that in the large cell bodies of the efferent group 
in the ventral horns of the spinal cord the “stainable 
substance” of Nissl is fully formed at birth—the 
other portions of the cytoplasm being correspondingly 
well differentiated. This does not mean that this stain- 
able substance is formed in all these cells at this time, 
but only that those neurones which have first devel- 
oped have already attained this differentiation. The 
process repeats itself as the neuroblasts, with longer 
latent periods, gradually enlarge. The neurone in its 


‘first embryonic stages stains by the Nissl method so 


as to reveal a faint blue tint evenly distributed in the 
cytoplasm. As the element grows, the blue tint be- 
comes denser at the periphery of the cellbody. Here 
discrete particles, stained intensely, appear, and these, 
increasing individually in size, also form a wider band 
which spreads toward the nucleus. As the features 
of the mature’ cell become more evident the diffuse 
blue tint disappears, as though the constituent capa- 
ble of that reaction had by degrees become concentrated 
in the masses of stainable substance. This process 
of the formation of stainable masses is carried farthest 
in the largest cell bodies—for example, in the large cells 
of the spinal ganglia; those of the ventral horns of the 
cord and the large pyramids of the cerebral cortex. The 
smaller cells of the neuraxis exhibit varying degrees of 
a less complete formation of the stainable substance, rep- 
resenting in their final condition phases through which 
the largest cells have already passed. In old age the 
neurones undergo involutionary changes one at a time. 
The masses of stainable substance become disorganized ; 
the changes progressing from the centre or nucleus 
toward the periphery. When this occurs, a black or 
yellow pigment-like substance, often in very fine grains, 
appears to take the place of the masses destroyed. In 
the ventral-horn cells true pigment is to be found about 
the twentieth year, though it comes much earlier in 
other portions of the neuraxis. With the destruction of 
the stainable substance, the cell body, as well as the 
nucleus and its contents, tends to shrink and to stain less 
strongly. 

In correlating growth with function, it is often stated 
that a neurone which is destined to become medullated 
does not become functional until its medullary sheath 
has been acquired. The young white rat, in the 
nervous system of which there is at birth not a medul- 
lated fibre, is a sufficient contradiction to this dic- 
tum. It is admitted, nevertheless, that in general the 
appearance of functional adjustments runs parallel with 
the medullation of the neurones by which those adjust- 
ments are mediated; but the two events do not stand in 
a strict causal relation. The same is true of the stain- 
able substance of Nissl in the cell body, where the for- 
mation of well-marked masses is characteristic of full 
development and full functional power, without being 
absolutely necessary. By prematurely exposing to light 
the eyes of young rabbits, the optic nerves of which 
were unmedullated, Held 2° was able to hasten the forma- 
tion of the medullary sheath in the stimulated animals. 
Just how this experiment should be interpreted is not 
perfectly clear; but if we consider it as due to exercise, 
then the unmedullated fibres must, in spite of statements 
to the contrary, have been capable of being exercised 
even before they acquired their sheaths. Beyond this 
experiment there are no data on the effect of activity on 
the growth processes in the central nervous system. In 
this connection we recall that the encephalon has at- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tained very nearly its full weight at seven years, that is, 
at a time before any formal school training has begun. 
If this is granted, then the subsequent functional powers 
which the child may attain are correlated with a very 
small addition of substance to the encephalon. This 
seeming paradox disappears, I think, when the very 
small volume of the cell bodies in the central system is 
considered (27.2 gm.), and when it is remembered how 
avery slight additional weight of material could be so 
disposed as to add greatly to the physiological complex- 
ity of the system. 

Judging by every-day experience, it appears that 
favorable growth conditions have their effect more in 
prolonging the growth changes that have once been in- 
itiated than in hastening prematurely the onset of any 
given set of changes, and that when growth is hindered, 
there often appears in the individual a “ prematureness,” 
which we might call precocity, if it did not tend to be- 
come permanent in spite of increasing age, and thus in 
later years show itself in its real form as an arrest of 
development. 

C. GROWTH OF THE CEREBRAL CorTEX.—Despite the 
great interest which attaches to changes in the cerebral 
cortex, our information is very imperfect. In one local- 
ity in the white rat, on the lateral aspect of the hemi- 
sphere at the level of the optic chiasma, the thickness of 
the cell layer increased as follows between birth and 
maturity: 


TABLE XIIJ.—WHITE RAT—THICKNESS OF CELL LAYER OF CORTEX 
IN MILLIMETRES. 








Weight of rat in grams. Age. ER 
BRACE as cio tieicitiwivis aibie;e'e sta. e s SITE Ne sericea 40 
MEE er etteteateiciales eras sive craic lsi@is, fe evers Ten days...... 82 
me OO SI OCLC BO OAR ESRC OREO Twenty days.. 1.32 
Rie Sines oa wetenleeatrals lcs fie we cele ous Pio8,0 Fifty days..... 1.37 
dbssdberoeeatsteteieletts siethavcicte ais sieve ere Uo.cle a 07s Maturity ...... 1.49 
PAPE RAS eet aivle Dole eis sinis cies 2 ajsisia.a.s'.0, 010 OLAS) ccc 1.36 





The data on the change in the thickness of the human 
cortex are contradictory, some observers claiming that it 
actually becomes thinner with age. For this reason we 
omit a discussion of this point and pass to the determina- 
tion of the increase in the medullated fibres, which all 
investigators have found. 

The general course of the development of the fibre 
systems of the human cerebral cortex is described in the 
following way by Kaes,*? and we here quote from a sum- 
mary of his observations given by Miss Thompson. *! 
_ For the stages earlier than one and one-quarter years, 
Kaes relies on the observations of Vulpius,?* but the 
subsequent history is based on his own investigations. 
The first group of fibres to become medullated are the 
cortical projection fibres. At birth these appear raying 
out almost as far as the cortex. At about four months 
the fibre proprie, the first of the cortical association 
fibres, become medullated (Fig. 904). At about eight 
months the first of the intracortical fibres begin to be 
medullated in those regions which are most advanced. 
The description of the further development cannot be 
accurately assigned to definite ages, partly because some 
regions of the cortex develop so much more rapidly 
than others, and partly because Kaes examined no brains 
between the ages of one and one-quarter and eighteen 
years. A general description of the course of events 
can, however, be easily derived from a comparison of the 
different stages of advancement within the same brain. 
The first cortical fibres which develop shortly after the 
fibree propriv are a few scattered fibres running parallel 
to the layer of the fibre propriz on its ectal border. 
Gradually these latter increase in number, spread for a 
short distance toward the surface of the cortex and as- 
sume a stratified appearance. These form the beginning 
of the “outer association layer” of: Kaes. Before the 
formation of the outer association layer is completed two 
other sets of fibres appear; one of these surrounds the 


Vou. I.—21 





Brain, 
Brain, 





outer limit of the projection fibres, which by this time 
have completed their normal growth into the cortex. 
This is the Baillarger or Gennari layer. It marks the 
ectal border of the outer association layer, but is com- 
posed of fibres of larger calibre than the remainder of 
that layer. The second set of fibres which appears at 
this period is the zonal layer, at the ectal border of the 
cortex and immediately beneath the pia. It also is com- 
posed of fibres of large calibre. The stage of develop- 
ment just described is characteristic of the advanced 
portions of the cortex in a child of one and one-quarter 
years. Its distinctive features are, in brief, a partly 
formed outer association layer, consisting of some strati- 
fied fibres lying next the fibree propriz, and the Baillarger 
layer at its ectal border. At this stage these two por- 
tions of the outer association layer are separated by a 
region free from medullated fibres. On its ectal side 


Zonal layer. 









Il and Il Meynert layers. 


pasa 


a / Stripe of Gennari 
Ror Baillaréer, 


\Oufer Associafion 


Fibrae 
propriae 


of Mey nerf 5 


Fig. 904.—Semidiagrammatic Representation of the Cortical Fibres 
in a Section of the Occipital Cortex of a Male Child of One and One- 
Fourth Years. (From Theodore Kaes, 1894. The designations are 
the same as those used in Kaes’ papers.) 


the Baillarger layer is separated from the zonal layer by 
a second region free from medullated fibres, the region 
corresponding to the “IT. and III. cell layers” of Meynert. 

As development continues, the layer formed by the 
outer association fibres spreads gradually toward the 
Baillarger layer until it reaches the latter. At the same 
time the Baillarger and zonal layers grow broader and 
richer in fibres. The next stage is marked by the ap- 
pearance of the inner Baillarger layer, and of the first 
fibres of the II. and III. Meynert layers. The inner Bail- 
larger layer appears as a narrower line of coarser fibres 
among the fine fibres of the outer association layer, just 
ental to the outer Baillarger layer. 

The fibres in the II. and III. Meynert layers are the 
finest of the cortex. The first of these to become medul- 
lated are those lying nearest-the outer Baillarger layer. 
From the region of its first appearance, this layer (II. 
and III. Meynert layers) gradually extends ectad, and this 
process continues until these fibres meet those of the 
zonal layer. The final stage in the development of the 
cortex is the addition of a secondary system of coarse 
fibres to those which have been already described. The 
fibres of this secondary system are first seen in the outer 
association layer. Shortly afterward fibres of the same 
sort are found scattered through the II. and III. Meynert 
layers. At first these appear singly, but later are organ- 
ized into a stratum which Kaes identifies with “ Bech- 
terew’s streak.” Still later, similar fibres appear in the 
Baillarger layer, and in the most highly developed cortex 


321 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





known they appear as a secondary system of coarse 
fibres generally distributed through its entire thickness. 
Very few regions of the cortex reach this highest stage, 
however, even in the fully grown adult. The period 
from youth (eighteen years) to maturity is in general 
characterized by the gradual appearance of the fine fibres 
in the II. and III. Meynert layers, and the formation of 
the secondary fibre system of coarse fibres; but in the 
fully grown cerebrum there are regions which do not 
reach even the stage at which the fibres of the II. and 
III. Meynert layers become medullated. 

The central gyri exhibit the most highly developed 
fibre systems. The addition of new medullated fibres 
may continue, according to Kaes, up to the fiftieth year 
of life, though this limit must certainly be subject to 
wide individual variations. 

Flechsig?* has shown that the cortico-petal projection 
fibres first became medullated in the regions of the cortex, 
which mediate sensations, and thus by following the proc- 
ess in these fibres, the sensorimotor areas of the cortex 
can be mapped out. Their demarcation occurs within 
the first three months after birth. The intervening por- 
tions of the cortex form the association centres of Flech- 
sig and develop later. In the great sensorimotor region 
about the central fissure Passow*®® has been able to 
show that the association fibres are at maturity best de- 
veloped in the more ventral portion which contains the 
(discharging) pyramidal cells controlling the movements 
of the lower arm, hand. and face. In the child at one 
and one-quarter years this layer is equally developed 
through the length of the gyri, that is, there is no differ- 
entiation between the cell groups controlling the leg and 
the proximal portions of the arm and those which con- 
trol the distal portions of the arm, and from this we infer 
that the cortical control of the finer muscles and finer 
movements increases for some time after that for the 
coarser movements has been completed. 

Henry Herbert Donaldson. 


REFERENCES. 


1 Boyd: Phil. Trans., 1861. Marshall: Journal of Anatomy and 
Physiology, 1892. 

2 Vierordt: Arch. f. Anat. u. Physiol., 1890. 
aed Correspondenz-Blatt der Deutsch. Anthropolog. Gesellsch., 

894. 

4 Pfister: Archiv f. Kinderheilkunde, 1897. 

5 Topinard: Eléments d’anthropologie générale, 1885. 

® Franceschi: Bull. d. Soc. Med. di Bologna, 1888. 

7 Ambialet: La déformation artificielle de la téte dans la région 
Toulousaine, Toulouse, 1893. 

8 Boas: American Anthropologist, July, 1899. 

® Von Gudden: Experimental-Untersuchungen tiber das Schaedel- 
wachsthum, Miinchen, 1874. 

10 His: Arch. f. Anat. u. Physiol., 1889. 

11 Cajal: Rev. de Ciencias Médicas, Barcelona, 1893. 

12 Birge: Arch. f. Anat. u. Physiol., 1882. 

13 Hardesty : Journ. Comp. Neurol., 1899 and 1900. 

14 Dale: Journ. Physiol., 1900. 

15 Kaiser: Die Funktionen der Ganglienzellen des Halsmarkes, 
Haag, 1891. 

16 Schiller: Compt. rend. Acad. d. Sci., Paris, 1889. 

17 Thompson : Journ. Comp. Neurol., 1899. 

18 Hammarberg: Studien uber Klinik und Pathologie der Idiotie, 
Upsala, 1895. 

19 Marinesco : Revue neurologique, No. 20, 1899. 

20 Donaldson: Note on the Significance of the Small Volume of the 
Nerve-Cell Bodies in the Cerebral Cortex in Man. Journ. Comp. 
Neurol., vol. ix., 1899. 

21 Westphal: Neurologisches Centralblatt, No. 2, 1894. 

22 Dunn: Journ. Comp. Neurol., 1900. 

23 Athias: Journ. de l’anatomie et de la physiologie, Ann. Xxxiii., 
No. 4, 1897. 

24 Hodge: Journ. Physiol., 1894. 

25 Biervliet: Le néuraxe, 1900. 

26 Held: Arch. f. Anat. u. Physiol., Anat. Abth., Leipzig, Jahrg. 
(1896), H. iii. u. iv., S. 222. 

27 Kaes: Jahrb. d. Hamburg Staatskrankenanstalten, Bd. iv., 1893- 
94, 1896. Since this date Kaes has published several important Hegety 

28 Vulpius: Arch. f. Psychiat. u. Nervenkrank., Bd. xxiii., 1892. 

29 Flechsig : Gehirn und Seele, Leipzig, 1896. 

3@ Passow : Arch. f. Psychiatrie, 1899. 

31 Thompson: Journ. Comp. Neurol., vol. x., No. 3, Oct., 1900. 

32 Donaldson: Journ. of Nery. and Ment. Dis., Oct., 1900. 


BRAIN, HISTOLOGY OF.—Mernops.—The nerve tis- 
sues of the brain may be studied fresh or in frozen sec- 
tion, by maceration and isolation, or after hardening by 
various methods. 


322 


Fresh Tissues.—Nervous tissues from animals can be 
obtained immediately after death. In human beings a 
certain number of hours practically always elapse be- 
fore the material can be removed from the body. Cer- 
tain post-mortem alterations occur early, particularly in 
the most labile constituents of the nerve-cell protoplasm. 
But for ordinary histological purposes tissue obtained 
from the central or peripheral nervous system within 
twelve hours after death, provided the body has been 
kept cool, is sufficiently fresh for minute microscopic 
examination. For many studies, too, tissue removed as 
late as twenty-four hours after death, provided the body 
has been kept cool, is quite satisfactory, though one 
should be sceptical in such tissue in drawing conclusions 
from the condition of certain of the microscopic pictures, 
for example, those of the Nissl bodies, and the so-called 
fibrillary structures. 

In examining fresh tissues either teased particles or 
sections made by the double knife of Valentine may be 
employed. The teasing method is particularly applica- 
ble to the study of the peripheral nerves. These may be 
observed in an indifferent fluid like physiological salt 
solution. or blood serum, or after the addition of some 
reagent (acetic acid, osmic acid, caustic potash). Sec- 
tions of entirely fresh tissue made with the double knife 
of Valentine are very fragile, besides being extremely 
difficult to prepare. They may be examined in physio- 
logical salt solution, care being taken that the cover 
slip is not pressed upon. Ehrlich’s method of staining 
fresh masses of tissue will be referred to later. 

Maceration and Isolation.—F¥or the isolation of histo- 
logical elements, especially in the central nervous system, 
the use of some macerating fluid is desirable. <A large 
number of these have been employed, but only the more 
important ones need be mentioned. Osmic-acid solutions 
(one-tenth of one per cent.) work well, any fatty struc- 
tures, including of course the myeline sheaths, being 
stained of a dark color. Miller’s fluid and dilute chromic- 
acid solutions (one-one-hundredth of one per cent. to four- 
one-hundredths of one per cent.) are useful macerating 
reagents provided the fluids are not allowed to act too 
long. ‘Tissues macerated in these solutions should be 
teased and examined at the end of twenty-four hours. 
Ranvier’s alcohol (thirty-three and one-third per cent.) 
yields very good results. 

The tissues intended for maceration should be divided 
into small pieces before being placed in the macerating 
fluid. At the end of the period of maceration gentle 
shaking in a test tube often facilitates the isolation of 
elements. A pipette may be used for transferring minute 
particles suspended in the fluid to the microscopic slide 
for examination. Coarser particles may be teased upon 
me slide or squeezed between the cover slip and the 
slide. 

The fluid used for maceration may be employed as a 
mounting medium for the microscopic observations, but 
as a rule it is better to render the tissues somewhat trans- 
parent. For this purpose dilute solutions of acetic acid 
(one per cent.), saturated aqueous solution of potassium 
acetate, diluted glycerin, or salty glycerin may be used. 

Hardened Tissues.—The three fluids most frequently 
employed at present for the hardening of nerve tissues 
are: (1) Miiller’s fluid, (2) alcohol, and (8) formol. 

Miller’s Fluid. This hardening reagent consists of 
potassium bichromate, 2.5; sodium sulphate, 1; distilled 
water, 100. If desired the sodium sulphate may be 
omitted, simple solutions of bichromate of potash appear- 
ing to act as well as the fluid prepared according to the 
original formula. Miller’s fluid should be changed fre- 
quently during the hardening process. Hardening in 
this fluid requires from several weeks to several months 
at the ordinary temperature, though if the tissues be 
kept in the fluid in a thermostat at the body temperature 
the process may be much shortened. In summer the 
fluid is particularly prone to become contaminated with 
growths of fungi. This may be prevented by the addi- 
tion of a small quantity of camphor. After Miiller’s 
fluid hardening, the tissues are best prepared for em- 


‘ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


bedding by dehydration in alcohol, as a rule without 

previous washing out in water. Tissues hardened in 

Miiller’s fluid stain well in carmine and with Weigert’s 

myeline stain. They are not suitable, however, for the 

oa alia of finer histological methods, such as that of 
issl. 

Alcohol. This reagent should be employed when the 
original Nissl procedure is to be applied, small pieces of 
the tissue being left in ninety-five-per-cent. alcohol for 
about three days (see Nissl’s method). Alcohol hard- 
ening is also desirable if Weigert’s fibrin stain or Gram’s 
method of staining bacteria is to be utilized. The per- 
iphery of bits of tissue hardened in strong alcohol is 
likely to undergo marked contraction and distortion. 
The blood at the periphery of such tissue is also much 
altered. Artefacts in various parts of the tissue may 
result from the action of the alcohol. 

Formol. At present solutions of this substance are 
much employed in neurological technique since tissues 
fixed in them can be stained by several different methods. 
Formol, or formalin, is a forty-per-cent. aqueous solution 
of formaldehyde. As a rule, ten-per-cent. solutions of 
formol are used for hardening pieces of the central ner- 
vous system. This corresponds to a four-per-cent. aque- 
ous solution of the gaseous formaldehyde. The whole 
brain may be hardened more or less satisfactorily in such 
a solution, but it is better, as a rule, to more or less sub- 
divide the organ. Formol does not contract the tissues 
hardened in it, but fixes them rapidly in their original 
form, thus differing markedly from many other harden- 
ing fluids. The fluid has a characteristic odor and gives 
off irritating fumes. Injury to the eyes must be care- 
fully avoided when using it, and it is also well to keep 
the hands as much out of the fluid as possible, as some- 
times a troublesome form of dermatitis is set up by it. 
After hardening in formalin for a few days the tissue is 
ready for further manipulation. If Weigert’s myeline 
stain is to be employed the tissue may be placed in Miil- 
ler’s fluid or his chromic acid mordant. The latter also 
suffices for the application of Weigert’s neuroglia stain. 
Formalin tissues can also be used for studies by Marchi’s 
method; the ordinary Marchi proeedure is gone through 
with after the formalin hardening. Tissues prepared in 
formalin do not warp so much as those simply hardened 
in Miiller’s fluid. Very good Nissl preparations can also 
be made from formalin tissues provided they have been 
gotten fresh and cut into small pieces. The results are 
not equal, however, to those obtained after fixation in 
alcohol or sublimate. Marini’s modification of the for- 
malin hardening is especially recommended when it is 
desired to examine tissue by several different methods. 
This investigator recommends a fluid consisting of five 
per cent. formol with one-tenth of one per cent. chromic 
acid in ninety per cent. alcohol. Large pieces of the 
tissue put into this fluid for twenty-four hours are then 
removed and divided into small pieces. The latter are 
placed in more of the fluid freshly prepared, which is 
changed every day for from three to five days. The 
blocks of tissue are then fastened upon cork (without any 
other preparation), and kept in ninety-per-cent. alcohol 
or in a one-per-cent. solution of chromic acid in ninety- 
per-cent. alcohol. Sections for staining with methylene 
blue or thionin are placed in ninety-per-cent. alcohol; 
those for Weigert’s myeline stain in Miiller’s fluid or in a 
three-per-cent. solution of potassium bichromate, while 
sections to which Weigert’s method for studying neurog- 
lia is to be applied are placed in a solution of chromogen. 

When the material to be studied is not limited in 
amount it is preferable to use at least three hardening 
fluids: (1) alcohol for Nissl’s method; (2) formol for 
Weigert’s myeline stain, for Marchi’s and for. Golgi’s 
methods; and (3) Weigert’s formol-chrome-alum mordant 
for the neuroglia stain. 

Sublimate solutions, Orth’s fluid, Erlitzki’s fluid, 
Flemming’s mixture, Van Gehuchten’s fluid are all recom- 
mended for special purposes. The formule for these 
fluids are to be found in the text books of histological 
technique. (See also article: Histological Technique.) 


Brain, 
Brain, 








Embedding.—Three methods are ordinarily employed 
for embedding neurological tissues: (1) embedding in 
pith or gum; (2) celloidin embedding; and (8) paraffin 
embedding. 

Pith or gum embedding may be dispensed with. Nissl, 
for his method, insists upon the avoidance of embedding 
entirely. He simply fastens the mass of tissue to the 
block by a solution of gum arabic. He fears that cel- 
loidin or paraffin embedding will interfere with the 
structure of the protoplasm of the nerve cells. He is 
here in error. Careful embedding in celloidin or paraf- 
fin, especially the latter, preserves beautifully the struc- 
ture of the protoplasm. 

Celloidin embedding is carried out as follows: After 
dehydration in absolute alcohol the tissues are left for 
twenty-four hours in equal parts of absolute alcohol and 
ether. They are then transferred to a very thin solution 
of celloidin dissolved in alcohol and ether. Here they 
remain until the thin fluid has penetrated the tissue. 
Small blocks are sufficiently penetrated if they remain 
for from two to five days. Large pieces, however, as, 
for example, a whole hemisphere of a baby’s brain, must 
remain in a thin celloidin for a much longer time. The 
tissues are next transferred to a solution of celloidin 
which has the consistency of thick syrup. They need 
not remain in this fluid long; twenty-four to forty-eight 
hours suffice. There is a widespread idea that the longer 
tissues stay in thick celloidin the better are the sec- 
tions obtained. The reverse rather is true, especially 
when we have to deal with large pieces. The penetration 
by the thin celloidin should, however, be complete. The 
thick celloidin may be allowed to stiffen very gradually 
through evaporation of the alcohol and ether, anda block 
of it containing the tissue be fastened by means of cel- 
loidin on a piece of cork or wood. Or it may be placed 
directly, without previous stiffening of the celloidin, ona 
block, allowed to stand in the air for a few minutes until 
the surface of the celloidin has hardened, after which it 
may be immersed in eighty-per-cent. alcohol. The blocks 
may be kept in eighty-per-cent. alcohol until the sec- 
tioning is carried out. Instead of celloidin, photoxylin 
may be employed if desired; it is more transparent than 
celloidin. 

Celloidin embedding is to be preferred when large 
pieces of tissues are handled, when the tissue is friable, 
or when the staining method to be employed is one 
involving considerable manipulation. It is always to be 
used when Weigert’s myeline stain is to be applied. 

For embedding in paraffin small pieces should be 
taken, thoroughly dehydrated in absolute alcohol (twenty- 
four hours), cleared in xylol or chloroform, and then 
passed through equal parts of the clearing reagent and 
soft paraffin, thence into melted paraffin (melting point of 
52° C.) for two to eight hours, the paraffin being changed 
twice during this period. After complete penetration by 
the paraffin, best in the thermostat kept at the melting 
point of the substance, the piece of tissue is placed in» 
shallow dish and covered with paraffin. This is rapidly 
cooled with cold water until the paraffin stiffens, after 
which the paraffin block, properly trimmed, can be 
fastened on the platform of a microtome, when it is ready 
for cutting. 

In warm weather it may be necessary to use a paraftin 
of higher melting point (60° to 65° C.); in cool weather, a, 
paraftin of low melting point will be found useful (45° to 
50° C.). If two kinds of paraffin, very soft and very hard, 
be kept in stock, it is easy, by mixing them in variable 
proportions, to make a paraffin of any desired melting 
point. 

Paraffin is to be preferred when very thin sections are 
desired, or when staining in toto, before embedding, is 
possible. It is especially useful, therefore, in the study 
of the embryology of the nervous system, and also in the 
investigation of the finest histological details of the neu- 
ral elements. It is one of the best methods which can be 
used when Nissl’s method is to be applied. 

A combination of the celloidin and paraffin. methods 
may sometimes be used with advantage. The tissue after 


323 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





dehydration is passed through equal parts of absolute 
alcohol and ether and then soaked for twenty-four hours 
in a solution of celloidin. The object is then cleared in 
oil of origanum, after which it is to remain in a mixture 
of oil of origanum and fluid paraffin for one or two hours 
at a temperature of 40° C. It is then placed in melted par- 
affin of a melting point suitable to the temperature of the 
time of year and embedded in paraffin in the ordinary 
way. Now that methods of fastening paraffin sections 
to the slide have been very much improved, this combina- 
tion of celloidin and paraffin is very little in vogue. 

Sectioning.—In making sections of nervous tissue we 
have to consider: (1) frozen sections; (2) sections after 
celloidin embedding, and (8) sectioning after paraffin em- 
bedding. 

Frozen sections may be made of fresh tissues or of 
tissues which have been hardened in Miiller’s fluid or 
formalin. Frozen sections should be very thin, since to 
get the most out of them they have to be studied with 
high powers of the microscope, and unless the sections 
are thin this is of course impossible. An ether-freezing 
microtome may be employed, or, better still, a carbon- 
dioxide freezing microtome. If fresh tissues are used 
they should be transferred from the knife to physiologi- 
cal salt solution and mounted onaslide in the same fluid ; 
if they have been fixed in formalin or Miiller’s fluid be- 
fore freezing they may be examined either in Miiller’s 
fluid, Farrant’s medium, or salty glycerin. 

Celloidin Sectioning.—The sections may be made with 
any good microtome. The microtomes made by Bausch 
& Lomb, by Schanze, and by Jung are good. The 
knife must be kept very sharp, and it is important to 
have it constantly flooded with eighty-per-cent. alcohol. 
The whole edge of the knife should be made to cut from 
the heel to the tip. If very large sections are to be cut, 
it is best to use a microtome which is so arranged that 
the knife and tissue mass are entirely immersed in alco- 
hol. Such microtomes are now available at a moderate 
cost. If sections of a whole hemisphere are to be made, 
it is important that the knife should be clamped at both 
ends; otherwise the vibration of the blade will’ lead to 
streakiness or even more marked irregularity in the thick- 
ness of the sections. 

Serial sectioning in celloidin is quite possible if care be 
taken. The most convenient method is that employed 
by Obregia. The glass slides upon which the sections 
are to be employed are coated twenty-four or forty-eight 
hours before they are to be used, with the following solu- 
tion: 30 c.c. of a thick syrup made by dissolving pow- 
dered candy sugar in boiling distilled water is mixed 
with 10 c¢.c. of a thick solution of pure dextrin in dis- 
tilled water and 20 c.c. of absolute alcohol. The glass 
slides after partial drying are quite sticky. On a large 
white plate two or three thicknesses of good toilet paper 
are thoroughly moistened with eighty-per-cent. alcohol; 
on the toilet paper an area is marked off in lead pencil 
which corresponds to the size of the large cover glass 
which is to cover the preparations on the slide. Each 
celloidin section, as it is cut, is taken up from the knife on 
a strip of moist toilet paper and transferred by means of 
this to the plate. Some regular arrangement of sections 
in the area marked off on the plate is to be maintained. 
When the area is full of sections the sticky side of the 
prepared glass slide is pressed firmly down upon the 
series of sections. On lifting the glass slide all of the 
sections adhere to the glass slide. With a sharp knife 
the celloidin protruding beyond the edge of the glass slide 
is trimmed off. After a moment’s drying to permit any 
excess of alcohol to disappear, a thin solution of photoxy- 
lin is poured over the sections on the glass slide, care 
being taken to have the photoxylin solution evenly dis- 
tributed. For this latter purpose it may be desirable to 
use a glass plate carefully levelled, upon which the glass 
slide may be laid, while the photoxylin is stiffening. As 
soon as the photoxylin has stiffened on the surface the 
glass slide with the sections now covered by a thin sheet 
of photoxylin can be thrown into a large dish of water. 
The water dissolves the sugar-dextrin and the photoxy- 


324 








lin sheet floats off into the water. Each sheet of this sort 
may then be treated as a single section. Just before im- 
mersion in the water it is well to number the photoxylin 
sheet with some quickly drying oil paint. This method 
of serial sectioning of tissues embedded in celloidin is the 
best one I know of when the Weigert-Pal staining is to 
be employed, Weigert’s celloidin method is also a very 
useful method, and Obregia’s procedure is really only-a 
modification of this. 

Serial sectioning of tissues embedded in paraffin is a 
very simple matter, especially if the Minot or Blake- 
Minot microtome be used. It is possible with these 
microtomes to make serial sections of small pieces of tis- 
sue as thin as 1 yor less. In order that the series may 
be satisfactory the temperature of the room and of the 
knife must be very accurately adjusted, so that they 
shall be of the proper temperature to suit the paraffin in 
which the tissue is embedded. In very cold weather and 
in very hot weather this is not always easy. When the 
conditions are perfect, however, each section lies flat and 
smooth, and the sections one after another hold together 
at their edges in the form of a delicate ribbon. The 
problem of transferring the ribbon to the slide and of 
fastening the sections upon the slide so that when the 
paraftin is removed no particle of tissue may be lost or 
displaced, has been variously solved. Three principal 
methods are employed: (1) Schallibaum’s collodion; (2) 
Mayer’s albumen, and (3) the water or alcohol method. 

In 1883 Schaliibaum recommended mixing one part of 
collodion with three or four parts of oil of cloves or oil 
of lavender. The mixture, which makes a clear solution, 
is spread thinly over the surface of a glass slide by 
means of acamel’s-hair brush. Sections are placed upon 
the surface and gently warmed over a water bath for 
from five to ten minutes until the oil has evaporated. 
The sections adhere firmly and can be passed through 
almost any fluid without being removed. Absolute al- 
cohol, or equal parts of alcohol and ether, will dissolve 
out the collodion, and hence in these fluids sections may 
be lost if they are left in them for a long time. The 
method is of especial advantage when tissues have been 
stained in bulk, but is not quite safe when the staining 
is to be done upon a slide. 

Mayer’s albumen is made as follows: 50 c.c. of glyce- 
rin is mixed with the same quantity of fresh egg al- 
bumen. To the mixture 1 gm. of sodium salicylate 
is added. ‘The whole is well shaken and filtered into a 
clean bottle. Instead of salicylate of soda some other 
preservative, like carbolic acid or thymol, may be em- 
ployed. The mixture is spread in a thin layer witha 
camel’s-hair brush on the surface of the slide, each sec- 
tion being well pressed down upon the albumen with the 
brush. The sections are then warmed for a few minutes 
ona water bath, kept just above the melting point of the 
paraffin. As soon as the paraffin has melted the slide is 
put into xylol, which dissolves out all the paraffin, and 
then placed in absolute alcohol, after which it is passed 
through graded alcohols to water, and is then ready for 
staining. Care should be taken not to have too thick a 
layer of albumen, otherwise as it coagulates a slight 
opacity occurs which may interfere with the study of 
the finest structures in the cytoplasm or nucleus. - 

Most of the disadvantages of the above two methods 
are avoidable if the water or alcohol method be employed. 
In this method water or alcohol is placed upon a per- 
fectly clean glass slide, the sections are arranged on it 
with the aid of a brush which has also been moistened 
with alcohol, the slide then warmed up to about 40° C. 
(never up to the melting point of the paraffin); the alco- 
hol or water is allowed to evaporate slowly, best in the 
thermostat kept at about 37° C. for twenty-four hours, 
after which the slides may be raised in temperature 
to the melting point of the paraffin, transferred to xylol 
to remove the paraffin, thence to alcohol to remove the 
xylol, and afterward passed through graded alcohols to 
water, when the staining may be undertaken. The warm 
alcohol or water spreads the sections evenly, removing 
any creases which may have been present in the section 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





when it came from the knife. Care must be taken not 
to have too thick a layer of water or alcohol, or it-will be 
found difficult to keep the sections in their proper order 
and position on the slide. The water or alcohol will not 
spread uniformly over the slide unless every particle of 
grease has been removed from the slide. Sections after 
hardening in most of the fluids employed in histological 
technique generally adhere very firmly to the slide by 
this method. An exception to this statement, however, 
has to be made with regard to tissues which have been 
fixed in solutions which contain chrome salts. Those 
tissues which have been hardened in Miiller’s fluid or in 
Flemming’s solution do not adhere well, and it is useless 
to try to employ the method in such cases. One great 
advantage of the alcohol or water procedure is the ab- 
sence of any precipitate or opacity due to foreign sub- 
stances. 

When the block of tissue to be cut in paraffin is large 
it is best not to try to make ribbons of the sections, but 
to remove each single section from the knife and put it 
in its proper place on the slide. 

Flatau, of Berlin, has recently described a method by 


means of which serial longitudinal sections through the | 


whole spinal cord can be prepared. It is especially ap- 
plicable when it is desired to use the method of Marchi 
for the study of recent secondary degenerations. The 
spinal cord of the animal which has been submitted to 
experiment is removed whole about fifteen or twenty 
days after the operation. A weight is attached to the 
cauda equina in order to avoid twistings or distortions 
of the cord. Two threads are drawn through the dura 
mater of the upper part of the cord, and the whole spinal 
cord suspended in a glass jar 3 or 4 cm. broad and about 
40 em. long filled with Miiller’s fluid. The threads are 
drawn out of the mouth of the glass jar so that they are 
held in place by the cork when this is put in. Twenty- 
four hours later the dura mater is cut open along the 
ventral and dorsal surface and the Miiller’s fluid is re- 
newed. The cord remains in this fluid for from two to 
three weeks, after which it is taken out and hung by 
means of the threads on a stand where it swings free in 
the air. It is then split lengthwise through the ventral 
longitudinal sulcus and the dorsal longitudinal septum 
by means of a Graefe’s cataract knife, in order that 
Marchi’s fluid may better penetrate the tissue. The 
splitting is not carried as far as the lowest part of the 
conus medullaris. The spinal cord thus retains its con- 
nection in its lower part, and the two halves can later 
be very easily applied to each other. The spinal cord 
is next hung in a tall glass jar filled with Marchi’s fluid 
and kept ina warm place. Flatau recommends gradual 
increase in the strength of the osmic acid of the solution 
with frequent changing of the fluid. He leaves the 
tissue in the Marchi’s fluid for from three to five weeks, 
after which the cord is washed for twenty-four hours in 
running water, dehydrated in alcohol, and embedded in 
celloidin. The tissue is then placed upon a specially 
prepared block of wood and fastened in Becker’s micro- 
tome. The sections are cut of a thickness varying from 
60 to 80 uw, are dehydrated in alcohol, cleared in carbol 
xylol, and mounted in balsam on long glass slides. 


STaArniInc METHODS. 


These may be divided into: (1) those used for staining 
masses of tissue in bulk, and (2) those used for the stain- 
ing of sections. : 

Staining in Bulk.—This method is particularly appli- 
cable to the staining of the whole nervous system, for 
example, of embryos or of small animals where serial 
sections are to be made. For ordinary purposes, per- 
haps no better stain is available than the alum cochineal 
of Czokor or Partsch. Powdered cochineal is boiled for 
a long time in a five-per-cent. solution of alum. After 
filtration some preservative like salicylic acid is added 
to prevent the growth of moulds or bacteria. Herrick 
recommends sulphate of aluminum instead of alum. 

Alum cochineal stains very well after nearly all kinds 








of fixation and hardening. According to the size of the 
mass of tissue to be stained it is left in the alum cochineal 
for from one to four days; then washed out thoroughly 
in water and passed very gradually through graded alco- 
hols, embedded in paraffin, after which serial sections may 
be made. Grenacher’s alum carmine may also be used 
if desired. Beale’s ammonia carmine and Grenacher’s 
borax carmine are also much employed for staining in 
bulk. If desired tissues may also be stained in bulk by 
one of the various heematoxylins which have been intro- 
duced. The formula of Boehmer and that of Delafield 
are especially to be recommended (vide infra). 

Golgi’s method and Ehrlich’s method may be consid- 
ered as methods for staining in bulk. They will be 
described further on. 

Staining of Sections.—For the staining of sections very 
different methods have been employed, some being suit- 
able for the demonstration of one element, others for the 
demonstration of other elements in the tissue. Every 
attempt has been made by neurologists to devise elective 
staining methods suitable for the demonstration of the 
various constituents in the nervous organs. Sections 
may be stained upon the slide after fixation thereon, or 
they may be first stained and afterward transferred to 
the slide. 

It will be convenient to divide the staining methods as 
follows: A. Methods which give information concerning 
the external form of the nerve units or neurones. B. 
Methods which demonstrate the internal morphology of 
the neurones. C. Methods which demonstrate especially 
the myeline sheaths. D. Methods especially devised for 
the demonstration of axones or axis-cylinder processes. 
E. Methods especially applicable ‘to neuroglia, F. 
Methods for demonstrating certain fibrillary and reticu- 
lar structures. : 

A. Mretnops Wurcu Give INFORMATION CONCERNING 
THE EXTERNAL ForM oF THE NERVE Units or NEv- 
RONES.—The method above all others which has been of 
service in recent years in demonstrating the external 
morphology of the nerve cells and their processes is that 
introduced by Golgi and the various modifications which 
his method has undergone in the hands of other investi- 
gators. 

The slow method is carried out as follows: The fresh, 
small pieces not over 1 to 1.5 cm. large are immersed in 
a large quantity of a two-per-cent. solution of bichro- 
mate of potash, where they remain for a month in sum- 
mer or two months or more in winter, the strength of 
the solution being gradually increased to five per cent. 
The pieces are then placed in a 0.75 solution of silver 
nitrate, where they remain for from twenty-four to forty- 
eight hours, after which sections are cut. 

The second method of Golgi is sometimes known as 
the mixed method; small pieces of tissue remain for three 
or four days in bichromate of potash solution, after 
which they are transferred to a mixture of two parts of 
a one-per-cent. acid solution and eight parts of a two- 
per-cent. bichromate of potash solution. Here they re- 
main for from three to eight days, after which they are 
passed through a silver bath as by the other method. 

The rapid method of Golgi, which. is the one so much 
used by Ramon y Cajal, is carried out as follows: Very 
small pieces of tissue are placed directly in a mixture of 
one part of one-per-cent. osmic acid solution and four 
parts of a three-and-one-half-per-cent. solution of bichro- 
mate of potash. In this fluid they remain fora few days, 
after which they are passed through the 0.75-per-cent. 
solution of silver nitrate. The impregnation of the ner- 
vous elements varies according to the length of time the 
tissues are immersed in the first solution. Thus in the 
human spinal cord, neuroglia is best stained by an im- 
mersion of from two to three days; the cell bodies. of 
neurones by an immersion of from three to five days; 
axones and collaterals by an immersion of from five to 
seven days. 

The so-called double method gives very good results 
with some tissues; the bits of tissue after having been 
passed through the procedure above described are sub- 


325 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





jected at once to a repetition of the process, after which 
the sections are cut. 

Cox’s modification of Golgi’s method is very valuable 
when it is desirable to impregnate a large number of 
elements in the tissue. He proceeds as follows: Bits of 
fresh tissue are immersed for from two to three months 
in the following fluid: bichromate of potash (five-per- 
cent solution), 20 parts; bichloride of mercury (five-per- 
cent. solution), 20 parts; distilled water, 30-40 parts; 
chromate of potash with strong alkaline reaction (five 
per-cent. solution), 16 parts. The bits of tissue are then 
washed for half an hour in ninety-per-cent. alcohol to 
remove the excess of sublimate, after which sections are 
cut and mounted by Golgi’s method. The sections can 
be counterstained, if desired, with carmine or hzema- 
toxylin. 

EHhrlich’s Vital Staining with Methylene Blue.—This 
method, introduced by Ehrlich in 1886, has been of very 
great importance, inasmuch as it is an elective stain for 
nerve elements in fresh tissues. Ehriich injected a solu- 
tion of methylene blue dissolved in salt solution into the 
vessels of animals, and found that the axis cylinders of 
many of the nerve fibres as well as numerous nerve end- 
ings stained after a time ‘when the animal was killed and 
the tissues exposed to the air. While the nerve elements 
stain of a deep blue color, the other structures in the 
tissue remain but little or not at all affected. The stain- 
ing was transient. 8. Meyer recommends subcutaneous 
injection of the methylene blue, using 2 c.c. of a satu- 
rated solution beneath the skin every fifteen minutes 
until the animal dies. A method of fixation was intro- 
duced by Dogiel. This investigator laid the pieces of 
tissue after staining in an aqueous solution of ammonium 
picrate. A much better fixing method is that of Bethe, 
who proceeds as follows: the tissue at the acme of 
staining is immersed in the following mixture: am- 
monium molybdate, 1 gm.; distilled water, 10 c.c.; 
hydrogen peroxide, 1 ¢.c.; pure hydrochloric acid, 1 
drop. The fluid must be well cooled before the stained 
tissues are immersed in it, after which they remain im- 
mersed for from two to five hours in the ice box. They 
are then removed from the refrigerator, left at the room 
temperature for a few hours, washed for thirty minutes 
in distilled water, dehydrated quickly in cool alcohol, 
cleared in xylol, embedded in paraffin, and finally, after 
sectioning, mounted in balsam. Alum cochineal may be 
used asa contrast stain. Neuroglia does not stain by 
Ehbrlich’s method. A slight modification has been intro- 
duced by Ramén y Cajal in order to demonstrate the 
gemmules or lateral buds on the dendrites of the primary 
cells in the brain. He uses a saturated solution of Griib- 
ler’s methylene blue by covering thin pieces of the fresh 
brain with the fluid by means of a small brush. The 
fluid is allowed to act for three-quarters of an hour, 
after which the tissues are washed in salt solution and 
fixed in the following modification of Bethe’s fluid: am- 
monium molybdate, 1 gm.; distilled water, 10 c.c.; 
pure hydrochloric acid, 1 drop. After fixation for from 
two to three hours the excess of ammonium molybdate 
is removed by washing in water. The tissues are then 
hardened for from three to four hours in a forty-per-cent. 
solution of formol to every one hundred parts of which 
five parts of a one-per-cent. solution of platinum chloride 
have been added. The formol is washed out by passing 
it through an alcoholic platinum chloride solution, after 
which the tissues are embedded in paraffin; thick sec- 
tions are made, ‘They are passed through absolute alco- 
hol to which platinum chloride has been added, cleared 
in xylol, and mounted in balsam. 

Other methods which stain the nerve-cell protoplasm 
deeply, leaving the fibres almost unstained, are of value 
for demonstrating the external form of the nerve cells. 
These all, however, illustrate also the internal morphol- 
ogy of the nerve cells, and the methods will accordingly 
be described under the next heading. 

B. MetnHops Wuich DEMONSTRATE THE INTERNAL 
MorpPHOLoGy oF THE NEURONES.—The methods to be 
considered here are those which bring out especially well 


326 


the nuclear and cytoplasmic structures. Generally 
speaking, it may be said that basic dyes stain the chro- 
matic part of the nucleus, and certain substances (e.g., 
the Nissl bodies or tigroid masses) in the cytoplasm, 
while acid dyes stain the other cytoplasmic structures 
and some of the so-called achromatic substances in the 
nucleus. It is not unusual in staining methods to em- 
ploy combinations of the two procedures. Thus, in the 
much-used hematoxylin and eosin stainings, the heema- 
toxylin differentiates the chromatic part of the nucleus, 
while the eosin stains more particularly the protoplasm. 
Again, when methylene blue and erythrosin are employed, 
the methylene blue stains the nucleoli, the chromatin of 
the nuclei, the tigroid bodies, and the neurosomes of the 
protoplasm, while the erythrosin stains the meshwork- 
like structure which is visible in the cell protoplasm as 
well as certain constituents of the nucleus. Sometimes 
structures are present in the cells or nuclei which take 
up both kinds of dye and assume a color intermediate 
between them. The most common stains perhaps are 
the carmine and cochineal stains, hematoxylin and its 
derivatives, and various aniline dyes. 

Carmine and Cochineal Stains.—These have already 
been referred to above. Alum carmine, alum cochineal, 
and borax carmine are important stains, and are all appli- 
cable to tissues which have been hardened in formalin or 
in Miiller’s fluid. <A large part of the older work on the 
nervous system was carried out with the aid of such 
stains. Various: picrocarmines have been used, but in 
the writer’s experience they possess no distinct advan- 
tages and can well be omitted from ordinary technique. 
Carmine is of no value for demonstrating the finer struc- 
tures in the nerve-cell protoplasm or in the nerve-cell 
nucleus. It is, however, generally useful when simply 
the gross relations of the white and gray matter need to 
be studied. 

The Hematoxylin Stains.—Hematoxylin is an exquis- 
ite nuclear stain and differentiates the structures in the 
nuclei far better than does any of the carmine stains. 
Tissues left long in hematoxylin solutions are usually 
overstained, and it is accordingly desirable to differen- 
tiate, after staining, with some decolorizing agent like acid 
alcohol. The two best solutions of haematoxylin for or- 
dinary work are those of Boehmer and Delafield. 

Boehmer’s hematoxylin is made as follows: two solu- 
tions are kept ready: (@) a ten-per-cent. solution of hema- 
toxylin in absolute alcohol; (0) a one-per-cent. solution of 
alum. <A few days before it is desired to use the stain 
one adds enough of the first solution to the second to 
make the colora bright violet. The fluid is then exposed 
to the light for a few days, by means of which it is turned 
much darker. Sections can be stained in the fluid for 
from two to five minutes, after which they are quickly 
differentiated in one-per-cent. solution of hydrochloric 
acid in seventy-per-cent. alcohol. They are then thor- 
oughly washed out in water and allowed to remain in the 
water until they turn blue (fifteen minutes); they can 
then be dehydrated (after previous counterstaining, if 
desired), cleared in creosote or oil of origanum, and 
mounted in balsam. The nuclei are stained of a deep 
blue violet color, while the protoplasm retains only a 
light blue tinge. 

Delafield’s hematoxylin is made as follows: 2 gm. of 
hematoxylin are dissolved in 10 c.c. of absolute alco- 
hol. This solution is mixed with 200.¢.c. of an ammonia- 
alum solution. The mixture is exposed to the light in 
an uncorked vessel for four or five days, after which it 
is filtered; 100 c.c. of alcohol aud the same quantity of 
glycerin are then added. The fluid is again filtered and 
the bottle corked. It is then permitted to stand for a 
long time, at least six weeks, generally several months, in 
order to ripen. It is then ready for use. It is employed 
in much the same way as Boehmer’s hematoxylin. 

Ehrlich’s acid hematoxylin has been mueh recom- 
mended, but possesses no especial advantages over the 
two formule given above. It is stated, however, that 
it stains more quickly and that the staining is more per- 
manent. 


- 


- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The iron hematoxylin stains are very valuable as 
nuclear dyes and for the demonstration of particular ele- 
ments of the cytoplasm, especially the centrosomes. 
The method of Heidenhain or that of Benda may be 
employed. According to Heidenhain, sections hardened 
in sublimate are immersed for from half an hour to three 
hours in a one-and-one-half to four per-cent. solution of 
ferric alum (clear violet crystals). After washing with 
water the sections are stained for thirty minutes in an 
aqueous 0.5-per-cent. solution of hematoxylin. They are 
then quickly washed in water, immersed again in a solu- 
tion of ferric alum, which removes a part of the stain, 
the differentiation being followed under the low power of 
the microscope. After the differentiation has been com- 
pleted the preparations are washed for fifteen minutes in 
running water, dehydrated, cleared, and mounted in bal- 
sam. The method is applicable to sublimate or alcohol 


material, but gives less good results with tissues hard- ' 


ened in chrome salts. It is best in using it to make sure 
that the sections are thin. They should not be thicker 
than 54. A contrast stain may be used if desired. 

Benda’s method also gives very good results and is 
applicable to tissues fixed inall of the ordinary reagents. 
Sections are immersed for twenty-four hours in the liquor 
sulfurici oxydati of the German Pharmacopeeia, diluted 
with one or two volumes of water. After thorough 
washing, first with distilled water and afterward with 
water from the tap, the sections are stained in a one-per- 
cent. aqueous solution of hematoxylin until they turn of 
a deep black color. After rinsing in water they are then 
differentiated in a thirty-per-cent. aqueous solution of 
acetic acid, the decolorizing process being carefully con- 
trolled by means of the low power of the microscope. 
The method is very valuable for the study of the central 
nervous system and the peripheral nerves. Acid fuchsin 
or eosin may be used with advantage as a contrast stain. 
Mayer’s hemalum may be used instead of the ordinary 
hematoxylin solutions. The particular application of 
hematt#in, by Apathy, for the demonstration of special 
elements will be referred to further on. 

Weigert’s hematoxylin method for demonstrating 
karyokinetic figures is as follows: «tissues which have 
been hardened in ninety-six-per-cent. alcohol are cut into 
very thin sections and placed in tinctura ferri Rademach- 
eri for thirty minutes. They are then washed quickly 
in water and stained for half an hour in a fluid of the 
following formula: hematoxylin, 1; absolute alcohol, 
10; distilled water, 100. The sections are washed in 
water, differentiated in feeble acid alcohol, after which 
they are allowed to remain in ordinary tap water for ten 
minutes. They are dehydrated in absolute alcohol, 
cleared in xylol or some essential oil, and mounted in 
balsam. 

The Aniline Stains.—Of the aniline dyes the most 
useful in histological work are methylene blue, gentian 
violet, thionin, and toluidin blue. Aniline blue black, 
and saffranin have also beenemployed. The triple stain 
of Biondi-Ehrlich, which consists of a mixture of methy- 
lene green, acid fuchsin, and orange G, is of advantage for 
the differentiation of some elements, but is especially 
difficult to apply successfully to the staining of tissues. 
Saffranin is particularly valuable as a nuclear stain, espe- 
cially in the study of karyokinesis. Methylene blue is 
most employed in the study of the nervous system for 
the staining of the nerve cells according to the method 
of Nissl or some modification of this method. Thionin 
may, if desired, be used in its place. Toluidin blue also 
appears to yield equally good results. 

Nissl’s Method of Staining with Methylene Blue.—Nerve 
tissues as fresh as possible are hardened in ninety-six-per- 
cent. alcohol for three days. After the hardening has 
been completed small blocks of tissue are fastened to cork 
by Weigert’s method with gum arabic without embed- 
ding. The sections are cut in the ordinary microtome, 
placed in ninety-six-per-cent. alcohol, and stained in a 
watch glass of the dye. The dye has the following con- 
stitution: methylene blue B. pat., 3.75; Venetian soap, 
1.75; distilled water, 100. A watch glass full of this dye 


Brain, 
Brain, 


containing the sections is heated over a spirit flame until 
small bubbles arise, making a crackling noise. The tem- 
perature corresponds to about 65° or 70° C. The sec- 
tions are then transferred to a differentiating fluid which 
has the following composition: colorless aniline oil, 10 
parts; ninety-six-per-cent. alcohol, 90 parts. The aniline 
oil must not only be colorless at first but must be kept 
carefully protected from the light. The process of dif- 
ferentiation of the sections is considered complete when 
no more coarse clouds of color go off into the fluid. 

The differentiated sections are placed upon glass slides, 
carefully dried with filter paper, cleared in oil of caje- 
put, and again dried with filter paper. 

The slide is then flooded with benzin, after which 
benzin colophonium is placed over the sections, and the 
whole slide is heated until all the benzin gas has been 
driven off. Should the material catch fire no harm will 
be done provided the flame is blown out immediately. 

To make the benzin colophonium, one adds benzin 
to pure white rosin and allows the mass to stand for 
twenty - four hours. <A fluid, transparent substance 
should be obtained which is ready for use. If it is too 
thin it may be allowed to evaporate until of the correct 
consistency ; if too thick, more benzin may be added. 

With this method the tigroid masses in the cytoplasm 
are exquisitely demonstrated. The method is especially 
valuable for the pathology as well as for the anatomy of 
the nerve cell. 

Held’s Modification of Nissl’s Method.—This investiga- 
tor,-after hardening in alcohol, sublimate, Van Gehuch- 
ten’s fluid, or other fluids, embeds small blocks of tissue 
in paraffin and cuts sections of a thickness varying 
from 1 to10y. For the finest histological details sec- 
tions of 1 » or less are sometimes valuable, but for gen- 
eral pathological studies thicker sections are of much 
greater service. A thickness of from 15 to 30 » is by no 
means too great for most purposes. 

The paraffin sections are fastened upon the slide by the 
alcohol method (vide supra). 

The sections, after they have been fastened to the slide, 
are first stained in the following solution: erythrosin, 1; 
distilled water, 150; acetic acid, 2 drops. This stain is 
permitted to act fora minute or two, and may be slightly 
warmed. Sections are then washed in water, after which 
they are stained in methylene blue. Held’s staining 
fluid consists of equal parts of the methylene-blue solu- 
tions used by Nissl (vide supra) and a five-per-cent. aque- 
ous solution of acetone. The sections are heated in this 
staining fluia and the heating is continued until all smell 
of acetone disappears. The sections remain in the fluid 
while it cools, after which they are differentiated in a 
one-tenth of one-per-cent. solution of ordinary alum. 
The process of differentiation requires from a few sec- 
onds to several minutes, according to the nature and 
thickness of the section. When the differentiation is 
complete sections are quickly washed in water, dehy- 
drated as quickly as possible in absolute alcohol, passed 
through xylol for clearing, and then mounted in benzin 
colophonium according to the method advised by Nissl. 

The Nissl bodies are stained of a deep blue color, 
sometimes showing a slight violet tint. The ground 
substance of the protoplasm stains red, as do the nuclear 
membrane and certain other structures in the nucleus. 
The nucleolus itself stains blue, the neurosomes stain 
violet, as do also the accessory nucleoli. 

Mann's Method of Staining with Eosin and Toluidin 
Bilue.—The sections are fixed in sublimate solution, sec- 
tioned in paraffin, fastened upon the slide, treated with 
iodine to remove the sublimate, and then washed for two 
minutes in water. The sections which are still some- 
what yellow are then placed for from five to ten minutes 
in a one-per-cent. aqueous solution of eosin. They are 
then washed in ordinary water, after which they are 
stained in one-half-per-cent. aqueous solution of toluidin 
blue for from twenty to thirty minutes. The sections 
are then quickly washed off in distilled water to remove 
the excess of toluidin blue, quickly dehydrated in abso- 
lute alcohol, during which blue clouds of color go off. 


327 


Brain, 
Brain, 


The sections are cleared in xylol and mounted in turpen- 
tine balsam. The tigroid bodies and the chromatin of 
the nucleus and nucleolus stain of a dark blue color; 
while fibrillary and interfibrillary structures stain red. 
The method is very safe and reliable. 

Harris’s Method of Staining with Tolwidin Blue.—The 
tissues are hardened in mercuric chloride, stained in car- 
bolic-acid-water solution of toluidin blue for’ several 
minutes, differentiated in alcohol, cleared, and mounted 
in balsam. If desired, benzo-purpurin may be used as a 
contrast stain. 

Method of Staining with Thionin.—Sections hardened 
in alcohol or sublimate or formalin are embedded in par- 
affin and fixed to the slide in the ordinary way. The 
staining is carried out with a concentrated aqueous solu- 
tion of thionin, the dye being allowed to act for from 
three to five minutes. The sections are quickly washed 
in water and are then differentiated in a ten-per-cent. so- 
lution of aniline oil in absolute alcohol. They are cleared 
in oil of cajeput, then passed through xylol and mounted 
in xylol balsam. 

Gram’s Method of Staining, with Gentian Violet, Tis- 
sues Which have been Hardened in Alcohol.—Sections are 
cut in celloidin or paraffin. They are then stained in 
Ehrlich’s solution of gentian violet, which consists of: 
gentian violet, 1; alcohol, 15; aniline oil, 3; water, 80. 
The sections are transferred, after staining, to a slide, 
spread out flat, and treated with the foilowing solution: 
iodine, 1; iodide of potassium, 2; water, 300. They are 
then dehydrated in absolute alcohol, cleared in xylol, 
and mounted in xylol balsam. 

Weigert’s Fibrin Stain with Gentian Violet.—Sections 
from tissue hardened in alcohol are stained in Ehrlich’s 
aniline gentian violet (vide supra). They are then placed 
on a slide and blotted with filter paper ccvered with 
Lugol’s solution. After this has been allowed to act for 
from fifteen to thirty seconds the sections are blotted 
again. They are then dehydrated and cleared in a mix- 
ture of two parts of aniline oil with one part of xylol. 
This treatment is followed by pure xylol, in which the 
sections are washed until all the aniline oil has been re- 
moved. They are then mounted in xylol balsam. The 
method is of particular advantage in pathological his- 
tology. 

Method of Staining with Aniline Blue Black.—Sections 
are stained for from thirty to sixty minutes in the fol- 
lowing solution: aniline blue black, 0.25; distilled water, 
100. The sections are then washed in water, dehydrated 
in alcohol, cleared in creosote, and mounted in balsam. 

The Method of Staining with Saffranin.—Sections of 
tissue fixed in Flemming’s solution are stained in a con- 
centrated aqueous solution of saffranin for from twelve 
to twenty-four hours. They are then carefully differen- 
tiated in absolute alcohol, or, if necessary, in weak acid 
alcohol. The sections are cleared in oil of cloves and 
mounted in balsam. With proper differentiation karyo- 
kinetic figures are intensely stained, while resting nuclei 
retain only a feeble pink tint. 

Rosin’s Method of Staining with the Triple Stain of 
Biondi-Ehrlich.—Sections which have been hardened in 
alcohol and embedded in celloidin are treated as follows: 
They are stained for one minute in the following solu- 
tion: one part of one-half-per-cent. solution of acid 
fuchsin is added to four parts of a solution of the follow- 
ing constitution: dry triple stain (Griibler), 0.4; distilled 
water, 100; 0.5 per cent. acid fuchsin solution, 7 (if the 
sections are not embedded in celloidin they can be stained 
for five minutes in the latter solution alone), 

After staining, the sections are quickly washed in dis- 
tilled water which is changed once, the washing requir- 
ing from one to two minutes; they are then treated 
for ten seconds with a feeble aqueous solution of acetic 
acid (one drop of glacial acetic acid in 100c.c. of distilled 
water); they are then again washed in distilled water 
for sixty seconds to remove all trace of acetic acid. Dif- 
ferentiation is carried out with the aid of absolute alco- 
hol for from two to three minutes, during which clouds 
of violet color are given off. The sections are cleared in 


328 


2 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


xylol and mounted in balsam. The method requires con- 
siderable practice before good results are obtained. 

C. Mernops Wuich DEMONSTRATE ESPECIALLY THE 
MYELINE SHEATHS.—Method of Hxner.—Pieces of per- 
fectly fresh tissue not more than 1 cm. broad and 0.5 cm. 
thick are placed in a one-per-cent. solution of osmic acid. 


There must be at least ten times as much osmic-acid - 


solution as there is tissue by volume. After two days 
the osmic acid is changed. The tissue can be examined 
between the fifth and the ninth day. It is washed in 
water, dried on the surface with filter paper, fastened to 
cork by means of sealing wax, and then sectioned in 
the microtome. The sections are placed in glycerin, 
whence they are brought upon a glass slide and treated 
with a drop of weak solution of ammonia (20 drops of 
liquor ammonii caustici in 50 c.c. of water). The mye- 
line sheaths of the nerve fibres are stained black; all other 
structures remain pale. 

Weigert’s Method of Staining Myeline Sheaths.—Tissues 
are hardened in Miiller’s fluid or in formol followed by 
Miller’s fluid, or in Orth’s fluid or in formol followed by 
four days in the following solution: Potassium bichro- 
mate, 5 parts; chrome alum, 2 parts ; dilute water, 100 
parts. The blocks of tissue are transferred without 
washing into alcohol and are embedded in celloidin. The 
sections are placed for twenty-four hours in a saturated 
solution of acetate of copper diluted with an equal vol- 
ume of water. They are stained for from twenty min- 
utes to twenty-four hours in the following solution: 
hematoxylin, 1; absolute alcohol, 10; lithium carbonate, 
1; distilled water to make up 100 parts. The sections 
are next washed in water and differentiated in the fol- 
lowing solution: borax, 2; ferricyanide of potash, 2.5; 
distilled water, 100. The sections are then thoroughly 
washed in water, dehydrated in alcohol, cleared in xylol 
or carbol xylol, and mounted in balsam. The myeline 
sheaths of medullated nerve fibres are stained bluish 
black, the background being of a brownish-yellow color. 

Weigert’s Rapid Myeline Stain.—Small blocks of tissue 
are placed for from four to five days in ten-per-cent. 
solution of formol (four-per-cent. solution of formalde- 
hyde); after this they are placed in a mordant of the 
following formula: bichromate of potash, 5 parts; 
chrome alum, 2 parts; boiling water, 100 parts. If de- 
sired the hardening and mordanting can be done to- 
gether by adding 10 gm. of the ten-per-cent. solution 
of formol to 100 parts of the mordant. If desired, in- 
stead of the above treatment Weigert’s copper mordant 
(used for his neuroglia stain) may be employed. ‘This 
consists of five-per-cent. copper acetate, five-per-cent. 
acetic acid, and two-and-one-half-per-cent. chrome alum 
dissolved in water. It has the advantage of making no 
precipitates on the tissues, and, further, does away with 
the necessity of treating the sections with copper acetate 
after they have been cut. If left longer than eight days 
in the fluid the tissues become very brittle. 

Pal’s Modification of Weigert’s Stain for Myeline Sheaths. 
—The tissues are prepared as for Weigert’s method, ex- 
cept that the sections are not treated with acetate of 
copper. Sections are stained in Weigert’s hematoxylin 
solution for from twenty-four to forty-eight hours in 
the cold; they are then washed in lithiated water (four 
per cent.); after washing they are placed in a freshly 
prepared 0.33-per-cent. solution of potassium permanga+ 
nate for from twenty to thirty seconds, or until the gray 
matter looks yellowish. The sections are transferred 
immediately to the following solution: oxalic acid, 1; 
potassium sulphite, 1; distilled water, 200. The differ- 
entiation is watched closely to see that it does not go too 
far. Should it not proceed rapidly enough the sections 
are put back into the solution of potassium permanga- 
nate and again exposed to the oxalic-acid solution. 
When the differentiation has gone far enough the sec- 
tions are washed out in water, and transferred to a strong 
solution of lithium for five orten minutes until they turn 
of an intense blue color. They are finally thoroughly 
washed in water, dehydrated in alcohol, cleared in xylol 
or carbol xylol, and mounted in balsam. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Schaefer’s Modification of Weigert’s Method.—The treat- 
ment is the same as for Weigert’s method, except that 
the sections after having been passed through water are 
left in Marchi’s fluid for some hours; they are then 
thoroughly washed and stained in the following solution: 
hematoxylin, 1; absolute alcohol, 10; two-per-cent. 
solution of acetic acid, 100. After they have remained 
in this fluid for twenty-four hours the sections are washed 
in water and decolorized according to Pal’s method (vide 
supra). 

Vassale’s Modification of Weigert’s Method.—Sections 
are prepared as in the method of Weigert. They are 
then stained in a one-per-cent. aqueous solution of hema- 
toxylin for from three to five minutes, after which they 
are washed in water, exposed for a few minutes to the 
action of a saturated solution of neutral acetate of cop- 
per. They are then washed in water and differentiated 
by Weigert’s ferricyanide solution. They are again 
washed in water, dehydrated in alcohol, cleared in carbol 
xylol, and mounted in balsam. 

Berkley’s Modification of Weigert’s Stain.—Pieces of 
tissue 2 mm. in thickness are hardened in Flemming’s 
solution for from twenty-four to thirty hours. They 
are transferred directly to absolute alcohol which is 
changed twice on the following day. As soon as the 
consistency will permit of the making of very thin sec- 
tions the pieces of tissue are embedded in celloidin and 
cut under ninety-five per cent. alcohol. After quick 
washing in water they are laid in a saturated solution 
of acetate of copper and heated on a water bath for from 
twenty to thirty minutes, at a temperature of from 100° 
to 110° F. The fluid is allowed to cool, after which the 
sections are quickly washed in water and then stained 
in the following fluid freshly prepared: to 50 c.c. of 
boiled distilled water are added 2 c.c. of saturated solu- 
tion of lithium carbonate. The boiling is continued for 
another minute, after which 1.5 or 2.c. of a ten-per- 
cent. solution of hematoxylin in absolute alcohol is 
added little by little with constant stirring. As soon as 
cool the fluid is ready for use. Sections placed in the 
stain are warmed ona water bath to a temperature of 
100° F. for from fifteen to twenty minutes or longer. 
After cooling they are twice washed in water, then dif- 
ferentiated in Weigert’s borax ferricyanide solution di- 
luted with one-half or one-third its volume of water. 
Usually five or six minutes suffice to complete the decol- 
orization. The sections are washed in two waters, dehy- 
drated in alcohol, cleared in oil of bergamot, and mounted 
in balsam. 

Herrick’s Modifications of Weigert’s Stain for Compara- 
tive Work.—For the formule used by Herrick his original 
article is referred to (“Report upon a Series of Experi- 
ments with the Weigert’s Methods—with Special Ref- 
erence for Use in Lower Brain Morphology.” The State 
Hospitals’ Bulletin, Utica, vol. ii., 1897, pp. 481-461). 

Marchi’s Method of Staining Degenerated Myeline 
Sheaths.—Small pieces of tissue are hardened for eight 
days in Miiller’s fluid, transferred without washing to 
Marchi’s fluid, which consists of two parts Miiller’s 
fluid mixed with one part of a one-per-cent. solution of 
osmic acid. In the latter fluid the bits of tissue remain 
for from five to ten days, after-which they are washed 
for twenty-four hours in running water, hardened in 
alcohol, embedded in celloidin, and cut in the microtome. 
The sections are cleared in xylol and mounted in xylol 
balsam. Chloroform balsam is to be avoided. Degener- 
ated myeline sheaths stain of an intense black, while all 
others remain of a light yellow color or of a slightly 
grayish tint. The method demonstrates of course only 
myeline sheaths in the process of degeneration. If degen- 
eration has existed for over three months and the myelin 
has been absorbed the degenerated fibres are not demon- 
strable by Marchi’s method. The method has proved to 
be of especial value in experimental work. It is also of 
great value in studying recent degenerations in human 
cases in which fresh autopsies can be obtained. 

The tissues may be fixed, if desired, in formol before 
treatment with Marchi’s fluid, but the results are not 


Brain, 
Brain, 





quite so satisfactory as when the original procedure is 
employed. Formol tissues have the advantage that they 
warp less than those prepared by the original method. 

Vassale’s Modification of Marchi’s Method.—Instead of 
two parts of Miiller’s fluid to one part of the one-per- 
cent. osmic-acid solution, Vassale uses three parts, and, 
further, to 100 c.c. of the Marchi fluid thus prepared he 
adds twenty drops of pure nitric acid. He asserts that 
by this method precipitates are less abundant and the 
degenerated fibres stand out much more sharply from 
the other tissues, 

Hamitlton’s Modification of Marchi’s Method.—Accord- 
ing to this method Marchi’s fluid is applied after the sec- 
tions are made. The sections are placed in a fluid ob- 
tained by macerating brains hardened in bichromate, in 
chromic-acid solution, and filtering. This bath, he as- 
serts, renders the sections susceptible to the osmium 
reaction when they are afterward treated with Marchi’s 
fluid. The method requires further testing. The writ- 
er’s experience with it has not been satisfactory. 

D. MretTHops FOR THE EsPECIAL DEMONSTRATION OF 
AXONES OR AXIS-CYLINDER PROCESSES.—Golgi’s method 
and the method of vital staining of Ehrlich are the best 
we have for the demonstration of the external form of 
axones. For the examination of the finer internal struc- 
ture of axones, various methods have been recommended. 

Van Gieson’s Method.—Tissues hardened in Miiller’s 
fluid are sectioned after embedding in celloidin. The 
sections are stained for from three to five minutes in 
Delafield’s hematoxylin, thoroughly washed in water, 
and afterward stained in a mixture of saturated picric- 
acid solution with saturated solution of acid fuchsin. 
They are then washed quickly in water, dehydrated in 
alcohol, cleared in oil of origanum, and mounted in bal- 
sam. The axis cylinders stain deep red in the acid fuch- 
sin, the myeline sheaths take a yellow tint from the picric 
acid; all nuclei stain in hematoxylin, while neuroglia 
tissue takes the acid fuchsin, especially in sclerotic areas. 

Stroebe’s Method for Axis Cylinders.—Tissues hardened 
in Miller’s fluid are sectioned after embedding in cel- 
loidin. The sections are stained in a saturated aqueous 
solution of aniline blue until they are of a deep blue-back 
color. The staining requires from fifteen to sixty min- 
utes. The sections are then washed in water, differen- 
tiated in absolute alcohol to which has been added a few 
drops of a one-per-cent. solution of caustic potash dis- 
solved in absolute alcohol and filtered after standing 
twenty-four hours. The sections remain in this fluid 
until they are of a light brownish-red color, which usu- 
ally appears after a very few minutes. They are then 
washed in water, in which the sections turn light blue. 
As a contrast stain a dilute solution of saffranin is al- 
lowed to act for from fifteen to thirty minutes. Sec- 
tions are dehydrated in absolute alcohol, cleared in xylol, 
and mounted in balsam. Axones stain deep blue, myeline 
sheaths orange red, glia fibres blue. The method requires 
some practice before good results can be obtained. 

Held’s Method for Studying Axones.—No better mode 
perhaps of studying the finer internal structure of axones 
has been devised than Held’s modification of Nissl’s 
methylene-blue staining (vide supra). The sections must 
be very thin. The neurosomes and fibrillary or honey- 
comb structures are exquisitely brought out by this pro- 
cedure. For showing the neurosomes alone in all parts 
of the neurones, perhaps the best method is another intro- 
duced by Held. The tissues are fixed in a solution of 
neutral chromate of potash, sectioned in paraffin, and 
stained with iron hematoxylin. 

E. Mernops EspeEcrALLY APPLICABLE TO NEUROG- 
LiA.— Weigert’s Neuroglia Stain.—This stain, the method 
for which was published in 1895 by Carl Weigert of 
Frankfort, is carried out as follows: Tissues are fixed 
and mordanted for eight days in the following solution: 
acetate of copper, 5; acetic acid, 5; chrome alum, 2.5; 
formol, 10; distilled water, 100. The chrome alum must 
be dissolved in boiling water, while the acetate of cop- 
per and acetic acid are added afterward. If these di- 
rections are not followed a precipitate will be formed. 


329 


Brain. 
Brain. 





In particular, Weigert advises boiling the chrome alum 
and water in an enamelled saucepan; when the boiling 
is active after the chrome alum has been dissolved the 
flame is turned out and the acetic acid and finely pow- 
dered neutral acetate of copper are added. One stirs 
vigorously until one can feel with the glass rod that the 
copper salt has almost entirely dissolved. The fluid is 
then allowed to cool and will remain clear. ‘Tissues 
which have been hardened for four days in formalin can 
be placed in this fluid and left for four or five days at 
the temperature of the thermostat or for eight days at 
the room temperature. It is perhaps better, however, 
to harden directly in a fluid to which ten-per-cent. formol 
has been added. The fluid should be changed on the 
second day. Weigert states that tissues never become 
brittle in this fluid. When desired to make sections the 
pieces of tissue are washed with water, dehydrated in 
alcohol, and embedded in celloidin. The sections are 
next placed in some reducing fluid. Weigert recom- 
mends a mixture of five-per-cent. chromogen and five- 
per-cent. formic acid (specific gravity, 1.20) in water. 
This mixture is filtered carefully, and before it is used 
one adds to 90 c.c. of the fluid 10 c.c. of a ten-per-cent. 
solution of ordinary sodium sulphite (that used in pho- 
tography). The sections are placed first for ten minutes 
in a 0.83-per-cent. solution of permanganate of potash. 
They are then washed in water, after which the water is 


removed and the reducing fluid above mentioned is . 


poured upon the sections. After a few minutes the sec- 
tions which were turned brown by the permanganate of 
potash become decolorized. Weigert recommends that 
the sections be left for from two to four hours in the 
chromogen mixture. 

After removal from the reducing fluid and washing 
twice in water the sections are placed in a simple satu- 
rated aqueous solution of chromogen (made by dissolv- 
ing five parts of chromogen in one hundred parts of dis- 
tilled water and filtering). 

The sections remain in this solution over night. The 
longer they stay in this fluid the more stained are the 
nervous elements of the tissue. They are washed twice 
in water, after which the sections are ready for the stain. 
If they cannot be stained at once the sections should be 
preserved in the following mixture: eighty-per-cent. 
alcohol, 90 c.c.; five-per-cent. solution of oxalic acid, 10 
€.C. 

The sections are stained in a methyl-violet solution 
prepared in the following way: methyl violet in excess 
is added to hot seventy-per-cent. alcohol, and after cool- 
ing the fluid is poured off from the undissolved methyl 
violet. To every 100 c.c. of this solution are added 5 
c.c. of a five-per-cent. aqueous solution of oxalic acid. 
The sections are placed upon a glass slide, treated with a 
solution of iodine and iodide of potash (as in Weigert’s 
fibrin stain), after which they are differentiated in a mix- 
ture of equal parts by volume of aniline oil and xylol. 
They are then washed in xylol very carefully several 
times. Otherwise the preparations do not keep well. 
They are then mounted in balsam, exposed for from two 
to five days to diffuse daylight, and afterward kept in 
cabinets in the ordinary way. 

An excellent staining method for neuroglia is that in- 
troduced by F. B. Mallory,* of Boston. The tissues are 
fixed in equal parts of a saturated aqueous solution of 
picric acid and a five-per-cent. solution of formalin. 
They remain in this for from four to seven days. The 
tissues are then transferred to a two-per-cent. solution of 
ammonium bichromate, where they remain for from one 
to two weeks. They are then washed in water, dehy- 
drated in alcohol, and embedded in celloidin. The cel- 
loidin is removed from the sections, which are then stained 
feebly in carmine and afterward stained by Weigert’s 
fibrin stain. 

F. METHODS FOR DEMONSTRATING FIBRILLAR AND 
RETICULAR STRUCTURES IN THE NERVOUS SystEeM.—S. 














REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








Apathy, of Klausenburg, has introduced several methods 
which are of the greatest value for staining the neuro- 
fibrils in lower animals. They do not stain, however, 
the same fibrils in vertebrates. Three principal methods 
have been introduced by Apathy. 

(1) Staining of Fresh Tissue with Methylene Blue.—This 
method is described in the Zettschr. f. wissensch. Mikr., 
Bd. ix., 1892. 

(2) Staining of Hardened Tissue with a Solution of 
Hamatéin.—The tissues may be fixed by any one of sev- 
eral methods: sublimate, sublimate alcohol, corrosive 
acetic, picric acid, Zenker’s fluid, etc. After fixation the 
tissues may be kept in ninety-per-cent. alcohol until it is 
desired to stain them. The pieces should not exceed 5 
mm. in thickness. They are stained in bulk ina solution 
of hematéin, prepared by successively pouring together 
equal volumes of the three following ingredients: one 
per-cent. hemat@in tincture, concentrated glycerin, and 
nine-per-cent. alum solution with addition of salicylic 
acid and acetic acid. The hsematéin solution is prepared 
from hematoxylin by ripening it. A one-per-cent. solu- 
tion of hematoxylin crystals in a seventy-per-cent. solu- 
tion of pure alcohol is first made. This is allowed to 
stand in a flask of good glass which is not quite full. 
The oxidation of the hematoxylin to hematéin should go 
on at the room temperature for from six to eight weeks. 
The alum solution is prepared as follows: 9 parts of 
alum, 3 parts of glacial acetic acid, and 0.1 part of sali- 
cylic acid are dissolved in 100 parts of water. 

The tissue remains in the dye for at least forty-eight 
hours. It is then washed for twenty-four hours in pure 
double distilled water, which must be often changed. 
The tissue is then placed in feebly alkaline water for 
from three io five hours, after which it is returned for 
two hours(at most) to distilled water. It is then quickly 
dehydrated in alcohol and embedded in either celloidin 
or paraffin. 

(3) Staining of Fresh and Fixed Tissues by the Gold 
Method.—The tissue is cut into thin pieces and placed in 
a solution of yellow gold chloride. The amount of fluid 
should be ten times the volume of the object. After the 
treatment with the gold solution the tissue is exposed to 
the light in a one-per-cent. solution of formic acid (crys- 
tallized, specific gravity, 1.228) in distilled water. The 
tissue should be exposed to direct or indirect sunlight 
from all sides, the vessel containing it sitting upon a 
mirror. The exposure to light should not be too short, 
but exposure for more than twenty-four hours is not 
advisable. At least six or eight hours is always needed. 
For full particulars regarding the methods, Apathy’s* 
article is referred to. 

Bethe has recently introduced a method by which the 
neurofibrils in the tissues of human beings and other 
mammals can be stained; it isas follows: Fresh tissue 
in discs 4 to 10 mm. thick are laid upon filter paper and 
immersed in nitric acid of a strength of from three to 
seven and one-half per cent., where they remain for 
twenty-four hours, the pieces being frequently turned. 
They are then transferred to ninety-six-per-cent. alco- 
hol, where they remain fdr from twelve to twenty-four 
hours. The pieces are then immersed for from twelve 
to twenty-four hours in the following mixture: ammo- 
nia (specific gravity, 0.95 to 0.96), 1 part; water, 3 
parts; ninety-six-per-cent. alcohol, 8 parts. The tem- 
perature should not exceed 20° C. The pieces are then 
transferred for from six to twelve hours to ordinary 
alcohol. After this they are placed in acid alcohol of 
the following constitution: hydrochloric acid, concen- 
trated, 1 part; water, 3 parts; ninety-six-per-cent. alco- 
hol, 8-12 parts. In this the tissues become light yellow 
or nearly white if they have only been feebly acted upon 
by the nitric acid. After treatment with acid alcohol the 
tissues are again placed in ordinary alcohol for from ten 
to twenty-four hours. They are then washed in water 
for from two to six hours. After this they are molyb- 








* Mallory, F. B.: Ueber gewisse eigenthiimliche Farbereactionen 
der Neuroglia. Centralbl. f. allg. Pathol. u. path. Anat., Jena, Bd. 
vi., 1895, October 81st, S. 753-758. 


830 


* Apathy, S.: Das leitende Element des Nervensystems und seine 
topographischen Beziehungen zu den Zellen. I. Mittheilung, Mittheil. 
d. Zool. Station Neapel, Bd. xii., p. 495-748. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





danized. The blocks of tissue are transferred to a four- 
per-cent. solution of ammonium molybdate, where they 
remain for twenty-four hours. They are then quickly 
washed in distilled water, dehydrated in ninety-six-per- 
cent. alcohol for from ten to twenty-four hours, then in 
absolute alcohol for the same length of time; cleared in 
xylol or toluol and embedded in paraffin (not in celloidin). 

The neurofibrils and the Golgi network can be stained 
by this method. 

For further details and for a modification of the method, 
Bethe’s original article is referred to.* 


Microscopic APPEARANCES. 


The brains of different animals vary, of course, in size 
and complexity. The present article deals almost en- 
tirely with the minute anatomy of the human brain. 

In human beings we designate as brain or encephalon 
that portion of the central nervous system enclosed 
within the skull. It is continuous at the level of the 
great occipital foramen with the spinal cord or medulla 
spinalis. The brain, like the spinal cord, is enclosed in 
membranes known asmeninges: (1) A firm tough mem- 
brane (dura mater encephali); (2) a very delicate mem- 
brane closely crowded with minute blood-vessels and 
closely attached to the surface of the brain substance 
{pia mater encephali); and (8) a membrane between the 
two former membranes, (arachnoidea encephali). 

The gross anatomy of the brain is described in another 
article in this HANDBOOK. ~ 

With the naked eye it is seen that the main mass of 
the brain consists of a very white substance, the so-called 
white matter, or substantia alba, and a gray substance, the 
so-called gray matter, or substantia grisea, The substantia 
alba is more abundant than the substantia grisea. In 
general it may be said that in the brain the gray sub 
stance is chiefly on the surface of the organ and in cer- 
tain large gray masses, the so called basal ganglia: while 
the white matter is situated internally. being surrounded 
by the gray. The relative positions of white and gray 
matter are, in the brain, exactly the reverse of those in 
the spinal cord, where the gray matter is inside and the 
white matter outside. In the region of the brain nearest 
to the spinal cord, a very irregular arrangement of gray 
and white matter is met with, the various masses of gray 
matter being known as “nuclei” of the gray substance. 
‘These nuclei include among other structures the nuclei 
of origin and termination of various cerebral nerves. 

Histological research has shown that the nervous 
system, like the other tissues of the body, consists of an 
aggregation of cells and intercellular substances derived 
from cells. All the cells of the central nervous system 
except those of the meninges and the blood-vessels, with 
the tissue immediately adjacent to the latter, are believed 
to be derived from the ectoderm or outermost layer of 
the embryo. 

The cells in the brain may be divided into two main 
groups: (1) the true nerve cells or newrones, and (2) all 
other cells including those of the newrogiia and ependyma. 

The nerve cells, or newrones, differ markedly from other 
cells in the body in that portions of the protoplasm are 
drawn out in many instances to form threads of great 
length. Nowhere in the body do cell processes so long, 
so complex, so much branched, and so delicate occur as 
in the nervoussystem. While nerve cells vary distinctly 
in size, shape, and mode of branching, the most common 
type possesses the following characteristics: each nerve 
cell or neurone consists of a cell body or perikaryon, a 
number of protoplasmic processes or dendrites, and a sin- 
gle long, delicate process which often becomes surrounded 
with an especial fatty sheath (myelin), the so-called azone 
or axis-cylinder process. 

The nerve cells, compared with other cells of the body, 
are as a rule, large, contain large nuclei, poor in chro- 
matin, and usually provided with a large nucleolus. 








* Bethe, A.: Das Molybdanverfahren zur Darstellung der Neuro- 
fibrillen und Golginetze im Centralnervensystem. Zeitschr. f. wis- 
sensch. Mikr., Bd. xvii., 1900, S. 13-35. 





The dendrites or protoplasmic processes are thick at 
their origin and gradually diminish in calibre as they 
pass from the cell, owing to manifold subdivision. 
Through the multiplication of these processes the area 
of the surface of the protoplasm of the cell is enormously 
increased. 

The azone differs from the dendrite in that it arises by 
a thin wedge of origin, usually from the cell body, but 





at —ff— 2ta 





Fig. 905.—Schematic Representation of a Lower Motor Neurone. The 
motor cell from the ventral horn of the spinal cord, together with all 
its protoplasmic processes and their divisions, its axis-cylinder proc- 
ess with its divisions, side fibrils, or collaterals, and end ramifica- 
tions (telodendrions or motor end-plates) in the muscle, represent 
parts of a single cellor neurone. a.h, Axone hillock devoid of Nissl 
bodies, and showing a tendency to fibrillation ; @.2, axis cylinder or 
axone, also indistinctly fibrillated. This process, at a short distance 
from the cell body, becomes surrounded by a myeline sheath, m, and 
a cellular sheath, the neurilemma, the latter not being an integral 
part of the neurone; ¢, cytoplasm showing the dark-colored Nissl 
bodies and lighter ground substance; d, protoplasmic processes 
(dendrites) containing Nissl bodies; n, nucleus; 7’, nucleolus; 
n.R, node of Ranvier; sf, side fibril; n of m, nucleus of neuri- 
lemma sheath; tel., motor end-plate or telodendrion ; m/’, striped 
muscle fibre; s.l., segmentation of Lantermann. (From “The 
Nervous System and Its Constituent Neurones,”’ D. Appleton & Co., 
New York, 1899.) , 


sometimes from one of the dendrites near the origin of 
the latter. The axone has a smooth, regular surface and 
very even calibre, even when followed for a long distance 
from the cell body which gives it origin. The length of 
the axone may vary greatly. If it is very long it usually 


331 


Brain, 
Brain. 


becomes surrounded by a myeline sheath (¢nawone, Golgi’s 
cell type I.) (Fig. 905); if itis very short, terminating near 
the cell body, it does not become surrounded by a myeline 
sheath (dendrazone, Golgi’s cell type I.) (Fig. 906). Many 





Fig. 906.—Golgi’s Cell of Type II. or Dendraxone from the Cerebrum of 
a Cat. (After Kélliker.) The coarse protoplasmic processes, x, are 
easily distinguishable from the axis-cylinder process, a, though the 
latter soon loses its identity, exhausting itself by multiple division 
at a short distance from the cell. 


axones, especially the longer ones, give off as they pass 
through the nervous tissue delicate lateral branches 
known as collaterals. These collaterals are also sur- 
rounded by fatty sheaths. 
off very close to the origin of the axone do not 
become surrounded by fatty sheaths inasmuch as 
this portion of the axone is also free from investing 
sheath. These non-medullated lateral branches are 
known as the side fibrils of Golgi. All collaterals 
and the terminals of the axones themselves ulti- 
mately become exhausted by manifold subdivi- 
sion in regions where these fine subdivisions can 
enter into relations with the cell bodies or branches 
of the cell bodies of other nerve cells or neurones. 
These ultimate branchings with formations of deli- 
cate terminal arborizations are the so-called teloden- 
drions. It is believed that it is the great mass of 
nerve cells or neurones which are responsible for 
the truly nervous functions, namely, the reflex, in- 
stinctive, and volitional activities of the body. 

The ependymal cells are those which line the cen- 
tral canal of the central nervous system. Thus, 
they line the walls of the ventricles of the brain, 
those of the aqueduct of the cerebrum and the cen- 
tral canal of the spinal cord. 

The neuroglia cells, also ectodermal in origin, are 
widely distributed throughout the nervous tissues 
of the brain and are believed by most observers to 
represent supporting cells. They include the spider 
cells, the stellate glia cells, and various other forms 
of cells. They are present in both the white and 
the gray substance. 

The intercellular substances in the brain have only 
begun to be worked out; while many believe that the 
only intercellular substances present are the fluids of 
the lymph derived from the blood, others maintain 
the existence of an enormous number of fibrils be- 
tween thecells. Studies of Weigert indicate the existence 
of neuroglia fibrils differentiated from the neuroglia cells. 
Many of these fibrils pass directly through the bodies of 
the glia cells. The studies of Apathy and Bethe indicate 
the presence of highly differentiated fibrils inside the 


332 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











A few lateral branches given | 


bodies of the true nerve cells or neurones. These fibrils 
they believe pass from one neurone to another. Nissl 
has gone even further and asserts that great masses of 
these fibrils exist outside the cells, and he believes that 
the peculiar character of the gray matter, especially of 
that of the cerebral cortex, is due to the presence of 
these fibrils between the cells. The views of Nissl have 
not as yet been confirmed. 

The gray and white matter of the brain are richly sup- 
plied with blood by means of a very indirect network of 
capillaries derived from the intracranial blood-vessels. 
The supply of blood to the gray substance is much more 
copious than that to the white substance. 

After these preliminary statements the cells and inter- 
cellular substances of which the brain is composed may 
be considered more in detail. 

The nerve cells or neurones will be considered first. A 
striking feature is the uniformity in type met with in va- 
rious parts of the brain. here are, however, differences 
even in external form which are easily recognizable by 
the trained histologist. The cells in certain of the gray 
masses have so distinct a type that their origin can be 
predicted at once when they are seen under the micro- 
scope. The differential features lie in the form and size 
of the cell body, the characters of the dendrites and ax- 
ones, and the relations of these to the cell body. 

Among the cell bodies or perikaryons there are great 
variations in size. Thus, for instance, the large cells of 
Betz in the paracentral lobule possess cell bodies many 
times the size of the minute perikaryons of the olfactory 
granules. The shape, too, of the cell bodies varies much. 
The pyramidal cell of the cortex of the cerebrum, the 
flask-shaped cell of Purkinje in the cerebellar cortex, and 
the large multipolar ganglion cells of Deiters’ nucleus 
may be recalled. 

The dendrites of the nerve cells are usually numerous, 
rarely single. These processes appear to be much drawn- 
out portions of the cell body. The relation of the proc- 
esses to the cell body varies with different types of 
neurones. Thus, in the nuclei of origin of the motor 





Fig. 907.—Photomicrograph of a Normal Purkinje Cell from the Human 


Cerebellar Cortex. (After Berkley.) 


cerebral nerves, large dendrites project from nearly all 
portions of the surface of the cell body. From the cells 
in the hippocampus, dendrites project only from the two 
poles of the cell. In the cerebellar cortex the neck of 
the flask-shaped cell is a huge dendrite which subdivides 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





soon into two or more large branches, which then go on 
to subdivide over and over again until a forest of dendritic 
branches has been formed which has no equal elsewhere 
in the nervous system (Fig. 907). In the cerebral cortex 
the pyramidal cells give off dendrites from the apex and 
from the lateral angles of the pyramid (Fig. 908). While 
in some of the neurones the various dendrites are ap- 
proximately equal in size and in extent of distribution 
(cells of motor nuclei), in other neurones the size and 
mode of distribution of fibres from a given cell may be 
very different. Thus, taking a pyramidal cell of the 
cerebral cortex again for an example, while the apical 
dendrite forms a large, strong, straight branch which as 
a rule extends a long distance from the cell before break- 
ing up into an end tuft of subdivisions, the smaller den- 
drites given off from the angles of the pyramid are of 
much smaller calibre, are often tortuous, branch quickly 
after leaving the cell body, and soon exhaust themselves 
by multiple subdivision in an area close to the perikaryon. 
The branches of the individual dendrites, no matter how 
far away from the cell they terminate, appear to end 
free. It was believed that they always came into direct 





Fic. 908.—Photomicrograph of a Normal Pyramidal Cell from the Cere- 
The single-branched 
apical dendrite and the basal dendrites show distinctly the lateral buds 


bral Cortex of the Guinea-Pig. (After Berkley.) 


or ““gemmules.’’ The axone is relatively smooth. 


contact or even into more intimate connection with the 
walls of blood-vessels, but this view has been given up. 
It has been proven, however, that they come into inti- 
mate relation with the terminals of the axones and col- 
laterals of other neurones, and it is believed by many that 
this relation is one which subserves the purpose of a 
transference of impulses, that is to say, the relation is 
thought to be a conduction relation. The surface of the 
dendrites is by no means smooth, and in this particular 
is in strong contrast with the surface of the axones. In 
well-impregnated Golgi preparations and in certain 
methylene blue preparations it is possible to make out 
minute projections from the surface of certain of the 
dendrites, especially from the apical dendrites of the 
pyramidal cells in the cerebral cortex. These prickle- 
like projections, when seen under very high powers, have 
a nodular extremity. They are the so-called lateral buds 
or gemmules (Fig. 909). In the course of a dendrite 
definite bulgings are sometimes met with. These bulg- 
ings or varicosities are at times found in what are believed 
to be normal tissues, but appear to be more frequent 





in the brains of individuals dead of certain pathological 
processes. In normal individuals these varicosities or 
bulgings are probably to be regarded as artefacts (Fig. 


: 
wees 
oe 
= 
z 


ery 
5, 
ie 











 tieeP i i ¥e 2 
Oo Bee Fe 
Bers Bio "a y 
“te z} if . 
a Sy -, Me ad 
Pian s 


Fira. 909.—The Lateral Buds or Gemmules on the Apical Den- 
drites of the Pyramidal Cells of the Cerebral Cortex. Methy- 
lene-blue preparation. (After Ram6én y Cajal, S., ** Textura 
del sistema nerviosa,” p. 55, Fig. 13.) 


910). Their pathological significance in abnormal 
brains is difficult to determine. A few nerve cells 





i 

fi 

Fic. 910.—Multipolar Nerve Cell from the Cord of the Embryo Calf, 
Showing Varicosities of the Dendrites. (After Van Gehuchten.) 


3338 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





have been described in which no dendritic processes 
could be made out. They are the so-called adendritic 
neurones. 

The azone, as has been stated, is usually single. There 
are neurones, however, which possess two axones, the 





Fig. 911.—Special Cells (Polyaxones) of Molecular Layer of Cerebral 
Cortex of a Dog One Day Old. (After Ramon y Cajal.) A, Fusi- 
form cell; B, triangular cell; OC, another fusiform cell; D, polyg- 
onal cell with numerous dendrites and an axone which divides re- 
peatedly ; ¢, axones. 


so-called diavones. In the cerebral cortex are found cer- 
tain cells which possess several processes which must be 
regarded as axones. They are known as polyazones (Fig. 
911). An axone which in its course divides or bifurcates 
into nearly equal parts is known as a schizazone. A few 
neurones devoid of axones have been designated as 
anaxones or amacrine cells, 

The telodendrions of axones come into relation with 
the cell bodies and dendrites of other neurones. This 
relation is very intimate, as will be described farther on, 
and is believed by many to be a conduction relation for 
the transference of impulses. Inasmuch as the teloden- 
drion of the axone of one neurone usually comes into 
such relation with the cell bodies and dendrites of a 
number of other neurones, it seems likely that there is 
under such, conditions a multiplication of elements in the 
direction of the conducting path. This anatomical re- 
lation is the basis of the “avalanche conduction” hypoth- 
esized by Ramon y Cajal (Fig. 912). Certain special 
forms of telodendrion are met with in different parts of 


: a nw, 


= 
Pd 


Fic. 912.—The neurone B has an axone which gives off a number of branches; by means of these branches con- 
duction-relation with the cell bodies of a number of Purkinje cells is established. 


S., ‘‘Textura del sistema nervioso,’’ Madrid, 1889, p. 69, Fig. 19.) 


the brain. Of these the calyx-like terminals in the 
nucleus of the trapezoid body and the climbing fibres of 
the cerebellar cortex (Fig. 913) may be mentioned. The 
term synapsis has been introduced to designate the ana- 
tomical relation of one neurone with another. 

It has been mentioned that the dendraxones have short 
axones without an investment, while the inaxones possess 
long axones provided with a myeline sheath. In the cen- 


B34 








tral nervous system these long axones do not, however,. 
possess any sheath which corresponds to the neurilem- 


ma of the peripheral 
nerves. 
The myeline 


sheath of the axones 
is strongly refrac- 
tive and glistening. 
Examined fresh it 
is quite homogene- 
ous, but soon un- 
dergoes certain al- 
terations. One of 
the most marked of 
these is the appear- 
ance of certain 
oblique splits in- 
the medullary sub- 
stances which di- 
vide the myelin into 
a number of seg- 
ments, known as 
Lantermann’s seg- 
ments. Treatment 
of the myeline 
sheath with hot 
ether or alcohol dis-. 
solves out a large 
portion of the my- 
elin, but leaves be- 
hind a delicate net- 
work which is very 
resistant (Fig. 914). 
This network is not digestible in artificial pancreatic 
juice. It is the so-called neurokeratin of Ewald and 
Kiihne, and is believed to be allied chemically to the 
keratin of the epidermis. 

The myeline sheath at certain 
intervals shows definite indenta- 
tions, the nodes of Ranvier. The 
thickness of the myeline sheath 
varies greatly for different fibres 
and does not appear to be entirely 
dependent upon the size of the 
axone contained. It is believed 
that the myelin is dependent for 
its origin and nutrition upon the 
integrity of the axone. If the 





F1G.913.—The So-Called “* Climbing Fibres ’” 
of the Cerebellar Cortex from the Brain: 
of a Child a Month and a Half Old. (After 
Kolker.) 


(After Ramon y Cajal, 





axone be cut through, the myeline 
sheath as well as the axone distal tel 
from the point of section under- 
goes complete degeneration and 
is absorbed usually in about three 
months. 

The medullated collaterals pos- 
sess the same structure and un- 


Fig. 914.—Nerve Fibre 
After Treatment with 
Ether. (After Ramén 
y Cajal, 8., “ Textura 
del sistema nervioso,” 
Madrid, 1899, p. 200;, 
Fig. 62.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





dergo the same mode of temination as do fine axones. 
The non-medullated side fibrils behave like the non- 
medullated axones of dendraxones. Some of the non- 
medullated side fibrils, however, have the peculiarity of 
running back to end in the form of flat terminal plates 
upon the cell body of the neurone to which they belong. 

The axone close to the nerve cell is usually entirely 
devoid of any covering of myelin (Fig. 915). A reticular 
investment, however, has been demonstrated upon the 
cell bodies and dendrites by Golgi (Fig. 916). This in- 


G 


Vj 
yy 
Sit 







J 


;, A 





Fig. 915.—Methylene-Blue Preparation. The axone close to the peri- 
karyon s devoid of myeline sheath. (After Ramon y Cajal, ‘‘ Tex- 
tura del sistema nervioso,” Madrid, 1899, p. 113, Fig. 34.) 


vestment may be homogeneous upon the finer branches 
of the dendrites. Its exact nature has not yet been de- 
termined, but Golgi suggests that it may be of the nature 





Fig. 916.—Nerve Cell Showing Reticular Investment. (After C. Golgi, 
Arch. Ital. de Biol., Turin, t. xxx., 1898, p. 62.) The cell is from 
the ventrai horn of the spinal cord of a cat. 


of neurokeratin. These fine networks are drawn, as it 
were, like stockings over the perikaryon and dendrites. 
Golgi’s network does not seem to be identical with the 
networks of Held and Bethe. Held’s networks (Fig. 
917) are believed to be formed by the subdivisions of fine 
terminal axones. The nature of Bethe’s pericellular net- 
work (Fig. 918) is not yet clear. 





We may pass now to a consideration of the finer struc- 
ture of the protoplasm and nucleus of the nerve cell or 
neurone, the observations which have preceded having 





Fic. 917.—Pericellular Networks Believed by Held to be Formed by 
the Terminals of Axones. Golgi preparations from a cat twenty days. 
old. Sections 70 » thick. (After H. Held, Arch. f. Anat. wu. 
Physiol., Leipsic, 1897, Anat. Abth., Suppl. Bd., Taf. xiv., Figs. 5, 7, 
and 8.) A, Cell with network from nucleus neryi cochlez yen- 
tralis. The pericellular network surrounds the whole cell and a 
dendrite passing upward. The fibre @ corresponds to one of the 
thickened fibres of the n. cochlezw described by Ramo6n y Cajal and 
Held. Beyond the thickened spot fibrils go to join the general peri- 
cellular network. 


dealt almost entirely with the external form of the neu- 
rone and its various branches. The protoplasm of the 
cell body and dendrites of the neurone varies consider- 





Fig. 918.—Network About Perikaryon and Dendrites Demonstrable by 
the Method of Bethe. (After F. Nissl, Miinchen. med. Wochenschr., 
Bd. xlyv., 1898, S. 1024, Figs. 1, 2.) Nerve cell from the nucleus 
dentatus of a dog. 


335 


Brain, 
Brain. 


ably in appearance from that of the axone, especially in 
fixed preparations. In entirely fresh specimens taken 
from an animal just killed, little if any difference can be 
made out, the protoplasm in all parts of the neurone be- 
ing homogeneous. The protoplasm of the cell body con- 
tains an attraction sphere or archiplasm within which 
are situated one or more centrosomes. The peripheral 
portion of the protoplasm or so-called exoplasm differs 
somewhat in appearance from the central portion of the 
protoplasm or so-called endoplasm, the former show- 
ing a more marked tendency to a fibrillar structure, the 
latter showing in most preparations a somewhat more 
granular appearance. The ground substance of both 
exoplasm and endoplasm looks in ordinary preparations 
to be more or less homogeneous. 

The nucleus of the nerve cell or neurone is always 
situated in the cell body, never in one of the branches, 
and as a rule occupies nearly a central position under 
normal conditions. This nucleus is larger than that of 
most cells of the body, is very poor in substances which 
stain in nuclear dyes, the so-called achromatic portion of 
the nucleus being relatively very abundant. There is 
nearly always one large, easily stainable nucleolus. 
Sometimes the nucleoli are multiple. 

The appearance of the protoplasm of the neurones 
varies with different methods of preparation. With cer- 
tain methods the protoplasm has a spotted appearance 
owing to the staining of bodies known as tigrotd masses, Or 
Nissi bodies (Fig. 919). By other methods a vacuolar or 
spongy network can be demonstrated, and in the meshes of 
the network certain minute staining bodies, the so-called 
neurosomes, appear. By still other methods of prepara- 
tion a fibrillar structure becomes apparent. Accord- 
ingly, very divergent views prevail as to the ultimate 
nature of the protoplasmic structure, each investigator’s 





ee RTE NAEEG ETE 
pisos Sa rig 


owas 


| 
Fig. 919.—Part of a Pyramidal Cell from the Cerebral Cortex Showing 


the Tigroid Masses. (After Ramén y Cajal, S., ‘“* Textura del sis- 
tema nervioso,’’ Madrid, 1899, p. 121, Fig. 37.) 


views being colored by the method with which he is 
most familiar and in the results of which he places most 
confidence. Until further knowledge has been gained it 
is safer for the neuro-histologist to work with the various 


336 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


methods, describing accurately the results attained with 
each, and holding his mind open with regard to the ulti- 
mate nature of the substance he is working with. 

In sections stained with Nissl’s and similar meth- 
ods the protoplasm of the neurone is seen to be made 
up, aside from any pigment which may be present, of 
two main constituents: one which stains in the basic dye 
employed, and another which remains unstained in this 
dye. The former substance is known as the stainable 
substance of Nissl, the latter as the wnstainable substance 
of Nissl. The terms chromatic and achromatic have been 
applied to these two substances, but there are objections 
to their use. 

The stainable substance of Nissl usually occurs in 
masses of varying size and form. Again, the masses 
themselves may be arranged in rows, groups, or networks 
so as to give acharacteristic appearance to the cell. Each 
of the masses in turn may possess a definite structure, but 
this varies greatly with the mode of fixation which has 
been employed. Thus a single mass may with one kind 
of fixation be made up of very minute granules, with an- 
other kind of fixation of very much coarser granules, 
Vacuole-like appearances in the individual stainable 
masses are also frequently met with. These stainable 
bodies in the nerve-cell protoplasm (first seen and de- 
scribed by Flemming) have been subsequently studied 
by a large number of investigators, and notably by Nissl, 
who has made the appearance caused by their presence 
in different nerve cells the basis of an elaborate classifica- 
tion. They are frequently spoken of in neurological 
articles as Nissl bodies, but it is better to employ the 
term introduced by von Lenhossék, namely, tigroid 
bodies or tigroid masses, from the Greek word tiypoecdhe, 
spotted. ; 

The larger tigroid masses tend to assume definite forms 
with a given method of fixation, and these forms appear 
to be constant in the same variety of nerve cell from dif- 
ferent individuals. Three of the more interesting forms 
of tigroid bodies are the nuclear caps, the wedges of 
division, and the tigroid spindles. 

Nuclear caps are masses of tigroid, shaped more or less 
like cones, each cone being hollowed out inside. These 
cones of tigroid sit usually upon the nucleus of the nerve 
cell. As a rule, when they are present in the neurone 
there are two nuclear caps corresponding to two opposite 
nuclear poles. 

The wedges of division are masses of stainable substance 
situated at the point where a dendrite divides into two 
branches. The base of the wedge is directed away from 
the body of the nerve cell. 

The tigroid spindles consist of oblong or spindle-shaped 
masses of the stainable substance. These spindles, thick 
in the middle, become thin at the extremities and some- 
times run out into long, thread-like forms. 

The stainable substance of Nissl is limited to the 
perikaryon and to the dendrites. It is not found in the 
axone nor in that portion of the cell body from which 
the axone is immediately derived. This area of the cell 
body free from the stainable substance of Nissl is known 
as the axone hillock. 

On the basis of findings in specimens stained by his 
method Nissl divides all nerve cells into two great 
groups. In the first, group, that of the somatochrome 
nerve cells, he includes the cells in which the cytoplasm 
surrounds the nucleus completely and exhibits a distinct 
contour. This group includes: (1) the arkyochrome nerve 
cells; (2) the stichochrome nerve cells; (8) the arkyosticho- 
chrome nerve cells, and (4) the gryochrome nerve cells. 

By arkyochrome nerve cells (Fig. 920) Nissl refers to 
those in which the stainable substance of the protoplasm 
is arranged more or less in the form of a network. 

The term stichochrome is applied to the nerve cells in 
which the masses of tigroid are arranged in rows or 
threads which run in a similar direction. The best ex- 
ample of a stichochrome nerve cell is met with in the 
nerve cells of the nuclei of origin of the spinal and cere- 
bral motor nerves. 

By arkyostichochrome nerve cell Nissl formerly meant 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 


—_——— ———— 


a type of cell in which there was a combination of the 
arkyochrome arrangement with the stichochrome arrange- 
ment. He cited, as an example of this type, the Purkinje 
cells of the cerebellar cortex. Since making his original 


classification Nissl has suggested certain alterations, 





Fig. 920.—Nerve Cell from Olfactory Bulb of Rabbit. (After Nissl.) 
Somatochrome nerve cell of the arkyochrome variety in the para- 
pyknomorphous condition. 


among which is one in which he gives up the term 
arkyostichochrome, classing cells of that group now 
among the arkyochrome cells. 

Nerve cells in which the stainable. substance is present 
in the form of minute granules without any very definite 
arrangement are called gryochrome nerve cells by Nissl. 

The second great group of nerve cells in Nissl’s classi- 
fication includes all cells not falling in the former group. 
And Nissl divides the cells of this group into (1) cytochrome 
nerve cells and (2) karyochrome nerve cells. 

In the cytochrome nerve cells only traces of a cell body 
are to be made out. The nucleus is about the size of 
that of an ordinary leucocyte. Several varieties of cyto- 
chrome cells are distinguished by Nissl. 4 


The karyochrome nerve cells also possess only traces of. 


a cell body; but the nucleus is larger than that 
of the cytochrome nerve cell, being always larger 
than the nuclei of the neuroglia cells and as a 
rule of the size of ordinary nerve-cell nuclei. 

A further subdivision of the cells of each of 
the categories above mentioned is based upon the 
differences in staining which the individual cells 
show. Thus, cells which are stained extremely 
deeply are designated by Nissl as pyknomorphous 
cells—that is, cells in which the tigroid masses 
are very closely arranged in the cell body. On 
the other hand, cells in which the stainable sub- 
stance is present in small amounts are designated 
as apyknomorphous cells, the tigroid masses being 
rather widely separated from one another by the 
non-stainable substance. The term parapykno- 
morphous has been introduced by Nissl for stages 
intermediate between the pyknomorphous and 
the apyknomorphous condition. 

Care must be taken in working with Nissl’s 
method not to lay too much stress upon certain 
appearances in the nerve cells. Now and then 
in ordinary preparations a single cell or a group 
of cells will be found to be stained most intense- 
ly, as though the stainable substance of Nissl 


Vou. II.—22 


were uniformly distributed through the cell and were 
present in large quantities. These cells are called by 
Nissl chromophile nerve cells. They are in all probability 
artefacts due to the mode of fixation of the tissue in 
which they occur. 

In sections of nerve cells stained by Held’s method, 
especially if the sections be cut very thin (0.5 to 1 y), 
the tigroid bodies are found to present a finely granular 
appearance. Each tigroid mass or Nissl body, if studied 
with an oil-immersion lens, is seen to be made up of a 
mass of granules often varying in size and sometimes 
exhibiting a characteristic arrangement. Along with 
the granules another substance, which Held describes as 
a coagulum-like mass which stains somewhat differently 
by his method from 
the principal gran- 
ules of the tigroid + fact, tne 


mass, can be made of at + ® 
OF pew Roa Fe 


+ \ 


out. Vacuoles of 
different sizes occur 
also in the tigroid 
bodies. Held is of 
the opinion that the 
tigroid bodies do 
not occur preform- 
ed in the nerve cell 
inasmuch as no in- 
dication of their 
presence can be 
made out in _ per- 
fectly fresh nerve 
cells when exam- 
ined with the very best optical apparatus. He believes, 
and [ agree with him, that the substances which form 
the tigroid are precipitated substances. By the use of 
fixing reagents of different kinds, or even by the use 
of alcohols of different strength, the constituent granules 
of a tigroid mass may be precipitated in different ways. 
Whereas forty-per-cent. alcohol throws down these sub- 
stances in very fine granules, ninety-six-per-cent. alcohol 
will precipitate them in much larger granules. The 
significance of such an observation for pathological his- 
tology is obvious, for if one is to draw conclusions with 
regard to changes in the tigroid masses in disease he 
should make sure that the pathological tissues he studies 
shall be compared with normal tissues from exactly the 
same region, fixed and prepared in precisely the same 
way. 

The tigroid masses are not digestible in artificial stom- 
ach juice; whereas the unstainable substance of Nissl 
quickly digests in this fluid (Fig. 921). Onthe contrary, 
weak and strong solutions of the alkalies will dissolve 
out the tigroid masses, but will leave the unstainable 


Ss 


ho, a 






Fig. 921.—Nerve Cell from Deiters’ Nucleus 
in the Rabbit. Section 3 » thick. The 
tissue has been exposed to the digestive 
action of a mixture of pepsin and hydro- 
chloric acid at 40° ©. for twelve hours. 
The ground substance has been dissolved 
out and the Nissl bodies alone remain. 
(After Held.) 





FIG. Poe es Cell from the Gray Matter of the Lumbar Cord of the Ox. Alco- 
hol fixation. 
lithium carbonate. The Nissl bodies have been dissolved out, and the ground 
substance alone remains. 


Treatment for four days in concentrated aqueous solution of 


(After Held.) 


337 


Brain. 
Brain, 


substance of Nissl practically unaltered (Fig. 922). The 
chemistry of the tigroid bodies is interesting. The sub- 
stances of which they are made up has been shown to 
contain ironand phosphorus. It seems not unlikely that 
these substances should be grouped among the nucleo- 
albumins or nucleo-proteids. 

As to the unstainable substance of Nissl, very little can 
be made out if the method of Nissl alone be employed. 
Stained by his method and mounted in benzin colo- 
phonium his unstainable substance shows no structure, 
or if any but little, and so in such preparations is often 
described as the colorless, homogeneous ground substance 
of the nerve cell. Other methods of preparation, how- 
ever, reveal in this unstainable substance of Nissl very 
remarkable appearances. Among the methods most 
suitable for its examination may be mentioned Held’s 
modification of Nissl’s method. Very careful studies by 
this method have been made by Held himself. The 
ground substance of the nerve-cell protoplasm which 
corresponds to the unstainable substance of Nissl is 
stained of a deep red color by this method; while the 
tigroid bodies or stainable substance of Nissl are stained 
of a bluecolor. It iseasy to estimate the relative quanti- 
ties of the two substances present and to make out their 
reciprocal relations in cells of different types. Thus, for 
example, the tigroid in the cell bodies of the nuclei of ori- 
gin of the motor cerebral nerves and the cell bodies of great 
reflex systems (such, for example, as those of Deiters’ 
nucleus) is found to preponderate, the ground substance 
in such cells being limited to what looked like narrow 
beams and bridges between the tigroid masses. On the 
other hand, the tigroid is relatively scanty in the large 
cells of Betz in the cerebral cortex, in the huge flask- 
shaped cells of Purkinje in the cerebellar cortex, and in 
numerous other cells in the brain. In these cells the 
amount of ground substance is relatively much greater 
than that of the tigroid. If the dendrites be followed 
out into their finer subdivisions one comes always sooner 
or later to a part of the dendrite where tigroid bodies 
disappear. 

The ultimate branchings of the dendrites, as far as 
can be made out by Held’s method, are devoid of the 
tigroid substance. These ultimate branches of the den- 
drites, together with the axones and the axone hillock 
which are also entirely free from tigroid, form the most 
suitable places for the study of the ground substance by 
itself. Held finds in this ground substance longitudinal 
threads and cross threads which he takes to be sections 
of honeycomb network, the spaces of which are stretched 
out lengthwise and arranged in rows; that is to say, 
Held sees in the ground substance of protoplasm a 
structure like that postulated by Biitschli for protoplasm 
in general. He lays emphasis on the fact that very dif- 
ferent pictures are obtainable by the use of a variety of 
fixing reagents. And he believes that the great differ- 
ences in the deviating views of investigators in general 
are to be attributed in large part to this fact. Held con- 
cludes from his studies that the fibrils which have been 
described by so many observers in the axis-cylinder proc- 
esses are nothing more than the sections of the longi- 
tudinal walls of the honeycomb structure above men- 
tioned. He has never been able to make out distinctly 
isolated fibrils running near one another, but in longi- 
tudinal sections of the axone or cross sections of the same 
structure he makes out constantly a network or mesh- 
work-like structure. The meshes vary in size. In the 
meshes can be made out granules, sometimes very fine, 
sometimes somewhat larger, lying most often in the nodal 
points of the network, or also frequently in its spaces. 
These granules are arranged so that two or several of 
them are always contained between one or several of the 
long oval spaces which vary in length and breadth. 
The granules are not arranged with perfect regularity, 
except in this: they are placed in definite rows behind 
one another parallel to the long axis of the axone. This 
arrangement in rows is explained from the position of 
the granules as regards the long-meshed network of the 
axone. Held designates that part of the protoplasm of 


338 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





the axone which gives the appearance of a meshed 
structure as the azospongiwm, while the granules just 
referred to he calls neurosomes. While these neurosomes 
are most easily demonstrable in the axone and axone 
hillock, they are by no means confined to these structures 
but are also present in the ground substance of the pro- 
toplasm of the cell body and of the dendrites; although 
in these latter regions they have a different arrangement 
from that met with in the axone. It will be seen that 
Held’s studies are closely in accord with the investiga- 
tions of Biitschli, who has always maintained that the 
fibrils described by other investigators are only appar- 
ently fibrils, and that they are everywhere connected by 
delicate transverse threads which arise from the minute 
nodular swellings seen on the so-called fibrils. The fact 
that fixing reagents of different concentration give rise 
to meshworks of different size makes it seem likely that 
the honeycomb appearance is due to a vacuolization of 
the protoplasm caused by the fixing reagents. In think- 
ing of the actual structure of protoplasm, therefore, one 
must conceive of certain peculiarities of its composition 
which determine its vacuolization in the way described. 
But one should not think of these vacuoles or meshes 
actually existing in the living protoplasm. 

The neurosomes described by Held in the axone have 
nothing in common with the Nissl bodies or tigroid sub- 
stance, but appear to be identical with the granules ob- 
served by various investigators in the axis-cylinder pro- 
toplasm. The number and distribution of the neurosomes 
vary markedly in the same and in different axis cylin- 
ders. They stain by Held’s method of a violet tint. At 
the axone hillock the neurosomes are arranged in rows. 
In the terminals of the axone and in the terminals of 





Fiq. 928.—Cell of the Nucleus Corporis Trapezoidei of an Adult Rab- 
bit. Fixation with Van Gehuchten’s mixture ; paraffin section 1.5 « 
thick ; erythrosin methylene-blue staining. (After H. Held, Arch. 
f. Anat. u. Physiol., Anat. Abth., Leipsic, 1897, Taf. x., Fig. 3.) 
The axis cylinders (a) which go by the cell are stained homogene- 
ously ; the fibres (b) terminating in the cell contain large numbers 
of isolated neurosomes ; the lower border of the cell enclosed by the 
terminal axone shows very distinctly a most intimate union between 
the axis-cylinder protoplasm and the ground substance of the cell 
body, since here the same plasma layer is common to both. On the 
right-hand side the cytospongium is wide-meshed, owing to coarse 
vacuolization, on account of which the axis-cylinder terminal looks 
to be more independent from the rest of the cell mass. 


collateral branches of the axone the neurosomes are ex- 
tremely abundant—much more abundant than in any 
other part of the nerve-cell protoplasm (Fig. 928). 

The protoplasm of an axis-cylinder process of a neu- 
rone is continuous through the axone hillock with the 
ground substance (unstainable substance of Nissl) of the 
cell body and dendrites. But in the cell body and den- 
drites the anatomical appearances are complicated 
by the presence of the tigroid bodies which are de- 
posited in them in various forms. Held’s method shows 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 








a very similar structure in the cell body and dendrites 
to that met with in the axone, as far as the ground 
substance is concerned. The meshwork in the cell body 
resembles the axospongium of the axone, but the meshes 
are somewhat less close and the staining shows some dif- 
ferences. The arrangement of the meshwork is of course 
aiso influenced by the deposition of the tigroid masses. 
Held calls the meshwork in the cell body the cytospon- 
gium, The neurosomes in the cell body vary in size, 
number, and distribution in different nerve cells. In the 
dendrites neurosomes can be seen in rows placed in such 
close apposition that they look like beaded rods. 

The neurosomes are well seen in specimens fixed in 
neutral chromate solutions which do not precipitate the 
tigroid bodies. Whensections of such tissues are stained 
with iron hematoxylin the form, number, and distribu- 
tion of the neurosomes are particularly clear. 

Other views of the ultimate structure of the ground 
substance are held by Flemming, Altmann, Ramon y 
Cajal, and Dogiel. 

Flemming maintains the existence of definite fibrils in 
the ground substance. He does not, however, deny the 
possibility that these fibres may form the network. 

Altmann, who has directed his attention chiefly to the 
granules in nerve cells observable by his particular 
method of staining, speaks of granules and of an inter- 
granular substance. At least a part of Altmann’s gran- 
ules corresponds to the neurosomes of Held; whilea large 
part of Altmann’s intergranular substance evidently cor- 
responds to Held’s cytospongium and axospongium. 

Ramon y Cajal describes the ground substance as con- 
sisting of a network with granules situated at the nodal 
points. 

Dogiel, who is an adherent of the fibrillar doctrine, 
describes very fine fibrils in the ground substance. He 
finds that the fibrils have a definite and peculiar arrange- 
ment, differing in different types of nerve cells. He de- 
scribes and pictures minute granules in his fibrils. As 
far as one can tell from a comparison of his illustrations 
with those of Held, it must be concluded that the granules 
in Dogiel’s fibrils are identical with the rows of neuro- 
somes described and pictured by Held. 

Very different appearances from those just described 
are met with in the protoplasm of the nerve cells if they 
be stained by the hematéin or the gold-chloride method 
of Apathy. These methods demonstrate morphological 
constituents inside the protoplasm which appear to be 
definite fibrils. In many places the fibrils are independ- 
ent of one another, but especially in the cell body they 
anastomose freely, according to Apathy, to form a neural 
reticulum. 

Apathy, whose work has been chiefly upon inverte- 
brate animals, divides all cellular elements within the 






_ FG. 924.—Motor-Nerve Spindle in Longitudinal Section of the Right Anterior Nerve Stem from the Leech. i 
The somatoplasm of the nerve cell is simply indicated around the cell nucleus, 


Zool. St. zu Neapel,” Bd. xii., 1897, H. 4, Taf. xxiv., Fig. 3.) 





proxinad ,* alt 


nervous system into two kinds of cells, which he desig- 
nates “nerve cells” and “ganglion cells” respectively. 
The “nerve cell” has the power of building neurofibrils 





pf 


Fic. 925.—Colossal Ganglion Cell (Type G) from the Leech. (After 8. 
Apathy, ‘‘Mitth. aus der Zool. St. zu Neapel,”’ Bd. xii., 1897, H. 4, 
Taf. xxviii., Figs. 4, 5, and 6.) 4 

(1) The neurofibrils of a colossal ganglion cell of a posterior me- 
dian section, with indication of the external glia sheath and connec- 
tive-tissue nuclei. bgk, Connective-tissue nucleus ; glh, glia sheath ; 


kgz, nu-2us of the ganglion cell; lpf, “conducting” primitive 
fibril. 

(2) Cross section of a ganglion cell of type G, showing plexus of 
neurofibrils. 

(3) Section of a colossal ganglion cell with plexus of neurofibrils. 
The meridian-like decussation of the neurofibrils at the pole of the 
cell is illustrated. 


\ 


P Ha cwcwcce mn 
OS OY =) 
pee 
x 


a 


k zkn 
(After S. Apathy, ** Mitth. aus der 


zkn. Near this nerve spindle are seen some primitive fibrils in sensory bundles, sb. ; the contours of the motor-nerve spindle correspond to 
a focus somewhat above the level of the nucleoli; those branches of the motor nerve-divide, mnf, which are visible, are a, b, ¢,d,e. pf I 
represents the primitive fibril projected upon the surface of the drawing paper as far as it is contained in the section. The dotted points 
correspond to the place where it is not contained in the section. The asterisk indicates a division of the primitive fibril into two limbs. 


339 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





(Fig. 924), while the “ganglion cell” does not possess 
this power. Neurofibrils built by “nerve cells” can, 
however, leave the cell in which they arise and pass 
through one or more ganglion cells and ultimately be- 





Fic. 926.—Three Pear-Shaped Ganglion Cells of Type K, in Longi- 
tudinal Section from the Leech. (After S. Apathy, ‘* Mitth. aus der 
Zool. St. za Neapel,’’ Bd. xii., 1897, H. 4, Taf. xxviii., Fig. 7.) The 
internal or perinuclear plexus of neurofibrils is well shown, as are 
also the radial fibres. The peripheral plexus is indicated. af, Axis 
fibril which Apathy takes to be motor; ag, external intracellular 
plexus of neurofibrils ; big, internal perinuclear plexus of neuro- 
fibrils; cfpf, cellulifugally “* conducting ’’ primitive fibril, see eppf, 
cellulipetally “* conducting ”’ primitive fibril; k, nucleus of the gan- 
glion cell; rf, radial fibrils connecting the external plexus with the 
internal plexus of neurofibrils; st, stem process of pear-shaped 
ganglion. 


come connected with a sensory surface or with a muscle 
fibre. One neurofibril can accordingly pass through a 
great number of cells, and inasmuch as the different neu- 
rofibrils are connected with one another by means of an- 
astomoses, Apathy conceives of the conducting apparatus 
in the whole nervous system as a continuum of neuro- 
fibrils. A neurofibril varies in calibre in different parts 
of its course, being largest where it arises. It consists, 
according to Apathy, of a complex of “ elementary fibrils,” 
and as the neurofibril follows its course through a series 
of “ganglion cells” it gives off on its way at shorter or 
longer intervals numerous elementary fibrillee until final- 
ly it itself consists of one elementary fibril. While the 
neurofibrils pass through ganglion cells which do not 
give origin to them, Apathy has put forward the hypoth- 
esis that the force which is to be conducted along the 
neurofibrils arises in the ganglion cell. Two kinds of 
these ganglion cells are met with in the leech: (a) the 
large ganglion cell and (0) the small ganglion cell. The 
large ganglion cell, Apathy’s type G (Fig. 925), possesses 
the following characters: each cell has a pear-shaped 
process by way of which neurofibrils arrive within the 
protoplasm of the cell. Once inside, the neurofibril 
breaks up into its elementary fibrils, and these can be 
seen to diverge like meridians into what Apathy calls the 
external chromatic zone of the cell. As these elementary 
fibrils pass peripheralward they can be seen to form free 
anastomoses with one another. On the far side of the 
cell the elementary fibrils turn round and converge again 
by passing through the body of the cell once more at the 
pear-shaped process, going out of the cell as another 
neurofibril. Each pear-shaped process accordingly con- 
tains two kinds of neurofibrils, and Apathy suggests that 
one of the fibrils carries impulses into the cell and the 
other carries impulses out of the cell. 

In Apathy’s second type of “ ganglion cell,” which he 
calls the “small ganglion cell” and designates as “type 
K” (Fig. 926), somewhat different appearances are met 
with. Each pyriform process contains within it one 
thick neurofibril, which passes nearly through the centre 


340 


of the process, and several finer neurofibrils in the per- 
iphery of the process. The finer neurofibrils, however, 
entering the cell body pass out to the periphery of the 
protoplasm of the cell and break up into a dense reticu- 
lum formed by the anastomosis of the “elementary fibrils ” 
of which they are composed. This anastomosis occurs 
in what Apathy calls the outer chromatic zone of the 
cell. Small rami of the fibrils pass from this peripheral 
plexus inward to reach the internal chromatic zone of 
the cell, where another rather fine plexus of elementary 
fibrils is formed. The composing fibrils of this plexus, 
after having undergone free anastomosis, converge and 
pass toward the pyriform process, where they unite to 
give rise to the single large neurofibril, which passes away 
from the cell through the centre of the pear-shaped proc- 





Fig. 927.—Neurofibrils in Pyramidal Cells of the Cerebral Cortex. 
(After A. Bethe, taken from A. Van Gehuchten’s “ Le systéme ner- 
veux de ’homme,”’ 3d ed., Louvain, 1900, vol. i., p. 302, Fig. 187.) 


ess. Apathy believes that the peripheral finer neuro- 
fibrils of the pear-shaped process are sensory and that 
the single central neurofibril of large calibre is motor. 

The descriptions of Apathy bearing upon the relations 
of the neurofibrils to sensory surfaces and to the constit- 
uent elements of muscular tissue and secreting glands 
do not concern us here. One important point, however, 
in connection with his work must be mentioned. He 
believes that the neuropilum of invertebrates is formed 
by a huge plexus of anastomosing neurofibrils. This 
plexus he designates as an “ Elementargitter.” 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





Bethe has been able to demonstrate similar fibrils 
within the protoplasm of the nerve cells of vertebrates, 
including human beings (Fig. 927). Bethe thinks that 
he can determine which neurofibrils conduct toward the 
cell and which conduct away from the cell. He finds 
that both kinds of fibrils occur in the dendrites of the 
cells, and argues that a dendrite accordingly carries 
both cellulipetal e 
and cellulifugal im- 
pulses. It must 
be remembered that 
many do not be- 
lieve that it has yet 
been proved that it 
is the neurofibril 
which is the actual 
conducting element 
in the nerve cell. 

Bethe in the main 
accepts Apéthy’s 
views ‘concerning 
the structure of the 
neuropilum of in- 
vertebrates, but in 
opposition to Apa- 
thy denies the oc- 
currence of anas- 
tomoses between 
the individual 
fibrils. 

Nissl accepts the 
doctrines of Apa- 
thy and Bethe ap- 
parently without 
question and has 
carried their hy- 
potheses much fur- 
ther than they 
themselves appear 
to have been will- 
ing to take them. 
According to a late 
hypothesis formu- 
lated by Nissl, neu- 
rofibrils exist out- 
side of the nerve 
cells and their proc- 
esses, these being 
especially abundant 
in the gray matter 
of the cerebral cor- 
tex. Nissl denies 
the interpretations 
of those who have 
worked with Gol- 
gi’s method, of the 
findings met with 
in silver prepara- 
tions, and asserts 
that a large part of 
the areas between the cell bodies in the cerebral cortex sup- 
posed by Golgi workers to be filled up by the multiple sub- 
divisions of dendrites, axones, and collaterals are not in 
reality so made up, but consist of an immense number of 
naked neurofibrils situated outside of the cells; these 
fibrils, Niss] thinks, correspond in a sense to a highly 
complicated neuropilum. In support of his view he 
publishes comparative pictures of the motor area of the 
cerebral cortex of a man (Fig. 928), a dog (Fig. 929), and 
a mole (Fig. 980). The increased distance between the 
cells in the higher animals he believes to be accounted for 
by the increased amount of his hypothetical neuropilum. 
Nissl was led all the more readily to accept the views of 
Apathy and Bethe inasmuch as Becker has also been able 
to demonstrate fibrillar appearances within “nerve cells” 
by hematoxylin staining. 

Still another mode of demonstrating networks of a 
curious character within the bodies of nerve cells has 


Staining by Nissl’s method. 


nert’s layer). 
fibres (= 5. Meynert’s layer). 





FIG. 928.—Reproduction of a Photogram of a Perpendicular Section through the Tip of 
tne Head of the Gyrus Centralis Anterior, Close to the Falx, of a Healthy Adult Man. 


I. Layer poor in cells. 
containing 2 = layer of small pyramidal cells (= 2. Meynert’s layer) +3 = layer of 
large pyramidal cells (= 38. Meynert’s lIayer). 
IV. Internal (6) and external (5) zone of the layer of medullated 
The region marked 5 corresponds to the ganglion- 
cell layer of Hammarberg, and the region marked 6 to the spindle-cell layer. 
F. Nissl, Miinch. med. Wochenschr., Bd. xly., 1898, S. 1027, Fig. 3.) 





been introduced by Golgi by a slight modification of his 
osmic bichromate method. <A definite endocellular net- 
work apparently different from that described by any 
previous observer can be demonstrated (Figs. 981 and 
932). Veratti has worked with the same method and 
has been able to impregnate networks in a variety of 
nerve cells similar to those described by Golgi. 

Nucleus.—The 
auclei of the nerve 
cells of the brain 
agree in structure 
with those of nerve 
cells in general 
(Fig. 9383). The nu- 
clei are relatively 
large and pale, and 
present in prepara- 
tions stained by 
Nissl’s method a 
chromatic mem- 
brane and a large 
deeply staining nu- 
cleolus. There is, 
as a rule, an abun- 
dance of achroma- 
tic substance. In 
the nucleolus it is 
possible in methy- 
lene-blue prepara- 
tions to make out 
minute deeply 
staining points, the 
nucleolult of von 
Lenhossék. The 
nucleolus some- 
times presents a 
vacuolated appear- 
ance. Itis believed 
by many that each 
nucleolus consists 
of a delicate baso- 
phile external layer 
and a central non- 
basophilic sub- 
stance. According 
to Scott each nucle- 
olus is a_ vesicle 
with an oxyphile 
centre and a_ baso- 
phile periphery. 
In preparations 
stained by Held’s 
method it is possi- 
ble to make out in 
the achromatic 
parts of the nu- 
cleus, strands and 
masses which take 
the erythrosin stain. 
These strands and 
masses may correspond to the lanthanin of Heidenhain. 
Careful microchemical studies of the nuclei and nu- 
cleoli have been made by Levy. Levy was unable to 
find nucleoluli in nucleoli stained by Biondi’s method. 
Scott believes that the basophile covering of the nu- 
cleolus contains both iron and phosphorus as does also 
the oxyphile nuclear substance. The latter is readily 
dissolved in pepsin and hydrochloric acid. It is altered 
but not dissolved by acids and alkalies, which liberate 
the iron from it. He believes that the tigroid masses of 
the cell protoplasm consist of chromatin that has ditfused 
itself from the nucleus into the cytoplasm. 

Various authors have proven that the nucleoli of the 
nerve cells change in size during functional activity. 
They are small when the cell is at rest, but increase in 
volume when the cells are active. 

The so-called supporting substances of the nervous 
tissue of the brain consist of ependyma cells and neu- 


II. Layer of pyramidal cells, 


III. Layer of small cells (= 4. Mey- 


(After 


341 


Brain, 
Brain. 


These cells, it is now 


roglia cells and their derivatives. 


et yENY 





Fig. 929.—Reproduction of a Photogram from a Perpendicular Corti- 
cal Section through the Summit of the Gyrus of an Adult Dog, Just 
in Front of the Sulcus Cruciatus Close to the Falx. Staining by 
the method of Nissl. 1= cortical layer free from cells; 2, sub- 
divisible into a narrower external and a broader internal zone, but 
in no way homological with II. of Fig. 928. On the other hand, 2 in 
Fig. 928 corresponds to 3 in Fig. 930; 3 in Fig. 928 corresponds to 4 
in Fig. 930; (4-+-5) = layer of medullated fibres corresponding to 
5+ 6 in Fig. 928, and also to 5+-6in Fig. 930. That is, 4 in Fig. 928 
corresponds to 5 in Fig. 930, while 5 in Fig. 928 = 6 in Fig. 930. 
ee F. Nissl, Mtinch. med. Wochenschr., Bd. xly., 1898, S. 1027, 
Fig. 4.) 


mesoblastic neuroglia has been given up. In the earlier 
stages of development the cells lining the cavities of the 


~ 


rf x soa UNE 
be 1 Gata ‘, aS 
i, 





Fig. 930.—Reproduction of a Photogram of a Perpendicular Section 
through the Cerebral Cortex of a Mole, 1 mm. in Front of the Crucial 
Suture Close to the Falx. Staining by the method of Nissl. 1= ex- 
ternal layer free from cells; 2, characteristic type of cell arrange- 
ment in all cortical areas connected with the olfactorius, especially 
in the lobus pyriformis; 3 (= 2 of Fig. 929, except the thin cell 
layer adjoining the cell-free layer, which reminds one still of 2 of 
Fig. 929); 4(=383 of Fig. 929); 5 (=4 of Fig. 929) ; 6 (=5 of Fig. 
929). (After F. Nissl, Miinch. med. Wochenschr., Bd. xlv., 1898, 
S. 1027, Fig. 5.) 


342 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


central nervous system extend through the whole wall 
of the neural tube, the peripheral processes being drawn 
out into long pillars or columns. Later, some of the 


cells become removed from the central canal; the cell 
bodies assuming positions at various distances from the 





Fic. 931.—Golgi’s Endocellular Network. (Taken from A. Van Ge- 


huchten’s work.) 


central canal Somewhere between it and the periphery. 
Those which remain in connection with the central canal 
are known in adult life as ependyma cells, while those 
the cell bodies of which are situated in the nerve sub- 
stance are known as neuroglia cells. A further origin 





huchten’s work.) 


of neuroglia cells from germinal cells quite like those 
which give rise to the neuroblasts and true nerve cells is 
assumed by a number of authors. 

The ependyma cells have bodies which are cubical or 
low columnar in shape and long peripheral processes 





Fig. 933.—Examples of a Variety of Nerve-Cell Nuclei. (After Ramén 
y. ee S., “‘Textura del sistema nervioso,’”? Madrid, 1899, p. 134, 
ig. 43. 


which extend for a shorter or longer distance into the 
gray and white substance. With ordinary nuclear stains 
the cell body and its nucleus near the cavity of the ven- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





tricles are well seen, but the processes are difficult to 
make out. In order to demonstrate the latter, the 
method of Golgi should be employed. With the silver 

i impregnation long strands with 
short, prickly processes on the sur 
face can be distinguished. 

Neuroglia cells as seen in prepa- 
rations stained by ordinary nuclear 
dyes are small cells with deeply 
staining nucleus and surrounded by 
very little protoplasm (Fig. 934). 
The cell often appears to be the 
centre of a radiating system of proc- 
esses or fibrils. These appearances 
in freshly teased and stained prep- 
arations were carefully investigated 
by Deiters, and they have since 
been spoken of as the “spider cells 
of Deiters.”. The most careful of 
the earlier investigations was made 
by Golgi in 1871. He studied neu- 
roglia chiefly by means of teased 
preparations and sections, and pic- 
tured the glia cells as small ele- 
ments from which numerous rigid 
glistening fibres radiated out into 
the nerve substance. He believed 
that these fibres did not branch 
and that they formed no anasto- 
moses. The processes of the glia 
cells in the gray substance are, ac- 
cording to Golgi, more delicate and 
less rigid than those in the white 
substance. The histogenetic posi- 
tion of the glia cells was not under- 
stood, however, by Golgi at the time 
of his earlier work. Although he 
recognized that the glia fibres differ 
materially from ordinary connec- 
tive-tissue fibres, still he believed 
them to be connective-tissue elements. 

A very important advance in our knowledge of glia 
followed upon the application of the silver chromate 
method. In preparations thus made the glia cells appear 
as small black masses from which radiate out into the 
nervous tissue great numbers of delicate black processes 








Fie. 934.—Neuroglia 
Cells. (After Ram6n 
y Cajal, S., ‘* Textura 
del sistema nervioso,” 
p. 188, Fig. 58.) 







(Fig. 935). These for the most part are unbranched, 
‘ <4 
| iH) ‘ 
= aN ‘e i} i A ; 
hf a i 4 
oe | 


Fie. 935.—Glia Cells as Impregnated in Silver-Chromate Preparations. 


(After Ramon y Cajal, S., ‘‘ Textura del sistema nervioso,” Madrid, 


1899, p. 175, Fig. 48.) 


and do not form anastomoses. While, as a rule, they 
appear to radiate out in all directions from the periphery 
of the cell, in other instances the processes project from 
the two extremities of the cell or even from one extrem- 
ity only. From the peculiar appearances presented by 
the radiating processes the name astrocyte has been used 
as a designation for the cell of Deiters or Golgi to dis- 
tinguish it from the ependyma cell. Kdélliker, who has 
given very exact descriptions of neuroglia, divides the 
astrocytes into two principal groups: first, those with long 





Fic. 936.—Neuroglia Fibrils as Demonstrated by Weigert’s Neuroglia 


Stain. (After Weigert, C., ‘‘Der menschliche Neuroglia,’’ Frank- 
fort, 189-.) 


branches (Langstrahler); and second, those with short 
branches (Kurzstrahler). The cells with short branches 
are more abundant in the gray substance and are charac- 
terized chiefly by the brevity and delicacy of their radi- 
ating processes. Their processes show a marked ten- 
dency to varicose swelling in Golgi preparations. They 
are much more difficult to impregnate with the silver 
chromate method and often assume a brownish rather 
than a black color. 

The glia cells with long processes occur in different 
parts of the gray and white substance. They are the 
typical glia cells which were studied by Deiters and 
Golgi. } 


343 


Brain, 



















Hirai! REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 
processes of the cells are in reality not 
head fold processes, but fibres running through the 
cells and more or less independent of 
them. In the embryo they may be re- 
garded as actual processes, but in the 
See A — adult the differentiation is always de- 
tes aa / monstrable. Weigert’s method shows 
protec lat that the fibres are more or less straight 
neers vesicle or they may run in stiff curves. They 
are never markedly tortuous. They are 
S solid, no central cavity being demon- 
ae ¢ Ae ose) middle strable in them. They are always 
| x ae - cerebral smooth, rarely presenting varicosities or 
head plate =------ ae & *  moss-like processes. They vary in thick- 
posterior ness from extremely fine fibres on the 
peer hear ir eee a) Wat toe soaae 2 oe eee econ ete. eee 1 cerebral Jimits of microscopic visibility to fibres 
\ | vesicle. 45 mu thick. Weigert has never been 
foregut Lo wco-eew hOarte able to observe division of his fibres nor 






could he make out in any case the exist- 







YOLK Vein, sseneeseesere: 


medullary 
groove 


i pment ener ee sae er 


Fic. 937.—Anterior Portion of the Body of a Chick, the Head Distinctly 
Differentiated; seen from the surface. (After J. Kollmann, ‘‘ Lehr- 
buch der Entwickelungsgeschichte des Menschen,’’ Jena, 1898, S. 
199, Fig. 120.) 


Through the use of certain special methods introduced 
by Mallory, Weigert, and Beneke, appearances are ob- 
tained which have led many to the conclusion that the 
so-called glia fibres are not really processes of the neu- 
roglia cells, but are fibrils which lie upon or which run 
through the cells. Ranvier was one of the first to pro- 
mulgate the view that the supporting tissue of the cen- 
tral nervous system presents a similar relation of cells 
and fibres to that met with in ordinary connective tissue. 
He asserted that the so-called Deiters’ cell as ordinarily 
described is an artefact, believing that he was able to 
demonstrate that the fibres looked upon as processes only 
apparently proceed from the protoplasm of the cell radi- 
ating out from the latter as a centre; but in reality are 
only attached to it. Ranvier’s method was very simple. 
He dissociated with thirty-three-and-one-third-per-cent. 
alcohol and afterward stained with picrocarmine. In 
these isolation preparations he convinced himself that 
the so-called cell processes are not actual prolongations 
of the protoplasmic body, but represent definitely differ- 
entiated fibres which go through the cell body or simply 
pass overit. Though they radiate out from the cell body 
as a central point, still the fibres are clinically and mor- 
phologically entirely different from the cell bodies. 

Weigert’s studies of the subject are the most extensive. 
The neuroglia fibrils by his method stain of a deep blue 
color and are exquisitely differentiated (Fig. 936). In 
the so-called astrocytes or Deiters’ cells Weigert finds 
that blue-stained neuroglia fibrils run directly through 
the protoplasm of the cells, the nuclei of the cells being 
entirely independent: of the fibrils. Weigert feels sure 
that the fibrils stained‘ by his method do not represent a 
new, hitherto unknown, structural element, but are 
identical with what have been described as the processes 
of Deiters’ cells. The fibrils are not chemically identical 
with the protoplasm, but are composed of an entirely 
different substance. Nor does this chemical difference 
between fibres and cell protoplasm appear at any distance 
from the cell body in the so-called processes of the glia 
cells, but the differentiation can be made out in the cell 
body. It is even quite close to the nucleus of the cell. 
Accordingly, Weigert believes that most of the so-called 


344 





ence of anastomoses. 


The arrangement of the various histo- 
logical elements in the different parts of 
the brain can best be studied by examin- 
ing a series of sections taken at different 


I= 


Titi ra 


Fia. 938.—Median Section through Embryo Human Brain at the End 
of the First Month. (After W. His, ‘‘ Anatomische Nomenclatur,” 
Leipsic, 1895, S. 158, Fig. 17.) 

I. Myelencephalon. 
I. 2. Pars dorsalis. 
II. Mesencephalon. 
Il. 2. Cerebellum. 
Ill. Isthmus. 


III. 1. Pedunculi cerebri. 


I. 1. Pars ventralis. 
II. 1. Pons. 


Ill. 2. Brachia conjunctiva, 
vel. med. ant. 
IV. Mesencephalon. 
IV. 1. Pedunculi cerebri. IV. 2. Corpora quadrigemina. 
VY. Diencephalon. 
V.1. Pars mammillaris hypothalami. V. 2. Thalamus. 
Vv. 3. Metathalamus. 
V. 4. Epithalamus. 
VI. Telencephalon. 
VI. 1. Pars optica hypothalami. VI. 2. Corpus striatum. 
VI. 3. Rhinencephalon. 
VI. 4. Pallium. 


levels and made in various directions. It will be most con- 
venient in this article to study a series of frontal sections 
passing from the spinal extremity of the brain forward. 
In describing these sections the nomenclature used will 
be that of the B. N. A.* Of the three primary cerebral 


* Those who are accustomed to the terms employed by Professor 
Wilder will find the equivalents of the terms of the Basle Commission 


{ 


Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. pe 











vesicles the first gives rise to the forebrain or telenceph- 
alon and the interbrain or diencephalon, the second to 
the midbrain or mesencephalon, and the third to the 
rhombencephalon. The relations of these parts are 
shown in the accompanying figures (Figs. 937, 938, and 
939). Perhaps the classification which follows will be 
found most satisfactory. It is that introduced by His of 
Leipsic. The encephalon or brain is divisible into the 
cerebrum and the rhombencephalon. The rhombenceph- 
alon in turn includes the myelencephalon, the meten- 
cephalon, and the isthmus rhombencephali. The myelen- 
cephalon corresponds to the medulla oblongata, the 
metencephalon to the pons and cerebellum. The cerebrum 
oy iaclepey bead 







Sulcus sub- 
parietalis. 





Sulcus cinguli (pars subfrontalia). 


Fig. 939.—Median Section through Foetal Human Brain of the Third 
Month. (After His, Arch. f. Anat. uw. Physiol., Anat. Abth., 1892.) 
Lettering same as in Fig. 988 (vide supra). 


isdivisible into the mesencephalon and prosencephalon. 
The mesencephalon includes the pedunculi cerebri and 
the corpora quadrigemina. The prosencephalon is divis- 
ible into the diencephalon or interbrain and the telen- 
cephalon or endbrain. The diencephalon includes the 
pars mamillaris hypothalami and the thalamencephalon, 
the thalamencephalon in turn including the thalamus, 
the metathalamus, and the epithalamus. The telen- 
cephalon includes the hemispherium and the pars optica 
hypothalami. The hemispherium is made up of the pal- 
lium, the corpus striatum, and the rhinencephalon. These 
relations are presented below in tabular form: 


Posterior { MIMPONS eee ec astinte 











the jfissura medi- 
ana ventralis, the 
COMMISSUTA VEN- 
tralis alba (Ca), 
the commissura 
grisea, containing 
the canalis centra- 
lis surrounded by 
the substantia gel- 
atinosa  centralis 
(Sac); behind is 
the septum media- 
num dorsalis sep- 
arating Goll’s fas- 
ciculi of the two 
sides. In the half 
of the cord shown, 
the gray sub- 
stance is seen to 
be completely sur- 
rounded by the 
white substance. 
The white sub- 
stance consists of 
the three funiculi, 
the funiculus ven- 
tralds in front, the 
Suniculus lateralis 
at the side, and 
the funiculus dor- 
salis behind. The 
funiculus ventra- 
lis includes the fas- 
ciculus cerebro-spi- 
nalis ventralis or 
ventral pyramidal 
tract (PyV), the 
Fasciculus ventra- 
lis proprius or ven- 
tral ground bun- 
dle (Vg), and the 
fasciculus suleco- 
marginalis (vm). 
The funiculus la- 
teralis includes 
the fasciculus spt- 
no-cerehellaris dor- 
so-lateralis or di- 
rect cerebellar 
tract (AS), the fasciculus ventro-lateralis Gowerst or Gow- 
ers’ tract (G), the fasciculus cerebro-spinalis lateralis or 





Fig. 940.— Schematic Transverse Section 
through the Pars Cervicalis of the Medulla 
Spinalis. (After H. Obersteiner, ‘‘ Anlei- 
tung beim Studium des Baues der nervésen 
Centralorgane,” iii. Aufl., Leipz. u. Wien, 
1896, S. 257, Fig. 113.) B, Fasciculus cuneatus 
Burdachi; Ca, commissura ventralis ; Coa, 
cornu ventralis; Cop, cornu dorsalis; G, 
fasciculus ventro-lateralis Gowersi; GS, 
fasciculus gracilis Golli; GSZ, mixed bun- 
dle of funiculus lateralis ; Ha, dorso-lateral 
fleld of funiculus dorsalis; iS, intermediary 
bundle of funiculus lateralis; KS, fascicu- 
lus cerebello-spinalis or direct cerebellar 
tract of Flechsig ; L, Lissauer’s fasciculus ; 
m, marginal zone; PyS, fasciculus cere- 
bro-spinalis lateralis or lateral pyramidal 
tract; PyV, fasciculus cerebro-spinalis yven- 
tralis or ventral pyramidal tract; R, sub- 
stantia gelatinosa Rolandi; Ra, radix ven- 
tralis; Rp, radix dorsalis; SC, comma of 
Schultze ; SG, lateral limiting layer; Sge, 
substantia gelatinosa centralis ; VG, fascic- 
ulus ventralis proprius; vH, ventral fleld 
of dorsal funiculi ; vm, fasciculus sulco-mar- 
ginalis ; w, dorsal root fibre. 


I. Medulla oblongata.... Wyelencephalon I, (Afterbrain). 
| Wetencephalon IX. (Hindbrain). 


Rhombencephalon I.-Ili, 


seach Il. Cerebellum......... (Rautenhirn). 
Acca a Oe Isthmus rhombencephali III. 
Middle ; F 
IV,. Pedunculi cerebri....... En- 
a pha IV. Corpora Gundy lectin ay Mesencephalon IV. (Midbrain). cephalon 
Vie Pars mammillaris hypothalami . (Brain). 
(Hypothalamus vice pars mam. and pars optica). ets Dario Ne Cerebrum = 
Vigee URALAMNUSiesieieieleiisieieiernlcieleate Thalamen- 25 IV.—VI. 
Anterior Vs. Metathalamus...........+. cephalon (Interbrain). Prosencephalon (Grosshirn). 
cerebral V4. Epithalamus....... aot Vo—V4. Ve tes Me 
vesicle. Wi. Pars optica hypothalami \ nes cccsccsencess r ‘orebrain). 
Via. Corpus eas staseora eeceiie a Felencephalon 
VI;. Rhinencephalon .......... spheerium s 
WiePalltiem aesgos omc. VIo-VIy. (Endbrain). 


In describing sections through these various parts it 
will be necessary, in order to make clear the connections 
of all, to begin with a section of the spinal cord in the 
cervical region. 

If we begin with a schematic transverse section 
through the cervical portion of the spinal cord it will 
be easy to localize the main features of the cross section 
and to connect these with the parts met with in sections 
higher up. In this section (Fig. 940) only one-half of 
the cord is shown. In the middle line in front is seen 





in Professor Wilder’s article entitled ‘** Neural Terms—International 
and National.’’ Journ. Comp. Neurol., Granville, vol. vi. (1896), pp. 
216-352, 


lateral pyramidal tract (PyS), the fasciculus Lissauert (L), 
the fasciculus lateralis limitans or lateral limiting layer 
(SG), the fasciculus lateralis proprius or lateral ground 
bundle (G@SZ 78). The funiculus dorsalis includes the 
fasciculus gracilis or Goll’s fasciculus (GS) and the fas- 
ciculus cuneatus or Burdach’s fasciculus (B). Goll’s fas- 
ciculus is separated from Burdach’s fasciculus by the 
septum paramedianum. 'The region of Schultze’s comma 
in the dorsal funiculus is designated as SC. 

The gray matter is divisible in this region into a ven- 
tral and a dorsal column. The columna ventralis (Coa), 
often spoken of as'the ventral horn or anterior horn, con- 
tains the motor cells; the columna dorsalis (Cop), often 


345 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








called the dorsal horn or posterior horn, contains a large 
number of small cells, probably sensory. The entering 
dorsal root, radix dorsalis 
(Rp), and the issuing ven- 
tral root, radia ventralis 
(Ra), are shown. The lat- 
eral horn is not well illus- 
trated in the schematic fig- 
ure. 

The more exact relations 
at the level of the third cer- 
vical nerve are shown in 
Fig. 941. The legend will 
explain the various parts 
sufficiently. 

A little higher up, just 
at the junction of the cer- 
vical spinal cord with the 
medulla oblongata, the 
relations of the gray mat- 
ter to the white matter 





Fia. 941.—Cross Section through the 





Human Spinal Cord, Stained with 
Carmine. (After H. Obersteiner, 
“ Anleitung beim Studium des 
Baues der nervésen Centralorgane 
im gesunden und kranken Zu- 
stande,”’ iii. Aufl., Leipzig und 
Wien, 1896, S. 227, Figs. 96-102.) 
A, Transverse section at the level 
of C iii; Cg, commissura grisea ; 
Ap, apex column dorsalis; Ca, 
commissura ventralis alba; Ce, 
canalis centralis; Cm, commis- 
sura medull spinalis; Cra, cornu 
ventralis; Crp, cornu dorsalis ; 
Fna, funiculus ventralis; FnB, 
fasciculus cuneatus Burdachi; 
FnG, fasciculus gracilis Golli; 
Fnl, funiculus lateralis; sla, 
fissura mediana ventralis; Fslp, 
sulcus medianus dorsalis ; kh, trac- 
tus solitarius ; Pr, formatio retic- 
ularis; Ra, radix ventralis; Rp, 
radix dorsalis; Sg, substantia 
gelatinosa Rolandi; Sld, sulcus 
lateralis dorsalis; Smd, septum 
medianum dorsale; Spd, septum 
intermedium dorsale; Til, tractus 


change considerably. In 
Fig. 942 one can easily 
make out that the gray 
matter is more abundant 
than at the lower level, 
that the dorsal horns of 
gray matter are inclined 
much more lateralward 
instead of dorsalward, 
while the neck of gray 
matter connecting the dor- 
sal horn with the rest of 
the gray matter is very 
long and narrow. In the 
region of the lateral horn 
of gray matter the white 
and gray matter are much 
mixed up, corresponding 
to the beginning of the 
formatio reticularis of the 
medulla oblongata. 


antermiedio lateralis: A section taken through 


one side of the central ner- 
vous system of the new-born babe at the junction of the 
cervical portion of the spinal cord with the medulla ob- 
longata will show certain particulars not brought. out in 
previous sections (see Fig. 948). Here not all the 
white matter ismedullated. Thus, forexample, the fibres 
of the pyramidal tract are not yet surrounded by myeline 
sheaths. In the centre is seen the ca- 
nalis centralis; ventral from it is a 
white area corresponding to the non- 
medullated decussation of the pyramids 
(decussatio pyramidum); dorsal from 
the central canal is a mass of gray mat- 
ter and a median dorsal septum and 
sulcus. The ventral part of the sec- 
tion has been cut off so that the gray 
matter of the ventral horn is not well 
shown. That of the dorsal horn (col- 
wmna dorsalis) is, however, well illus- 
trated. It is directed, however, far 
lateralward instead of backward, and 
is capped by a large mass of gelat- 
inous substance (substantia gelatinosa 
Rolandi). Between the dorsal horn 
and the median line are two new masses 
of gray matter not met with in the 
spinal cord lower down; one very well 
developed, occupying a large part of 
the region of the funiculus gracilis, is 
called the nucleus funiculi gracilis or 
Goll’s nucleus. Lateral from it, in the 
ventral part of the fasciculus cuneatus, 
amass of gray matter is beginning to 
appear which higher up becomes very 


: A. Karsted. 
voluminous and is known as the nucleus ) 


346 


Fasciculus cuneatus. \ 


Substantia gelatinosa. 


N. accessorius. 


Fasciculus spino-cere- 
bellaris dorso-lateralis. 


Canalis centralis. 


Fasciculus ventro-lateralis 
proprius. 


funiculi cuneati or Burdach’s nucleus. The white matter 
surrounds the gray matter as before, and is again divis- 
ible into the funiculus ventralis, the funiculus lateralis, 
and the funiculus dorsalis. The funiculus ventralis in- 
cludes the non-medullated pyramid and the partly 
medullated fasciculus ventralis proprius. The funiculus 





Fic. 942.—Transverse Section at the Junction of the Medulla Spinalis 


with the Medulla Oblongata. (After J. Henle, ** Handbuch der 
Nervenlehre des Menschen,” zweite Aufl., Braunschweig, 1879, 8. 
208, Fig. 124.) Ce, Canalis centralis; Cgd, columna (grisea) dor- 
salis ; Cgv, columna (grisea) ventralis ; F'v, funiculus ventralis ; Fe, 
fasciculus cuneatus; /g, fasciculus gracilis ; g, substantia gelatinosa 
Rolandi; gc, substantia gelatinosa centralis; I, ventral root of the 
first cervical nerve ; the asterisk * indicates a cross section of a blood- 
vessel; Fr, formatio reticularis. This section is below the level of 
the decussatio pyramidum. 


lateralis includes the partially medullated fasciculus ven- 
tralis proprius, the well-medullated fasciculus spino-cere- 
bellaris dorso-lateralis. In the funiculus dorsalis are seen 
the well-medullated fasciculus gracilis and the well- 
medullated fasciculus cuneatus. Passing transversely 
lateralward through the gray matter and through the 


Fasciculus gracilis. Nucleus funiculi gracilis. 













Decussatio pyramidum. 


Fic. 943.—Transverse Section through One Side of Central Nervous System of New-Born 
Babe at Junction of Pars Cervicalis Medullz Spinalis with the Medulla Oblongata, Show- 
ing the N. Accessorius. 


(Weigert-Pal preparation by Dr. John Hewetson, drawing by 


(Taken from *‘ The Nervous System and Its Constituent Neurones,”? New 
York, D. Appleton & Co., 1899.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





funiculus lateralis are seen the root fibres of the accessory 
nerve (radix nervi accessorit). 


mixed up with gray matter is visible in the lateral region. 








A good deal of white matter 


Fic. 944.—Transverse Section through the Medulla Oblongata at the 


Level of the Decussatio Pyramidum. 
der Nervenlehre des Menschen,” Zweite Aufl., Braunschweig, 1879, 
Cgv, Columna (grisea) ventralis or ventral horn; 


8. 211, Fig. 126.) 
Fv’, continuation in the 
medulla of the fascicu- 
lus ventralis proprius 
(Vorderstrangrest of 
the Germans); Fpy, fas- 
ciculi cerebro-spinales 
pyramidales undergoing 
decussation; g, sub- 
stantia gelatinosa Ro- 
landi; Vg, spinal ex- 
tremity of nucleus 
funiculi gracilis; XJ, 
nervus accessorius. 


‘This corresponds to 


the beginning of the - 


Sormatio reticularis. 
A section from a sim- 
ilar region in the 
adult is shown in Fig. 
944, In this figure 
the decussation of the 
pyramids is well 
marked. 

At a little higher 
level (Fig. 945), the 
relations of the gray 
matter to the white 
matter have become 
‘still more complex. 
The fasciculus gra- 
cilis is almost entirely 
replaced by the nu- 
‘cleus funiculi gracil- 
is, and the funiculus 
cuneatus is much en- 
croached upon by the 
nucleus funiculi cu- 
neati. The region of 
the lateral funiculus 
is being converted 
largely into a mass 
of formatio reticu- 
laris. The substantia 
gelatinosa Rolandi 
thas increased in bulk, 


(After J. Henle, ‘‘ Handbuch 


glossus. 





Fic. 946.—Transverse Section through the Medulla Oblongata in the Region of the 
Distal Portion of the Fossa Rhomboidea of an Adult Human Being. The nerve 
fibres have been drawn in on the left side (Weigert-Wolters’ staining) ; on the 
right side, the cells (Nissl’s stain). (After E. Flatau, *‘ Atlas Cerebri Humani,’’ Tab. 
x., Fig. B.) 1, Fissura longitudinalis mediana; 2, stratum interolivare lemnisci; 
3, pyramis; 4, radix nervi hypoglossi; 5, nucleus olivaris inferior ; 6, fibrae arcuate 
superficiales laterales: 7, nucleus olivaris accessorius dorsalis ; 8, nucleus lateralis ; 
9, substantia reticularis grisea with fibrze arcuatz interne; 10, fibree arcuate 
superficiales laterales; 11, tractus spinalis nervi trigemini; 12, corpus restiforme ; 
13, substantia gelatinosa ; 14, nervus hypoglossus; 15, fibrze arcuate superficiales 
dorsales; 16, funiculus cuneatus Burdachi; 17, nucleus funiculi cuneati ; 18, trac- 
tus solitarius; 19, nucleus funiculi gracilis; 20, funiculus gracilis Golli; 21, distal 
part of fossa rhomboidea ; 22, nucleus alze cinereze; 23, nucleus funiculi gracilis ; 
24, nucleus nervi hypoglossi; 25, nucleus funiculi cuneati; 26, scattered cells of 
the formatio reticularis grisea; 27, substantia gelatinosa; 28, dorsal part of sub- 
stantia reticularis alba (fasciculus longitudinalis medialis) ; 29, nucleus lateralis ; 
30, cells of the nucleus olivaris accessorius dorsalis; 31, cells of the nucleus oli- 
varis inferior; 32, raphe with the stratum interolivare lemnisci on each side of it. 
On both sides of the raphe lie some scattered small cells; 33, cells of the nuclei ar- 
cuati. Some large cells which lie in the region between the dorsal accessory olive 
(80) and the substantia gelatinosa (27) belong to the nucleus ambiguus. 


Brain, 
Brain, 


and between it and the surface lie, instead of the fascic- 
ulus of Lissauer met with in the spinal cord, the descend- 
ing fibres of the spinal tract of the trigeminal nerve (trac- 





Fig. 945.—Transverse Section through the Medulla Oblongata at the 
Level of the Most Caudal Fila Radicularia of the Nervus Hypo- 
(After J. Henle, ** Handbuch der Nervenlehre des Men- 


schen,” Zweite Aufl, 
Braunschweig. 1879, S. 
213, Fig. 127.) Fv’, Con- 
tinuation in the Medulla 
of the fasciculus ven- 
tralis proprius of the 
spinal cord; F'py, pyra- 
mis (at uppermost level 
of decussatio pyrami- 
dum); g, substantia 
gelatinosa; Ve, nucleus 
funiculi cuneati (Bur- 
dachi); Ng, nucleus 
funiculi gracilis (Golli). 
The decussatio lemnis- 
corum is not indicated 
in the figure, though it 
is to be seen at this level. 


tus spinalis nervi tri- 


gemini). 
In a section at a 
higher level (Fig. 


946) the central ca- 
nal has opened out 
into the lower part 
of the fourth ventri- 
cle. Below the stra- 
tum griseum centrale 
is the nucleus nervi 
hypoglossi (24). Just 
dorsad from this nu- 
cleus is situated part 
of the nucleus ale 
cinereze (22), while 
more laterally and 
dorsally placed is 
seen the upward con- 
tinuation of the nu- 
cleus funiculi gra- 
cilis (19, 28); some 
fibres of the funicu- 
lus gracilis are still 
present (20). Still 
more lateralward is 
seen the upward con- 
tinuation of the fu- 


347 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





niculus cuneatus (16), and ventrad from this the nucleus 
funiculi cuneati (17, 25). Curving around the funiculus 





' i 





4 § 51 3635 de 


Fic. 947.—Transverse Section through the Medulla Oblongata in the Region of the 
Nucleus Nervi Hypoglossi and Nucleus Al Cinereze in an Adult Human Being. On 
the left side the fibres are photographed (Weigert-Wolters’ stain); on the right side 


the cells have been drawn in from Nissl prepa- 
rations. (After E. Flatau, ‘‘ Atlas Cerebri Hu- 
mani,” Tab. xi., Fig. A.) 1, Stratum interoli- 
vare lemnisci; 2, fibraee arcuate superficiales 
ventrales; 8, nuclei arcuati; 4, pyramis; 5, 
fibrze arcuatze superficiales lateralis; 6, nu- 
eleus olivaris inferior; 7, nucleus olivaris ac- 
cessorius dorsalis; 8 and 9, fibree arcuate in- 
ternz; 10, tractus spinalis nervi trigemini; 
11, nervus vagus; 12, corpus restiforme; 138, 
nucleus funiculi cuneati; 14, remains of the 
nucleus funiculi gracilis and bundles of the 
radix descendens nervi vestibuli; 15, tractus 
solitarius; 16, nucleus ale cinerew; 17, for- 
matio reticularis grisea; 18, nervus hypo- 
glossus; 19, nucleus nervi hypoglossi; 20, 
raphe; 2k, nucleus neryi hypoglossi; 22, nu- 
cleus nervi vagi; 23, nucleus nervi vesti- 
buli; 24, groups of cells which belong partly 
to the nucleus funiculi cuneati and partly to 
the nucleus tractus solitarii ; 25, nucleus funic- 
uli cuneati; 26, scattered cells in the for- 
matio reticularis grisea; 27, cells of the sub- 
stantia gelatinosa; 28, cells of the nucleus 
lateralis; 29, cells of the nucleus ambiguus; 
80, cells of the nucleus lateralis; 31, cells of 
the nucleus olivaris accessorius dorsalis; 32, 
cells of the nucleus olivaris inferior; 33, cells 
of the nuclei arcuati; 34 and 35, cells of the 
nucleus olivaris accessorius medialis; 36, nu- 
clei arcuati. ‘ 


cuneatus are a few of the fibre arcuate 
superficiales dorsales. More ventrally 
situated is the corpus restiforme (12), 
here consisting chiefly of the upward 
continuation of the direct cerebellar tract 
from the spinal cord. The pale mass 
of substantia gelatinosa is visible at 18, 
while lateralward from it are seen in 
transverse section the descending fibres 
of the tractus spinalis nervi trigemini 
(11). Just lateralward from this are 
more lateral superficial arcuate fibres 
(10); ventralward from the substantia 
gelatinosa are situated the nuclei later- 
ales (8, 29). In the zone between the 
area above described and the radix n. 
hypoglossi (4, 14) are seen the following 
structures: the tractus solitarius (18), 
which represents chiefly descending 
fibres from the nervus glosso-pharyn- 
geus, the formatio reticularis with many 


348 





fibree arcuate interne (9), the nucleus olivaris acces- 
sorius dorsalis (7, 30), the nucleus olivaris inferior (5, 31), 

and the fibre arcuatee superficiales later- 
ales (6). In the middle line is seen the 
raphe extending from the fissura longi- 
tudinalis ventralis (1) to the floor of the 
fourth ventricle (21). From the dorsal 
6 surface ventralward between the raphe 
and the radix n. hypoglossi the following 
structures are met with: Below the gray 
matter are seen in transverse section the 
fibres of the fasciculus longitudinalis me- 
: dialis. Ventral from this are the trans- 
(_....28 verse sections of the fibres of the stratum 
interolivare lemnisci which are made up 
of internal arcuate fibres which have 
crossed the raphe and turned to run 
longitudinally. Among these fibres some 
small cells are present (32). At the most 
ventral part of the interolivary layer of 
the lemniscus are seen many transverse 
fibres; at the level of the olive (2) the 
large bundle of white fibres on the ven- 
tral surface is the pyramis (3). At the 
periphery of the pyramid a few cells are 
seen which represent a continuation 
downward of the nuclei arcuati of the 
pons. 

If a section be taken still higher up 
the relations become somewhat more 
complex (see Fig. 947), The fourth ven- 
tricle has become much wider, the two 
halves of the medulla are separated 


33 





Se ae} Te 49 


Fic. 948.—Transverse Section through the Medulla Oblongata at the Level of the Nervus 


Vagus and Nervus Glosso-Pharyngeus in an Adult Human Being. On the left side, 
photograph of a fibre preparation ; on the right side the cells have been drawn in from 
Nissl preparations. (After E. Flatau, ‘* Atlas Cerebri Humani,’’ Tab. xi., Fig. 13.) 1, 
Nuclei arcuati; 2, filbrae arcuati superficiales ventrales; 3, stratum interolivare lem- 
nisci; 4, pyramis; 5, nucleus olivaris inferior ; 6, fibre arcuatze superficiales laterales ; 
7, formatio reticularis grisea with fibre arcuatee interne ; 8, fibrae cerebello-olivares ; 9, 
tractus spinalis nervi trigemini; 10, extra-medullary bundle of the nervus vagus and 
nervus glosso-pharyngeus; 11, corpus restiforme; 12, bundle of the nervus glosso- 
pharyngeus (the radial fibres running medial from this and not lettered represent the 
inotor fibres of the vagus and glosso-pharyngeal nerves); 13, radix descendens nervi 
vestibuli; 14, tractus solitarius; 15, nucleus nervi vestibuli; 16, nucleus nervi glosso- 
pharyngei; 17, striz medullares; 18, radial fibres in the formatio reticularis grisea (at 
the boundary between the fibree arcuatze interne and the fibree cerebello-olivares) ; 19, 
nucleus funiculis teretis ; 20, fasciculus longitudinalis medialis; 21, raphe; 22, nucleus 
funiculi teretis; 23, cells which lie dorsalward from the fasciculus longitudinalis 
medialis and belong to the cells of the formatio reticularis grisea; 24, nucleus nervi 
vagi; 25, nucleus nervi vestibuli medialis; 26, nucleus nervi glosso-pharyngei; 27, 
cells of the nucleus nervi vestibuli lateralis (Deiters) and of the remains of the 
dorsal horn of the spinal cord; 28, scattered cells of the formatio reticularis grisea ; 
29, cells belonging to 27; 30, cells of the substantia gelatinosa; 31, nucleus lateralis; 
82, cells of the nucleus ambiguus; 33, nucleus lateralis (?) ; 34, cells of the nucleus 
olivaris accessorius dorsalis; 35, 36, 37, cells of the nucleus olivaris inferior; 38, 39, 
cells of the nuclei arcuati. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





from each other by the raphe (20). In the floor of the 
fourth ventricle, passing from the middle line lateral- 
ward, are seen the nucleus n. hypoglossi (19, 21), the 
nucleus ale cinerex (16, 22), the tractus solitarius (15), 
and the lower portion of the nucleus n. vestibuli (23), 
near which are a few fibres of the fasciculus cuneatus 
and some fibres of the radix descendens n. vestibuli (14). 
Each half of the medulla is divisible by means of the 
radix n. vagi and the radix n. hypoglossi into three com- 
partments: one lateral between 
the dorso-lateral edge and the 
radix n. vagi, one middle be- 
tween the radix n. vagi and the 
radix n. hypoglossi, and one 
medial between the radix n. hy- 
poglossi and the raphe. 

In the lateral compartment can 
“be seen the corpus restiforme 
(12), the nucleus funiculi cuneati 
(18, 25), the tractus spinalis n. 
trigemini (10), and the substantia 
gelatinosa (27). 

In the middle compartment 
there are the fibre arcuate super- 
ficiales laterales (5), the nucleus 
olivaris inferior (6, 32), the nu- 
cleus olivaris accessorius dorsalis 
(7, 31), the fibree arcuate in- 
tern (8, 9), the formatio reticu- 
laris grisea (17, 26), the nuclei 
laterales (28), and the nucleus 
ambiguus (29) which is regarded 
as the motor nucleus of origin 
‘of the n. vagus and the n. glosso- 
pharyngeus. 

In the medial compartment, 
passing from the dorsal surface 
ventralward, is seen the stratum 
interolivare lemnisci (1), the ven- 
tral superficial arcuate fibres (2), 
the pyramis (4), the nuclei arcu- 


to it the fasciculus longitudinalis medialis (20), the stra- 
tum interolivare lemnisci (3), and the pyramis (4); run- 
ning. around the pyramid are the fibre arcuate super- 
ficiales ventrales (2), and the nuclei arcuati (1, 38, 89). 
The section which follows (Fig. 949) is taken at the 
uppermost part of the medulla oblongata just where it 
goes over into the pons. Here the fourth ventricle is at 


its widest, and running transversely across it are.seen the 
strie medullares (16). 


Connected lateralward with the 





Fi@. 949.—Transverse Section through the Proximal Part of the Medulla Oblongata at the Region 
of Entrance of the Nervus Acusticus inan Adult Human Being. On the left the fibres have 
been photographed ; on the right the cells have been drawnin. (After E. Flatau, ‘t Atlas Cerebri 
Humani,” Tab. xii., Fig. A.) 


1, Nuclei arcuati; 2, fibre arcuatze superficiales ventrales; 3, 


ati (3), and the nucleus olivaris” 


accessorius medialis (34, 35). 

In the next section (Fig. 948), 
taken from the upper part of the 
medulla oblongata, the fourth 
ventricle is very wide and the 
corpus restiforme has become 
very markedly developed. In 
the floor of the fourth ventricle, 
passing from the middle line lat- 
eralward, are seen the nucleus 
funiculi teretis (19, 22), the nu- 
cleus ale cinerex (24), the striz 
medullares or striz acustici (17), 


the nucleus n. vestibuli medialis (15, 25). 


pyramis; 4, stratum interolivare lemnisci; 5, nucleus olivaris inferior; 6, filbrae arcuatee super- 
ficiales laterales ; 7, fasciculus tegmenti centralis, or centrale Haubenbahn of yon Bechterew ; 8, 
fibrze arcuate interne; 9, fibrze cerebello-olivares; 10, tractus spinalis nervi trigemini; 11, 
substantia gelatinosa; 12, nucleus nervi cochlez ventralis; 13, nervus cochlese; 14, nucleus 
nervi cochlez dorsalis (tuberculum acusticum); 15, corpus restiforme; 16, striz medullares 
(very markedly developed); 17, radix nervi glosso-pharyngei; 18, radix descendens nervi 
vestibuli; 19, nucleus nervi vestibuli medialis; 20, formatio reticularis grisea; 21, stratum 
interolivare lemnisci; 22, fasciculus longitudinalis medialis; 23, raphe; 24, cells dorsal from 
the fasciculus longitudinalis medialis connected with the nucleus reticularis tegmenti; 25, 
scattered cells of the tegmentum (von Bechterew’s nucleus reticularis tegmenti) ; 26, nucleus 
nervi vestibuli medialis; 27, nucleus nervi vestibuli lateralis (Deiters) ; 28, cells of the sub- 
stantia gelatinosa; 29, cells of the tuberculum acusticum; 30, tongue-like collection of cells; 
31, ventro-medial continuation of the nucleus neryi cochlee ventralis; 32, nucleus nervi 
facialis; 33, nucleus lateralis; 34, large multipolar cells (connected with the scattered cells of 
the formatio reticularis grisea); 35, nucleus olivaris accessorius dorsalis; 36, cells of nucleus 
olivaris inferior; 37, scattered cells at the dorsal periphery of the pyramid (beginning nuclei 
pontis) ; 38, cells of the nuclei arcuati. 


nucleus n. cochlese dorsalis or tuberculum acusticum (14) 
is the n. cochlexw. In the floor of the fourth ventricle, 


The cor- 


pus restiforme (11) is seen as a large mass of fibres 
cut transversely at the lateral dorsal angle of the cross 
section. Just medial to it are seen the bundles of the 
radix descendens n. vestibuli (13). In many of these 
bundles are masses of gray matter (27) which represent 
chiefly the nuclei of the descending root of the vestibular 
nerve. Theround bundle formed by the tractus solitarius 
(14) is clearly visible, and close to it the nucleus tractus 
solitarii (26); at 9 the tractus spinalis n. trigemini is seen 
crossed by black bundles of fibres, the fibre cerebello- 
olivares (8).. Medial from the tractus spinalis n. trigem- 
ini are situated the cells of the substantia gelatinosa (30). 
The nucleus lateralis (81) is still visible. The motor 
nucleus of the n. vagus and of the n. glosso-pharyngeus, 
or so-called nucleus ambiguus, is visible. At this level 
(38) the fibree arcuate interne (7) are numerous, crossing 
the formatio reticularis grisea and running toward the 
raphe. The nucleus olivaris inferior (5, 35) is accom- 
panied by the nucleus olivaris accessorius dorsalis (34) 
and the nucleus olivaris accessorius medialis (87). | Dorso- 
lateral from the olive are the fibre arcuatze superficiales 
laterales. In the middle line is seen the raphe and close 





passing from the middle line lateralward, can be seen 
some cells of the nucleus reticularis tegmenti (24) and the 
nucleus n. vestibuli medialis (19, 26). The corpus resti- 
forme (15) is separated from the periphery by the dorsal 
cochlear nucleus (14, 29); medial from it the radix de- 
scendens n. vestjbuli is present in the form of numerous 
discrete bundles in among which are situated the large 
multipolar ganglion cells of Deiters’ nucleus (nucleus n. 
vestibuli lateralis) (27). Ventral from the corpus resti- 
forme and the radix descendens n. vestibuli are seen the 
root fibres of the n. glosso-pharyngeus (17). A portion of 
the nucleus n. cochlese ventralis is visible (12, 31). Ven- 
tralward from the root fibres of the glosso-pharyngeal 
nerve are seen the fibres of the tractus spinalis n. trigemini 
(10), and medial from them the cells of the substantia gela- 
tinosa (11, 28). The formatio reticularis (20) is well de- 
veloped. It is crossed as in the sections below by many 
fibre arcuatee interne (8); the fibree cerebello-olivares are 
still visible (9). The section passes through the upper 
part of the nucleus olivaris inferior (5) and a portion of 
the nucleus olivaris accessorius dorsalis (21, 35). The fibree 


349 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





arcuate superficiales laterales are still present (6), and In sections through the pons we have to distinguish 
dorso-lateral from the olive are seen some of the fibres of | between the pars dorsalis pontis and the pars basilaris 
the fasciculus tegmenti centralis or centrale Haubenbahn | pontis. The pars basilaris pontis includes the large 





Fig. 950.—Transverse Section through the Pons at the Level of the Nervus Facialis and Nervus Abducens in an Adult 


fasciculi longitudi- 
nales of the pons, 
the large bundles of 
transverse fibres of 
the pons, and the 
great gray masses. 
known as the nu- 
clei pontis. The 
pars dorsalis pontis. 
includes the up- 
ward continuation 
of the medulla ob- 
longata with the 
exception ‘of the 
pyramids. It con~ 
tains the nuclei of 
the nerves connect- 
ed with the pons, 
the fasciculus longi- 
tudinalis medialis, 
the medial and. lat- 
eral lemnisci, the 
corpus trapezoide- 
um, the formatio: 
reticularis and the 
superior olivary 
complex. In Fig. 
950 some of the 
principal structures 
of the lower part of 


Man. On the left side the fibres have been photographed ; on the right the cells have been drawn in. (After E. the pons are shown. 


Flatau, ‘* Atlas Cerebri Humani,”’ 
Berlin, 1899, Tab. xii., Fig. B.) 1, 
Fibre pontis superficiales ; 2, fas- 
ciculi longitudinales pontis; 3, 
lemniscus medialis ; 4, fibrae pontis 
profunde ; 5, brachium pontis; 6, 
nucleus olivaris superior; 7, sub- 
stantia gelatinosa (beginning sen- 
sory nucleus of the trigeminus) ; 
8, tractus spinalis nervi trigemini ; 
9, corpus restiforme (ascending 
to cerebellum) ; 10, radix descen- 
dens nervi vestibuli; 11, radix 
nervi facialis pars secunda; 12, 
nucleus nervi vestibuli medialis ; 
13, formatio reticularis grisea with 
ascending fibres from the nucleus 
nervi facialis and fibres from the 
nucleus olivaris superior to the 
nucleus nervi abducentis; 14, 
nucleus neryi abducentis; 15, 
genu internum nervi facialis; 
16, nervus abducens; 17, fascicu- 
lus longitudinalis medialis; 18, 
nucleus nervi abducentis; 19, 
cells of formatio reticularis gri- 
sea; 20, nucleus nervi vestibuli 
lateralis Deiters ; 21, nucleus reti- 
cularis tegmenti yon Bechterew ; 
22, cells of the substantia gela- 
tinosa; 238, cells of the proximal 
part of the nucleus nervi facialis 
or of the distal motor nucleus of 
the nervus trigeminus ; 24 and 25, 
cells of the nucleus olivaris su- 
perior; 26, continuation of the 
nuclei pontis in the tegmentum ; 
27, nuclei pontis. 


of von Bechterew (7). A good 
many fibres run longitudinally 
in the raphe (28). The fasci- 
culus longitudinalis medialis 
(22) is larger than in the sec- 
‘tions below. The stratum in- 
terolivare lemnisci (4) is highly 
developed just before going 
over into the lemniscus medi- 
alis of the pons. The pyramis 
(3) is large, is surrounded by 
the fibree arcuate superficiales 
ventrales, and has close to it 
the nuclei arcuati (1, 38). 


350 





Fic. 951.—Transverse Section through the Pons at the Level of the Nervus Trigeminus in an Adult 


Human Being. On the left side the fibres have been photographed ; on the right side the cell bodies 
have been drawn in. (After E. Flatau, ‘“‘ Atlas Cerebri Humani,’”’ Tab. xiii., Fig. A) 1, Fibra 
superficiales pontis: 2, fasciculi longitudinales pontis; 3, fibrze pontis profundze; 4, radix nervi 
trigemini; 5, brachium pontis; 6, radix nervi trigemini; 7, nucleus olivaris superior; 8, radix 
nervi trigemini pars sensorius; 9, corpus restiforme; 10, nucleus sensorius nervi trigemini; 11, 
radix motorius nervi trigemini; 12, nucleus motorius princeps nervi trigemini; 13, radix de- 
scendens mesencephalica nervyi trigemini; 14, brachium conjunctivum ; 15, crossed fibres of nervus 
trigeminus; 16, lemniscus medialis; 17, formatio reticularis tegmenti; 18, fibree arcuatee internze 
tegmenti; 19, fibrze arcuatee internse ventrales (compact bundle) ; 20, fasciculus longitudinalis me- 
dialis; 21, raphe; 22, cells of the middle line; 23, cells at the dorso-lateral part of the fasciculus 
longitudinalis medialis (connecting with the cells of the middle line) ; 24 and 25, nucleus centralis 
tegmenti, a large aggregation of cells in the tegmentum at the ventral part of the middle line ‘re- 
lated to the nuclei pontis) ; 26, cells of the stratum griseum centrale ; 27, scattered large cells of the 
tegmentum (nucleus magnocellularis diffusus of von Kd6lliker); 28, nucleus motorius princeps 
nervi trigemini; 29, cells of the locus cceruleus; 30 nucleus sensorius nervi trigemini ;. 31, cells 
of the nucleus olivaris superior ; 32, nuclei pontis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain. 
Brain. 





The section is taken at the level of the nuclei of origin of 
the n. facialis and the n. abducens. In the pars dorsalis 
pontis the raphe is seen in the middle line. The nucleus 
n. abducentis is situated close to the floor of the fourth 
ventricle (14, 18). Running ventralward from the medial 
side of the nucleus are seen the root fibres of the n. abdu- 
cens (16); the nucleus n. facialis.is present (23); the pars 
prima of the radix n. facialis exists as a number of scat- 
tered fibres radiating dorsalward and medialward (18). 
The genu internum n. faci- 
alis (15) is indicated just 
medial to the nucleus n. 
abducentis, the pars se- 
cunda of the radix n. faci- 
alis passing obliquely ven- 
tralward and lateralward 
at 11. A portion of the 
nucleus n. vestibuli is 
shown near the floor of 
the fourth ventricle (12, 
20), and lateral from it 
still some fibres of the ra- 
dix descendens n. vesti- 
buli (10). At this. level 
the corpus restiforme (9) 
turns dorsalward to enter 
the cerebellum. The mass 
of fibres of the brachium 
pontis (5) are shown in 
their relation to the trans- 
verse fibres of the pons. 
Near the raphe, in the 
formatio reticularis, is a 
mass of cells, the so-called 
nucleus reticularis teg- 
menti of von Bechterew 
(21). The cells of the 
substantia gelatinosa (22) 
are seen chiefly medial to 
the fibres of the tractus 
spinalis n. trigemini (8). 
Running transversely 
across the pons at the 
most ventral part of the 
pars dorsalis pontis are 
seen the fibres of the cor- 
pus trapezoideum, and in 
between these fibres run 
lengthwise the fibres of 
the lemniscus medialis (3). 
In the lateral part of the 
corpus trapezoideum is 
seen the nucleus olivaris 
superior (6, 24, 25). In the 
pars basilaris pontis are 
the fasciculi longitudi- 
nales (2), the fibrze pontis : 
profunde (4) and the fibre pontis superficiales. In 
among these transverse and longitudinal bundles are 
situated the nuclei pontis (27). Some of the cells of this 
nucleug extend into the tegmental region (26). 

A section through the pons at the level of the root of 
the n. trigeminus is illustrated in Fig. 951. Here the pars 
dorsalis pontis or tegmentum is more sharply differenti- 
ated from the pars basilaris pontis than in the previous 
section. The fourth ventricle is narrowing as the aque- 
duct of Sylvius is approached. The raphe (21) separates 
the two halves of the section from: each other. Just 
lateral from the raphe on each side are seen the fibres of 
the fasciculus longitudinalis medialis. In the floor of the 
fourth ventricle are seen the cells of the stratum griseum 
centrale (26). At the lateralangle isa group of pigmented 
cells of the so-called locus cceruleus (29); the fibres of the 
corpus restiforme (9) are still visible at this level, and a 
cross section of the fibres, of the superior cerebellar 
peduncle or brachium conjunctivum (14) is met with. 
The junction of the n. trigeminus with the pons isshown 
at 4, the radix n. trigemini at 6, Lateral from it is seen 


Human Being. 
been drawn in. 


tegmentum ; 24, nuclei pontis. 











the brachium pontis (5). The sensory portion of the root 
of the n. trigeminus (8) is distinguishable from the motor 
portion (11). The sensory nucleus of termination of the 
n. trigeminus (10) is situated more lateralward than the 
nucleus motorius princepsn. trigemini (12). The crossed 
fibres of the trigeminal root are indicated at 15, while the 
radix descendens mesencephalica n. trigemini is shown 
at 13. The fibre arcuate interne (18) are present in the 
tegmentum of the pons, but are not so much curved as 


14. 15, 


Fic. 952.—Transverse Section through the Pons in the Region of the Velum Medullare Anterius in an Adult 
On the left side the fibres have been photographed ; on the right side the cell bodies have 

(After E. Flatau, *‘ Atlas Cerebri Humani,” Tab. xiii., Fig. B.) 
ficiales ; 2, fasciculi longitudinales pontis ; 3, fibrze pontis profundz ; 4, latero-dorsal compact peduncular 
part of pons ; 5, latero-dorsal part of nuclei pontis ; 6, lemniscus medialis ; 7, nucleus lemnisci lateralis ; 
8, lemniscus lateralis ; 9, continuation of nuclei pontis into lateral portion of tegmentum ; 10, formatio re- 
ticularis tegmenti ; 11, brachium conjunctivum ; 12, radix descendens mesencephalica nervi trigemini ; 13, 
fasciculus longitudinalis medialis; 14, lingula; 15, velum medullare anterius; 16, transition from the 
fossa rhomboidea to the aqueductus cerebri Sylvii; 17, aggregation of cells dorsal from the fasciculus 
longitudinalis medialis, continuous with the cells of the middle line; 18, cell bodies of the locus cceru- 
leus ; 19, continuation of the nuclei pontis into the tegmentum ; 20, cells at the ventro-lateral periphery 
of the brachium conjunctivum ; 21, scattered cells in the tegmentum (nucleus reticularis tegmenti of yon 
Bechterew) ; 22, nucleus lemnisci lateralis ; 23, continuation of nuclei pontis into the lateral part of the 


1, Fibrze pontis super- 


those which were seen in the medulla oblongata. They 
are more compact in the ventral part of the tegmentum 
(19). The lemniscus medialis (16) is more laterally placed 
than in sections lower down. Just dorso-lateral from it 
is seen the nucleus olivaris superior (7, 81); the nucleus 
centralis tegmenti (24, 25) at’ this level makes a large 
mass of cells near the raphe on each side. In the pars 
basilaris pontis are seen the fasciculi longitudinales (2), 
fibre pontis superficiales (1), the fibre pontis profundse 
(3), and the nuclei pontis (82). 

A section taken at a higher level (Fig. 952) shows the 
beginning of the aqueductus cerebri (16), the root of which 
is formed by the velum medullare anterius (15). Above 
this a cross section of the lingula (14) is illustrated. In the 
lateral portion of the pars dorsalis pontis the large mass of 
fibres of the brachium conjunctivum (11) isseen. Lateral 
from the aqueductus cerebri are to be found the fibres of 
the radix descendens n. trigemini. In the floor of the aque- 
duct, close to the raphe on each side, is the fasciculus 
longitudinalis medialis (18); it is separated from the 
aqueduct by a mass of cells (17). The cells of the iocus 


351 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ceruleus (18) are situated just ventral from the radix 
descendens n. trigemini. The formatio reticularis teg- 
menti (10) contains scattered cells of the nucleus reticu- 
laris tegmenti (21). Ventro-lateral from the brachium 
conjunctivum are seen the fibres of the lemniscus lateralis, 
and among them the cells of the nucleus lemnisci lateralis 
(22). The lemniscus medialis (6) forms a broad, flat rib- 
bon in the floor of the pars dorsalis pontis. In the pars 
dorsalis pontis are met with again the fasciculi longi- 
tudinales (2), the fibree pontis superficiales (1), the fibree 
pontis profundee (8), and the nuclei pontis (24). 

The next section is taken at the level of decussation of 
the trochlear nerves of the two sides (Fig. 953). The 
lumen of the aqueductus cerebri (20) is small and diamond- 
shaped. In the roof is seen the decussatio nervorum 
trochlearium, and dorsal from it the lateral part of the 
velum medullare anterius (16). The radix n. trochlearis 
before decussation (15) is seen in the central gray matter 
(21). The locus cceruleus (22) here contains large cells. 
The comma-shaped cross section of the fasciculus longi- 
tudinalis medialis (18) is a striking feature at this level. 
The lemniscus lateralis (10) is situated lateralward, many 
of its fibres coming into relation with the nucleus lemnisci 
lateralis (11). The lemniscus medialis (7) becomes dis- 
placed more and more lateralward. The brachium con- 





junctivum (9, 12) is undergoing decussation (8) at this 
level; its fibres run through the formatio reticularis teg- 
menti (17, 25). At the junction of the pars dorsalis with 
the pars basilaris pontis, near the middle line, is seen the 
tractus mamillo-peduncularis (Edinger), and lateral from 
it the bundle from the lemniscus medialis to the basis pe- 
dunculi. Close to the middle line, at about this level, are 
seen cells of the corpus interpedunculare (28). In the 
pars basilaris pontis the same structures are to be met 
with as at lower levels. 

The next section (see Fig. 954) passes through the 
midbrain and shows the corpora quadrigemina and the 
pedunculi cerebri. In the middle line is situated the 
aqueductus cerebri (24). On each side of the aqueduct 
dorsalward the section passes through the superior colli- 
culus of the corpora quadrigemina. The amount of the 
stratum griseum centrale (25, 26) is large in this region. 
In the superior colliculus passing from the dorsal surface 
inward can be seen the stratum zonale (20) or superficial 
white layer, the cappa cinerea (17) or superficial gray 
layer, the stratum opticum (16) or external grayish-white 
layer, the middle gray layer (15), the stratum lemnisci 
(14), the deep white layer (19), and the commissure be- 
tween the two superior colliculi (21). The cerebral 
peduncle is divisible into two parts, the tegmentum and 





Fig. 953.—Transverse Section in the Region of the Proximal Portion of the Pons and of the Decussation of the Trochlear Nerves (Close Behind 


the Inferior Colliculi of the Corpora Quadrigemina) in an Adult Human Being. 
on the right side the cell bodies have been drawn in from Nissl preparations. 
1, Blood-vessel ; 2, fibree pontis superficiaies ; 3, fasciculi longitudinales pontis; 4, lateral portion of basis pedunculi; 5, fibrae pontis 


1899.) 


On the left side a photograph of the fibres is represented ; 
(After E. Flatau, ‘‘ Atlas Cerebri Humani,” Tab. xiy., Berlin, 


profundse ; 6, tractus mamillo-peduncularis (Hdinger) and lateral from it the bundle from the medial lemniscus to the pons (or to the basis 
pedunculi) ; 7, lemniscus medialis; 8, decussatio brachii conjunctivi; 9, brachium conjunctivum; 10, lemniscus lateralis; 11, bundles of 
the lateral lemniscus cut transversely (in the nucleus lemnisci lateralis); 12, brachium conjunctivum; 18, radial transverse bundles of the 


lemniscus lateralis passing across the radix descendens neryi trigemini; 


14, nervus trochlearis after the decussation; 15, nervus 


trochlearis before the decussation; 16, lateral part of the velum medullare anterius going over into the substance of the tegmentum; 17, 
formatio reticularis tegmenti ; 18, fasciculus longitudinalis medialis ; 19, decussatio nervyorum trochlearium ; 20, aqueductus cerebri Sylvii; 
21, cell bodies of the stratum griseum centrale; 22, cells of the locus coeruleus (the dorso-lateral cell bodies belong probably to the radix 
descendens nervi trigemini); 28, cell bodies of the middle line; 24, nucleus lemnisci lateralis; 25, cell bodies of the formatio reticularis ; 
26, gray intermediary layer of the formatio reticularis (dorso-medial from the lemniscus) ; 27, scattered cells in the neighborhood of the 
decussatio brachii conjunctivi; 28, cells of the corpus interpedunculare (substantia perforata posterior) ; 29, nuclei pontis. 


352 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 








the basis pedunculi. Between the two is the substantia 
nigra (3, 39). In the tegmentum, below the stratum 
griseum centrale, are seen some deep arcuate fibres (18) 
which represent the continuation of the fibres of the deep 
white matter of the superior colliculus. The large 
nucleus ruber (13) is seen at this level in cross section. 


whole is well shown in Plate A and Fig. 955. In Plate A 
the model is viewed from the lateral surface and its rela- 
tions to the spinal cord and cerebellum and the third 
ventricle are illustrated. In Fig. 955 it is viewed from 
the dorsal surface and the fourth ventricle is seen to be 
an important guide. A large central fibre mass contain- 


as 38 27 99 


RL 2223 oy 
i 


3 





36 
37 


Fie. 954.—Transverse Section through the Superior Colliculi of the Corpora Quadrigemina and the Pedunculi Cerebri in an Adult Human 


Being. On the left side the fibres have been photographed; on the right the cells have been drawn in, 


Humani,”’ Berlin, 1899, Tab. xy.) 


1, Ventral tegmental decussation of Forel; 2, radix nervi oculomotorii; 


(After E. Flatau, ‘* Atlas Cerebri 
3, substantia nigra Soem- 


meringi; 4, basis pedunculi; 5, longitudinal bundles in the lateral part of the substantia nigra; 6, lemniscus medialis; 7, tractus 
opticus entering the corpus geniculatum laterale; 8, corpus geniculatum mediale; 9, formatio reticularis tegmenti; 10, brachium 
quadrigeminum superius; 11, thalamus; 12, lemniscus lateralis; 13, nucleus ruber (proximal part); 14, part of lemniscus medialis; 15, 
middle gray layer; 16, stratum opticum (external grayish-white layer) ; 17, cappa cinerea (superficial gray layer of superior colliculus); 
18, deep arcuate fibres; 19, deep white layer of superior colliculus; 20, stratum zonale (superficial white layer of superior colliculus); 21, 
commissure of superior colliculi; 22, fasciculus longitudinalis medialis; 23, dorsal tegmental decussation of Meynert; 24, aqueductus 
cerebri Sylvii; 25, cell bodies in stratum griseum centrale; 26, aggregation of cells in peripheral part of stratum griseum centrale; 27, cell 
bodies of internal grayish-white layer ; 28, cell bodies of middle gray layer with scattered large multipolar cells; 29, cell bodies of the cappa 
cinerea; 30, cell bodies of the radix descendens nervi trigemini; 31, aggregation of cell bodies in latero-dorsal part of tegmentum; 32, 
cells of distal part of thalamus (pulvinar) ; 33, cell bodies of corpus geniculatum mediale; 34, cell bodies of substantia nigra; 35, cell bodies 
of proximal part of nucleus ruber; 36, nucleus nervi oculomotorii extending ventralward into the region of the fasciculus longitudinalis 


medialis; 37, nucleus nervus oculomotorii; 38, most proximal remnant of nuclei pontis; 39, cell bodies of substantia nigra; 40, cell bodies 


of the middle line. 


The formatio reticularis (9) is very highly developed. 
Lateral from the nucleus ruber are seen the fibres of the 
lJemniscus lateralis, and still more lateralward those of 
the brachium quadrigeminum superius (10). The cor- 
pus geniculatum mediale is shown at 8 and 33, while 
the pulvinar of the thalamus is seen at 11 and 82. En- 
tering the corpus geniculatum laterale and the pulvinar 
is the tractus opticus (7). The fibres of the lemniscus 
medialis (6) are seen between the nucleus ruber and the 
substantia nigra. Near the middle line the fasciculus 
longitudinalis medialis (22) is met with in cross section. 
Just dorsal to it is the nucleus n. oculomotorii (86, 37). 
The root fibres of this nerve (2) are shown passing ven- 
tralward to the interpeduncular space. The ventral teg- 
mental decussation of Forel is visible at 1. 

The basis pedunculi consists of a compact mass of 
fibres that is sometimes known as the pes pedunculi 
cerebri. Through it run the fibres of the pyramidal tract, 
those of the frontal cerebro-cortico-pontal path, and those 
of the temporal cerebro-cortico-pontal path. 

One of the most satisfactory methods of studying the 
structure of the medulla, pons, and midbrain is by wax 
reconstruction from serial sections. The model con- 
structed by Miss Florence Sabin from specimens prepared 
by Dr. John Hewetson is of especial value inasmuch as 
it gives ideas in three dimensions of the form relations of 
this part of the brain.* The model and its parts are de- 
picted in Plate A and Figs. 955-962. The model as a 





* Sabin, Florence R.: ‘‘ A Model of the Medulla Oblongata, Pons, 
and Midbrain of a New-Born Babe.’’ Contributions to the Science of 
Medicine, dedicated by his pupils to William Henry Welch on the 
Twenty-fifth Anniversary of his Doctorate. The Johns Hopkins Press, 
Baltimore, 1900, pp. 925-1045. 


Vou. I1.—238 





ing the medial, lateral, and superior lemnisci has formed 
the basis of the model. This central fibre mass is divided 
into two parts by a cross bar of fibres, the corpus trape- 
zoideum. ‘The distal part consists of a thin sheet of fibres 
extending the whole length of the medulla and reaching 
almost from the dorsal to the ventral surface (Fig. 958); 
Miss Sabin calls it the medulla sheet. The proximal part 
is divisible into three subdivisions, the ventral division 
(lemniscus medialis), a dorsal division (fasciculus longi- 
tudinalis medialis), and a middle portion (formatio reticu- 
laris). The medulla sheet corresponds dorsalward to the 
upward continuation of the ground bundles of the spinal 
cord, ventralward to the stratum interolivare lemnisci. 
The ventral fibres of the proximal subdivision of the 
central fibre mass are divisible into: (1) a horizontal 
pontal sheet and (2) a vertical midbrain sheet. The 
lateral portion of the pontal sheet contains the bulk of 
its fibres. It is the lemniscus medialis on its way to the 
diencephalon. By gradual rotation the horizontal pontal 
sheet becomes the obliquely vertical midbrain sheet 
(Fig. 959). In the centre of the midbrain sheet runs the 
lemniscus medialis, Ventral to it is a part of the cap- 
sule of the nucleus ruber, while dorsal to it are the fibres 
of the lemniscus superior or Obereschleife of the Germans. 
The dorsal portion of the proximal subdivision of the 
central fibre mass is the fasciculus longitudinalis medi- 
alis and is obviously the continuation of the dorsal part 
of the medulla sheet (Figs. 957 and 960). It follows the 
course of the floor of. the ventricle. The bundles of the 
two sides form a trough at the beginning of the mid- 
brain (Fig. 956). In the sides of the trough are shallow 
depressions, three on the right side and two on the left. 
They correspond in position to the nuclei of the oculo- 


353 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





motor and trochlear nerves (Fig. 960). (The space cere- 
bralward from these depressions left in the wall cor- 
responds to the region of exit of the main mass of fibres 


4 


y, 





Fig. 955.—View of the Model from the Dorsal Surface. The right 
side of the view shows the surface form, the left the structures of 
the model. The position of these structures can be related to the 
dorsal funiculi of the spinal cord, the fourth ventricle, and the in- 
ferior and superior colliculi. 1, Fasciculus retroflexus (Meynerti); 
2,stratum album profundum; 3, nucleus n. oculomotorii; 4, com- 
missurz nuclei colliculi inferioris; 5, nucleus n. trochlearis; 6, 
substantia ferrugine; 7, ventriculus quartus; 8, brachium con- 
junctivum; 9, corpus restiforme; 10, radix n. facialis (genu in- 
ternum); 11, nucleus n. abducentis; 12, fasciculus longitudinalis 
medialis; 13, nucleus olivaris inferior; 14, nucleus n. hypoglossi ; 
15, fasciculus gracilis; 16, nucleus funiculi gracilis; 17, fasciculus 
ecuneatus; 18, nuclei funiculi cuneati; 19, tractus solitarius et 
nucleus ale cinerez; 20, corpus restiforme; 21, nucleus n. cochleze 
dorsalis; 22, nucleus et radix n. vestibuli; 23, corpus restiforme ; 
24, nucleus n. vestibuli lateralis; 25, nucleus n. trigemini (sens.) ; 
26, nucleus motorius princeps n. trigemini; 27, radix n. trigemini 
(sens.); 28, radix n. trigemini (mot.); 29, locus coeruleus; 30, radix 
descendens n. trigemini; 381, brachium conjunctivum; 32,4; 33, 
radix n. trochlearis; 34, nucleus colliculi inferioris; 35, lemniscus 
medialis. 

Nucleus et radix n. vestibuli: The ascending root is marked 
by the most proximal of the three lines on the figure; the descending 
by the most distal line, while the nucleus n. vestibuli medialis is 
indicated by the middle of the three lines. The nucleus n. vestibuli 
superior is continuous with the medial nucleus and lies opposite the 
ascending root. The nucleus n. vestibuli lateralis consists of two 
parts, one between the corpus restiforme and the ascending root, the 
other in the notch between the medial aud superior nuclei. 

Nucleus n. cochleew dorsalis: The more proximal of the two 
lines points to the strize acusticee. (After Sabin, F. R.) 


354 





of the root of the oculomotor nerve (Fig. 960). Prox- 
imal from this space is a long groove which opens out 
into the proximal capsule of the nucleus ruber. The 
groove contains the nucleus of Darkschewitsch and marks 
the junction of three different masses of fibres: (1) the 
fasciculus longitudinalis medialis; (2) the commissura 
posterior, and (8) the capsule of the nucleus ruber. The 
sides of the trough formed by the fasciculi longitudinales 
mediales of the sides are related in the model to a large 
hollow shell which occupies the centre of the dorsal part 
of the midbrain. It represents the stratum album pro- 
fundum. The relations of the fasciculus longitudinalis. 
medialis to the nuclei of the motor cerebral nerves is strik- 
ing. Itis in intimate relation with the nuclei of the n. 
hypoglossus, n. abducens, n. trochlearis, and, n. oculo- 
motorius. 

The middle portion of the proximal subdivision of the 
central fibre mass corresponds toa part of the formatio. 
reticularis alba. The relations of the nuclei of the cere- 
bral nerves to the central fibre mass are interesting. In 
Fig. 957 of the model can be seen the trough which 
contains the ventral column of gray matter of the spinal 
cord, opening out on to the medulla sheet. From this 
point two separate groups of nuclei belonging to the 
cerebral nerves can be traced: a median motor group, 
and a lateral group containing both motor and sensory 
nuclei. The median motor group includes the nucleus. 
n. hypoglossi, the nucleus n. abducentis, the nucleus n. 
trochlearis, and the nucleus n. oculomotorii. The lateral 
group, lying near the formatio reticularis, can be subdi- 
vided into a ventral motor group and a dorsal sensory 
group. The motor group includes the nucleus n. ac- 
cessorius of the motor nuclei of the n. glosso-pharyngeus, 
n. vagi, n. facialis, and n. trigeminus. The sensory 
group includes the nuclei of termination of the sensory 
portions of the n. glosso-pharyngeus, n. vagus, n. inter- 
medius, and n. trigeminus, together with all the nuclei of 
the cochlear and vestibular nerves. 

The corpus restiforme and brachium conjunctivum are 
well illustrated in the model. The corpus restiforme is. 
made up at this stage chiefly of the direct cerebellar tract. 
from the lateral funiculus from the spinal cord and the 
dorsal external arcuate fibres from the dorsal funiculi. 
The fibre olivo-cerebellares are non-medullated at this. 
stage. The relation of the corpus restiforme to the 
spinal cord, as well as its position with reference to the 
cerebellum and to the other cerebellar peduncles, is shown. 
in Plate A. 

The brachium conjunctivum or superior cerebellar pe- 
duncle is illustrated in Plate A, and Figs. 955, 956, and 
960. The part of it which forms the commissure between 
the superior nuclei of the vestibular nerve is well shown 
(Fig. 960). 

A number of facts concerning the cerebrai nerves and 
their nuclei are made apparent in the model. The nuclei 
of the median group all lie near the middle line just. 
ventral to the central canal and are closely related to the 
fasciculus longitudinalis medialis (Fig. 957). The nuclei 
of the n. hypoglossus and n. abducens are very near the 
dorsal surface, while the nuclei of the n. trochlearis and 
n. oculomotorius are farther ventral inasmuch as they 
lie on the midbrain curve. The nerve fibres from all 
the nuclei of the groups except those of the root of the 
n. trochlearis pass ventralward to the surface near the 
middle line. The root of the n. trochlearis takes an 
anomalous course since it passes dorsalward, decussates. 
in the velum, and leaves the brain on the dorsal surface 
of the isthmus of the rhombencephalon. The motor 
nuclei of the lateral group lie in the formatio reticularis. 
at a considerable distance from the middle line and at a. 
level ventral from the central canal. The root fibres from 
these nuclei, with the exception of those of the n. tri- 
geminus, do not follow a direct course toward the sur- 
face of the central nervous system. The root fibres of 
all four nerves take their exit at the lateral sulcus. 

The sensory nuclei of the entire region belong to the: 
lateral group, and their root fibres enter without excep- 
tion on the lateral surface (Plate A and Fig. 956). From 


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Reprinted from Vol. IX 
Reports of the Johns Hopkins 


REFERENCE HAND BOOK CF THE MEDICAL SCIENCES. 


Hospital, by permission. 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


what we know of the relation of sensory fibres to motor 
fibres in the spinal cord, it is not surprising that the sen- 
sory nuclei tend to occupy a position farther dorsalward 
than the motor nuclei of the lateral group. ° 

The n. hypoglossus arises from the nucleus n. hypo- 
. glossi which is seen to be long, and its dorsal border con- 
forms to the cervical curve. The nucleus extends more 
than one-half the length of the medulla, corresponding 
in general to the extent of the nucleus olivaris inferior, 
The root fibres leave the nucleus from its ventral border 
and have their superficial origin between the olive and 
the pyramid. The nucleus n. abducentis is well shown 
in Figs. 957 and 958. It lies in the distal part of the pons 
just below the floor of the fourth ventricle and just lateral 
from the fasciculus longitudinalis medialis. Its relations 
to the knee of the facial nerve are beautifully shown in 
three dimensions. The root fibres of the nerve leave the 
nucleus at its ventro-medial borderand pass ventralward 
and slightly spinalward, emerging between the pons and 
the medulla near the middle line. The root fibres of the 
n. abducens pass through the trapezoid body. 

The nuclei of the trochlear and oculomotor nerves are 
illustrated in Plate A and Figs. 955 and 956. These 
nuclei lie in a trough formed by the fasciculus longitudi- 
nalis medialis on its midbrain curve. The nucleus of the 


trochlear nerve is distally and dorsally situated on the 
curve, lying as it does in the proximal part of the collicu- 
There is alack of symmetry in the nuclei of 


lus inferior. 





Fic. 956.—View of the Model from the Lateral Aspect. 
substantia nigra, and the medial, lateral, and superior lenmisci. 


(2) the midbrain. The nuclei of the dorsal funiculi represent a way station for the sensory fibres from the spinal cord; 
cerebral nerves are represented by the nuclei nervi glosso-pharyngei, vagi, vestibuli, et trigemini. 
of the region of the model, except the n. cochlez, which was removed with the corpus restiforme. 





od Saal, 


Brain, 
Brain, 





the two sides, as the mass of cell bodies is single on the 
left side and double on the right. The volumes of the 
cell masses of the two sides are, however, about equal. 
The root fibres leave the lateral and dorsal border of the 
nucleus and pass at first lateralward in scattered bundles. 
They then turn dorsalward and slightly spinalward. In 
this dorsal course the fibres of the root bundles are col- 
lected into from two to four compact bundles, lying in 
the central gray matter just inside the stratum profundum 
album. The decussation dorsal to the central canal is 
well illustrated in Fig. 955. 

The nucleus of the n. oculomotorius is seen in Fig. 
955 to consist of a long mass of cells lying in the trough 
before mentioned. The nucleus as a whole lies farther 
ventralward than does the nucleus n. trochlearis. The 
nucleus is placed obliquely to a horizontal plane so that 
the distal end is situated farther dorsalward than the 
proximal end. The nuclei of the two sides lie so close 
together that they have been modelled as a single mass, 
which consists of two lateral parts which are fused to- 
gether in their ventral portions so as to make a gutter in 
which lies the median nucleus. The whole mass has the 
shape of a triangular prism with the apex pointing ven- 
tralward and the base dorsalward. The course of the 
root fibres leaving the nucleus is best seen in Fig. 956. 
The root bundle runs ventralward between the brachium 
conjunctivum and the red nucleus to the superficial 
origin in the fossa interpeduncularis. 


After removing from Plate A the following structures: the corpus restiforme, the 
The view is designed to show (1) the sensory nerves and their nuclei, and 


the sensory 
These include all of the sensory nerves 
1, Nucleus motorius princeps n. 


trigemini; 2, nucleus n. trigemini (sensory) ; 3, radix descendens (m.) n. trigemini; 4, stratum album profundum;_ 5, nucleus n. oculo- 
motorii; 6, radix n. oculomotorii; 7, radix descendens (m.) n. trigemini; 8, 2; 9, brachium conjunctivum; 10, fasciculus longitudinalis 
medialis; 11, nucleus n. vestibuli superior; 12, radix n. facialis (genu internum); 13, nucleus n. abducentis; 14, nucleus n. vestibuli 
lateralis; 15, radix descendens et ascendens n. vestibuli; 16, fibres to tractus solitarius; 17, radices n. IX. and X.; 18, tractus solitarius; 19, 
nucleus funiculi cuneati: 20, nucleus funiculi gracilis : 21, nucleus funiculi cuneati lateralis ; 22, fasciculi graciles ; 23, fasciculus cuneatus : 
24, substantia gelatinosa (Rolandi) ; 25, fasciculus cerebellospinalis; 26, fibrae arcuatze interns: (distal bundle); 27, substantia gelatinosa 
(Rolandi) ; 28, fasciculus cerebro-spinalis; 29, radix n. hypoglossi; 30, nucleus olivaris inferior; 31, radices n. IX. and X.; 32, tract from 
Deiters’ nucleus to spinal cord: 33, fasciculus lateralis; 34, radix n. vestibuli; 35, radix n. facialis; 36, corpus trapezoideum ; 37, radix n. 
trigemini (sens.) ; 38, radix n. trigemini (mot.); 39, lemniscus lateralis; 40, lemniscus medialis; 41, fibres to decussatio tegmenti dorsalis ;. 
42, radix n. oculomotorii ; 43, nucleus columnaris; 44, nucleus capsulze lateralis nuclei rubri; 45, lectus substantiz nigrz; 46, nucleus ruber. 


Radia n. trigemini (sens.) : 
fete Be) 


The proximal line runs to the root bundle, the distal to the tractus spinalis n. trigemini. 


(After Sabin, 


355 


Brain, 


Brain. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





As to the n. accessorius, only the extreme proximal | the superficial origin, thus forming what Miss Sabin re- 
part of the spinal portion isshownin the model. The so- | fers to as a pars prima and a pars secunda of the root. 
called vagus portion of the nerve is not illustrated. The The nucleus ambiguus or motor nucleus of origin of the 





it 15 
6 





32 
42 41 33 


34 


Fig. 957.—View of the Model from the Lateral Aspect. The sensory nerves of Fig. 956 have been removed and all of the motor cerebral 


nerves except the n. trochlearis are now shown. 1, Fasciculus retroflexus (Meynerti); 2, capsula dorsalis nuclei rubri; 3, nucleus n. 
oculomotorii; 5, radix descendens (m.) n. trigemini; 6, lemniscus medialis; 7, locus coeruleus; 8, lemniscus lateralis; 9, fasciculus 
longitudinalis medialis; 10, formatio reticularis alba; 11, nucleus motorius princeps n. trigemini; 12, formatio reticularis alba; 13, radix 
n. facialis (genu internum); 14, nucleus n. abducentis; 15, nucleus n. facialis; 16, tract from Deiters’ nucleus to funiculus lateralis; 17, 
nucleus ambiguus; 18, radices n. IX. and X. (mot.); 19, fasciculus longitudinalis medialis ; 20, nucleus n. hypoglossi; 21, radix n. hypo- 
glossi; 22, radix n. accessorii; 28, fasciculus gracilis; 24, canalis centralis; 25, position of columna ventralis; 26, fasciculus ventralis 
proprius; 27, fasciculus cerebello-spinalis; 28, fasciculus cerebello-spinalis; 29, fasciculus lateralis; 30, radix n. hypoglossi; 31, nucleus 
olivaris accessorius medialis; 32, nucleus olivaris superior; 33, radix n. facialis, pars secunda; 34, corpus trapezoideum; 35, radix n. 
trigemini (mot.); 36, lemniscus medialis to substantia nigra; 37, radix n. oculomotorii; 38, nucleus columnaris; 39, nucleus capsule 
lateralis nuclei rubri ; 40, lectus substantiz nigree ; 41, capsula lateralis nucleirubri; 42, lemniscus medialis ; 48, capsula superior nuclei rubri. 
(After Sabin, F. R.) 


root fibres of the nerve, instead of passing directly from | n. glosso-pharyngeus and the n. vagus is diagrammati- 
the cell bodies of origin to the lateral groove, pass dorsal- | cally represented in Fig. 957. It lies in the formatio re- 
ward and then turn ventralward and lateralward toward | ticularis, dorso-lateral to the dorsal accessory olive and 


lateral from the tract from Deiters’ nucleus to the spinal 
cord. It is on about the same horizontal level as the 
nucleus n. facialis. The root fibres are divided by Miss 
Sabin into a pars prima and a pars secunda. In the 
pars prima they pass medianward and dorsalward toward 
the floor of the fourth ventricle. Then the pars secunda 
begins, the fibres turning sharply to pass ventralward 
and lateralward, where they follow the same course as do 
the entering sensory fibres of 
the same nerve. The root 
fibres plunge through the 
tractus spinalis n. trigemini. 
The nucleus n. facialis, 
situated in the dorsal part of 
the pons just dorsal to the 
level of the corpus trapezoid- 
eum, is seen in Fig. 957. It 
isa compact oval mass of cells 
having its long axis parallel 
to the long axis of the pons. 
The illustration in three di- 
mensions of the root fibres, 
including the pars prima, the 
genu internum, and the pars 











Fig. 958.—View of the Lateral Surface of the Medulla Sheet. The view can be related to Plate A  secunda, represents one of 


and Figs. 955 and 956 by the position of the nucleus n. abducentis. 1, Fasciculus longitudinalis ; 
medialis; 2, formatio reticularis alba; 3, nucleus n. abducentis; 4, position of nucleus centralis S nae mare see 
inferior; 5, fasciculus longitudinalis medialis; 6, formatio reticularis alba; 7, lemniscus medialis ; 1) Ne model, . e mo or 
8, nucleus of Roller; 9, position of part of nucleus accessorius medialis; 10, position of columna part of the n. trigeminus is 


ventralis in fasciculus ventro-lateralis (1); 11, nucleus olivarius superior; 12, radix n. abducentis; * . 
13, corpus trapezoideum; 14, radix n. facialis, pars secunda; 15, lemniscus lateralis; 16, lemniscus sits Oe Fig S peace Se sc 
medialis; 17, corpus trapezoideum. (After Sabin, F. R.) entire nerve 1s Well 1llustrate 


356 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





in Fig. 956. The nucleus motorius princeps n. trigem- 


ini lies in the middle of the pons, just proximal to the 
transverse part of the knee of the facial nerve. 


The dis- 





Fig. 959.—View of the Model from a Dorso-Median Aspect. This 
view is designed to show the central fibre mass, that is, the me- 
dulla, pontal and midbrain sheets, together with the corpus tra- 
pezoideum. 1, Capsula superior nuclei rubri; 2, radix n. oculo- 
motorii; 3, nucleus ruber; 4, fasciculus retroflexus (Meynerti) ; 5, 
lemniscus medialis; 6, corpus trapezoideum; 7, nucleus olivaris 
superior; 8, stratum interolivare lemnisci: 9, nucleus n. hypo- 
glossi; 10, nucleus olivaris accessorius medialis; 11, decussatio 
lemniscorum ; 12, canalis centralis; 13, substantia gelatinosa (Ro- 
Jandi) ; 14, nucleus funiculi gracilis; 15, fasciculus cuneatus to for- 
matio reticularis; 16, nucleus funiculi cuneati; 17, nucleus olivaris 
inferior; 18, radix n. cochlezw; 19, corpus trapezoideum; 20, radix 
n. vestibuli; 21, nucleus n. cochlez dorsalis; 22, strize acustice ; 
23, nucleus n. abducentis; 24, radix n. facialis; 25, nucleus olivaris 
superior; 26, formatio reticularis alba; 27, fasciculus longitudinalis 
medialis; 28, lemniscus lateralis. 

a, Fibres running from lemniscus lateralis to the brachium con- 
junctivum. (After Sabin, F. R.) 


tal end lies opposite the proximal end of the nucleus 
olivaris superior. The radix descendens mesencephalica 
n. trigemini is seen in the model starting at the distal 
border of the stratum album profundum and traversing 
the pons as a narrow bundle parallel to the raphe. Its 
relation to the locus cceruleus is obvious. The decussat- 
ing fibres pertaining to the n. trigeminus are shown in 
Fig. 955. 

As regards the sensory nuclei in the model, those con- 
nected with the n. glosso-pharyngeus and n. vagus may 
first be referred to. They include the nucleus ale cineresx 
and the nucleus tractus solitarii. These are well illus- 
trated in Figs. 955 and 956. The mass of cell bodies situ- 
ated at the distal end of the tractus solitarius, shown in 





Fig. 955, possibly corresponds to the commissural nucleus 
of Ramon y Cajal. 

The sensory nucleus of the n. trigeminus corrresponds 
to the substantia gelatinosa. In Fig. 956 the sensory 
fibres of the n. trigeminus are seen to enter the lateral 
surface of the pons just distal tothe motor bundle. The 
fibres form a compact mass, which extends dorsalward 
past the lemniscus lateralis into the region of the pars 
dorsalis pontis. The bundle bifurcates into a Y, corre- 
sponding to the Y-shaped bifurcation of its constituent 
fibres. Into the notch of the Y fits the upper end of the 
sensory nucleus. The lateral and longer arm of the Y 
forms the tractus spinalis n. trigemini. The medial and 
shorter arm of the Y passes dorsalward just medial to the 
sensory nucleus. The tractus spinalis n. trigemini ex- 
tends from the middle of the pons to the upper part of 
the cervical spinal cord. It lies medial to the cochlear 
nuclei but lateral from the nuclei of the dorsal funiculi. 
For details with regard to the sensory nucleus of the 
trigeminal nerve and the tractus spinalis n. trigemini, 
Miss Sabin’s article may be consulted. 

The various nuclei connected with the n. vestibuli are 
depicted in three dimensions in the model. The root 
fibres of the vestibular nerve, on entering the central 
nervous system, bifurcate into short ascending limbs and 
long descending limbs. The bundle of descending limbs 





17 
Fig. 960.—View of the Midbrain from the Superior or Cerebral As- 


pect. This view can be understood by comparing it with Plate 
A and Figs. 956 and 957, which show the stratum profundum 
album, the lemniscus superior, and the capsula nuclei rubri from 
the lateral aspect. 1, Nucleus n. abducentis; 2, fasciculus longi- 
tudinalis medialis; 3; nucleus reticularis tegmenti; 4, nucleus colli- 
culi inferioris; 5, capsula nuclei colliculi inferioris; 6, position of 
nucleus n. trochlearis; 7, lemniscus superior; 8, y; 9, position of 
nucleus n. oculomotorii; 10, stratum album profundum; 11, lem- 
niscus medialis; 12, commissura posterior; 13, fasciculus retro- 
flexus (Meynerti); 14, capsula superior nuclei rubri; 15, lectus 
nuclei rubri; 16, nucleus fasciculi longitudinalis medialis; 17, fas- 
ciculus longitudinalis medialis; 18, decussatio tegmenti ventralis ; 
19, decussatio tegmenti dorsalis; 20, capsula dorsalis nuclei rubri; 
21, decussatio tegmenti dorsalis: 22, brachium conjunctivum : 23, 
a; 24, brachium conjunctivum (dorsalis bundle) ; 25, corpus trape- 
zoideum and nucleus olivaris superior; 26, commissure between 
Bechterew’s nuclei. 

y is a space in the model, in the stratum profundum album, where 
fibres of the formatio reticularis alba are related to the substantia 
centralis grisea. (After Sabin, F. R.) , 


is known as the radix descendens n. vestibuli. There 
are four nuclei, namely: (1) the nucleus n. vestibuli 
medialis; (2) the nucleus n. vestibuliradicis descendentis, 
which is directly continuous with (1); (8) the nucleus n, 


357 


Brain. 
Brain. 





vestibuli superior or nucleus of von Bechterew, and (4) 
the nucleus n. vestibuli lateralis or nucleus of Deiters. 
The last-mentioned nucleus is divisible into two parts, 
one part lying lateral to the root bundle of the vestibular 


F.p. 










Fs. 


Fd. 





/ CEREBRAL. \ 







| LATERAL. 


S.p. 


CEREBRAL. 


MESIAL. 


Fig. 962. 


Fies. 961 AND 962.—FIG. 961.—View of the Dorso-Lateral and Lateral Surfaces of the Nucleus Olivaris 
f.dl., Facies dorso-lateralis; f.l., facies lateralis; f.p., fissura prima ; /.s., fissura secunda ; 


Inferior. 
f.t., fissura tertia; f.q., fissura quarta; l.p., lobus primus; 1.s., 
lobus secundus; l.t., lobus tertius; l.q., lobus quartus. 

Fic. 962.—View of the Ventral Surface of the Nucleus Olivaris Su- 
perior. s.p., Sulcus primus; 8.s., sulcus secundus; 8.t., sulcus 
tertius. (After Sabin, F. R.) 


nerve and the other part lying in an angle between the 
superior and medial nuclei of the vestibular nerve. The 
model illustrates further a set of internal arcuate fibres 
passing from the medial nucleus to the raphe, a com- 
missure between the superior vestibular nuclei off the 
two sides, a tract from Deiters’ nucleus to the spinal cord, 
and two sets of fibres relating the vestibular 
area with the cerebellum. 

Connected with the n. cochlez near its en- 
trance are two definite nuclei of termination, 
namely, the nucleus n. cochlee ventralis and 
the nucleus n. cochlez dorsalis (Plate A). The 
relation of the ventral cochlear nucleus to the 
corpus trapezoideum is shown in Figs. 959 and 


VENTRAL. 


Corpus geniculatum laterale. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


A surprising feature of the model is the appearance 
presented by the nucleus olivaris inferior (Figs. 961, 962). 
Sections through the medulla have long taught us that 
the gray matter of the olive forms a hollow shell with a 
wrinkled wall, but the method 
of reconstruction indicates that 
the olive has a constant and 
definite shape, its surface be- 
ing marked by gyri and sulci 
as definitely as that of the 
cerebral cortex. Miss Sabin 
describes the lateral surface as 
presenting four lobes. The 
first or proximal lobe is the 
largest; it is subdivided in the 
dorsal portion by two or three 
groups or sulci. It contains 
three gyri. The second and 
third lobes each consist of a 
single convolution or gyrus; 
the fourth lobe is the smallest 
of all, and consists like the sec- 
ond and third of a single gyrus. 

In the midbrain the main 
bundles of fibres have been 
modelled as well as the nu- 
cleus ruber and its capsule, 
the fasciculus retroflexus of 
Meynert, the various decus- 
sations of the tegmentum, the 
stratum album profundum, the 
substantia centralis grisea, and 
the substantia nigra. 

Passing now to the histology 
and microscopic anatomy of 
the prosencephalon, we may 
begin by a description of some 
sections which pass through 
the hypothalamus and _ the 
thalamencephalon. 

In - Fig. 963, which repre- 
sents a transverse section 
through the human brain at 
the level of the decussatio bra- 
chii conjunctivi, the positions 
of the lemniscus superior and 
of the main portions of the 
lemniscus medialis are out- 
lined. Lateral and dorsal from 
the lemniscus superior is seen 
the brachium quadrigeminum 
inferius. 

In a section higher up (Fig. 
964), in addition to structures 
met with in sections lower 
down, some of the nuclei of the 
thalami are seen, the nucleus 
ventralis lateralis thalami and 


= 


"TVNIdS 


“TV NIdS 


Pulvinar: 








; Brachium quadrigeminum inferius. 
am 12) oy peter superior. 


fost Aqieductus cerebri. 


A? 


\ Decussatio brachit 
= conjunctivi. 


Nucleus posterior thalamé. t 


Fria. 963.—Frontal Section through a Normal Human Brain at the Level of the 
Decussatio Brachii Conjunctivi. 
Berlin, bd. xxvii., 1895. 


(After C. von Monakow, Arch. f. Psychiat., 
(Taken from ‘‘The Nervous System and Its Constituent 


960. Neurones,’? New York, 1900.) 


358 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


a 





the nucleus posterior thalami. 


j 





Corpus geniculatum laterale. 
eas geniculatum mediale. 


Lemniscus. 


The relation of the lem- 
niscus to the nucleus ventralis lateralis thalami is obvious. 








ees 


Basis pedunculi. 





Nucleus ventralis lateralis thalami. 


Pulvinar. 
hy Colliculus superior. . | 
/ Commigsura posterior cerebri. 
, Aqueductus cerebri, 
tt 


Fasciculus longitudi- 
nalis medialis. 


=. Brachium conjunctivum 
G et nucleus ruber. 


'Lemniscus medialis. 


Fic. 964.—Frontal Section through a Normal Human Brain at Level of Upper Extremity of 


Corpus Geniculatum Mediale. 
xxvii., 1895, Taf. ii., Fig. 13.) 
lateral white matter of pulvinar. 
Neurones,’’ New York, 1900.) 


More ventrally situated are seen the lateral and medial 


geniculate bodies. 


In a section higher up (Fig. 965) the nucleus hypo- 


thalamicus, or 
Luys’ body, is il- 
lustrated. In the 
thalamus are seen 
the tzenia thalami, 
the nucleus medi- 
alis thalami, the 
lamina medullaris 
thalami, the nu- 
cleus medialis 
thalami (or centre 
median of Luys), 
the lamina medul- 
laris medialis, the 
nucleus ventralis 
thalami (4), the 
lamina medullaris 
media, the nucleus 
ventralis thalami 
(a). Lateral from 
the latter is seen 
the capsula inter- 
na, and more lat- 
eral still the nu- 
cleus lentiformis. 
In the hypothala- 
mus the nucleus 


hypothalamicus or corpus Luysi is seen just dorsal to the 
base of the peduncle where it goes over into the capsule. 
A little higher up (Fig. 966), passing from the third 


ventricle lateralward, are seen the 
tenia thalami, the lamina medullaris 
medialis, the nucleus anterior thal- 
ami, the nucleus lateralis thalami, 
and the zona reticularis. Lateral 
from the latter is seen the capsula 
interna. The anterior part of the 
nucleus ventralis thalami is met with 
in the ventral part of the thalamen- 
cephalon. At the ventral extremity 
of the lamina medullaris medialis, in 
transverse section, is the fasciculus 
thalamo-mammillaris (Vicq d’Azyri). 
In the hypothalamus are seen a part 
of Forel’s field H and the two parts 
of the ansa lenticularis, namely, the 
pars dorsalis and the pars ventralis. 
Ventro-medially situated is the colum- 
na fornicis, and most ventral of all in 
section is the tractus opticus. 

In the next section (Fig. 967) the 


Nucleus lentiformis.~——: 


the Nucleus Hypothalamicus. 
xxvii., 1895, Taf. iii., Fig. 20.) 
matter of nucleus ruber; y, lateral white matter of nucleus ruber. 
Nervous System and Its Constituent Neurones,”” New York, 1900.) 


(After C. von Monakow, Arch. f. Psychiat., Berlin, Bd. 
x, Lateral white matter of lateral geniculate body; y, 
(Taken from ‘‘ The Nervous System and Its Constituent 


phous cells. 





Lamina medullaris media. 
Lamina medullaris medialis. 

» Nucleus medialis thalami (b) 
(centre median). 






} 









a. 


- 
-- 


4 
1 
| 
J 
£ 
i 
f 
i 


Ventriculus lateralis (cornu inferius). iy 
Nucleus ventralis thalami (a). : 
Nucleus ventralis-thalami (6) 


Basis peduncult. 


Fi@. 965.—Frontal Section through a Normal Human Brain at the Level of the Lower End of 
(After C. von Monakow, Arch. f. Psychiat., Berlin, Bd. 
a, Dorsal white matter of nucleus ruber; 8, ventral white 









Capsula interna. «:§ 


Zona reticularis (Gitter- ss 
schicht) ee 


Nucleus lentiformis. } 


Nucleus ventralis thalami = ‘i 


(ant.). Re RR 
Ansa lenticularis, pars 7X07" “EX 
dorsalis. . 


Commissura anterior cerebri.” ! 
Ansa lenticularis (pars ventralis), 


Pedunculus cerebri. 


-L-<Lamina medullaris thalami#. 


t-Fasciculus retroflexus 
(Meynertt). 


\Fasciculus pedunculomant: 
\\ millaris, pars tegmentalis, 


Nucleus hypothalamicus 
(corpus Luysi). 


Brain, 
Brain, 


part cut through corresponds to the most anterior portion 
of the thalamencephalon. 


Passing from the middle line 
lateralward are seen the stratum griseum 
centrale, the tenia thalami, the nucleus 
anterior thalami with its ventral capsule, 
the fasciculus thalamo-mammillaris (Vicq 
d’Azyri), the nucleus lateralis thalami, 
and the nucleus ventralis thalami (an- 
terior part). Bounding the thalamus 
lateralward is the capsula interna of the 
nucleus lentiformis. The three parts 
of the nucleus lentiformis are represent- 
ed, namely, the pars medialis and pars 
lateralis of the globus pallidus and the 
putamen. Ventral to the globus palli- 
dus is the commissura anterior cerebri. 
A portion of the ventral part of the ansa 
lenticularis is seen in the ventro-medial 
part of the section. 

The histology of the cerebral cortex 
varies in different parts. At least four 
layers are usually described (Fig. 968): 
(1) an external molecular layer; (2) a 
layer of small pyramidal cells; (8) a 


layer of large pyramidal cells, and (4) a layer of polymor- 
The molecular layer contains a very large 
number of nerve fibres which run in various directions. 


They represent 
for the most part 
terminals of other 
cortical cells or of 
projection or asso- 
ciation fibres. 
The subdivisions 
of the apical den- 
drites of the pyra- 
midal cells consti- 
tute a large part 
of this layer. 
Three types of 
cells exist here: 
(1) polygonal 
cells, (2) spindle- 
shaped cells, and 
(3) triangular or 
stellate cells. 

The layer of 
small pyramidal 
cells and that of 
the large pyrami- 
dal cells are very 
characteristic. 
They contain the 
pyramidal-shaped 


(Taken from ‘* The 


perikaryons which are so characteristic of the micro- 
scopic picture of the cerebral cortex. 
gives off an ascending dendrite known as the chief proc- 


Each perikaryon 


Nucleus lateralis thalami. 
Nucleus anterior thalami. 


Lamina medullaris medialis. 


--- Tenia thalumi. 


+ > A Fasciculus thalamo mammil- 
ae j laris (Vicg ad’ Azyri). 


- ENN f-"{Columna fornicis. 
i 


we 
MY ractus opticus. 







Fic. 966.—Frontal Section through a Normal Human Brain at the Level of the Ansa Lenticu- 


laris (Anterior to the Nucleus Hypothalamicus). 


Berlin, Bd. xxvii., 1895, Taf. iii., Fig. 28.) 
stituent Neurones,”’ New York, 1900.) 


(After C. von Monakow, Arch. f. Psychiat., 
(Taken from *‘ The Nervous System and Its Con- 


359 


Brain, 
Brain, 





ess and several basilar dendrites. A single axone de- 
scends into the white substance. 

The layer of polymorphous cells contains also a few 
pyramidal cells, but a large proportion of cells in this layer 


¥ 















Capsulau interna. ~ thalami! 


See 


thalami (ant.). 


Nucleus ies 1 < 
A 
\ 
a 


Piittamen.” he is Fee ce 
Aw. iS 
Globus pallidus, pars“ Nee 
lateralis, eo 
Globus pallidus, pars medialis. 
Commissura anterior cerebri., 


Fic. 967.—Frontal Section through a Normal Human Brain at Level of Anterior Part of 
(After C. von Monakow, Arch. /. Psychiat., Berlin, Bd. xxvii., 1895, Taf. 
(Taken from *‘ The Neryous System and Its Constituent Neurones,’’ New 


Thalamus. 
iv., Fig. 33.) 
York, 1900.) 


are dendraxones (Golgi cells of type II.), and the so- 
called Martinotti cells which have ascending axones. 

The cortex in the region of the sense centres has a 
peculiar stamp for each particular sense centre. The 
structure of the occipital cortex near the calcarine fissure 
may be cited as an example. A section is shown in Fig. 
969. The enormous complexity of the various layers is 
obvious. 

The cortex varies much in appearance, too, in different 
animals, as will be seen by comparing a section through 
the human cortex with one from that of the dog and of 


/ Nucleus lateralis thalami. 
/ Nucleus anterior thalami (a). 
Capsula ventralis nucl. ant. 


/ Tenia thalami.; 

art Fasciculus thalamo-mammil- 
fie laris (Vicq d’ Azyri). 

ay Stratum griseum centrale. 

i--k--Pedunculus thalami medialis. 


&\-" Columna fornicis. 


v 
8 Ansa lenticularis; pars ventralis. 





the mole (vide supra). 

A schematic section of the cerebellar cortex is shown 
in Fig. 970. The structures seen in ordinary hema- 
toxylin and eosin preparations are illustrated in Fig. 971. 

hésumé of Conduction Paths in the Brain.—The prin- 
cipal conduction 
paths in the brain 
are made up of 
several sets of 
superimposed 
neurones or neu- 
rone systems. 
The conduction 
paths may be di- 
vided into the 
centripetal or sen- 
sory, the centrif- 
ugal or motor, 
and the associa- 
tive. 

The centripetal 
or sensory con- 
duction paths in- 
clude those (1) of 
bodily sensation ; 
(2) of taste; (8) 
of smell; (4) of 
sight; (5) of hear- 


Sane (eS molec- 
ular layer. 


pyramidal 


layer of small 
cells. 


pyramidal 


layer of large 
rt cells. 


layer of poly- 





morphous ing. ; 
cells. The centripetal 
conduction path 


of bodily sensa- 
tion carries the 
impulses concern- 
ed in touch, tem- 
perature, pain, 
muscle sense, and 
visceral sensa- 
tions. It consists 
of a direct con- 
duction path and 








Fig. 968.—Golgi Preparation of the Cerebral 
Cortex. (After Béhm u.-yon Davidoff, 
‘*Lehrbuch der Histologie,”’ 8. 282, Fig. 201.) 


360 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


several roundabout conduction paths. Just which im- 
pulses are carried by these various portions of this cen- 
tripetal conduction path is not known. The most direct 
conduction path consists in all probability of three sets 
of superimposed neurones or neurone 
systems: (1) The peripheral sensory neu- 
rones (including the ganglion cells, and 
their prolongations, of the ganglia on 
the dorsal roots of the spinal nerves, 
and the ganglia on the sensory cerebral 
nerves). (2) A 
set of neurones 
extending from 
the nuclei of ter- 
mination of the 
peripheral sen- 
sory nerves to 
the ventro-later- 
al region of the 
thalamus (in- 
cluding the nu- 
clei of Goll and 
Burdach in the 
medulla and the 
fibres of the me- 
dial lemniscus). 
(5) A set of neurones, the cell 
bodies of which are situated in 
the ventro-lateral part of the 
thalamus and the axones of 
which reach to the someesthetic 
area of the cerebral cortex, that 
is, to the central gyri, the feet of 
the frontal gyri, and the gyrus 
fornicatus. 

The less direct portions of this 
conduction path concern mainly 
the portion of the conduction 
path situated between the per- 
ipheral sensory neurone systems 
and the neurone system extend- 
ing from the diencephalon to the 
somesthetic area of the cortex. 
Roundabout routes are made 
through the cerebellum by way 
of Gowers’ tract and the direct 
cerebellar tract to the cerebellum, 
and by way of the brachium con- 
junctivum from the cerebellum 
to the red nucleus. From the 
red nucleus a neurone system 
extends higher up, probably to 
the cortex, possibly indirectly, 
by way of a new neurone whose 
cell body is situated in the hy- 
pothalamus. The conduction 
path just described is diagram- 
matically illustrated in Fig. 
972. 

The peripheral sensory neu- 
rones of the path concerned in 
bodily sensation have their cell 
bodies situated in ganglia. 
These cell bodies give off an 
axis-cylinder process which bi- 
furcates T-shaped to form two 
fibres. One of these fibres runs 
to the periphery, the other into 





Fic. 969.—Section through 
the Cortex of the Gyrus 
Occipitalis Superior. 
(After C. Hammarberg, 
““Studior ofver Idiotiens 


the central nervous system.  xlinik och Patologi, ete., 
That going to the periphery is Upsala, 1893, Taf. ii. 
the stronger, the central fibre Ms-4:) 


being of smaller calibre. The 

bundle of medullated central fibres froma given ganglion 
forms the dorsal root of onespinal nerve. The peripheral 
fibres are connected in their distal parts frequently with 
special kinds of terminal sensory apparatus; sometimes 
they end free in among the cells of the tissues at the per- 
iphery. The central fibres entering the spinal cord un- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





dergo Y-shaped division with formation of a long ascend- 
ing limb and a short descending limb. On their way 
they give off collaterals which run in to end in the gray 
substance, and the main. fibres themselves ultimately 


of the sensory neurones of the second order chiefly termi- 
nate, a new neurone system (sensory neurones of the third 
order) begins. The perikaryons of this neurone system 
are situated in the ventro-lateral nuclei of the thalamus. 





Fic. 970.—Schematic Diagram of the Cerebellar Cortex. 
Ordinary nuclear staining (the layer of Purkinje cells is omitted); B, section vertical to the surface of a convolution; C, longitudinal 
section through a convolution. Band OC by the chrome-silver method. 1, Stellate cell; 2, molecular layer; 3, granular layer; 4, medullary 
layer; 5, axone of a Purkinje cell; 6, moss fibre; 7, cell of granular layer; 8, axone of cell of granular layer; 9, climbing fibre; 10, teloden- 
drion of collateral of climbing fibre; 11, axone of cell of granular layer; 12, large stellate cell; 13, stellate cell. 


terminate by running in to end in the gray matter of the 
central nervous system. The longest fibres from the 
dorsal roots reach the medulla oblongata and terminate 
in the nucleus funiculi gracilis of Goll or the nucleus 
funiculi cuneati of Burdach. The shorter fibres of the 
dorsal roots end in the gray matter of the central system 
near the point of entrance. The collaterals and termi- 
nals of the sensory fibres end in the spinal cord, chiefly 
about the cell bodies of neurones in the dorsal horns and 
in the middle zone of the gray matter. The axones of 
these cells carry impulses farther cerebralward. <A cer- 
tain number of collaterals, the so-called reflex collaterals, 
end about the cell bodies of the lower motor neurones in 
the ventral horns. Another group of collaterals crosses 
through the posterior commissure to end about the cell 
bodies of neurones in the gray matter of the opposite side 
of the cord. An important group of collaterals ends in 
among the cell bodies of the nucleus dorsalis (Clarke’s 
column). 

The sensory neurones of the second order of the con- 
duction path now under discussion include the cell 
bodies of the nucleus funiculi gracilis and the nucleus 
funiculi cuneati and their axis-cylinder processes. The 
medullated axones from the perikaryons in these nuclei 
go as internal arcuate fibres to the middle line of the 
medulla oblongata where they cross over, decussating 
with similar fibres from the opposite side, to form the 
decussatio lemniscorum. On crossing, these medullated 
axones turn and run cerebralward, first in the stratum 
interolivare lemnisci, higher up forming the lemniscus 
medialis. These fibres in the lemniscus medialis are 
joined by medullated axones from the sensory nuclei of 
termination of the cerebral nerves. The fibres of the 
lemniscus medialis pass through the pons and enter the 
cerebral peduncle lying in its tegmental portion. They 
pass through the hypothalamus and end chiefly in the 
ventro-lateral region of the thalamus. Not all the fibres, 
however, of the lemniscus medialis reach this diencephalic 
termination. Many endin the pons andmidbrain. From 
the ventro-lateral region of the thalamus, where the axones 


(After B6hm u. von Davidoff, ‘‘ Lehrbuch der Histologie des Menschen,”’ S. 279.) 











cA 


The medullated axones of these neurones pass through 
the internal capsule in the posterior part of its occipital 
subdivision and extend to the gyri of the cerebral cortex 
in the regions previously designated under the term 
somesthetic area. According to the period of medul- 


— 
gah 





[teres = 


Fig. 971.—A Section through the Cerebellar Cortex Stained with 
Hematoxylin and Eosin. (After BOhm u. von Davidoff, ** Lehrbuch 
der Histologie des Menschen,” S. 278, Fig. 197.) 1, Blood-vessel ; 
2, dendrite; 3, Purkinje cell; 4, large stellate cell ; 5, cell of granu- 
lar layer; 6, layer of nerve fibres. 


361 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





lation, these diencephalo-telencephalic neurones are di- 
visible into at least three systems (Flechsig). 

While the above sensory neurones of the second order 
account for the further conduction of sensory impulses 


the Cte Gea. 





ae * 





espeurds eyinpew 


Fig. 972.—Scheme of General Someesthetic Paths. (Taken by permission from 
“The Nervous System and Its Constituent Neurones,”’ p. 744, Fig. 470, New 


York, D. Appleton & Co., 1900.) 


which reach the nuclei of Goll and Burdach in the medul- 
la, there are other sensory neurones of the second order 
which carry farther cerebralward the impulses which are 
brought to the spinal cord by means of the shorter fibres 
of the dorsal roots and the collaterals of the longer fibres 
which end in the gray matter of the cord. These include 
the neurones, the axones of which make up the direct 
cerebellar tract, Gowers’ tract, and the ground bundles 
of the lateral and ventral funiculi. 

Those the axones of which make up the direct cere- 
bellar tract have their cell bodies situated in the nucleus 
dorsalis (Clarke’s column). The tract is first well marked 
in the lower part of the thoracic cord. The medullated 
axones run cerebralward in the dorso-lateral region of the 
lateral funiculus of the cord, pass through the corpus 
restiforme, and terminate chiefly, without crossing to the 
opposite side, in the vermis of the cerebellum. 

Those the axones of which make up Gowers’ tract 
have their perikaryons situated chiefly in the region of 
the gray matter of the cord, partly of the opposite side. 
The medullated axones run upward in the ventro-lateral 
region of the cord, pass through the medulla oblongata 
and pons as far as the level of the root of the trigeminal 
nerve. The fibres hook about this and then pass back- 


362 





ward through the velum medullare anterius to end in 
the cerebellum. 

The neurones of the second order whose axones run in 
the ground bundles of the ventral and lateral funiculi 
chiefly represent short tracts which run in to 
end in the gray matter of the central system at 
various levels, so that the conduction path of 
which these neurones constitute a member is 
probably a multiple-membered path. 

The sensory neurones of the second order 
whose axones end in the cerebellum transfer 
their impulses in all probability to neurones of 
a higher order, the axones of which are rep- 
resented by the fibres of the brachium conjunc- 
tivum. Many of these fibres end in the red nu- 
cleus of the opposite side. Others pass by the 
red nucleus and end in the hypothalamus. 
From the red nucleus and from the hypotha- 
lamic region neurone systems carry impulses 
through the posterior part of the internal cap- 
sule out to the somesthetic area of the cortex. 

The centripetal conduction path of taste is not 
so well known as some of the other conduction 
paths. The peripheral sensory neurones of this 
path include a portion of those of the nervus 
glosso-pharyngeus and probably also of the ner- 
vus trigeminus and nervus intermedius. The 
perikaryons of these neurones are situated in the 
ganglia on the roots of these nerves. The periph- 
eral fibres run out to the tongue and are there 
connected with the peculiar bodies known as the 
taste buds. The central fibres of the n. glosso- 
pharyngeus and of the n. intermedius run into 
the medulla and are situated chiefly in the trac- 
tus solitarius. The central fibres of the n. tri- 
geminus run into the pons in the sensory root 
of this nerve, there bifurcate into a short ascend- 
ing limb and a long descending limb, the latter 
running down and helping to form the so-called 
tractus spinalis n. trigemini. These fibres give 
off collaterals which, together with the ultimate 
terminals, end in the gray matter which repre- 
sents the nucleus of termination of the sensory 
part of the n. trigeminus. The central neurones 
of this path are very incompletely understood. 
Those of the second order have their perikaryons 
situated in the nuclei of termination of the n. 
glosso-pharyngeus, n. intermedius, and n. tri- 
geminus. Their axones probably run longitu- 
dinally in the formatio reticularis. But the fur- 
ther continuation of the conduction path, the 
number of neurone systems superimposed in 
this path, and the cortical termination of the 
path are not yet satisfactorily understood. 

The centripetal conduction path of smell has been in 
part carefully worked out. The peripheral sensory 
neurones of this path (olfactory neurones of the first 
order) include peculiar bipolar cells situated in the nasal 
mucous membrane. The central processes are non- 
medullated axones which perforate the cribriform plate 
of the ethmoid bone and terminate by multiple ramifica- 
tions in the olfactory glomeruli of the bulbus olfactorius. 
The olfactory neurones of the second order have peculiar 
perikaryons, known as the mitral cells of the olfactory 
bulb. The impulsesare brought to the perikaryons from 
the olfactory glomeruli by means of the dendrites of the 
mitral cells. The axones of these cells run through the 
olfactory tract, some of them entering the gyrus olfac- 
torius lateralis, others the gyrus olfactorius medialis. 
A good many of the axones end in two small gyri in the 
uncus of the temporal lobe (gyrus semilunaris rhinen- 
cephali and gyrus ambiens). This is the temporal olfac- 
tory centre of Flechsig. Others of the fibres end in the 
gyrus subcallosus and the substantia perforata anterior 
(frontal olfactory centre of Flechsig). Some axones pass 
through the anterior commissure of the brain to the 
olfactory region of the opposite side. The connections 
of the temporal and frontal olfactory centres with other 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





portions of the brain are very complex and special treat- 


ises must be consulted for a description of them. 
of them are shown in Fig. 973. 


The centripetal conduction path concerned in carrying 
the visual impulses is made up as follows: The peripheral 





Cyr. subeahkK > ‘ 
Mitral cells 


Nasal 
Muc. Memb. 


Brain, 
Brain, 


running through the occipito-thalamic radiation of Gra- 
tiolet to terminate ultimately in the gray matter of the 
cortex of the occipital lobe, especially that about the 
fissura calcarina (Fig. 974). 

The centripetal conduction path which carries the im- 


Corpus Soratc’s 
: Str medull. 







Fic. 973.—Schematic Representation of Some of the Principal Neurone Systems of the Olfactory 


Conduction Path. Projected into sagittal plane. Bulb. olf., bulbus olfactorius; Col. forn., 
columna fornicis; Col. sup., colliculus superior; Comm. ant., commissura anterior cerebri; 
Corp. mam., corpus mammillare; Corp. pin., corpus pineale; G.0.b., ganglion opticum basale ; 
Gl. olf., glomeruli olfactorii; Gyr. amb. rhin., gyrus ambiens rhinencephali; Gyr. olf. lat., 
gyrus olfactorius lateralis; Gyr. 0. m., gyrus olfactorius medialis; Gyr. semiann. rhin., gyrus 
semilunaris rhinencephali; Gyr. subcall., gyrus subcallosus; Lam. crib., lamina cribrosa ; 
NV. a. th., nucleus anterior thalami; Nn. olf., nervi olfactorii; Nucl. hab., nucleus habenule ; 
Ped. cerebri, pedunculus cerebri; Str. long. med., stria longitudinalis medialis; Str. medull., 
stria medullaris; Tract. olf., tractus olfactorius; Tract. opt., tractus opticus; J, axones of 
mitral cells going to stria olfactoria lateralis; I’, axoue of mitral cell terminating in gray matter 
of trigonum olfactorium; JJ, axone of mitral cell terminating in gray matter, whence axone 
goes to commissura anterior cerebri; II’, axones to anterior commissure; II’’, centrifugal fibre 
terminating in bulbus olfactorius; JJ, axone of mitral cell terminating in gyrus olfactorius 
medialis; JV, axones of neurones connecting the olfactory portion of the uncus (gyrus ambiens 
and gyrus semilunaris) with the hippocampus (cornu ammonis) ; V, axones from hippocampus to 
fornix; V’, axone to commissura hippocampi; V’’, axones from fornix to septum pellucidum ; 
vV’’’, axones from fornix to corpus mammillare; V’’’’, axone from fornix to nucleus habenulz by 
way of the stria medullaris; VJ, fasciculus mammillaris princeps; VJ’, fasciculus thalamo- 
mammillaris Vieq d’Azyri; VI’’, fasciculus pedunculo-mammillaris, pars tegmentalis (Hauben- 
biindel of von Gudden); VII, fasciculus pedunculo-mammillaris, pars basilaris (pedunculus 


corporis mammillaris); VIII, fasciculus retrofiexus 
Meynerti extending from the nucleus habenulz to 
the ganglion interpedunculare. (Taken from ‘The 
Nervous System and Its Constituent Neurones,”’’ p. 779, 
Fig. 501, New York, D. Appleton & Co., 1900.) 


visual neurones or optic neurones of the first 
order are the bipolar cells of the retina. The 
optic neurones of the second order or central 
visual neurones include the cell bodies of the 
ganglion cell layer of the retina and their ax- 
ones. The axones of these neurones run through 
the optic nerve to the optic chiasm, where part 
of them cross over, decussating with similar 
fibres of the opposite side. In the decussation 
the fibres from the lateral half of the retina run 
into the optic tract of the same side, while those 
from the medial half of each retina cross over 
to enter the optic tract of the opposite side. 
The fibres of each optic tract terminate chiefly 
in the lateral geniculate body, but some of the 
fibres terminate in the superior colliculus of the 
corpora quadrigemina and others in the pulvinar 
of the thalamus. These are the so-called pri- 
mary optic centres in the brain. Extending from 
the primary optic centres, especially from the 
lateral geniculate body to the occipital cortex, 
is a third group of neurones (optic neurones of 
the third order), their cell bodies being situated 
in the primary optic centres and their axones 


pulses concerned in hearing is 
a complex path. The periph- 
eral auditory neurones (audi- 
tory neurones of the first 
order) have their cell bodies 
situated in the spiral ganglion 
of Corti. Their peripheral 
processes run out to end free in 
among the cells of the organ of 
Corti; their central processes 
run in through the cochlear 
nerve to terminate in the pons, 
chiefly in the nucleus n. coch- 
lez ventralis and the nucleus 
n. cochlez dorsalis. In these 
two nuclei are situated the cell 
bodies of the majority of the 
auditory neurones of the second 
order. The axones from the 
cell bodies in the ventral coch- 
lear nucleus go to form the 
main portion of the corpus 
trapezoideum, the fibres of the 
two sides decussating in the 
middle line. These axones 
terminate in part in the su- 
perior olivary complex of the 
opposite side, but some of them 
run forward in the lateral lem- 
niscus of the opposite side. 
The axones from the dorsal 
cochlear nucleus run through 
the striz medullares and 
plunge down to the region of 
the superior olivary complex 
of the opposite side, where 
some of them terminate, others 
entering the lateral lemniscus 
of that side. The lateral lem- 
niscus receives also axones 
from cell bodies situated in the 
superior olivary complex. In 
the pons, then, the lateral lem- 


BG badge i on 
Y.\ Presse C. (/ 


Nasal portion 


Temporal portian 
Fic. 974.—Scheme of Visual Conduction Path. 
System and Its Constituent Neurones,”’ New York, 1900, p. 833, Fig. 533.) 


Chiesma opticum 
2 






niscus represents the main 
Gea. 
p, y \ 
( oar 
Y 65) G ° \ = 
a AS 
° - Re < 
We 
= * 





(Taken from *“*The Nervous 


363 


edie REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain. 











through the anterior two-thirds of the posterior limb of 
the internal capsule, through the middle portion of the 
base of the cerebral peduncle, form the bulk of the longi- 
tudinal fibres in the basilar part of the pons and the pyr- 
amids of the medulla. The majority of the fibres un- 
dergo decussatiou in the medulla and pass down in the 
lateral funiculus of the opposite side of the cord. Some 
of the fibres do not decussate but pass down chiefly in 
the ventral funiculus of the same side of the 
cord. A few of the uncrossed fibres descend in 
the lateral funiculus of the same side of the cord. 
The axones of the pyramidal tract terminate in 
the gray matter of the pons, medulla, and spinal 
cord. 

The impulses running along the upper motor 
neurones are transferred to the lower motor neu- 
rones. ‘The lower motor neurones have their 
cell bodies situated in the so-called motor nuclei 
of the cerebral nerves and in the ventral horns 
of the spinal cord. Their axones form the motor 
roots of the cerebral nerves and the ventral roots 
of the spinal nerves. They run out to the vari- 
ous muscles of the head, trunk, and limbs (Fig. 
976). 

The frontal cerebro-cortico-pontal path consists 
of a set of neurones whose cell bodies are situat- 
ed chiefly in the feet of the frontal gyri. Their 
medullated axones descend through the corona 
radiata and through the anterior limb of the 
internal capsule to the base of the cerebral pe- 
duncle occupying its most medial region. These 
fibres terminate in the pons among the cell bodies 
of the nuclei pontis. 

The temporo- and occipito-cerebro-cortico-pon- 
® tal path consists of neurones the cell bodies of 
which are situated in the temporal and occipital 
lobes of the brain. Their axones descend to 

















Pulvinar of 
Thalamus 


esa WU 2 
ne i eae FY 


Nglosso- 
ry% 


Fig. 975.—Scheme of Neurones Superimposed to 
form the Auditory Conduction Path. (Taken 
from ‘‘ The Nervous System and Its Constituent 
Neurones,”’ p. 880, Fig. 565, New York, 1900.) 


ip Knee ad Ankle 
B£8) sen Mallon end small Toes 






conducting path for auditory impulses toward Shoulder 
higher centres. . A large proportion of these fibres 
terminate in the nucleus colliculi inferioris of 
the corpora quadrigemina, which therefore repre- 
sents a very important way-station in the audi- 
tory conduction path. Some of the fibres of the 
lateral lemniscus run past the inferior colliculus 
and terminate first at a higher level. These fibres 
are joined by the axones of neurones whose cell “%2% 
bodies are situated in the nucleus colliculi in- 
ferioris. The conjoint bundle is known as the 
arm of the inferior colliculus (brachium quad- 
rigeminum inferius). These fibres terminate 
chiefly in the corpus geniculatum mediale, though 
some go by it. In the corpus geniculatum medi- 
ale are situated the cell bodies of neurones, the 
axones of which run out through the posterior 
part of the occipital limb of the internal capsule 
to terminate in the cortex of the temporal lobe. 
This auditory centre in the temporal lobe is situ- 
ated at the junction of the third and fourth fifths 
of the gyrus temporalis superior and includes the 
two transverse temporal gyri situated in the fossa 
Sylvii. The main features of this conduction path 
are illustrated in Fig. 975. 

The principal centrifugal conduction paths to 
be considered are: (1) the general cortico-muscular 
conduction path; (2) the frontal cerebro-cortico- 
pontal path, and (38) the temporal cerebro-cortico- 
pontal path. 

The cortico-muscular conduction path consists 
of at least two sets of superimposed neurones. 
The upper set of motor neurones consists of neu- 
rones whose cell bodies are situated in the motor 
region of the cerebral cortex (central gyri and 
paracentral lobule). They include the large py- 
ramidal cells of this area. Their medullated ax- 
ones are those of the so-called pyramidal tract. 
These axones descend through the corona. radiata, 







inp? 
ene? 
y 2 


Fia. 976.—Scheme of Upper 
and Lower Motor Neurones. 
(Taken from ‘The Nervous 
System and Its Constituent 
Neurones,”’ p. 1037, Fig. 657, 

arcle New York, 1900.) 


srseurde ey 


364 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain. 





the base of the cerebral peduncle, where they form the 
lateral mass of fibres. Passing through the peduncle 
they terminate in the nuclei pontis. From the nuclei 
pontis go off axones through the brachium pontis of the 
cerebellum, there to commu- 
nicate with cerebellar neu- 
rone systems which in turn 
are capable of throwing the 
lower motor neurones under 
their influence. 

A word must be said con- 
cerning the commissural neu- 
rones and the associative neu- 
rones of the telencephalon. 
Of the commissural neurones 
the most important are: (1) 
those whose medullated ax- 
ones make up the corpus cal- 
losum,; (2) those whose med- 
ullated axones constitute the 
principal part of the anterior 
cerebral commissure, and (8) 
those whose medullated ax- 
ones make up the commissura 
hippocampi. 

The medullated axones of 
the corpus callosum connect 
the two hemispheres with 
each other, possibly identi- 
cal portions of the two hemi- 
spheres. The anterior com- 
missure of the brain may be 
looked upon as a supplement 


The fasciculus uncinatus extends between the uncus 
and the basal portions of the frontal lobe. It is probably 
olfactory in function. The fornix contains the medul- 
One impor- 


lated axones of many association neurones. 





FIG. 977.—Lateral Surface of the Left Cerebral Hemisphere. The edges of the fissura cerebri lateralis 
(Sylvii) have been pulled apart to show the insular and retroinsuler region. 


The fasciculus 


of the corpus callosum. It 
is generally supposed that 
this commissure connects the 
temporal lobes, the basal sur- 
face of the occipital lobes, 
and the olfactory bulbs with 
one another, the corpus cal- 
losum connecting similar por- 
tions of the rest of both cere- 
bral hemispheres. The fibres 
of the commissura hippo- 
campi, or so-called “lyre of 


uncinatus, the fasciculus longitudinalis superior, and the fascicuius occipitalis verticalis are 
seen in transparency. (After J. Dejerine, ‘Anatomie des centres nerveux,’’ Paris, 1895, p. 757, 
Fig. 377.) Arc, Fasciculus longitudinalis superior; Fy), M2, gyrus frontalis medius and gyrus 
frontalis inferior; f,, sulcus frontalis inferior; fo, sulci orbitales; I3 (C), gyrus frontalis inferior 
pars triangularis ; Fa, gyrus centralis anterior; Fu, fasciculus uncinatus; Ja, Ip, gyri insule; ip, 
sulcus interparietalis; ma, mp, mf, sulcus circularis Reili; 0), 02, gyri occipitales; oa, sulcus 
occipitalis anterior of Wernicke; oOF,, of, oF'3, orbital portion of frontal gyri; OpR, operculum, 
pars frontalis; OpP.2, operculum, pars parietalis; Ov, fasciculus occipitalis verticalis ; P,, lobulus 
parietalis superior; P»,, lobulus parietalis inferior; Pa, gyrus centralis posterior; Pc, gyrus 
angularis ; Po, fissura parieto-occipitalis; por, portion of sulcus interparietalis behind the upper 
part of the gyrus centralis posterior ; pri, sulcus preecentralis ; R, sulcus centralis Rolandi; S (q@), 
S (v), anterior and vertical ramus, anterior horizontalis, and ramus anterior ascendens of fissura 
cerebri lateralis Sylvii; 7, gyrus temporalis superior; 7',, gyrus temporalis medius; ¢,, sulcus 
temporalis superior; t’, t’, vertical rami of the sulcus temporalis superior; ZJ'p, gyri temporales 
transversi; VS, fossa cerebri lateralis Sylvii. 


David,” connect the hippo- 
campus of one side with that of the other. It is prob- 
ably to be regarded as an olfactory commissural path. 

The association neurones of the telencephalon connect 
a portion of one hemisphere with another portion of the 
same. Some of them have short axones, others have 
long axones. Those with short axones connect adjacent 
gyri, those with long axones connect distant gyri, with 
one another. 

The association neurones with short axones include the 
fibre propriz of the cerebral gyri. In the occipital lobe 
a number of neurone systems with short axones have 
been worked out. They include the stratum calcarinum, 
the fasciculus occipitalis verticalis, the fasciculus occip- 
italis transversus cunei, fasciculus occipitalis transver- 
sus gyri lingualis, and the stratum proprium. 

The association neurones which have long axones in- 
clude the cingulum, the fasciculus longitudinalis superior, 


the fasciculus uncinatus, the association bundles of the . 


fornix, and the tapetum. 

The cingulum is an olfactory tract which extends in a 
sagittal direction in the white matter of the two main 
parts of the gyrus fornicatus, namely, the gyrus cinguli 
and the gyrus hippocampi. 

The fasciculus longitudinalis superior is a curved 
bundle extending in a sagittal direction, apparently 
between the frontal lobe and the occipital lobe (Fig. 
977). 

The fasciculus longitudinalis inferior is usually de- 
scribed as extending between the lobus occipitalis and 
the lobustemporalis. The anterior part of the fasciculus, 
however, is difficult to differentiate, and accordingly its 
anterior connections are disputed. 








tant bundle connects the hippocampus with the sub- 
stantia perforata anterior and is probably olfactory in 
function. 
The tapetum is an association bundle connecting the 
occipital lobe with the frontal lobe (Dejerine). 
Lewellys F. Barker. 


REFERENCES, 


Barker cpa : The Nervous System and Its Constituent Neurones, New 

ork, 

Bechterew, W. von: Die Leitungsbahnen im Gehirn und Riickenmark, 
Leipzig, ii. Aufl., 1899. 

Bruce, A.: Illustrations of the Nerve Tracts in the Mid- and Hind- 
brain, ete., Edinburgh and London, 1892. 

Dejerine, J.: Anatomie des centres nerveux, Paris, 1895. 

Edinger, L.: Nervése Centralorgane, v. Aufil., Leipzig, 1896. 

Van Gehuchten, A.: Anatomie du systéme nerveux de l’homme, iii. 
ed., Louvain, 1900. 

Golgi, C.: Untersuchungen ueber den feineren Bau des centralen und 
peripherischen Nervensystems, Jena, Fischer, 1894. 

von Gudden, B.: Gesammelte und hinterlassene Abhandlungen, 
Hrsg. von Dr. H. Grashey, Wiesbaden, 1889. 

von Kolliker, A.: Handbuch der Gewebelehre des Menschen, Bd. i. u. 
ii., Leipzig, 1896 

yon Lenhossék, M.: Der feinere Bau des Nervensystems im Lichte 
neuester Forschungen, zweite Auflage, Berlin, 1895. 

von Monakow, C.: Experimentelle u. pathologisch-anatomische Unter- 
suchungen ueber die Haubenregion, den Sehhiigel und die Regio 
subthalamica, nebst Beitrage zur Kenntniss frih erworbener Gross- 
und PS eins ay Arch. f. Psychiat., Berlin, Bd. xxvii., 1895, 
S. i, 386. 

Obersteiner, H.: Anleitung beim Studium des Baues der nervésen Cen- 
tralorgane, iii. Aufl., Leipzig u. Wien, 1896. 

Ramon y Cajal, S.: Beitrage zum Studium der Medulla oblongata. 
Deutsch von Bresler, Leipzig, 1896. 

Sabin, Florence R.: A Model of the Medulla Oblongata, Pons, and 
Midbrain of a New-Born Babe. Contributions to the Science of Med- 
icine dedicated by his pupils to William Henry Welch. Baltimore, 
1900, pp. 925-1045. 


365 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





BRAIN: HYDROCEPHALUS.—See Hydrocephalus. 


BRAIN, HYPERAMIA OF.—A term used to signify 
augmentation of the mass of blood in the vascular de- 
partment of the brain. An equivalent meaning is con- 
veyed by cerebral congestion. Both terms indicate in 
the main an extra-physiological accumulation in the cir- 
culation of the encephalon, and express the same cause 
united to different symptoms, although congestion seems 
to apply rather to the sudden or the so-called fluxionary 
hyperemia resulting from pathological conditions in 
other parts of the body. Some writers claim that in- 
crease of arterial blood passing through the encephalon 
is the only true hyperemia, and that fulness of the brain 
should more properly be described by “ venous conges- 
tion,” which is associated with the anzemia consequent 
upon impaired vaso-motor innervation of the neuras- 
thenic state. 

Like that of many questions in medicine, the history 
of cerebral congestion is old, and so completely chaotic 
that in recent times the possibility of its occurrence, and 
consequently its clinical importance, have been doubted. 
Putting aside its existence as a separate disease, or as a 
morbid entity having pathognomonic and regular symp- 
toms, we will assume that the brain, like any other organ, 
may be the seat not only of anemias but of hyperzemias 
either circumscribed or generalized. Analogical justifi- 
cation so obvious as that furnished by experimental in- 
vestigation on the lower animals, having reference to 
venous hyperemia, renders the possibility of increased 
vascularization of the brain admissible. Further evi- 
dence that the contents of the cranial cavity may vary 
in quantity is furnished by the intracranial pressure de- 
tected in infants in whom the fontanels are open, the 
scalp being raised above the level of the skull, or de- 
pressed, according as the head is raised or lowered, or 
when the tension of the fontanel is increased by com- 
pression of the jugular veins. When a portion of the 
brain is exposed, after an injury of the skull, it will be 
observed to enlarge and to-contract in correspondence 
with the elevation or depression of the head, the presence 
or absence of sleep and emotional excitement, or with 
the action of any cause that accelerates the circulation. 
Any cause that constricts the neck may produce a sen- 
sation of fulness and pain about the head, with bleeding 
from the nose; and as a fact of pathological moment that 
should be emphasized, there may be mentioned the ob- 
struction to the flow of venous blood resulting from in- 
sufficient removal of carbon dioxide. In dependent 
positions of the head, indications of congestion are notice- 
able in the bloodshot countenance and other evidences 
of imperfect return of blood. The existence of intra- 
cranial congestion in such circumstances is further demon- 
strated by the very red papille and much-congested 
vessels of the optic nerve. These changes at the fundus 
of the eye are not found in such gymnasts as trapeze 
performers and “fly walkers,” because by constant train- 
ing and habit the animal economy accommodates itself 
to the abnormal positions. Variability of the cerebral 
circulation is further shown in the pallor of the fundus 
of the eye, following the administration of drugs that 
are known to irritate the vascular nerve centres, as ergo- 
tin and belladonna. Finally, the existence of cerebral 
hyperemia is revealed by the necroscopic appearance of 
the brains of persons or of animals who during life suf- 
fered from interruption to the perfect return of blood 
from the head. 

PaTrHoLoGicaL ANATOMY. —It is quite difficult to recog- 
nize cerebral hyperszemia on the cadaver, since evident 
traces are not always left in the brain, and there may be 
sanguinary ‘stases brought about by gravity and the 
position of the cadaver which do not exist during life. 
Venous hyperemia is more easily recognizable after 
death than the arterial form. In a severe case of hyper- 
zemia the tissues over the cranium are often found to 
contain an abnormal quantity of blood; drops of extrava- 
sated blood from ruptured vessels are seen on the dura 
after removing the calvarium; the dura, when detached, 


366 


is of a bluish tint; the sinuses of the dura, the veins 
emptying into the sinuses, the veins of the pia and the 
choroid plexuses are distended with blood; and degen- 
eration of the vessels themselves has been frequently ob- 
served. The mass of the brain appears larger and 
swollen, the gyri are flattened, the sulci effaced, and the 
ventricles may be filled from subarachnoidean effusion; 
there is a reddening of the whole organ, and the mem- 
branes are dry and viscous. This reddish or deep-red 
tint is particularly noticeable in the intense hypersmia 
of the new-born. 

The gray substance, increased in consistence, presents 
a reddish-gray color, and if the hyperzemia has been in- 
tense, small punctiform hemorrhages are observed. The 
white substance, also increased in consistence and in den- 
sity, is of a uniform rose color. On section the brain, 
without being edematous, shows numerous sanguinary 
points which are larger than usual, owing to increased 
size of the capillaries. The meninges are usually filled, 
and the veins of the cortex are tortuous. If the case has 
been a chronic one, uniform widening and tortuosity of 
the vessels are much more pronounced, showing the devel- 
opment of small aneurismal dilatations, and sequelse con- 
ditioned by the increased vascularization, such as vascular 
development of the cellular tissue which enters into inti- 
mate relations with the glia. The cribriform or sieve- 
like appearance observed on making a transverse section 
of the hemispheres is usually regarded as a consequence 
of long-standing stasis, especially if found in the brains of 
old people, of chronic drunkards, of opium-eaters, or of 
maniacs. There are also reasons for believing that cere- 
bral atrophy may be developed in old people in con- 
sequence of continuous venous stasis. The pathological 
changes of arterial hypereemias peculiar to the cranial 
cavity are rarely observed on the cadaver, as they usu- 
ally disappear, with its causes, after death. When we 
take into consideration the imperfect knowledge both of 
its mechanism and of its anatomical details, and the diffi- 
culty to establish the relations existing between its numer- 
ous symptoms and the lesions that determine them, it is 
not surprising that the existence of cerebral hyperemia 
is not always easily demonstrable. The condition may 
sometimes be studied on the large arteries of the pia, but 
no one has yet distinguished an arterial from a venous 
hyperemia in the cortical portion of the brain. It is only 
in such processes as Basedow’s disease that chronic arterial 
hyperemia is recognized. The difficulty of recognition 
is increased by the inflammatory changes and simple 
hyperplasias that are often present, and often overlooked 
after frequent and long-continued attacks of chronic 
arterial hyperemia. According to recent researches, 
when the disorder has run a rapid course pathological 
changes may be found in the ganglion cells, or in the 
cortical connective tissue, with nuclear proliferations in 
the walls of the vessels, and in the fibrillary plexus of 
the cortical substance. 

Errotogy.—If there exists a disproportion between the 
clinical and the post-mortem phenomena of cerebral 
hyperemia, it must be admitted that the mass of the 
blood within the skull varies according to certain cir- 
cumstances, and that the brain, like other organs of the 
body, is subject both to anemia and to hyperemia; in- 
deed, it would be surprising if it were not. The question 
of hyperemia resolves itself into that of a liquid circu- 
lating in tubes, in which repletion or engorgement can 
be produced in but two ways, namely, by increase of the 
inflow, or by diminution of the outflow. Active fluxion- 
ary hyperzemia may be caused by the augmentation, and 
passive hyperemia, or that of stasis, by diminution of 
the sanguinary flow. The force and abundance of the 
inflow of blood into the vessels of the brain are influenced 
by the general increase of pressure, and by diminution 
of local resistance, and it seems as if the greater number 
of active congestions should be brought under the first 
category. For a long time the congestive influence of 
certain exciting drinks, as tea, coffee, and alcohol, has 
been admitted; and violent muscular exertion, general 
plethora, cardiac hypertrophy, emphysema of the lungs, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain. 
Brain, 





the effects of strong emotion, and the exaggeration of 
normal functional activity, are believed to take great 
part in the production of cerebral congestion. But the 
general increase of blood pressure plays simply a second- 
ary part in the production of hypersemia, which it can 
facilitate or augment only when there exist local altera- 
tions, such as inflammations or vascular lesions. Hyper- 
trophy of the heart can scarcely be said to cause conges- 
tion of the brain, except in cases in which the cerebral 
vessels have become weakened on account of other causes, 
and the same may be said of other agents that increase 
the cardiac impulse. 

Other conditions that tend to produce congestion of 
the brain, by excess of arterial tension and too consider- 
able affux of blood, are chronic Bright’s disease, Base- 
dow’s disease, intermittent fever, extremes of heat and 
cold, and the tension produced in the vessels of the head 
and neck when the aorta is constricted or strongly com- 
pressed by a thoracic or an abdominal tumor. This in- 
creased arterial tension may also be brought about by the 
suppression of the normal or pathological secretions, as 
the menses at the menopause or other period, by the 
sudden stoppage of hemorrhoidal bleeding when general 
plethora exists, by the checking of a chronic diarrhea of 
long standing, or by stopping the hemorrhages in hzema- 
- tophilia, and it may result from facial erysipelas, or any 
cerebral or meningeal phlegmasiz, from diverse periph- 
eral irritations, from extended lesions of the skin pro- 
duced by burns and eruptive diseases, as variola, scarla- 
tina, and measles. 

An important and considerable class of congestions 
may result from local increase of pressure or collateral 
fluxions, by means of which the entrance of blood is shut 
out from the organs. The pathological phenomena sus- 
ceptible of giving place to collateral fluxions are acute 
inflammations, thromboses, and embolisms, and the in- 
farctions resulting therefrom. Interstitial hemorrhage 
may have the same result; and the energetic local com- 
pression excited on the skin by the application of thick 
layers of collodion also produces a considerable local 
hyperemia. Fluxionary hyperemias from exaggeration 
of pressure result from general pressure only, not from 
local, and the greater part of them result from the patho- 
logical causes above mentioned. 

Hyperemias of fluxion, by diminution of local resist- 
ance, may result when atmospheric pressure is dimin- 
ished or defective, the simplest type of which is furnished 
by the application of the large exhausting apparatus 
used to produce cutaneous revulsion. The opposite 
condition may bring about the hypersemias peculiar to 
workmen in condensed air (see Caisson Disease). The 
congestive phenomena brought about by the rapid dis- 
appearance of a considerable effusion, as ascites, and 
even by the extirpation of certain tumors, belong to the 
same category. The condition is also brought about by 
direct or reflex paralysis of the vaso-motors which influ- 
ence the dimensions of the vessels in the brain cavity. 
The innervation of the vascular walls may be directly 
diminished by any pressure whatever, as that of a tumor, 
or they may be paralyzed by reflex action in consequence 
of an irritation of the sensitive nerves of a part, as ob- 
served in inflammation and in lesions of the nerve cen- 
tres. Direct paralysis of the muscular walls of vessels 
may be brought about by variations of temperature. 
Extreme heat and cold and insolation are capable of pro- 
ducing intense congestion, and the action of rubefacients 
is analogous. Direct insolation doubtless acts by raising 
the temperature of the cranium to such a degree as to 
cause incipient paralysis of the muscular action of the 
vessels, and consequent diminution in the tonic force of 
their walls. The same nervo-vascular phenomena are 
asserted to be brought about by the action of such sub- 
stances as opium, alcohol, belladonna, hyoscyamus, 
hasheesh, stramonium, and amyl nitrite. Fatty or 
amyloid degeneration of the vascular walls, especially 
in old people, transforms the vessels into inert and dilat- 
able tubes, which may favor hypereemias of this order. 
The presence of entozoa, or of any pre-existing focus of 


disease in the brain, is also an etiological factor. Finally, 
all the processes that decrease intracranial pressure favor 
the creation of cerebral hyperemia. Among them must 
be reckoned such causes as intense excitement, no matter 
whether produced by imagination, temperament, or 
thought. Intellectual work that consists in logical com- 
binations of ideas seems to be less hurtful in this respect 
than the more exciting results of a heated imagination, 
or the depressing effects of sadness, sorrow, and sudden 
shocks. 

Passive hyperemia, or the hyperemia of stasis, may re- 
sult from the active or fluxionary form. It happens that 
the capillary vessels do not regain their first tonicity after 
the enormous distention of an active hyperemia, so that 
the stases become confused with the preceding fluxions. 
The causes of hyperzmia by stasis are principally those 
that retard the return of blood from the brain, either by 
diminution of the local pressure or by increase of the 
obstacles opposed to the returning circulation. The 
former exists in the case of alterations of the arterial 
walls, or when their contractility and elasticity are lost, 
and in obliteration of the arteries; the second is seen in 
the hypostases of certain congestions resulting from the 
long continuance of one position of the body, or in those 
following certain maladies, and in the compressions ‘of 
the venous system by tumors or any neoplasm whatever. 
Venous congestion or hemorrhagic stasis may result from 
thrombosis, or it may result from congestion of the vena 
portee, from compression of the jugular, from a stasis in 
the region of the lesser circulation, from mitral insuffi- 
ciency, emphysema, and stenosis of the larynx, from all 
forced expiratory efforts made with closed glottis, and 
from all processes that invade the abdominal cavity, 
especially in plethoric individuals. Chronic constipation 
and flatulence, blowing wind instruments, violent vocal 
efforts, parturition, epilepsy, hysteria, and chlorosis — 
these causes are all at fault in producing this variety of 
hyperemia. 

Symproms.—Although no one sign of cerebral hyper- 
zmia is of absolute diagnostic value, yet its existence is 
often established by the symptoms alone. Fluxionary 
hyperemia constitutes rather a phenomenon superadded 
to various morbid states, but in certain cases of mental 
alienation over-activity of the mind, though always 
secondary, is very nearly the only pathological manifes- 
tation. As in anemia, the symptoms met with in exag- 
gerated distention of the vessels of the brain are those 
arising from derangements of the sensorium, the organs 
of special sense, and of the sensitive and motor nerves. 
The manifestations of cerebral hyperemia are perhaps 
better known to alienists and neurologists than to other 
physicians. They are most important as throwing light 
on the general pathology of insanity, many cases of 
which, having unknown or undetermined lesions, are 
doubtless owing to encephalic congestions. Of the cere- 
bral functions the most strongly affected is the intelli- 
gence. Delirium is the prominent symptom of cerebral 
hyperemia. It is generally that of excitement, and in 
many cases in no way connected with general paralysis 
there are found to predominate the delusions of grandeur, 
riches, ambition, and the like, characteristic of conges- 
tive mania. The superactivity of the cerebral. circula- 
tion, as well as that of thought and well-being, may be 
recalled in the rosy excitement produced by wine and 
good cheer, in the artificial excitement of poetic frenzy, 
in the beatific visions of psychopathic women, and in re- 
ligious ecstasy. Insomnia is one of the surest signs of 
hyperzmia of the brain. In many cases mania and cer- 
tain hallucinations are connected with a notable hyper- 
semia of the gray layer. The delirium of febrile conges- 
tion, which is of a more distressing character, is owing 
less to quantity than to the quality of the blood, which 
is warmer, and besides charged with pyrogenic sub- 
stances, as miasms, pus, and the like. 

DraGnosts.—General hyperzsthesia most often coin- 
cides with furious delirium, and headache also exists in 
a great number of cases. The troubles of the organs of 
sense are characterized by excitement and irritability. 


367 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





It is claimed that paresthesia may be detected with the 
zesthesiometer. Generally the pupil is contracted. This 
has been noted in the greater proportion of cases. Paraly- 
sis of the dilator or irritation of the sphincter is met 
with. Photophobia, ocular spectra, and ringing in the 
ears are symptoms peculiar rather to cerebral anzemia or 
to the venous variety of hyperemia. The ophthalmo- 
scope teaches but little in regard to cerebral hypereemia. 
Its use has, however, justified the supposition of a tran- 
sitory vaso-motor paralysis during frequent and severe 
attacks of cerebral congestion in a case of hysteria with 
paralysis and other symptoms. Diplopia and illusive 
transformations of hearing are often present with the 
other derangements of the special senses. Recent obser- 
vations point to the connection between tympanic con- 
gestion and cerebral hyperemia. Examination of the 
membrana tympani appears to indicate the state of the 
cerebral circulation, a fact demonstrated by comparing 
the state of this membrane before and after the adminis- 
tration of quinia or amylnitrite. Itis remarked, in con- 
nection with this circumstance, that evidences of conges- 
tion are noticed in the vessels over the handle of the 
malleus, and that the membrana tympani is of a light 
pinkish color. There is also a rise of temperature in the 
external auditory canal. 

Motor disorders are seen in the agitations and strug- 
gles of the patient. There may be numbness and formi- 
cation of the extremities, but paralysis does not in any 
way belong to arterial hyperemia. Convulsions are 
most common in infants, and belong rather to anzemia or 
venous stasis than to arterial hypersemia, and they may 
be confounded with epilepsy. The vomiting sometimes 
met with belongs also most often to anzemia. The cir- 
culatory apparatus is more or less disturbed in cases of 
active congestion. There are palpitation and a sense of 
oppression; the pulse is full and rapid and the carotids 
pulsate. This morbid excitability of the heart is particu- 
larly influenced by emotional disturbance. There is, 
however, a difference of opinion as to its symptomatic 
importance. Reflex excitability is preserved. 

The phenomena of venous or passive congestions are in 
reality those that commonly relate to aneemia of the brain, 
and in a given case of anoxyheemia it is difficult to recog- 
nize whether the condition be owing to want of blood in 
totality or to venous stasis. In a venous stasis from 
thrombosis of the sinuses or from embolism the symptoms 
present are similar to those of congestion, namely, de- 
rangements of the intelligence, the sensibility, and the mo- 
tility, and sometimes there is an agitated state of mind, 
with dilated pupils. Vertigo, photophobia, auditory 
subjective phenomena, and incoherence of ideas exist, 
however, to a less degree in this form than in the fluxion- 
ary, and in the case of delirium it is rather of the mild or 
demented kind. The symptoms may vary according to 
age, sex, and other circumstances. Men are more sub- 
ject than women. The different periods of life known 
as increase, maturity, and decline are modifying influ- 
ences, but it does not appear that season exerts any in- 
fluence. The symptoms may be light or severe, and 
they may be acute or chronic. 

In a case of acute jluaionary hyperemia the patient 
may, after a short premonitory headache and dizziness, 
fall senseless, with or without convulsive movements. 
The face is red, the conjunctive are injected, the pupils 
contracted, the temporals and carotids pulsate vehe- 
mently, the pulse is hard and strong, the respiration 
stertorous. There are often convulsive movements and 
twitchings, especially in children, combined with slight 
paresis, and the condition often ends in stuporand death. 
If the case does not terminate fatally, the symptoms de- 
crease in severity and disappear entirely, or they may 
pass into the chronic form. The latter is characterized 
by a sense of fulness and heaviness in the head, by con- 
tinuous or paroxysmal headache, dizziness, and pulsa- 
tions of the temporal and carotid arteries. These symp- 
toms become worse by lowering the head, and by the 
influence of alcohol, if the hyperemia is still active. 
The frame of mind is rarely serene, the patient is morose, 


368 


excitable, and explosive. There is a disinclination to 
mental labor, with confusion of thought, the ‘combina- 
tions of which are illogical, morbid, and exaggerated; 
and symptoms of morbid apprehension, like those com- 
mon to agoraphobia, are often present. A morbid fear 
of impotence is a predominant idea in this condition. 
Other symptoms arrange themselves according to the 
fundamental conditions that originate the exaggerated 
distention of the cerebral vessels. 

The symptoms of passive hyperemia are not entirely 
identical with the foregoing. There ismore apathy, and 
the patient is more depressed. It should be taken into 
account that the poisonous influences of carbon dioxide 
obtain in this condition: it is the defect of oxygen in the 
venous blood, and not its quantity, which causes the 
characteristic phenomena. 

DraGnosis.—The diagnosis of cerebral hyperemia is 
often not clear, because of the likeness of the symptoms 
to those of anemia. The question here concerns the 
symptoms that have already been mentioned in connec- 
tion with the excitements of the three great faculties of 
the nervous system, another enumeration of which would 
be tedious. In the delirium of anemic origin, as in 
grave fevers and inanition, the aspect of the patient is 
quite the opposite of the flushed face, the brilliant eye, 
and general rugged appearance so often associated with . 
hyperemic delirium. The essentially transitory char- 
acter of the excitement met with in these cases, the syn- 
cope and convulsions, leave no doubt as to the anemic 
cause of the delirium. Delirium tremens and a certain 
kind of delirium from lead-poisoning resemble in some 
points the delirium of cerebral hyperemia, but the dis- 
crimination is easy when attention is directed to the his- 
tory of the case and a knowledge of the patient’s habits. 
Elevation of temperature is of use in distinguishing in- 
flammatory diseases of the brain from hyperemia. The 
latter condition is usually apyretic, but at times it is 
possible to detect an elevation of one or two degrees 
above the normal by means of the differential calorimeter 
applied to different regions of the head. Vertigo, epi- 
lepsy, uremia, embolism, thrombosis, softening, and 
hemorrhage may be confounded with cerebral hyper- 
emia; but each of these affections may be distinguished 
after careful examination into the condition of the urine, 
heart, lungs, and blood-vessels, and on comparing the 
symptoms of the afore-mentioned diseases with those of 
hyperemia. 

Proenosis.—The prognosis of cerebral hyperzemia de- 
pends upon the intensity and duration of the symptoms 
as well as on individual circumstances. Children are 
more liable to succumb to the intensity of congestion, and 
in old people cerebral congestion is particularly danger- 
ous because of the tendency to rupture in the degener- 
ated vessels. Strong cerebral congestions are as grave as 
cerebral hemorrhage, and may lead to death. They may 
also prove the immediate cause of death in such chronic 
conditions as tumor of the brain and senile degeneration 
of its vessels. The tendency to such secondary lesions as 
hemorrhage, softening, cerebritis, and the like is greatly 
increased by the frequency of the paroxysms. Active 
cerebral hyperemia, being more amenable to treatment, 
is consequently more favorable to recovery than is the 
passive variety. 

TREATMENT. —The chief therapeutic indication in acute 
fluxionary hyperemia is to diminish the sanguineous 
afflux, and this is perhaps best done by judicious inac- 
tion and careful watching of the symptoms. The condi- 
tion is not one either of pressure or of cedema, but of an 
over-active ‘circulation, and the treatment must vary 
according as the causes are primary or secondary. The 
nature of the treatment of active congestion from such 
causes as extremes of temperature, insomnia, or other 
irritable condition of the brain will, of course, differ 
from that required by the secondary congestions caused 
by suppression of the menses, by gout, or by rheumatism. 
Rest and position are of primary importance ‘during an 
attack. The head should be elevated and the arms 
stretched upward. Quiet surroundings, fresh air, and a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


darkened room are advisable. Local bleeding is recom- 
mended by most practitioners, but it should be done 
with a certain amount of discretion and caution. Asa 
rule it is contraindicated in children and old people, and 
in hysteric or chlorotic persons. The so-called derivation 
and revulsion, in which a considerable congestion of the 
whole or part of the intestinal canal is produced by the 
administration of 'a drastic purgative, may diminish the 
afflux of blood to the brain. In fact, main reliance is to 
be placed upon the derivative effects of croton oil, colo- 
cynth, and irritating enemata, as of vinegar; the irrita- 
tion of hot or mustard baths for both the hands and 
feet; and the production of diuresis. Reflex action is 
further brought about by the application of a mustard 
plaster to the epigastrium, and of the actual cautery to the 
nape of the neck. Cold vigorously applied to the head, 
in the form of ice, or cold douches upon the head, com- 
bined with a hot bath, are adjuncts in the treatment too 
valuable to be overlooked. When there is a heart com- 
plication it may be met with cardiac medicaments. 
Among the internal remedies that it is advisable to em- 
ploy as agents in relieving the cerebral congestion are 
the bromides, ergot, oxide of zinc, eucalyptus, and 
hydrobromic acid. When the symptoms of congestion 
have disappeared, strychnia, phosphorus, and cod-liver 
oil may be administered with advantage, and at the same 
time the patient’s nervous system is to be carefully 
nursed. This is particularly to be enjoined in the case 
of chronic hyperemia. Complete intellectual rest, fresh 
air, regular habits, and the disuse of tea, coffee, alcohol, 
and tobacco should form part of the hygienic treatment. 
The milk cure and the grape cure may be mentioned as 
valuable dietetic measures. If the congestion arises from 
stoppage of a hemorrhoidal flow, leeches may be applied 
to the anus. Wonderful effects have been thus brought 
about. Like results have been obtained by applying 
leeches to the mouth of the uterus in secondary hyper- 
gemia caused by suppression of the menses. In this con- 
dition the electric brush applied to the thighs, with 
douches to the loins and perineum, has been found effica- 
cious inrestoring the menses. Galvanization of the head 
and of the sympathetic nerve, having the power to con- 
tract the cerebral blood-vessels, may often be used with 
good effect. A systematic course of hydrotherapeutics 
is often advantageous. 

In passive hyperemia the causes are to be made the 
special objects of treatment. Generally, it is a question 
of restoring vascular tonicity and combating symptoms 
that in many respects resemble those of cerebral anzemia. 
Stimulants may be administered in many cases. Satis- 
factory results have been obtained from ether inhaled in 
small quantities. The use of cardiac tonics, as digitalis, 
when the stasis results from some vascular or cardiac 
lesion, or when there is cirrhosis of the kidney, is a ques- 
tion that still admits of a satisfactory solution. 

Irving C. Rosse. 


BRAIN: LESIONS OF THE CORPORA QUADRI- 
GEMINA.—In discussing the lesions of the corpora 
quadrigemina in man our material is scanty, and it is 
often impossible to distinguish between the results due 
to injury of one portion of the brain and those due to the 
destruction or irritation of neighboring parts. 

The corpora quadrigemina of mammals correspond in 
structure to the optic lobes of frogs, birds, and fishes. 
Little is known about purely destructive lesions of the 
corpora quadrigemina inman. Experiments on animals 
would lead us to suppose that destruction of the whole 
corpora quadrigemina would result in complete blind- 
ness, and unilateral lesion in hemianopsia. In man, how- 
ever, this does not always occur. In a case related by 
Eisenlohr, a revolver bullet entering through the forehead 
passed directly into the right corpus quadrigeminum 
and there remained. The power of sight was only par- 
tially lessened at first—R. $9, L. 28; later, R. 29, L. 29, 
(Monakow). Monakow concludes that the destruction 
of a whole anterior corpus quadrigeminum in man causes 
only moderate affection of sight and leaves the color 


Vou. IT.—24 





Brain, 
Brain, 





sense intact. Local lesions of the corpora quadrigemina 
may cause dilatation of the pupils in one or both eyes 
and the pupillary reaction to light and accommodation 
may be much impaired. As the process advances toward 
the base, disturbances of the ocular muscles become 
prominent. Total ophthalmoplegia is rare, but there is 
paresis of the various muscles, not homologous, incom- 
plete, and developing unvenly. The posterior corpora 
quadrigemina have nothing to do with sight; after iso- 
lated lesion of them no effect on vision is observed. 
Paralysis of the fourth nerve (unilateral or bilateral) and 
disturbances of chewing have been found in such cases. 
Lesions of the corpora quadrigemina also produce both 
ataxia of movement and cerebellar ataxia. Tremor re- 
sembling that of paralysis agitans and sometimes choroid 
movements either of the opposite extremities or bilateral 
may exist. 

An important symptom in cases of lesion of the pos- 
terior corpora quadrigemina is a dimunition of hearing 
in the opposite ear. 

In cases of tumor or foreign growth in the corpora 
quadrigemina or their neighborhood the adjacent regions 
are liable to be affected and symptoms strictly referable 
to the disturbance of these regions are apt to occur. 
These symptoms, as well as the general, that is non- 
localizing, symptoms of cerebral tumor cannot be dis- 
cussed here, but must be considered as of much impor- 
tance in forming the diagnosis. Welliam N. Bullard. 


BIBLIOGRAPHY. 


Bastian: Lancet, July 25th, 1874. 

Bernhardt: Beitrage zur Symptome u. Diagnostik der Hirngesch- 
wiiste, Berlin, 1881. 

Ferrier: The Functions of the Brain, London, 1876. 

Ferrier: Glioma of the Right Optic Thalamus and the Corpora Quad- 
rigemina. Brain, 1882, v., p. 123. 

Nothnagel: Topische Diagnostik der Gehirnkrankheiten, Berlin, 1879. 

Putzel: In Supplement to Ziemssen’s Cyclopzedia, New York, 1881. 

Ross: Diseases of the Nervous System, New York, 1883. 

von ate uf _m Nothnagel’s Specielle Pathologie u. Therapie, vol. 
ix; baeL, ie 


BRAIN: LESIONS OF THE CORPORA STRIATA.— 
By corpora striata is designated the lateral portion of the 
collection of gray matter called basal ganglia; these are 
further subdivided into two parts, the nucleus caudatus 
and nucleus lenticularis. 

These parts of the brain are rarely if ever the seat of 
independent states of disease. The lesions found in this 
region of the brain are almost exclusively vascular or 
tumors. 

The symptomatology of disease of the corpora striata 
is very obscure, and reports of pathological without dis- 
tinct clinical findings are often met with. 

The main symptoms to be expected from lesions in this 
neighborhood will be dependent upon implication of the 
adjacent capsular structures. As symptoms pointing 
with some probability to involvement of the corpora 
striata, these motorial irritation phenomena are cited: 
choreatic and athetotic twitchings and spasms or con- 
vulsive laughter or crying. Joseph Fraenkel. 


BRAIN: MALFORMATIONS. See Teratology. 


BRAIN: METHODS OF REMOVING, PRESERVING, 
DISSECTING, AND DRAWING.—S 1. This article has no 


‘direct reference to microscopical or pathological require- 


ments, which are provided for elsewhere in this work and 
in special papers.* Neither is it designed for neurologi- 
cal specialists, or for those who may have the benefit of 
their counsel, or access to large libraries; but physicians 
and students at a distance from medical centres, who de- 
sire to attain a real and personal acquaintance with the 
gross anatomy of the human brain as an aid to the com- 
prehension of its minute structure, its functions, diseases, 
and mental relations, may profit from an account of the 
methods found useful in a laboratory where many stu- 
dents have prepared for a medical course. 


* For example, that of Donaldson, 1894; see the Bibliography at the 
close of this article. 


369 


Brain, 
Brain, 





§ 2. Need of More Attention to the Subject.—In the large 
city schools considerable time is now devoted to the anat- 
omy and physiology of the nervous system, and instruc- 
tion is given especially in histological methods; but even 
there the gross anatomy is not always adequately worked 
out by the student himself upon good material, and it is 
to be feared that in some institutions the conditions de- 
scribed seventeen years ago (W., 1884, a) may still pre- 
vail. 3 

& 3. Inasmuch as he is permitted to clean scrupulously 
the abdominal muscles before examining the vastly more 
important viscera, the average.first-year student is at 
least consistent in deferring the removal of the organ of 
the mind until he has carefully dissected the muscle that 
wrinkles the forehead. With saw and chisel he lacerates 
the brain, tears it in the effort to save entire the sacred 
skull-cap; injures it yet more in the process of extrac- 
tion,* and places it upon a hard, flat surface, where its 
own weight completes the rupture of delicate connections 
and hopelessly distorts its shape. Here he leaves it 
(having to clean some bones), perhaps for a day or two, 
probably drying, and either freezing or decomposing ac- 
cording to the temperature. He then transfers it to a 
basin or pail, covers it with strong alcohol, notes with 
satisfaction that the surface hardens rapidly, feels sure 
of finding out all about the brain, and sees himself a fu- 
ture neurological expert, perhaps even an asylum super- 
intendent. In due time, armed with his “Gray” and a 
big knife, he succeeds in identifying the cerebellum, the 
chiasma, and the pons. Upon the cerebrum he recog- 
nizes the Sylvian fissure, but is doubtful about the cen- 
tral; moreover, the effort to detach the dried-on pia cre- 
ates so many undescribed depressions and _fissural 
confiluences that he imagines, d da Benedikt, that it be- 
longed to some hardened criminal. Lifting the occipital 
lobes, his fingers readily enter cavities which must be 
the “descending horns of the lateral ventricles,” a trium- 
phant refutation of the opinion of certain “theoretical ” 
anatomists that there is no such thing as a “ great trans- 
verse fissure” till artificially produced. He then slices 
the brain secundum professoris artem, and is so pleased at 
demonstrating the “centrum ovale majus” that he is not 
seriously disturbed at the presence of an unexpected rent 
in the callosum and an irregular orifice at either side. 
Continuing his operations, he finds the interior of the 
brain a mass of amorphous pulp; suspects that the names 
in the books have much the same significance as those of 
the heavenly constellations; modestly admits that he may 
not be sufficiently advanced to comprehend the brain, 
and resolves that, when this branch is undertaken again, 
his armamentarium shall consist not of a scalpel but a 
spoon. 

§ 4. The more important of the macroscopical methods 
of studying the brain, pursued in the Neurologic Labora- 
tory of Cornell University, are summarized in §§ 7-82. 
From the nature of the case a strictly logical sequence is 
impracticable; certain of them are subsequently described 
in detail.+ 

§ 5. Acknowledgments.—Did space permit, I would 
gladly specify the sources of such of these methods as 
are not original, and the points in which efficient aid has 
been rendered by my students, past and present, in 
either carrying out my own ideas or in improving upon 
them; the following deserve particular mention: P. A. 
Fish, 8. H. Gage, F. L. Kilborne, B. F. Kingsbury. W. 
C. Krauss, B. L. Oviatt, M. J. Roberts, M. G. Schlapp, 
Theobald Smith, H. E. Summers, B. B. Stroud, and F. 
L. Washburn. 





*The article ‘‘ Anatomy ’’ in the last edition of the Encyclopedia 
Britannica G., 876) seems to acquiesce in the present state of things as 
beyond remedy: ‘‘In taking the brain out of the cranial cavity this 
commissure [the medicommissure] is usually more or less torn through, 
and the cavity [diacele] is consequently enlarged.” 

+ That these methods are fairly successful may be concluded from 
the facility with which those who practise them receive the more 
advanced or specialized instruction imparted at the great medical 
schools, and from the nature of the preparations in the museum. Yet 
there is hardly one of these methods that is not susceptible of change 
for the better ; indeed, the constant effort to improve them has been a 
serious hindrance to the completion of this article. 


370 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


§ 6. Order of Treatment.—Introduction and Acknowl- 
edgments, §§ 1-6. 

Summary of Principal Methods, §§ 7-52. 

Preliminary Work upon Certain Animal Brains, $$ 
53-59. 

Removal of the Adult Human Brain, §§ 60-71. 

Removing the Brains of Infants and Fetuses, $$ 72-80. 

Preservative Liquids, §§ 81-90. 

Injection into the Cavities and Arteries, §$ 91-115. 

Dry Preparations, §§ 116-119. 

- Injection Mixtures, §§ 120-121. 

Economics of Alcohol, §§ 122-127. 

Storage and Transportation of Brains, §§ 128-181. 

Dissection, $$ 182-136. 

Instruments and Apparatus, §§ 137-144. 

Labelling and Recording, §§ 145-151. 

Methods of Representation, §§ 152-171. 

Bibliography. 

§ 7. Before dealing with the human brain, the various 
processes of removal, preservation, and dissection are 
practised upon the more accessible brains of the sheep 
(pp. 158, 178, 208, 209, 872, 374, 382) and the domestic 


cat (pp. 149 and 151): “ Fiat experimentum in corpore 


vii.” 

§ 8. Fetal and infant brains are utilized not only for 
what is learned from them as such (pp. 1386 and 185-189), 
but also as preliminary to dealing with the adult organ 
when, as is sometimes the case, the latter is less readily 
procured and removed. 

§ 9. Although, in most cases, the ultimate object of 
neurologic study is the comprehension of the structure 
and functions of the human brain, yet it is held to be de- 
sirable that students should understand the general pat- 
tern of the organ and recognize both the conformity of 
the human thereto and the degree of its departure there- 
from; for this purpose are studied the brains of certain 
lower vertebrates, especially the green turtle (Chelone 
mydas (p. 148) and the sheep (pp. 209 and 374).* 

§ 10. Although the pattern of the cerebral fissures of 
man and the other primates differs widely and perhaps 
irreconcilably from that of the other mammals (p. 198, § 
303), yet the methods of fissural study apply equally to 
all, and the comparative simplicity of the fissures in dogs 
and especially cats renders them convenient subjects 
upon which to commence a difficult branch of neurology 
(pp. 187-206).+ 

§ 11. Still other animal brains may be found useful in 
the illustration of special points (e.g., pp. 140, 148, 150, 
170, 204, and 207); but I strongly deprecate the extent 
to which merely curious or startling facts of compara- 
tive anatomy are sometimes introduced into medical pub- 
lications. 

§ 12. Before the detailed study of the contours of the 
masses there is gained a general idea of the cavities, their 
connections and their circumscription. 

§ 18. Skulls—which may be purchased or easily pre- 
pared under nearly all circumstances—are less esteemed — 
than brains; the “kernel” is more highly valued than the 
“shell.” 

§ 14. The infant cranium is divided with scissors and 
nippers (Fig. 986), or softened by ten per cent. nitric acid 
so as to be cut with the knife. 

§ 15. The common method of dislodging the adult cal- 
va (calvaria or skull-cap), after the circular cut with the 
saw, by “inserting a strong hook and giving a quick 
jerk,” is held to be artistically brutal and anatomically 
futile; a second, sagittal, section is made, a little way 
from the meson (middle line) and the calva removed in 
two pieces; § 60, Z. 

§ 16. Excepting for special reasons the dura is retained 





* Were opossums as common as cats in most civilized lands the less 
preponderance of the cerebrum and cerebellum over other parts would 
warrant the general study of their brains. 

+I desire to reiterate here the conviction expressed on several pre- 
vious occasions as to the inutility of the brains of ordinary monkeys 
for the elucidation of human fissural problems; indeed, our present 
comprehension and nomenclature of cerebral elevations and depres- 
sions would be far better than they are had neither Gratiolet nor any 
other anatomist ever examined a monkey brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 


until the calva is removed, and it is sometimes extracted 
with the brain. 

§ 17. The fresh brain is removed over brine (saturated 
and filtered), supported in it during the operation, and 
kept in it until its final disposition is made. 

§ 18. A fresh brain in the dura is lifted by the latter 
and supported in liquid by attaching cords to the dural 
edges, the other ends of the cords being carried over the 
rim of the pail or other vessel and wound about hooks, 
or otherwise attached. 

§ 19. A fresh brain deprived of its dura, if it is to be 
either studied from any aspect or injected into the arte- 
ries or the cavities, is supported and steadied in a pail of 
brine by passing under it a towel or broad strip of cloth, 
the ends of which are secured to the pail by hooks, tacks, 
or otherwise; the brain may thus be kept at any height 
in the brine, and rotated without touching it. 

§ 20. The fresh brain is never allowed to bear its own 
weight or to rest upon a flat surface, but is supported in 
the calva or in a bowl of appropriate shape, or in a liquid 
of equal specific gravity, or on a bed of ordinary cotton.* 

§ 21. The use to be made of a brain is, if possible, de- 
termined upon in advance. If only part is to be em- 
ployed for a specific purpose, the rest is cut away and 
preservative effort concentrated upon the selected por- 
tion. 

§ 22. When the brain is to be preserved entire, espe- 
cially for the elucidation of membranous attachments 
and the circumscription of the cavities, alcohol (or other 
active preservative liquid) is injected into the arteries by 
continuous pressure, and thus carried directly to the tis- 
sues; §§ 99 and 114. 

§ 23. When a separated head is obtained the brain is 
sometimes hardened in place by the continuous injection 
of alcohol (§ 99); it shrinks somewhat, but retains its 
natural proportions. Such a head, medisected with a 
sharp saw, is instructive in many respects (Fig. 670, p. 
141). Sometimes sections are made in other directions, 
or the calva removed as with the fresh brain (§ 60). 

§ 24. For macroscopic purposes freezing is avoided, as 
tending to leave the mass friable. 

§ 25. If a specimen is to be used especially for the elu- 
cidation or demonstration of the contours and circum- 
scription of the cavities and the lines of attachment of 
membranes and plexuses, strong alcohol, or an alcoholic 
solution of zinc chloride, is injected into the cavities and 
the arteries. 

§ 26. If certain portions of the cavities are in question, 
free access of the preservative is gained by widely open- 
ing some other region, as, ¢.g., by cutting off a frontal, 
temporal, or occipital lobe. 

§ 27. Unless there are special reasons to the contrary, 
brains are transected in the narrow region of the mesen- 
cephal (gemina or optic lobes) (Figs. 689 and 756); the 
cerebral and cerebellar portions are then removed sepa- 
rately with greater ease and less risk of laceration(§ 60, J). 
Each of these regions is medisected, if desired, more ac- 
curately than the entire brain can be, whether before or 
after hardening, and the two divisions of either half are 
subsequently apposed for study, or even attached for ex- 
hibition. 

§ 28. When the mesencephalic region itself is to be 
preserved intact, by lifting the occipital lobes a little 
more the transection is made through the diencephal 
(thalami) (Fig. 707). 

§ 29. For the study of fissures and gyres, the cerebrum 
(with the thalami) is commonly medisected (§ 61), and 
each half hardened by placing it on its mesal surface in 
the preservative. 


*So general has become the use of absorbent cotton that one does 
not always realize that its very excellence for certain purposes renders 
it less appropriate for others; when wet it packs very closely, where- 
ra in any liquid, the ordinary cheap cotton retains its elasticity much 

onger. 

+The city neurologist has perhaps only to decide that a brain is 
needed: but others, like the writer, may find it advantageous to keep 
in a portfolio slip memoranda of what he wishes to do with fresh 
brains, or heads, adult or young, as the case may be; when the op- 
portunity occurs he has only to decide among several things that 
might be done, and little time is lost. 


Brain, 
Brain, 








§ 80. So far as possible, incisions of the brain are made 
in liquid or while the scalpel is irrigated; with hardened 
brains alcohol is used; with fresh a salt solution. 

§ 31. Specimens which have become dry and distorted 
are immersed for a day in weak spirit (twenty-two per 
cent.), and then replaced in the strong alcohol. 

§ 382. When part of a thin brain preparation (¢.g., a hy- 
drocephalous cerebrum like that shown in Fig. 715) has 
dried, it is restored by placing on the spot a bit of absor- 
bent cotton wet in water. 

§ 33. To remove a delicate specimen from a vial, the 
vial is immersed in a dish of alcohol and the specimen 
floated out; to replace it, if the alcohol is clear, the vial 
is immersed and the specimen floated in; if turbid, the 
specimen may be transferred upon a bit of paper, a watch 
glass, spoon, or wpon—znot between—the points of the fine, 
curved forceps (Fig. 985). 

§ 34. Friable specimens are infiltrated with paraffin; 
see the paper by W. C. Krauss (Buffalo Medical and Sur- 
gical Journal, November, 1888) and publications there 
referred to. 

§ 35. Defibrillation—the tearing of brain substance in 
the direction of the least resistance so as to make “ cleav- 
age preparations ”—is not regarded as affording conclu- 
sive evidence of tract arrangement; but it is practised in 
illustration of facts determined by more exact methods, 
microscopical, pathological, and experimental. 

§ 36. For the decided maintenance or increase of the 
color differentiation of the two kinds of nervous tissue, 
alba and cinerea (p. 139, Fig. 66), specimens are im- 
mersed in, or injected with (or both), a solution of potas- 
sium dichromate (§ 85); or Miiller’s liquid (§ 86). 

§ 87. When the color and microscopic structure are 
subordinate to purely morphologic considerations a choice 
is made between four compound liquids devised by past 
or present assistants in the laboratory, the zinc-glycerin 
(§ 88) or the zinc-formalin (§ 89) of Fish, the saline-alco- 
hol ($ 90) or the simplified saline-alcohol (§ 90) of Stroud. 

§ 88. Dry (mummified) preparations are made accord- 
ing to the improved method (turpentine and castor.oil) of 
P. A. Fish (§ 117). 

§ 39. When the larger vessels are to be studied, 
Gage’s modification of Pansch’s starch mixture is em- 
ployed (§ 120); if the ultimate vascular supply is in ques- 
tion, a fine gelatin mass is used (§ 121). 

§ 40. When practicable the leptomeninges (pia and 
arachnoid) are removed as soon as they loosen from the 
surface, which is commonly within two days after im- 
mersion; but this is not essential, for they may be re- 
moved at any subsequent period, with merely somewhat 
more care against breaking or wounding the hardened 
brain. 

§ 41. Alcoholic brains are examined before fresh ones. 

§ 42. The size and form of the cavities are maintained 
and the preservation of their immediate parietes is in- 
sured by injecting alcohol into them; Fig. 731. 

§ 48. The forms of cavities are ascertained by making 
solid casts; Fig. 718. 

§ 44. Encephalic fragments, and poorly preserved or 
distorted specimens serve for preliminary dissections, so 
that the perfect material may be more completely uti- 
lized. 

§ 45. Before attempting to comprehend large sections, 
involving perhaps several parts but distantly related ex- 
cepting by topographical contiguity (Fig. 732), the be- 
ginner makes dissections for the exposure of parts in 
their structural continuity; Figs. 681, 682, and 801. 

§ 46. To facilitate discrimination of natural from arti- 
ficial surfaces, especially upon permanent preparations, 
incisions always follow straight lines and meet at angles 
rather than join by curves; see Figs. 708 and 733. 

§ 47. Specimens that might be injured by falling upon 
a hard surface from the height of even a decimetre (four 
inches) are held during examination over a pad of cotton 
or a dish of alcohol, and carried from room to room in a 
vessel and not in the hand. 

§ 48. Embryos and delicate brain preparations are dis- 
sected under alcohol, and sometimes pinned to a piece of 


371 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





cork loaded with sheet-lead; see Fig. 734. Preparations 
including the medicommissure (Fig. 709) are supported 
upon cork while making and for exhibition. 

§ 49. In brain dissection, as in surgery, the knife is 
made the last resort; blunt points and blowpipes are em- 
ployed as long as possible. When cutting is to be done 
the aphorism of Dr. Holmes is recalled: “ Let the eye go 
before the hand, and the mind before the eye.” 

§ 50. Delicacy of manipulation is cultivated and a 
prompt check put to all forms of anatomical Philistinism, 
whether in word or deed; the student is urged to prac- 
tise self-control, to restrain what Hyrtl calls the “furor 
secandi,” and never touch his specimen except for a good 
and sufficient reason. From the ecclesiastical standpoint, 
perhaps, the “laying on of hands” cannot be overdone, 
but in practical anatomy its excess is likely to prove the 
reverse of a blessing. These cautions are called for in 





Fig. 978.—Base or Ventral Aspect of the Sheep’s Brain with the Eyes Attached. Slightly enlarged. 
1, Frontal portion of pallium mesad of olfactory bulb; 
3, precribrum (‘‘anterior perforated 
space’’) just cephalad of the optic tract; 4, tip of temporal lobe overhanging optic tract ;* 5, root 
of trifacial (trigeminus or fifth craniai nerve): 6, opposite the narrow band of fibres crossing the 
crus, called by von Gudden “tractus peduncularis transversus,” cimbia by the Ass’n Amer. 
Anatomists ; 7, trapezium, concealed in man by the overhanging margin of the pons; 8, pyramid. 
Compare Figs. 672 and 689, pp. 143 and 154. Most of the nerve roots and many other details are 


(From ‘* Physiology Practicums.”’) 
row portion of olfactory tract (compare Fig. 688, p. 153); 


omitted. 


respect to the dissection of muscles, etc., to which the 
examination of the brain is as watchmaking to the wield- 
ing of hammer and tongs. 

§ 51. All specimens are numbered as soon as received 
(§ 146), and the essential data preserved in the form of a 
card catalogue (§ 151). 

§ 52. From the beginning students are required to 
make outline drawings, accurate if not artistic, and clear 
rather than shaded. 

§ 58. Preliminary Work upon Animal Brains.—I can- 
not too strongly emphasize the view indicated in § 7 as 


372 


to the desirability of gaining from the comparatively in- 
expensive brains of lower mammals the manipulative 
dexterity and the familiarity with parts and their names 
so essential to making the best possible use of the pre- 
cious and costly brain of man. The two particularly 
recommended are of the sheep and the domestic cat; but 
the methods of removal and dissection appropriate for 
the latter may be applied to the rabbit and to small dogs, 
while larger dogs, the pig, the calf, and cattle may be 
dealt with substantially as indicated for the sheep. 

§ 54. Removal of the Sheep’s Brain.—Unless already 
familiar with the general form and size of the organ it 
will be well to consult the representations of it on pp. 
158, 178, 208, 209, 372, 374, 382, ora plaster cast such 
as may be had for a small sum at Ward’s Natural History 
Establishment, Rochester, N. Y. The mode of extrac- 
tion recommended was devised by Prof. P. A. Fish 
while instructor in my depart- 
ment in 1890, and is indicated, 
perhaps sufficiently, in Figs. 
979 and 980. In brief, the cra- 
nium, containing the brain, is 
removed from the facial por- 
tion of the head by sawing in 
a plane coinciding with the 
ventral margins of the orbits 
and of the foramen magnum. 
The corners of the cranium are 
then sawn off and the brain ex- 
posed with nippers, beginning 
with the base. The nerve 
roots must be divided with the 
scissors. The dura must be 
divided about the hypophysis, 
and special pains taken to dis- 
lodge the olfactory bulbs from 
their fossee (§ 60, H). 

§ 55. Instruments Required. 
—In addition to a stout knife, 
coarse forceps, and coarse 
curved scissors, strong nip- 
pers, and a medium-sized saw, 
the sawing will be easier and 
more expeditious if the head 
can rest against the edge of a 
board or in an oblique sort of 
miter-box: the form of this 
will readily suggest itself if 
the operation is repeated sey- 
eral times. 

§ 56. Removal of the Cat’s 
Brain.—The following direc- 
tions are condensed and modi- 
fied from W. and G., pp.'423- 
432. The brain only is con- 
sidered here and other parts 
are disregarded. Consult Figs. 
682 and 686, pp. 149 and 151. 
The head is supposed to have 
been cut off. 

A. Instruments and Materi- 
als,—Arthrotome or stout scal- 
pel; coarse curved scissors and 
forceps; nippers of medium 
size. 

B. Removing the Skin. — 
With arthrotome or knife, di- 
vide the dorsal skin from near the nose to the caudal free 
margin. Remove the skin in the easiest way by putting 
the connective tissue on the stretch and cutting. Note 
the third eyelid or plica at the mesal angle, represented 
in man by a vestigial fold of mucosa. 

C. Removing the Mandible.—Dissect the temporal mus- 
cles from. the side of the cranium. Divide the zygoma 
with the nippers, its cephalic end by pushing a point 


2, nar- 


* According to the view expressed on p. 209, § 371, the part marked 
3 and the olfactory tract cephalad of it, are parts of the rhinencephal, 
while 4 and 6 are portions of the prosencephal. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ventrad, between it and the eyeball; its caudal end by 
pushing a point ventrad from the temporal fossa just 
cephalad of the auditory meatus. The mandible may 
now be moved up and down so as to indicate the location 





Fic. 979.—Left Side of Head of Sheep, Skinned. 


orbit O, and of the occipital condyles V. See § 54. 


of the joint; open this with the arthrotome; cut the soft 
parts about the mouth and throat and remove the mandi- 
ble together with the larynx, esophagus, etc. 

D. Remove the eyes by cutting the muscles, etc., with 
curved scissors. The white cylindric optic nerve at the 
bottom of the orbit is to be cut, not torn. 

E. Remove the cervical muscles by cutting lengthwise 
at either side of the cervical spines and then dissecting 
off the muscles. With the nippers cut off the spines; 
the atlas, of course, has none. Note the occipital crest 
for attachment of the strong musclés. 

F. Opening the Cranium.—Rest the head on either side. 
Apply the nippers at nearly right angles to the convex 
temporal region and “gnaw” through the cranium till 
the dura is reached, taking care not to plunge the points 
into the brain. The dura may be recognized by tough- 
ness and non-vascularity. It may adhere so closely to 
the bone as to come off with it, but should be left on the 
brain for the present if possible. Continue to expose 
the brain by nipping off successive fragments, by break- 
ing rather than by direct cutting. Before crossing the me- 
son expose the entire lateral aspect of the cerebrum and 
continue cautiously cephalad to the olfactory bulb. 

G. The Cerebellum.—Expose this from the same side. 
Between it and the cerebrum is a bony tentorium, which 
may be removed without injuring the brain if the nippers 
are introduced sidewise for about 1 cm. between the 
cerebellum and the cerebrum at the meson and just above 
the meatus. Continue caudad by nipping the sides of 
the atlas and axis so as to expose a portion of the myel. 

H. The other haif of the brain is most easily exposed 
by passing the nippers-point between the cranium and 


dura at the meson, and nipping or breaking off fragments - 


as before; but constant care will now be needed lest the 
fingers crush the side already exposed. 

I. Remove the mazilla by cutting with the nippers 
across the spongy ethmoid region about 1 cm. cephalad 
of the cerebrum, and then dividing the base and sides of 
the maxillary bone. The olfactory bulbs may now be 
exposed; at the first trial one or both is almost sure to 
be torn or crushed. 

J. Remove the base of the cranium, in fragments, using 
both nippers and coarse scissors cautiously until at about 
the middle of the cerebrum is seen the chiasma; try to 
expose the optic nerves for a few millimetres; avoid pull- 
ing upon them lest the brain be torn. The hypophysis 
lies just caudad and is to be saved if possible. 

K. Hold the specimen, ventral side up, the brain just 


(From my paper, 1896, g.) 
Along the line A-B the butcher may cut with saw or cleaver so as to remove 
most of the face; it extends from the angle of the jaw to a point about mid- 
way between the nose and the prominence of the head between the eyes. 
The rest of the face is then to be separated from the cranium by sawing some- 
what accurately along the line A-C, intersecting the ventral margins of the 


Brain, 
Brain, 





resting in a dish of brine. By raising the base of the 
cranium carefully there may be recognized successively 
the pairs of cranial nerves; each is* to be cut with the 
scissors as far as possible from the brain. Continue 
caudad as far as the myel was exposed; then 
divide the myel. 

L. The ventral dura has probably been re- 
moved with the base of the cranium. Remove 
the remainder as convenient, noting the mesal 
fold between the two hemicerebrums, constitut- 
ing the falx, and its connection with the layers 
of dura between which was the bony tentorium. 

§ 57. Hndymal Continuity and Celian Cireum- 
scription.—A detailed account of these features 
of the mesal cavities of the human brain occurs 
on pp. 151-152 in connection with Fig. 687. In 
connection with it, and preferably as preliminary 
to it, the mesal aspect of the sheep’s brain may 
be studied by the aid of Fig. 981. 

§ 58. Transections.—Before transecting or dis- 
secting the human brain it is well to make and 
study carefully transections of the sheep’s brain 
at levels such as are indicated in Fig. 981; and 
at others as preferred. They are more instruc- 
tive in some respects if the alba and cinerea 
are differentiated as by some chromic acid com- 
pound (§§ 84-86). 

§ 59. Fig. 981 illustrates: A. The general 
similarity to the corresponding aspect of the 
human brain as shown on pp. 141, 189, and 213. 

B. The slighter cranial flexure; p. 142, § 36. 

C. The smaller relative size of the cerebrum, permit- 
ting the cerebellum and even the olfactory bulbs to ap- 
pear in a dorsal view of the organ; p. 144, § 40. 

D. The large size of the medicommissure; p. 166, § 151. 

E. The distinctness of the crista in the adult sheep; p. 
208, § 366. 

F. The non-extension of the callosal rostrum, as a 
copula, to join the terma, as in man and the chimpanzee, 
and the consequent closure of the narrow pseudocele by 
the pia only; p. 184, § 228. 

G. The absence, as in mammals generally, of small 
foliums upon the lingula; p. 160, § 119. 

H. The absence, as in mammals generally, of a meta- 
pore (foramen of Magendie); p. 154, § 78. 

I. The completeness of the endymal continuity or celian 
circumscription; p. 151, § 63. 

J. The possibility of transecting several of the seg- 
ments without cutting others. A-—A crosses the myel; 


nasal bone 


maxilla 
nasal septum 


eye 


zygoma 


coronoid process 


: jmenaiule fossa (or 
condyloid process) 


basioccipital 


- oblongata 





Fig. 980:—Ventral or Cut Surface of the Cranium as Separated from 
the Face Along the Line A-C (Fig. 979). If the parts outside the lines 
D-E and F-G are sawn off, the brain may be exposed by removing 
with the nippers the base and one or both sides of the cranium. 


B-B the postoblongata, metencephal, overhung by the 


cerebellum; C-C, the epencephal (cerebellum, preoblon- 
gata, and pons); D-D, the mesencephal (crura and quad- 


373 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





rigeminum); E-E, the diencephal (tuber, medicommis- 
sure, thalami, etc.), overhung by the cerebrum; HY; the 
prosencephal (cerebrum) just cephalad of the chiasma 









DIACOELE” 
tuber 


Fig. 981.—Mesal Aspect of the Right 
Half of the Sheep’s Brain; xX 2. 
(From “Physiology Practicums.’’) 
This figure is semi-schematic, cer- 
tain details being omitted for the 
sake of clearness, ¢.g., the divisions 
of the cerebellum, the vessels, and the meninges, 
arachnoid and pia. The cut edge of the pia, 
however, is represented by the line between the 
rostrum and the crista, The names of the cavi- 


albicans 


removal is done leisurely * and with care so as not to dis- 
tort form or rupture membranous connections. Secondly, 
the calva (calvaria or skull-cap) is divided sagittally 1 to 


-—.. Splenial fissure 


ae diatela 


habena 
, splenium 1 


supracommissure 






tA 
~" 
ae eg 


epiphysis 


METATELA 


ties, Diacale, etc., should be spelled Diacele, ete. The endyma lining the diatela is really continuous at each end with that of the adjacent 


parts. The lines A—A to G-G represent planes of instructive transections. 


G-G, the rhinencephal, at the junction of the olfactory 
bulb and tract (pp. 153, 178, 208, 209) overhung by the 
cerebrum. 

§ 60. Removing the Adult Human Brain.*—The method 
here recommended and described differs from those some- 
times employed in three respects: First, since the brainis 





Fig. 982.—Head-Rest Devised by Stroud, in Use. 
1900, b.) A, Baseboard; B, upright board; D, chin-rest; E, lateral 
iron bar. For details see Figs. 988-989, and §§ 142-143. 1-1, Reflect- 
ed portions of the scalp. 


(From his paper, 


not to be sliced or cut into small pieces for histologic 
examination, but preserved entire or in large divisions 
for morphologic investigation and demonstration, the 


* See also the articles Autopsies and Brain, Surgery of. 


374 


See § 58, J. 


2cm. from the meson and removed in two pieces. Thirdly, 
the subject lies upon the belly with the head supported 
and steadied in the “head-rest” devised by Dr. Stroud 
(Figs. 982, 988). 

A. Instruments and Matertals.—In the absence of a 
well-equipped post-mortem case (see the article Aw- 
topstes) the following should be provided: Scalpel, me- 
dium size; arthrotome (Fig. 985) or a similar stout knife; 
syringotome (Fig. 985); probe-pointed bistoury (§ 138); 
coarse scissors and forceps; fine scissors and forceps; 
tracer; bone-chisel (§ 139); mallet or hammer; strong 
hook, for catching on the divided margin of the calva 
and dislodging it;+ saw (§ 140); drill or awl or wire 
nail; wire and cutting pliers (p. 385); | surgeon’s needles 
and silk; absorbent cotton; common cotton; plaster of 
Paris; towels and Japanese napkins; scales; several pans 
of water and of brine, one large enough for medisection 
of the cerebrum. The beginner will do well to have at 
hand for consultation a hardened brain and a preparation 
of the dural folds (falx and tentorium) or models or good 
figures of the same (Fig. 800). 

B. Dividing the Scalp.—Between the roots of the ears 
carry a cord over the highest region of the head. Wet 
the hair along this line over a zone 2-3 cm. wide.§ With 


* Commonly an hour and a half is allowed for the operation ; but on 
one occasion, in an emergency, With the aid of a single assistant, Dr. 
Stroud removed a brain and made the head presentable for waiting 
friends within forty minutes. 

+ In the absence of one made for the purpose it may be made from 
stiff wire; some large pocket knives have a hook of suitable size and 
strength. 

t¢ The pliers used by the linemen of the telegraph and telephone 
answer admirably for both cutting and twisting. ‘ 

§ This and some other details presuppose that the body may be 
viewed by friends or that there are other reasons for the minimum of 
disfigurement. Under certain circumstances they may be disre- 
garded, although I think it well to maintain an almost esthetic and 
artistic attitude toward all dealings with the human brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brain, 
Brain, 





a narrow scalpel handle or any convenient instrument 
part the hair along the cord so that none remains cross- 
ing the line of incision. Mark the proposed line with a 
soft pencil or a fine point, and remove the cord. Insert 
a scalpel point at the top of the head with the edge away 
From the head and cut toward either ear along the chosen 
line, avoiding deflections and the division of hairs. Di- 
varicate the edges and repeat the incision if necessary 
so as to divide fat and connective tissue to the periosteum, 
or, at the sides, over the ears, to the firm fascia covering 
the thin (temporalis) muscle in that region. 

C. Reflecting the Scalp.—Dissect up the scalp at either 
side and reflect it over the neck and the face to a level, if 
possible, a trifle lower than the first incision between the 
roots of the ears. Before reflecting the frontal portion 
it may be well to cover the face with a pad of cetton to 
protect the features from undue pressure. 

D. Circular Division of the Cranium.—Tie a cord 
around the head just dorsad of the ears, the frontal por- 
tion passing about 15 mm. from the brows; mark this 
line with a pen, or cut the periosteum to the bone. If 
the fresh calva is to be secured in place after the extrac- 
tion of the brain, leave the fibrous cephalic and caudal 
margins of the temporal muscles for the stitches to be 
taken in; otherwise these muscles may be removed en- 
tirely. 

In sawing,* three points are to be observed: (1) The 
thicker frontal and occipital regions should be taken first ; 
(2) at four places, preferably what might be called the 
four corners of the cranium, the bone is not to be divided 
completely until the calva has been sagittally divided (§ 
66); (3) if the ectal features of the brain are to be pre- 
served intact, a sectioned cranium should be consulted in 
order to estimate the thickness at variable points, and 
frequent trials should be made by pushing a point, like 
the probe end of the tracer, into the kerf (saw-cut) at the 
middle of that part of the convexity; when it can be 
pushed through, the sawing should proceed with care in 
each direction. 

E. Sagittal Division of the Calwa.—After the circular 
kerf has been completed, but before the calva has been 
loosened by the chisel,+ carry a cord from the brows to 
the occiput, over the head, at about 138 mm. (half an 
inch) from the meson; along this line cut or mark the 
periosteum, and saw completely through the bone. 
Then, with taps of the hammer upon the chisel, sever 
the remaining attachments of the smaller part of the 
calva along the circular kerf. Sometimes that piece will 
come off readily; if not, introduce the spatula in the 
temporal region, where the bone is thin, keep its point 
pressed against the bone and so detach the piece; in some 
cases the spatula must be introduced at other points, 
always with the minimum amount of pressure upon the 
brain. 

The mesal adhesions along the sinus are now directly 
accessible, and a sharp edge may be employed if neces- 
sary. The location of any other adhesions may commonly 
be inferred from what existed upon the first piece, and 
the removal of the larger side of the calva is completed 
without difficulty. 

F. The Dura.t—Unless it is desired to retain the calval 
dura entire the longitudinal sinus should be slit to let 


out the blood. Commonly, notwithstanding all precau-_ 


.tions, the saw has cut the dura at some point. There— 
or at any other point—commence with the scissors or 
probe-pointed bistoury, and cut the dura along a line 
about 2 cm. from the margin of the cranium and turn 


* Most of the sawing should be done by an assistant, that the chief 
‘may better accomplish the later operations. 

+ If the conditions are such that the calva must be kept entire there 
seems to be no other way than to remove it by pulling upon either the 
frontal or occipital edge with a hook as is commonly done at post- 
mortems; but this is almost certain to tear the brain or its telas or 
plexuses so as to render them unsuited for morphological elucidations. 

t Space will not permit detailed directions for removing the brain 
in the dura; suffice to say that with care and patience and anatomical 
knowledge it may be accomplished so that only a small part of the 
dura is absent from the central region of the base. For the safe 
‘handling of the brain and for alinjection purposes even the dorsal 
half of the durais worthsaving. See pp. 171 and 213, Figs. 720 and 801. 


it outward so as to protect the delicate brain from the 
sharp or rough edges of the cranium.* Lift the sides of 
the dura in turn, cutting with scissors any vessels or 
fibrous connections between the dura and the cerebrum; 
near the meson there are several veins entering the longi- 
tudinal sinus. Unless the entire calval dura is to be 
preserved the two sides may now be cut away along the 
margins of the sinus. 

G. The Falx.—On Figs. 800, 801, and 804 (pp. 212, 
218, 215) note its form and its relations to the crista galli, 
the tentorium, and the callosum. Ina good light divari- 
cate the frontal lobes so as to expose the narrow cephalic 
portion of the falx and transect it with scissors. Lift the 
end slowly, dividing membranous and vascular attach- 
ments as they appear; at its wide occipital end there will 
be need of especial care lest the traction dislocate the im- 
portant relations of parts about the splenium. The wide 
end of the falx may now be divided along its attachment 
to the tentorium. 

H. Freeing the Ventral Attachments of the Cerebrum.— 
These are (a) the entocarotid arteries (“internal carotids,” 
Fig. 803, p. 214) and some smaller vessels and fibrous 
bands; (0) the optic nerves (Fig. 672, p. 143), the hy poph- 
ysis (Fig. 689, p. 154), and the filamentary olfactory 
nerves passing from the ventral side of the bulb (Fig. 
672, p. 148) through the cribriform plates. Unless these 
filaments are divided the bulbs or their tracts are likely 
to be torn. The head should be tilted a little so as to per- 
mit some recession of the frontal lobes. Raise these and 
allow a good light to enter between them and the cranial 
floor. With the syringotome or other small curved in- 
strument, divide or tear the soft olfactory nerves as they 
enter the cribriform plate so as to free the bulbs; some- 
times it may be done most easily with fine curved 
scissors. 

The carotids are easily recognized at the sides of the 
chiasma and should be cut with the scissors. 

The optic nerves are tough and not apt to tear, but 
the slender infundibulum is very easily broken; hence, 
before dividing the nerves, it is well to cut the dura at 
the margins of the hypophysial (pituitary) fossa and so 
dislodge the hypophysis as completely as possible. 
When this is accomplished divide the optic nerves close 
to the cranium. 

Now tilt the head first to one side and then to the other 
so as to permit the division of some veins connecting the 
temporal region with the cranium. 

I. The remainder of the operation will differ according 
as the brain is to be removed entire or in two portions, 
cerebral and cerebellar. For most purposes the latter is 
preferable, and it is so much easier that the beginner is 
advised to adopt it until familiarity with the parts has 
been gained by experience. 

J. Transecting the Mesencephal.—Tilt the head so that 
the cerebrum tends to slidesomewhat cephalad. Lift the 
occipital lobes and with the scissors cut the vessels and 
connective tissue and membranes just caudad of the 
splenium (Fig. 801) so as to expose the gemina, the 
dorsal lobes of the mesencephal corresponding to the 
crura ventrad (Figs. 707, 708). This is the narrow region 
connecting the wider cerebellar mass with the still wider 
cerebral portion, and hence called sometimes the “isth- 
mus.” With the probe-pointed bistoury or sharp, narrow 
scalpel cut this just caudad of the epiphysis; the knife 
should point almost directly at the tip of the nose if the 
pons is to be wholly avoided. It is sometimes well to 
make two cuts, one from either side, directed slightly 
cephalad as well as mesad so as to avoid the curved mar- 
gin of the pons. The trochlearis and oculomotor nerves 
will probably be cut during the transection. If not, they 
are to be watched for and divided during the next step. 

The cerebrum may now be lifted out with both hands 
and weighed (§ 62) or otherwise dealt with as desired 

§ 61). 
Re Tentorium.—This is to be cut, with the blunt- 
pointed bistoury or the coarse-curved scissors, along its 


* For this valuable suggestion I am indebted to Dr. Stroud. 


375 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





attached periphery and removed entire, thus exposing 
the cephalic (“upper ”) aspect of the cerebellum (Fig. 700, 
p. 159). If the head is tilted a little to one side and the 
other, the fingers may be safely passed under the com- 
paratively firm pons so as to lift the whole mass and 
expose the remaining cranial nerves (Fig. 681, p. 154). 
When these and the vertebral arteries are divided (Fig. 
808, p. 214) the myel itself may be cut well down in the 
spinal canal. Lastly, afterreplacing the parts and tilting 
the head cephalad, may be divided the attachment of the 
arachnoid about the foramen magnum, and the mass may 
now be removed. It is advantageously kept entire till 
hardened, but the cerebrum is more easily dealt with and 
commonly more instructive if medisected at once. 

§ 61. Medisecting the Fresh Cerebrum.—This is to be 
done with a large knife, thin and very sharp. The mass 
should rest in a wide dish of brine and be steadied but 
not actually supported by cotton at the sides. The 
frontal lobes are held closely together by the arachnoid 
along a line corresponding with the ventral (concave) 
margin of the falx (Figs. 800 and 801, pp. 212, 218). 
This arachnoid must be torn or carefully divided so as to 
permit the slight divarication of the hemicerebrums and 
the exposure of the mesal zone of the callosum, recogniz- 
able from its white color at the bottom of the intercerebral 
fissure. 

If there are special reasons for obtaining an accurate 
medisection of the callosum itself or of the pseudocele 
(Fig. 756, p. 189) the section may begin with the callosum, 
preferably the genu or cephalic curvature. 

Commonly, however, I have found the delicate terma 
and medicommissure more perfectly preserved when the 
cerebrum rests upon its dorsum and the chiasma is divided 
first. In either case the knife should be constantly irri- 

ated. 

§ 62. Weighing the Fresh Brain.—This may be done 
in any of three ways. 

A. With an animal of moderate size, or a child, ora 
separated head, the weight of the brain represents the 
loss of weight of the animal, child, or head after its re- 
moval. 

B. A vessel partly full of water, salt solution, or brine, 
is balanced upon the scales;* the brain is lifted from the 
liquid in which it has been, in the hollowed hands; they 
and the brain are rinsed with water, and the brain is 
transferred to the vessel on the scales. If the dura re- 
mains the weighing cannot be accurate, even by deduct- 
ing its weight when removed. 

C. After recording the weight required to balance the 
added brain, then—having first wet the hands with a 
liquid identical in composition with that in which the 
brain is immersed—remove the brain and record the loss 
of weight. Theoretically it should be the same as had 
to be added before; practically there is usually some dif- 
ference, and the average of the two may be taken as 
representing the true weight. 

§ 68. Determining the Volume of a Brain.—This is 
done, as with any other mass, in either of two ways. 

A. Into a vessel of accurately known capacity pour a 
given volume of liquid; dip the hands in the same, and 
transfer to it the brain; then from a graduated vessel 
add enough more of the liquid to fill the first vessel. The 
difference between the total capacity of the vessel and 
the sum of the two volumes of liquid introduced repre- 
sents the volume of the brain. 

B. Set a vessel in a deep pan, dish, or pail. With any 
liquid (salt solution, water, or alcohol and water) that is 
lighter than the brain, fill the vessel just to the brim. 
Let the brain into it gradually; the overflow will repre- 
sent its volume. 

Obviously a combination of the two methods is most 
satisfactory. 

§ 64. Dividing Nerves and Vessels.—As a rule this 
should be done with the scissors, not so much to avoid 


*Some trouble will be avoided if, after the pan of liquid has been 
counterpoised upon the scales by an approximately equal weight, say 
500 or 1,000 or 1,500 gm., the exact balancing is accomplished by 
removing or adding liquid with a syringe. 


376 


blunting the scalpels by contact with bone as to avoid 
the almost inevitable traction and breakage of delicate or 
important attachments. 

§ 65. Closing Divided Vessels.—This may be desirable 
either to prevent the disfigurement of the body or cloth- 
ing by blood, or to permit the injection of the general 
vascular system. In the latter case, unless the divided 
vertebrals and carotids can be tied or caught with se77es- 
jines, the regions in which they open may be filled with 
plaster of Paris. In the former case, plugs of absorbent 
eotton may be pushed into the spinal canal and the vas- 
cular orifices at the base of the skull, and the cranium 
then filled firmly with the cotton so as to be compressed 
and crowded down by the calva. 

§ 66. Reuniting the Divided Calva.—lf necessary, at 
once, or at any time, the two parts of the calva may be 
united by wires, or even cords, passed through holes at 
the middle and at each end; such holes may be made 
with a drill, awl, or wire nail. 

§ 67. Reattaching the Calua.—Whether reunited or not 
the two pieces of the calva may be secured by wires 
through holes at each of the four “corners” (§ 60, D). 
Further stability is gained by stitching the divided edges 
of the temporal fascia. 

§ 68. Sewing up the Scalp.—A knot should be tied at 
the end of the silk and the needle introduced at the root 
of the ear, at first ecto-entad (from the surface inward), 
afterward ento-ectad (from within outward); the stitches 
not too long, and not entangling the hair. Even if the 
concealment’ of disfigurement is not essential the opera- 
tion should be neatly done unless there are special reasons 
for unusual haste. 

§ 69. Other Methods of Removing the Adult Brain.* 

§ 70. By Removal of the Occipital Region of the Cra- 
nium.—At the meeting of the American Neurological 
Association, June 22d, 1883, as reported in its Transac- 
tions, p. 84, as reprinted from the Jowrnal of Nervous 
and Mental Disease, July, 1883, Dr. Spitzka described as 
follows a method which, he informs the writer, he has. 
known to be employed by some German anatomists. 
The writer has not tested this method personally, but is 
disposed to regard it as better adapted to pathological 
than to anatomical purposes, and as such entitled to be 
considered in connection with the usual method, and 
with that described on pp. 789-791 of Vol. V. of the first. 
edition of the REFERENCE HANDBOOK: 

“The scalp is divided in the median line, beginning a 
little in front of the coronal suture, and extending down 
the neck. If it is desired to remove the spinal cord the 
incision is extended to the lumbo-sacral region. Two 
lateral flaps are formed in the head region, the soft parts 
being peeled from the dorsal aspect of the cervical verte- 
bra and the posterior half of the skull. A circular in- 
cision is made [with the saw] in the skull, behind the 
ears, and completely encircling it down to the foramen 
magnum, care being taken not to injure the connection 
between the articular processes of the atlas and the oc- 
cipital condyles; the posterior half of the skull is removed 
exactly as the calvarium ordinarily is, by taps of a chisel; 
sometimes a rongeur forceps suffices to complete the 
division near the foramen magnum. The adhesion about, 
the lateral [and longitudinal] sinus and torcular Hero- 
phili can be readily overcome by a home-made apparatus 
like the knife [spatula, or round-pointed knife, curved 
flatwise] shown by Professor Wilder. The advantages 
of this method are: 1, The spinal cord and brain can be 
demonstrated in continuo; 2, the critical operation of 
lifting the hemispheres and gouging out or injuring the 
cerebellum in dividing the tentorium is obviated; 3, the 
nerves and arachnoidal laminze at the base may be divided 
without allowing the brain to drag by its own weight. 
These nerves are divided from behind forward. As soon 
as the chiasm is divided, the skull is inclined a little, and 
the brain allowed to fall into the hands of the operator 
by its own weight, it being completely separated, except 
where the olfactory filaments pass through the ethmoid; 





* See the article Autopsies. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


but these yield readily, and I have gotten the olfactory 


bulb intact as often by this as the other method. The 
removal accomplished, the occipital segment is riveted 
back, and a stick of wood inserted in the spinal canal and 
extending to. the cranial interior restores the strength to 
the head support, impaired by the breaking up of part 
of the vertebral attachments.” 

§ 71. The method of Féré (as briefly described in a 
paper “ Procedé de coupe du crane,” Soc. Anat. de Paris 
Bulletin, ii., 206-207, March, 1877) is by a circular incision 
very low down from the eyebrows ventrad of the auditory 
meatus to a point between the foramen magnum and the 
dorsal arch of the atlas. This, if successful, would un- 
cover the brain very fully and permit its replacement in 
the calva after extraction: but it seems inevitable that 
the petrous bones should give trouble as well as be them- 
selves destroyed. 

§ 72. Removing the Brain from Late Fetuses, Still-Borns, 
or Young Children.—This is most conveniently done if 
the cranium and maxillary region are first cut away from 
the neck and mandible by cutting with coarse-curved 
scissors from the corners of the mouth to the nape of the 
neck. The mass thus obtained is compact and may stand 
upright in liquid. 

A. Instruments and materials required. Coarse for- 
ceps; coarse-curved scissors for bone; another sharp pair 
for soft parts: tracer (Fig. 985): nippers (Fig. 986); 
large scalpel; narrow-bladed scalpel, preferably a probe- 
pointed bistoury; four vessels, holding about two litres 
each; twoof water; one of preservative; one of saturated 
brine; if the weight of the brain is to be ascertained (§ 
62) the body should be weighed before the head is re- 
moved, and there should be provided a fifth vessel of 
normal salt solution (15 to 2,000). 

B. The scalp should be removed completely, together 
with the ears, and temporal musclesas faras the zy gomas. 

C. Cranium and dura. In young subjects these ad- 
here closely; hence, contrary to what is recommended 
with adults, they should be removed together in pieces. 
With the tracer-point lift the united pericranium (ectal 
periosteum) and dura near the left margin of the prefon- 
tanel (p. 212, § 388), and with the scissors or scalpel slit 
the tough membrane so as to expose a little of the brain. 
Grasp the cut edge with the forceps and with the scissors 
cut out a piece including pericranium, dura, and interven- 
ing area of parietal bone. Continue in this way, using the 
nippers when necessary, until the entire left hemicerebrum 
isexposed. More and more care will be required to avoid 
injuring the delicate brain, either by the instruments or 
the cut edges of bone. 

Leaving the falx undisturbed, expose the right hemi- 
cerebrum in the same way, but with even more precau- 
tion and holding the head so that the left is more or less 
completely supported in the brine. 

D. Proceed then, mutatis mutandis, as directed for 
the adult (§ 60, G). 

& 73. Removing the Hemicerebrums Separately.—The 
following modification of the method just described has 
some advantages. After the exposure of the left hemi- 
cerebrum cut the veins as before. Let the head tilt to 
the left so as to expose the callosum. Divide it, as 
directed above, down to the base of :the skull; then the 
left half of the mesencephal; then the infundibulum and 
optic nerve; and finally dislodge the olfactory bulb. 

These last parts are then to be attended to first on the 
right side; the falx is easily removed, and the hemicere- 
brum comes out as soon as the veins are cut. The chief 
objection to this method is the danger of cutting the 
mesal aspect of one of the frontal lobes. 

§ 74. When there are reasons for not mutilating the 
head, the removal of a child’s brain is much less con- 
venient. The body and legs should be wrapped up so as 
to be held and turned easily. Unless the child can be 
held by an assistant, it will be found convenient to let it 
rest in a sort of trough, like a piece of large roof-gutter; 
or to roll it up in a sheet of lead, which, upon pressure, 
will flatten so as to maintain any desired position. The 
tray or trough must be supported at a level with the rim 


Brain, 
Brain. 





of the vessel of brine, so that the head may hang over 
into it when desired. Needle and thread must be pro- 
vided for sewing up the scalp. 

§ 75. Ventral Eaposure.—For some purposes, e.g., 
when the organ is tu be kept entire, or when the nerve- 
rogts are to be retained, the young brain may advantage- 
ously be exposed from the ventral side; this aspect 
should be first studied, as shown in Figs. 672 and 806; 
then the base of the cranium may be nipped away, or 
cut with the coarse scissors; it will be well to expose one 
side completely first, so that any errors detected may be 
avoided on the other. With care the hypophysis (Figs. 
689 and 708) may be retained. 

This method is less applicable to adult brains, on ac- 
count of the thickness of the skull; this, however, may 
be softened by nitric acid (§ 127). 

On February 1st, 1884, the writer removed the cranium 
of a small monkey (Midas, No. 342) by means of a dental 
engine, working a small saw and a burr. It may be pre- 
dicted that in time the work now done laboriously with 
saw and nippers will be accomplished more neatly and 
expeditiously by some apparatus like the electro-osteo- 
tome of the late Dr. M. J. Roberts (Virginia Medical 
Monthly, March, 1887). 

§ 76. Brains of the middle and later gestative periods and 
at term are most useful for the comprehension of the 
early and simple condition of the fissures and of the order 
of their appearance. The best results are obtained by 
their prompt removal as described in §§ 72-75, and hard- 
ening with some zinc-chloride mixture (§ 89). The arte- 
rial injection of such brains rarely preserves them well, 
and the gyres are commonly so pressed together as to 
interfere with both the removal of the pia and the recog- 
nition of their relations. 

§ 77. Harly Fetal Brains, Two to Four Months.—Un- 
less one has acquired considerable skill in manipulating 
such delicate objects, these should be hardened in place 
by one of the following methods, or by a combination of 
them; a five-per-cent. solution of zinc chloride in alcohol 
is very effective with embryo brains: 

A. Injection of the preservative through the umbilical 
vein. 

B. Immersion; if alcohol, or the above solution, is 
used the specimen should be suspended in it. 

C. Injection of the preservative with a hypodermic 
syringe both into the body in general and into the cavities 
of the brain.* The cannula should be pushed through the 
scalp at the margin of the prefontanel (p. 212, § 388), 
obliquely latero-ventrad so as to traverse the thin parietes 
and enter the large frontal portion of the paracele (Figs. 
667, 716, 747). The success of the injection is shown by 
the expansion of the opposite half of the head due to the 
passage of the liquid through the portas (“foramina of 
Monro”) into the corresponding paracele. 

The exposure of such brains must be done under or over 
alcohol; the cranium and dura must be divided together 
at each cut (§ 72, C). The operation is tedious, but the 
results are revelations, no matter how often performed ; 
no specimens. are more beautiful or instructive; see Figs. 
667, 746, 748. 

§ 78. Hydrocephalic brains, and those of fetuses be- 
tween the second and seventh month, are alinjected in 
place from the aorta or other artery, and also have the 
more or less abundant neurolymph replaced by strong al- 
cohol. This direct, entocelian alinjection is done as soon 
as possible after the arterial has begun; it is most con- 
veniently accomplished by making a slit at one margin 
of the prefontanel large enough to permit the introduc- 
tion of a cannula and the escape of liquid at itsside. The 
injection need not be continuous, and, of course, should 
not be under pressure, but may be repeated at intervals 
of an hour or two. 

§ 79. When a hydrocephalic or fetal brain is wanted 
for a special object involving the integrity of the entire 
cerebrum or the complete distention of the metepenceph- 





* So far as the writer is aware, this was first done by Professor S. H. 
Gage, May 17th, 1892, upon specimen 2,947. 


377 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








alic cavities, then the undesired region is cut away, the 
desired region left in the cranium, and the alcohol in- 
jected through the mesocele, continuously, in order to 
make up for the non-injection of the arteries. 

§ 80. Removed embryo and hydrocephalous brains are 
relieved from pressure during hardeuing by inflating the 
cavities; Fig. 715. The buoyancy of even an adult 
normal brain is sometimes increased by injecting air into 
the arteries through a bulb syringe. 

§ 81. Preservative Liquids.—Al\cohol is a perfect pre- 
servative, but it bleaches the cinerea, and in any mixture 
with water strong enough to be effective the brain sinks 
and becomes distorted. The specific gravity of the mix- 
ture may be increased by glycerin, zinc chloride, or other 
heavy soluble salts (§ 82-84). Strong alcohol may be ne 
jected into the cavities and blood-vessels of the brain ($$ 
91- 108). 

$82. Alcohol and Glycerin.—One of my most perfect and 
instructive fetal brains (1,820; Fig. 751, p. 187) was first 
placed in equal parts of alcohol and glycerin; after two 
days half the mixture was replaced by alcohol; after two 
days more alcohol alone was used, and this was renewed 
ie the following. The mixture merits systematic trial. 

& 838. Alcohol and Zine Chloride.—A_ five-per-cent. 
solution of this salt in ordinary (ninety-five-per-cent.) 
alcohol is very effective with embryo and fetal brains, 
whether by injection or immersion. 

& 84. Ammonium Dichromate.—Our use of this has 
not been sufficiently extensive for a general statement, 
but, at the suggestion of Professor Gage, it was employed 
in association with alcohol very successfully in the prepa- 
ration of the specimen represented on pp. 176 and 184 
(Figs. 732 and 744). In equal parts of alcohol and water 
the salt was dissolved in the portion of 2.5 gm. to the 
litre. In addition to the thorough hardening of the sub- 
stance and the unusually perfect maintenance of the 
membranous and plexal attachments, the color differentia- 
tion was sufficient, although the subsequent prolonged 
preservation in alcohol alone has nearly bleached the 
cinerea. This salt merits further trial in various com- 
binations. 

§ 85. Potassium Dichromate.—This is the essential in- 
gredient of Miiller’s liquid (§ 86). Dr. Stroud has deter- 
mined that, at the temperature of 20° C. (68° F.), a 
saturated solution of potassium dichromate contains 
about ten per cent. of the salt; at boiling the per cent. is 
forty-four. His method of using it is to effect the solu- 
tion rapidly in boiling water; when cool, enough water 
is added to float the brain just below the surface. 

The specimens in this solution or in Miiller’s liquid 
should be kept in the dark, z.e., in metal pans with metal 
covers, or in a dark room. 

As soon as the brain is firm to the touch it may be 
soaked for a day in water and then in alcohol, at first 
about forty per cent., then stronger, until the alcohol 
ceases to be colored, after which it may be kept in al- 
cohol of not less than eighty per cent.* 

The alcohol that is so colored may be used for the same 
purpose with other brains, or for the storage of specimens 
not requiring it to be either colorless or very strong. 

§ 86. Miller’s Liquid.—This consists of two parts of 
potassium dichromate and one part of sodium sulphate 
in one hundred parts of water. Beyond increasing the 
buoyancy of the liquid, the sodium sulphate seems to 
have no special value for either microscopic or macro- 
scopic purposes and is often omitted. Sufficient buoy- 
ancy may be attained by increasing the per cent. of the 
essential ingredient (§ 85). 

§ 87. The Incompatibility of Alcohol with Potassium 
Dichromate.—A. chemist to whom the matter was sub- 
mitted states that when alcohol and potassium dichromate 
are mixed in any proportion the salt will be at least 
partially reduced, and there will also be formed, from 
the alcohol, various compounds, as acetic acid, acetic 





* The specimens may be more completely decolorized by absolute 
alcohol (W. C. Krauss), by hydrogen peroxide (Unna, Arch. ftir 
mokros. Andat., xXxx., 48, 1887), or by a one-per-cent. solution of 
chloral hydrate (Lee, ** Microtomist’s Vade Mecum”’). 


378 


aldehyde, etc. These processes take place in either the 
light or the dark, but more rapidly in the light. 

§ 88. Zine-Glycerin Mixture.—After careful considera- 
tion of prior suggestions, and prolonged experimentation, 
P. A. Fish published (1898, p. 398; 1894, p. 101) the 
formula of a liquid which, “though not ideal in its effects, 
seems to answer the requirements of economy, fixation 
of the structural elements, differentiation of tissue, a 
minimum amount of distortion, firmness of texture, and 
rapidity of action. 

~“The formula is as follows: 


Water. a. soi.cecisys pales oek een 400 c.c 
Ninety-five-per-cent. alcohol........... 400 c.c. 
GAY COPIN ovis foroiesdinta hae isiars oon 250 c.c. 
Zine Chloride@ iets sites) Jt ete eee 20 gm 
Sodium. chlorid@.< <5 cs:sitep «<0 nee 20 gm 


“The specific gravity of the mixture should be about 
1.04, a little greater than that of the brain itself (1.038). 
The slightly greater density of the fluid is believed to be 
more advantageous than otherwise, since it buoys the 
brain until the tissue has begun to harden and can par- 
tially support its own weight. The pressure is nearly 
enough equal on all sides to prevent any noticeable 
change of form. It is recommended that the cavities of 
the brain be filled with the mixture (celinjected) and if 
practicable the blood-vessels also injected. After an im- 
mersion of about three days the specimen should be 
transferred to equal parts of the foregoing mixture and 
seventy-per-cent. alcohol for a week or more, where on 
account of the lesser specific gravity it should rest upon 
a bed of absorbent cotton; it is finally stored in ninety-per- 
cent. alcohol.” 

§ 89. Zine-Formalin Mixture.—Two years later Fish 
published (1895, @ and 0) the results of two experiments 
with an agent then comparatively little known. Refer- 
ring to the zinc-glycerin liquid he says: “ Experiments 
with formalin (forty-per-cent. formic aldehyde) show that 
practically as good results may be obtained at less cost 
when the following mixture is employed: 


Waters isisc ee mesg hectibs Ree eee 2,000 c.c 
Formalings....: = << sects eee 50 c.c. 
Zin’ Chlorides cmigecisseee a cee eee 15 gm 
Sodium chlorides oa. -e.. eee 100 gm 


The brain is left in the mixture for a week or ten days 
(a longer stay is not detrimental); when practicable the 
cavities and blood-vessels are injected with the same to 
insure a more uniform hardening.” 

Respecting the subsequent treatment Dr. Fish writes 
me that he recommends a course slightly different from 
that indicated in the papers quoted. For storage, a five- 
per-cent. solution of formalin, ¢.e., 50 c.c. to 1,000 of 
water.* In this it may remain indefinitely if properly 
covered. For museum purposes it may be placed suc- 
cessively for a few days each in alcohol, 50, 70, 90, and 
95 per cent. 

§ 90. Saline Alcohol.—Dr. Stroud, the successor of Dr. 
Fish, continued experiments with the same important 
end in view and devised a liquid which dispenses with 
the irritating zinc chloride, combines the two liquid 
preservatives, alcohol and formalin, and overcomes the 
difficulty due to the slight solubility of the sodium chlo- 
ride in an alcoholic mixture by employing a somewhat 
larger portion of another salt, sodium acetate. The 
formula as published in 1896 is as follows: 


Sodium acetate... 2... assem ee eee 130 gm 
Sodium Chlorides «4.0. .eaeer oe nee 110 gm 
Formal [formalin] (forty-per-cent. 
formaldehy.de)ie= eee 20 c.c. 
Alcohol (ninety-five per cent.)........ 460 c.c. 
Water. ics S52 ceo ane eee 540 c.c. 


Dissolve the sodium acetate and the sodium chloride in 
the water. Cool and filter, then add the alcohol. With 


* As the formalin does not prevent the freezing of the water, cold 
must be guarded against. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





alcohol free of tax the cost is about fourteen cents per 
litre. 

For a human brain is required about 8 litres, 7.e., three 
times the above formula. For a sheep’s brain, about 
400 c.c., or half the formula. 

Brains should remain in brine to soak out the blood for 
a time dependent on their size. They should remain in 
the saline alcohol for ten or fifteen days, but a longer 
period is not harmful. Then they may be transferred to 
increasing percentages of alcohol. 

During the last four years there have been prepared 
by the saline-alcohol scores of human brains and hun- 
dreds of brains of sheep and other animals, and it has 
proved wholly satisfactory for macroscopic purposes, 
whether for dissection or permanent preservation. The 
* structural and color distinctions between alba and cinerea 
are well maintained. 

§ 91. Experiments are making with a saline-alcohol 
in which the components have a simpler ratio, and the 
results will be announced as soon as practicable. 

§ 92. Hntocelian Injection.—To fill with a hardening 
and preservative liquid cavities surrounded by flexible 
walls would seem to be a natural device both for the 
better preservation of the mass and for the maintenance 
of the forms and relations of the cavities.* 

A small glass syringe may be employed for injecting 
preservative liquids into the brain cavities, either directly 
or by attaching a rubber tube and cannula. 

§ 93. Seldom, if ever, excepting perhaps with very 
small or thin-walled specimens (e.g., the brain of Crypto- 
branchus shown on p. 170, Fig. 717) is a single or mo- 
mentary introduction of the preservative sufficient. 

§ 94. Continuous Injection.—This involves, first, the 
elevation of the reservoir of preservative to a height 
(upon a shelf or at the end of a cord) sufficient to insure 
steady and adequate pressure; secondly, the avoidance 
of damage from the clogging or twisting of tubes or the 
overflow of the liquid that has escaped after traversing 
the vessels or the cavities. The various requirements 
may be met by simple arrangement of pinchcocks and 
flexible wire supports of copper or lead. 

§ 95. Without conceding the existence of other natural 
orifices from the paraceles (lateral ventricles) (p. 171, 
Fig. 721), both human and animal brains present outlets 
for the escape of the injected liquid so as to obviate the 
danger of rupturing the thinner parietes under any 
pressure that might be required for filling the cavities. 
With animals the myelocele (central canal of the spinal 
cord) is pervious through life. With a cat, for example, 
where 4 cm. of the myel remained attached to the brain, 
alcohol injected into the diacele (third ventricle) with a 
syringe escaped from the myelocele in a stream 8 to 10 
cm. long, although the orifice of exit was 42 mm. from 
the tip of the metacele and 66 from the place of injection. 
With human brains (excepting early stages when the 
myelocele would probably be sufficiently pervious) there 
is anample outlet at the metapore (foramen of Magendie), 
(p. 154, § 78). The same is the case with apes and some 
monkeys. Hence the cannula, instead of fitting loosely, 
may be tied into the infundibulum, or made large enough 
to fit it closely. In the latter case the cannula may need 
a rubber collar to prevent its entrance so far as to lacerate 
the medicommissure or parietes. This precaution may 


be rendered superfluous by using a cannula which is bent 


upon itself at a right angle, in the form of a capital letter 
L turned one quarter way around, thus, —; the shorter 
arm enters the orifice (for tying in the infundibulum a 
slight enlargement of the point is desirable); the longer 
rests upon the base of the brain and has attached to it 





*The method was first employed by me, as assistant to the late 
Prof. Louis Agassiz, at Nahant, Mass.,in July, 1867, for permanent 
preparations of great vascular sinuses in rays. Since that time it has 
been applied in the anatomical laboratory of Cornell University to the 
preparation and study of hollow organs of all kinds, stomach, cecum, 
heart, uterus, kidney, and brain. In 1880 I first learned that the in- 
jection of alcohol into hearts was advised in 1860 by Hyrtl, and in 1879 
by Mojsisovics; the former ascribes the idea to William Hunter. I am 
not aware that injection of a preservative into the brain cavities was 
practised or suggested by any one prior to December 14th, 1881, when 
I employed it upon a child’s brain. 


the tube connected with the syringe or injection reservoir 
This tube should be short and slender; in the intervals of 
injecting it may be compressed, or plugged with a glass 
or cork. 

§ 96. Entocelian injection, whether repeated or con- 
tinuous, may be accomplished from any artificial orifice. 
The most favorable place is the mesocele (aqueduct) after 
transection of the brain; the cannula may be selected so 
as to fit it closely. With the cerebellar portion of the 
brain the metapore would serve as the outlet; with the 
cerebral it might be necessary to tie the infundibulum to 
prevent too ready escape therefrom; with a small stream 
at a slight elevation above the brain it is probable that 
any excess would be provided for by oozing along the 
rima. 

§ 97. Entocelian Alinjection per Luram.—Four points 
are to be kept in mind: (1) The smallness of the orifice 
(Fig. 672), which may be enlarged, if desired, with the 
probe or by clipping the infundibulum shorter; (2) the 
general dorso-caudal direction of the passage (Fig. 687) ; 
(8) the danger of wounding the parietes, and especially 
the medicommissure ; the cannula should therefore be 
short, the tube small and flexible, and the cannula 
pushed through a disc of rubber so as not to enter more 
than 1 cm.; (4) the weakness of the encephalic substance 
after death; hence no more pressure should be exerted 
than suffices to fill the cavities and cause a slight eleva- 
tion of the tips of the temporallobes. The alinjection can 
should be just above the level of the brain, and the can- 
nula fit loosely in the lura so that the excess of alcohol 
may escape. 

§ 98. Combined Arterial and Entocelian Alinjection,— 
This very effectual method of preserving a brain removed 
in the dura for any macroscopic purpose was employed 
with the specimens shown in Fig. 720. A separate reser- 
voir must be used for the entocelian alcohol (§ 97), or the 
branch tube leading to the lura must be small and kept 
compressed so that—when the cavities are once filled— 
the flow will be very slight. 

$ 99. Arterial Injection of the Preservative.—This is 
somewhat fully described in &§ 101-108, and is exem- 
plified in Figs. 670 and 801. As compared with immer- 
sion it has the great advantages of rapidity and thorough- 
ness. Any preservative may be employed, and alcohol 
may be used at full strength. A low temperature is 
needless, and even perhaps undesirable. 

Barring a slight shrinkage, the natural conditions and 
relations are maintained. 

It must be admitted, however, that sometimes the 
gyres are somewhat crowded against each other, so that 
the pial folds are less readily and safely extracted, and 
the fissural relations less easily determined. This applies 
particularly to infant brains. 

§ 100. This is not the occasion for a complete history 
of injection processes or for the presentation of claims 
to originality. The transmission of preservative liquids 
to the tissues by a constant pressure apparatus connected 
with the vessels by which blood reached the parts during 
life is really so simple as well as effectual that it is hard 
to account for its comparatively infrequent suggestion 
and adoption. Without previous acquaintance with 
what had been done by others,* on October 7th, 1888, with 
the co-operation of Prof. S. H. Gage, I began upon the 
body of a young chimpanzee (No. 265) an alinjection of 
the entire body, which was prolonged for ten days and 
was completely successful. In November, 1885, a man- 
atee (No. 844), 150 cm. long, was prepared in like man- 
ner. Allthe cats used by the general class in physiology 
are alinjected and packed away till wanted. Still-born 
children are commonly so preserved, and I recommend 
that, with alcohol obtained free of tax, all anatomical 
material in medical dissecting rooms be thus rendered 


* Arterial alinjection of the brain is named or implied by Ecker 
(‘Cerebral Convyolutions,’’ p. 45); by Mondino (Trans. Roy. Micros. 
Society, 1885, p. 904); by Foster and sto! 8 Pract. Physiology,” p 
215) ; by Key and Retzius (“ Studien,”’ i 104) ; and by the eee 
of the tenth edition of ‘* Quain,”’ vol. iii., “Hig. 88. It was done in 1 
for Marshall upon a Bushman (Philos. Trans., cliv., p. 501); the dates 
of its performance for Flower and Owen are mislaid. 


379 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








innocuous, free from unpleasant odor, and fit for pro- 
longed and thorough examination. 

$101. Location of the Arteries.—Nearly opposite the 
hyoid bone, or the cephalic margin of the larynx, each 
common carotid divides into an ectocarotid (“external ”) 
and anentocarotid (“internal”). In the adult they differ 
little in size, but may be distinguished in that the ecto- 
carotid branches at once and lies farther ventrad, while 
the entocarotid continues unbranched to the cranium and 
is accompanied by the vagus nerve. 

If the neck was severed close to the head the two 
arteries may be dealt with independently. If at the 
level of the chin (as in the head shown in Fig. 670) the 
common carotid may be followed up between the mus- 
cles, using the tracer rather than the scalpel as much as 
possible. But if the neck is entire, and especially if it is 
to be kept so, the ectocarotid may be exposed as for sur- 
gical ligation by an incision along the ventral (“anterior ”) 
margin‘of the sternomastoid from the lobule of the ear. 
In any case the ligature must be applied close to the 
bifurcation of the common carotid or the superior thyroid 
artery may not be included. As to the vertebral artery, 
unless there are special reasons for not injuring the 
vertebre, the transverse process may be nipped away in 
order to expose the vessel. The cannula is to be inserted 
in one, and the other tied after the arteries have been 
cleared. Since the two arteries unite to form the basilar 
it makes no difference which has the cannula, excepting 
that there is some convenience in placing it and the 
carotid cannula on the same side (Fig. 808). 

§ 102. Secwring the Cannulas.—Preferably one cannula 
is to be inserted in the carotid, whichever is the longer, 
and another in the vertebral of the same side. Each is 
to be very securely tied; if there is no shoulder at the 
cannula point, then tie also around the rubber tubing at 
its base. All the knots should be the so-called “sur- 
geon’s,” one end of the thread being passed through 
twice instead of once; W. and G., Fig. 41. 

§ 103. Clearing the Vessels.—Inject “normal salt solu- 
tion” (sodium chloride, 15 gm.; water, 2 litres) into a 
vertebral and entocarotid artery (preferably on the same 
side) until the liquid runs clear from the other arteries. 
Place in the alinjection can about 5 litres of twenty- 
two-per-cent. alcohol, strained through absorbent cotton 
or filter paper; raise the can to about 1 metre. In 
connecting the tubes let all air bubbles escape. Small 
arteries that leak must be tied or secured with serres-fines. 
The liquid should escape in six to eight hours and be 
quite bloody. If the last of it is nearly free from blood, 
the strong alcohol may be used; if not, repeat, using 
half the quantity of twenty-two-per-cent. 

§ 104. The strong (ninety-five-per-cent.) alcohol may 
now be used at the same ‘pressure; it will pass through 
at a rate varying from one-third to eight-tenths of a litre 
per hour, and be reduced to seventy-five or eighty per 
cent. At the end of the third day, and perhaps earlier, 
the strength of the alcohol will be but little reduced; the 
pressure may then be lessened by lowering the can to 
one-half the height. By the sixth day the loss in strength 
may be no more than three per cent., and the discolora- 
tion insignificant. The alinjection may then be discon- 
tinued, and the head medisected (§ 109) or otherwise pre- 
pared. If desired, a colored injection mass may be 
thrown into the arteries of either the face (ectocarotids) 
or the brain (entocarotids and vertebrals), or all. 

§ 105. Turning the Head.—There are reasons for be- 
lieving that the position of a head under injection should 
be changed daily, in order that no one region of the cere- 
bral surface shall be more than twenty-four hours in close 
contact with the cranial wall. ; 

&§ 106. Repeated Alinjection.—It is probable that the 
injection of, say, 1 litre of ninety-five-per-cent. alcohol, 
morning, noon, and night, for a week would harden a 
brain very well, but accurate experiments on this point 
have not been made as yet under the writer’s observation. 
If it be tried especial care should be taken to exclude air 
bubbles (§ 107), to keep the brain wholly submerged or 
its base covered with a layer of absorbent cotton dipping 


380 





into the alcohol. Such injections may be made con- 
veniently with an ordinary rubber-bulb syringe. Re- 
peated injection will conduce to the preservation of the 
celian parietes and of the plexal attachments, but is less 
effectual than continuous for maintaining the size and 
form of the cavities. 

§ 107. Exclusion of Air Bubbles during Arterial Injec- 
tion.—This is accomplished by letting the alcohol run 
until no bubbles appear either in the cannula or in a 
glass tube which is introduced near the can. The can 
itself should always be at a higher level than the adjoin- 
ing tube, especially when it is lowered for the introduc- 
tion of fresh alcohol, since bubbles are then most apt to 
be formed; on this account the tube should be of ample 
length. 

§ 108. Hiltration.—Whatever liquid is to be injected~ 
into the encephalic vessels must be carefully filtered 
through filtering paper, or through absorbent cotton 
crowded into the pipe of a funnel. This necessity ap- 
plies to unused alcohol as well as to that which has al- 
ready passed through tissues. 

§ 109. Medisection of the Head.*—Determine the plane 
of section by the following mesal points, some of which, 
of course, are subject to variation: (1) Interval between 
the central incisorsin each jaw; (2) dimpleat tip of nose; 
(8) occipital protuberance (inion); (4) myel; (5) vertebral 
centrum; (6) notch in cephalic margin of larynx; (7) 
dimple of chin; (8) middle of top of head. This last is 
ascertained by carrying a piece of inelastic cord over the 
top of the head, securing each end in an auditory meatus 
by crowding cotton in with it, and then finding the 
middle of the cord. At each mesal point make a short 
but deep incision. Knot one end of a cord long enough 
to surround the head and neck at the meson; place the 
knot entad of the central maxillary (“upper”) incisors, 
and carry it over the nose, head, neck, and chin, back to 
the mandibular incisors, between which it may be secured 
by a wedge or otherwise. With the arthrotome divide 
the scalp, etc., along one side of the cord. Remove the 
cord, and at the occipital convexity (about at the line 
from 7 in Fig. 670) bore a hole at the meson deep enough 
to permit a screw to be firmly fixed. 

§ 110. Adjusting the Head.—Place the head in the saw- 
box and mark with a pencil the points where the bottom 
and one side are in contact with the occipital region and 
the vertex; at these points bore a hole in the kerf large 
enough to admit one of the screws. Replace the head in 
as nearly as possible the same position; pass the spatula 
through the kerf above the hole in the side opposite the 
vertex, and adjust the head so that the end of the spatula 
is in thecut inthe scalp. While steadied in that position 
pass the gimlet or awl through the hole and bore into the 
skull for a short distance, 8 to 5 mm.; insert the screw 
at this point. Repeat the operation for the occipital 
region. This screw should bring the head firmly against 
the bottom of the box. If it is necessary or desirable to 
remove the head in order to bore the holes, when the head 
is replaced the holes may be found by means of the probe 
end of the tracer. 

§ 111. Packing.—Draw through the kerfs in the two 
sides a cord just large enough to fit tightly, and pull it 
down so that it coincides with the cut in the skin of the 
face. Pack the cotton first in the angle between the two 
screws; then under the neck, keeping the whole con- 
stantly adjusted by means of the thread and the kerf at. 
the neck side of the box. When firmly packed, pour 
over the cotton some water until no more is absorbed. 

§ 112. Sawing.—Remove the cord from the kerf; insert. 
the saw so that the handle is close to the side of the box, 
and make the first few strokes by drawing only—ther 


* The following instruments and materials should be provided: Saw 
($ 140) ; saw-box (§$ 141) ; scalpel, the handle of which is smoothly 
rounded ; small, narrow-bladed scalpel, arthrotome, and tracer: two. 
screws, slender rather than thick, and 5-8 mm. longer than the thick- 
ness of the side and bottom of the saw-box; gimlet to fit the screws; 
short, stout awl, medium size; spool of stout saddler’s thread ; spat- 
ula ; cotton, or cotton waste or tow or bits of cotton cloth, previously 
soaked in water and well squeezed, enough to fill the saw-box quite 
firmly ; large agate pans or other suitable vessels; jars and alcohol. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 


—_——— ua eeoeoeoeoeoeoeoeoeoeoeseseseseseseseseseseaeseseaeseaseaoaoaoaon_ 


saw in the usual way; a fine stream of alcohol (any per 
cent. above forty-eight) should irrigate the blade during 
the entire operation. The back of the saw should be re- 
tained as long as possible, and screws not removed until 
nearly reached by the saw. Let a gentle stream of water 
flow over the sawn surfaces. 

§ 118. Removal of Hither Half of the Hardened Brain.* 
—A. Remove the falx and falcula (fala cerebell’). At 
the base divide the infundibulum close to the tuber, leav- 
ing the hypophysis to be removed separately. Note the 
location of the optic nerve, and divide by carrying the 
scalpel point latero-cephalad from the infundibulum for 
1 to 2.cm., close to the dura, lest the olfactory crus be 
injured. Dislodge the olfactory bulb with the syringo- 
tome, turn it just over the margin of the hemicerebrum, 
and secure it by a small pin at either side. 

B. Transection of the Hemicerebrum.—Recognize, if 
possible, the dorsal end of the central fissure, nearly 
dorsad of the splenium. Place a strip of paper or a cord 
across the hemicerebrum between points about 5 mm. 
caudad of the fissure and the splenium. The half-head 
should be in alcohol or the blade should be flooded. The 
vertex should be toward the operator. Note on the 
empty half-head the angle formed by the tentorium with 
the meson, or observe on the preparation in hand. Push 
the scalpel into the brain close to the tentorium, and with 
a gentle sawing movement carry its point as faras it will 
go; continue the movements dorsad, making sure that 
the broad edge of the haft of the scalpel does not bruise 
the brain. The completion of the transection is an- 
nounced by the loosening of the occipital region. Prob- 
ably the greatest difficulty will be the division of the ex- 
treme ventral part. 'To remove the occipital part, push 
the probe end of the tracer or avery narrow-bladed scalpel 
into the brain 10-12 mm. caudad of the section plane, 
near the tentorium and between two fissures; the 
direction should be dorso-laterad at an angle of 45°, 
thus nearly perpendicular to the ental surface of the 
cranium toward which it is pointing. Dislodge the tip 
of the occipital lobe by coaxing with the scalpel handle; 
lift the whole piece slightly with the inserted instrument; 
it will come out for a certain distance, and then be 
checked by veins, which may be divided with scissors. 

C. Mesencephalic Transection.—From Figs. 706 and 708 
note that (1) the crusta projects considerably ventrad of 
the mesal cut surface and (2) that the greatest width of 
the crus is not more than 15mm. Hold the scalpel with 
the flat side at an angle of about thirty degrees with the 
meson, let the ink mark be at the ventral margin of the 
crus, and cut dorsad with sawing strokes. Place the 
specimen so that the depths of the incision are illumi- 
nated, and divide whatever may appear; the hemicere- 
brum will float up, and be readily removed if the dorsal 
margin be first disengaged and the prominence of the 
temporal lobe kept in mind. 

D. Removal of the Metepencephal.—If the tentorium is 
to be retained, divide it by cutting laterad from a point 
just caudad of the angle between the natural, curved 
margin and the cut, straight margin; it is more conve- 
nient to remove it entirely. The half-head may now be 
placed upon a tray and supported, or held by an assist- 
ant. Crowd the edge of the round scalpel handle be- 
tween the dura and the myel for 2-3 mm., beginning at 
whatever point a slight interval already exists, and con- 
tinue the separation by gentle, yet firm pressure; special 
difficulties will be encountered at and near the occipital 
foramen, requiring perhaps the scalpel edge. Do the 
same for the cerebellum and pons, keeping in mind the 


+ The following instruments and materials should be provided: A 
pan to contain the half-head (about 11 X 4in.), half full of alcohol of 
forty-eight to fifty-six per cent., this strength sufficing to fioat the 
separated pieces so that they may be extricated without. injury (of 
course, water would do this, but would rapidly soften the brain); a 
large scalpel, the blade at least 5cem. long and the haft 1.5 to 2 cm. 
more—a round-pointed “shoe knife’’ will serve; a medium-sized 
scalpel, marked with ink across the blade on each side 15 mm. from 
thetip; syringotome. Unless oneis very familiar with the topography 
of the parts a model or preparation of the hemiencephal is desirable, 
also a hemicranium of the same side—if possible two, one dry, the 
other wet, with the falx, tentorium, etc. (Figs. 670, 800, 801). 





natural curvatures of the surfaces and the locations of 
the larger nerves, especially the trifacial, the auditory 
and facial. Specific directions are hardly needed or pos- 
sible for the rest of the operation. 

§ 114. Arterial Alinjection of a Brain in the Dura.—If 
the dura has been retained, at three places upon each 
side, frontal, temporal, and cerebellar (or occipital if the 
metepencephal has been removed), pin to the dura pieces 
of broad, stout tape (or strips of cloth 2 to 8 cm. wide) 
10 to 15cm. long. In place of pins there may be used 
garment-clasps with serrated edges. 

§ 115. For temporary purposes, e.g., examination of 
the base, preparation for injection, and the single injec- 
tion of a mass, etc., the brain, supported as directed in 
$§ 18-19, may be steadied and raised or lowered as re- 
quired, within any vessel of appropriate size. If of wood, 
the strips of cloth may be secured by tacks (artists’ 
“thumb tacks” are most convenient); if of glass or metal 
then an elastic band (e.g., a rubber ring from a jar, or an 
elastic tape) may be stretched about the rim and the strips 
passed under it. The vessels must be washed out (§ 108), 
and the small arteries tied or secured with serres-fines. 

§ 116. Dry Preparations.—The methods of making 
these have been considered by Fish, who has also devised 
improvements. The following abstracts are largely de- 
rived from his papers, 1898, 1894, and 1897. 

§ 117. Fish’s Improved Castor-oil Method.—The value 
of this is attested by Figs. 983 and 984, and by numerous 
excellent preparations in the museum of Cornell Uni- 
versity, brains, infant limbs, and entire small animals. 
“The essential factor is the complete dehydration of the 
specimen.” If originally hardened in any other than an 
alcoholic mixture it is placed successively for at least 
one week each, in fifty-per-cent. alcohol, seventy, eighty, 
and ninety-five percent. If carried through too hurriedly 
there will be more shrinkage. It is then placed in oil of 
turpentine until translucent, the time required varying 
according to the size of the specimen. The superfluous 
turpentine is then allowed to drain off for a few hours 
and the specimen is placed in castor oil. Here it may 
remain indefinitely or until all the tissues are thoroughly 
infiltrated. Draining off the superfluous oil requires a 
day or two and the specimen then receives a coat of an 





FIG. 983.—Right Side of the Brain of a Monkey, Macacus cyno- 
molgus, Prepared by the Castor-Oil Method. x1. (From Fish, 1893.) 


alcoholic solution of white shellac with a camel’s-hair 
brush. This is repeated at short intervals until the sur- 
face is firm and glossy. 

§ 118. Laskowsky’s method is here translated from the 
abstract in the Newrologisches Centralblatt, vi., 841-342: 

A. Rinse the fresh specimen in water to remove blood. 

B. Place in a mixture of water, 100 parts; alcohol 
(ninety-five-per-cent.), 20 parts; boric acid, 5 parts; let 
it remain in a cool place [for at least three days; time not 
given]. 

C. Remove the pia. 

D. In a saturated solution of zinc chloride in alcohol 
let the brain remain five or six days; the bottom of the 
vessel should be covered with cotton. 

E. For fifteen to twenty days soak in a mixture of 
glycerin, 100 parts; alcohol, 20 parts; carbolic acid, 5 
parts; boric acid, 5 parts. 


381 


Brain. 
Brain, 





F. Let it dry i in the air, protected from dust. 

The specimen is claimed to retain its natural volume, 
distinction of color, and elasticity. 

& 119. A temporary dry preparation for demonstrative 
purposes has been recommended by Lenhossek (Anat. 
Anzeiger, 1887, ii., 8-17; also Amer. Nat., xxii., 858-859). 
A thoroughly hardened alcoholic specimen, W hen needed 





Fic. 984.—Transection of the Brain of a Sheep, Prepared by the 
Castor-Oil Method, and Exhibiting the Differentiation of the Alba and 
Cinerea. 1. (From Fish, 1893.) 


for demonstration, is dried in soft linen for absorbent 
cotton], and coated with a thin layer of celloidin with a 
soft brush. The celloidin dries in a few minutes, form- 
ing a thin and transparent yet tough membrane. After 
two hours’ exposure the brain will begin to shrink and 
should be returned to alcohol. 

& 120. Starch-Injection Miatwre.—Of the mixture first 
proposed by Pansch, the following modification has been 
devised by 8S. H. Gage and the writer: 


Dry starch pow derssteen creme cere aie 100 c.c. 
Chioral hydrate se cmachi ects seeker 10 gm 
Watery eternal? 5 restos te incre mis eters one 50 c.¢. 
Alcohol (ninety-five per cent.)......... 50 ¢c.c 
Gly cerin'yetme as tee ou tein a tetas etere 29 ¢.c 


Coloring matter. 


After thoroughly mixing the mass it should be filtered 
_ through one or two thicknesses of wet cheese cloth. To 
prev ent the starch from settling, the cloth should be tilted 
from side to side or the mass may he stirred during the 
filtration. If the mass is not freshly prepared for every 
injection, the stock mass should be filtered occasionally 
to remove hair or any other object that might clog the 
cannula. 

Among the colors that are available, probably ver- 
milion, red lead, ultramarine, Berlin blue, chrome orange, 
yellow, or green, is preferable. 

§ 121. A Fine, Gelatin Injection-Mass.—The follow- 
ing ingredients represent about 2 litres, enough for a 
human brain; gelatin may be used instead of the glue, 
and no egg would then be needed, but it costs three or 
four times as much: Best clear glue, 200 gm. (about 7 
ounces); carmine, 20 gm. (about 0.7 ounce); glycerin, 
240 ¢.c. (about 8 fluidounces); alcohol, 80 c.c.'(about 3 
fluidounces); strong ammonia, 30 c.c. (about 1 fluid- 
ounce); acetic acid (50 per cent.), 80 ¢.c. (about 1 fluid- 
ounce); one egg. Grind the carmine to a paste with a 
little water; mix the ammonia with 250 c.c. (about 8 
fluidounces) of water, add the carmine paste, and filter 
through filter paper. Place the glue in a clean dish and 
cover with cold water; after two or three hours pour off 


the unabsorbed water, and melt the softened glue. ‘Beat 
the white of an egg well and mix it with the clue. Heat 


until it begins to bubble, then filter through fine flannel. 
Add the coloring liquid to the glue while warm. WNeu- 
tralize the ammonia by stirring in the acid, a little at a 
time, until there is no distinct odor of either the acid or 
the ammonia. Until one has had considerable experience 
it will be necessary to close the ammonia and acid vials, 
let a current of air sweep over the mixture, and then de- 
termine the presence of the odor. Blue litmus paper may 
be used until there is no distinct coloration of the band 


382 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


formed by absorption just above the line made by the 
mass itself. Mix the alcohol and glycerin and add to the 
mass. Unless, as with a freshly killed animal, the injec- 
tion is made before the body has cooled, the part to be 
injected must be heated, in water, to 40° C. (about 105° F-.). 
§ 122. Alcohol.—Unless otherwise specified, the alcohol 
mentioned in this article is of the usual str ength, ninety- 
five per cent. The admixture of alcohol with water in 
the following proportions gives various percentages: 


Alcohol 6, water 1 = 84 per cent.; 5: 1 = 82; 4:1 = 78; 
321 = 76: 221 = 67; 1.5.21 = 62% 125% G0 eee 
Ei 1:1.5 =42a 12) soon 


OE ei at 45; 
6s == 18; 
g 123. Obtaining valoohet Free of Tax for Scientific Pur- 
poses.—Blank forms for this and all the information re- 
quired may be obtained from collectors or deputy col- 
lectors of United States Revenue or from manufacturers of 
alcohol. See U. 8. Revised Statutes, Section 3297, Treas- 
ury Circulars of July 2d, 1886, and March 26th, 1889, and 
New York Medical Journal, March 30th, 1889. 

§ 124. The surface of a fresh brain is never exposed to: 
strong alcohol without a previous wetting with salt solu- 
tion or water. 

§ 125. The alcohol in which brains are stored is main- 
tained at not less than eighty-two per cent. upon the al- 
coémeter scale of Tralles (§ 126). Weaker alcohol is 
employed for the immersion of fresh brains, for soaking 
out the dark coloring matter from brains that have been 
hardened in Miiller’s liquid, or for the preservation of 
other specimens requiring a less strength.* 

§ 126. Alcodmeter (Alcoholometer).—This form of hy- 
drometer, for determining the percentage of alcohol in 
a given liquid, should be marked with Tralles’ scale. 
With the slender jar for containing the tested liquid, the 
cost is about $2.50, but its employment is to be recom- 
mended upon the ground of ultimate saving of alcohol. 

§ 127. Dilute Nitric Acid.—Thisis useful for softening 
the cranium of infants or small animals so as to permit 
cutting with knife or scissors. A ten-per-cent. solution 
is sufficient. Ordinary commercial acid is about sixty 
per cent. ; the desired reduction is accomplished by add- 
ing five parts of water to one of the acid by weight, or 
seven of water by volume. The specific gravity of the 
mixture is about 1.057. In any mixture the per cent. of 
acid may be determined by the method recommended by 
Fresenius, second American edition, p. 688. 

§ 128. Storage of Hemicerebrums.—The human hemi- 
cerebrum is a somewhat bulky mass, and may occupy 
a six-by-eight-inch Whitall & Tatum jar (Fig. 990). 
Sometimes both halves of a cerebrum may be accommo- 
dated, although the undivided cerebrum or entire brain 
commonly requires a nine-by-eight-inch jar. 

The most favorable method of storing several hemi- 
cerebrums is in jars nine inches in diameter and of any 
desired height. The specimens are set in tiers of three, 
their dorsal convexities against the sides of the jar. Suc- 
cessive tiers are so placed that a hemicerebrum rests upon 
the interval between two below. There will be a central 
vacancy which, if the jar is to be transported, may be 
filled with absorbent cotton; the alcohol (ninety-five per 
cent.) should be introduced last. 

§ 129. Transportation of Fresh Brains. — Without 
affirming the impossibility of transporting a fresh brain 
safely in a bed of cotton or other soft material, I have 
found it much better toemploy a liquid of approximately 
its own specific gravity, about 1.04. The most easily 
prepared is brine, nearly saturated. Nor is it best to put. 
in cotton or other material. The brain should just float, 
without pressing upon the bottom of the pail or rising 
above the surface. The cover of the pail may be secured 
with strips of surgeon’s plaster. 

In cool weather a journey of two or three days may be 
safely accomplished. In warm weather, if the brain is 
well cooled inadvance and the smaller pail set in a larger 
and surrounded with rather large pieces of ice, a day’s. 


* The “ economics of alcohol ”’ is treated somewhat fully in W. & G..,, 
pp. 111-1380. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





journey may be accomplished safely. Such open pack- 
ages should be plainly marked “Specimens of Natural 
History. This side up with care.” (See also p. 206.) 

§ 180. Other Liquids.—It must be remembered that 
while brine supports the brain and thus averts mechani- 
cal injury, and while it retards decomposition, it is not 
strictly a preservative of nervous tissue. Hence, espe- 
cially if the weather is warm or transportation is to occupy 
more than a few hours, it is well to place the brain at 
once in a liquid which will not only support but preserve 
it. Several such are enumerated in §§ 81-90. 

§ 131. Transportation of Hardened Brains.—Already 
hardened brains may be transported either in a small pail 
of alcohol with cotton as a padding; or in a soldered 
box; or in a jar (the rubber of which must then be well 
covered with vaseline to be afterward removed) ;* or simply 
wrapped inalcoholic cotton covered with paper and oiled 
silk, or rubber sheeting, and packed in a box with soft 
material. Glass and metal packages are always enclosed 
in wood + or corrugated pasteboard. 

§ 182. Removal of the Pia.—The early removal of the 
pia t has been already recommended, € 40. I have seen 
some otherwise valuable cerebrums materially injured by 
faulty methods, and a few suggestions are here offered. 

A. Begin with the central fissure, if it can be recog- 
nized, and at about the middle of its length. Apply the 
coarse forceps so that their approaching points move in 
the direction of the length of the fissure; pinch up a fold 
of pia; with the scissors snip at either side of the fold so 
as to raise it a little; then carry the forceps, held in the 
same way, more deeply into the fissure, not more than 1 
cm. deep, and attempt to draw out the intrafissural fold 
of pia. If successful, continue to pull lengthwise of the 
fissure, cutting the pia at either side whenever necessary. 

B. Most of the other fissures may be dealt with in the 
same way; but some, notably the occipital and calcarine, 
are very deep, and arteries traverse them which must 
usually be cut more than once. 

C. The Sylvian fissure is not only deep, but spreads 
laterad over the insula, and there are several arteries. 
Rather than run the risk of tearing the adjoining gyres it 
is better to remove only so much pia as easily separates, 
leaving the rest and the arteries until one of the opercu- 
lums can be cut off and afterward replaced. 

D. While removing the pia or studying the lateral 
fissures of young or fetal brains, breaking is avoided and 
divarication of the gyres facilitated if the hemicerebrum 
is placed on its meson on a piece of thick Manila paper 
(such as is used for the portfolios), which is sufficiently 
firm to support the organ and yet yields so as to permit 
the exposure of the fissural depths. When the mesal 
surface is studied the specimen should rest in a thick bed 
of cotton. 

§ 183. Prevention of Drying.—The strong alcohol in 
which brains are preserved (eighty per cent. and upward) 
evaporates rapidly while the brain is exposed, as in ex- 
amination or dissection. It may be dipped in the alcohol 
occasionally, or—which is preferable with delicate speci- 
mens—the alcohol may be allowed to drip gently upon it 
from a pledget of absorbent cotton. When a specimen 
only partly submerged in alcohol has to be left for a short 
time, drying may be prevented by covering it witha thin 
layer of cotton, one end of which dips into the liquid. 

§ 134. Dissection of the Brain.—As commonly practised 
this contrasts strongly with the examination of the rest 
of fhe body. With the latter dissection is universal, and 
sections are seldom made or even studied;§ but with 
the former, sections, macroscopic or microscopic, are the 


* Vaseline will prevent the leakage of alcohol or other liquid ; but, 
like oils and grease, it disintegrates rubber; hence the rubber rings 
should be thoroughly cleansed from it after use. 

+ For mailing alcoholic specimens contained in vials of not over four- 
ounce capacity, see circular of the Denison Manufacturing Company, 
New York City, as to “‘iiquid mailing boxes.’’ See also a paper by F. 
T. Gordon, Medical Record, \vii., 696. 

¢It is understood that this includes the arachnoid, which on most 
parts of the cerebrum adheres closely to the pia; Fig. 796. 

§ Notwithstanding the example and opportunity offered by works 
like Braune’s *‘ Atlas of Topographical Anatomy’’ and Dwight’s 
“Frozen Sections of a Child’ and ‘‘ Anatomy of the Head.”’ 








rule, and dissections, careful, prolonged, and thorough, 
are nearly unknown in medical schools. Like the pre- 
ponderance of osteology over neurology, the difference is 
due to the “nature of things”; but like many other nat- 
ural conditions it may need modification. 

The advantages of sections for surgical, pathological, 
and regional study are obvious; they are easily made, 
even with the fresh adult human brain, especially by 
means of the apparatus devised by Professor Dalton.* If 
the human brain were like that of the frog or opossum, 
with the several segments of approximately equal size, 
and nearly upon the same plane, the common method 
would be more appropriate for macroscopic study. But, 
in view of the extreme cranial flexure and the overlapping 
of certain segments by others, the objections to sections 
are as follows: 

1. They present plane surfaces which do not naturally 
exist in the brain. 

2. They are almost invariably oblique with respect to 
the axis. 

3. They commonly include more than one encephalic 
segment, and are, therefore, so far as the beginner is con- 
cerned, apt to be more confusing than instructive. 

4. They present the parts in contiguity rather than 
continuity.+ 

The foregoing objections apply to all sections. A 
macroscopic section, especially of a brain which has had 
the cavities alinjected, presents the advantage of exhibit- 
ing in perspective enough of the natural contours of parts 
to facilitate their recognition and comparison. 

Admitting, then, that sections have their uses, what is 
urged is, not that section-making be practised less, but 
dissection more. 

§ 185. Preliminary Dissection of Alcoholic Brains.—I 
am yearly more convinced of its importance on four 
grounds: 

A. The brain is a complex organ and at the best per- 
plexing; the simpler features of form, location, and rela- 
tion to cavities are morphological, while color, like his- 
tological composition, has a physiological significance. 

B. The fresh brain is less easy to dissect neatly, and 
requires constant support against its own weight, whereas 
the alcoholic may be held in any position and carved like 
cheese. 

C. The beginner should advance cautiously, and there- 
fore slowly, and the medical student is especially liable 
to interruption. The fresh brain remains fresh but a 
very short time, while the alcoholic is in itself imperish- 
able. Leisure means not only more careful dissection, 
but also the taking of notesand the making of drawings; 
hence all the arguments which I have advanced (W. and 

G., pp. 55, 56) in favor of preliminary anatomical work 
upon a small animal, which may be kept in alcohol for 
an indefinite time at slight expense, apply to all alcoholic 
brains in general, and to those of moderate size in par- 
ticular. 

D. After repeated dissection of alcoholic preparations, 
the anatomist is better qualified to manipulate the fresh 
brain and to appreciate its beauty. The last word is used 
advisedly, for, however unattractive may be “subjects” 
and pathological “cases,” the most exacting artistic sense 
can hardly fail of satisfaction with the soft white and 
gray and pink of the newly extracted brain. Resting 
securely in its calva, for him who has been disciplined by 
prolonged experience with the “ pickled” organ, there are 
few more attractive, stimulating, or nourishing articles 
of intellectual pabulum than a fresh brain “upon the half 
shell.” 

§ 136. Déssection.—Whether fresh or hardened, I be- 





* ** Topographical Anatomy of the Brain,’’ Philadelphia, 1885, vol. i., 
pp. 4-10; abstracts in New York Med. Record, February 15th, 1879; 
July 31st, 1880. , 

+ Solly’s vigorous reprobation refers particularly to horizontal slic- 
ing: ‘It is unfortunate indeed that candidates for the medical dip- 
loma are still very generally required to describe the appearances 
presented by the brain dissected, or rather destroyed, by the old 
method of slicing—a method most unphilosophical in its conception, 
and totally inadequate to impart any real information in regard to the 
structure of the brain.” 


co 
6) 
oo. 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





lieve the first step should be to slice off the dorsal parts 
of the cerebrum to near the level of the callosum and the 
next the exposure of the paraceles as described in con- 
nection with Fig. 735. 

The occipital lobes may then be cut off opposite the 
splenium and one or both medicornua followed to the tip 
of the temporal lobe. 

The next object should be to remove the overlapping 
parts of the cerebrum from the subjacent diencephal 
(and so much as may remain of the other segments) so as 
to obtain a view of the ventral aspect of the splenium 
and fornix. These may be transected a little caudad of 
the portas. 





There will then appear the velum, with the epiphysis. 
If the velum be lifted carefully there will be recognized 
the attachments along the dorso-mesal curvature of the 
thalami which are commonly ignored but insisted upon 
in Fig. 732. 

A transection through the portas will give a view of 
their boundaries, of the cephalic aspect of the medicom- 
missure, and of the caudal surface of the fornix and the 
precommissure; most of the other features are more easily 
examined upon the mesal aspect of the medisected brain. 

Somewhat full directions for dissection are given by 
Edinger. Complete directions are desirable, accompanied 
by figures indicating the appearances presented at each, 

















































































































Blunt-Pointed Scalpel. 





Syringotome. 


























OX, 





Wi 


Hl 


| 
3 










J 


ei 
il 


i 
‘a 


cox | 


it i 






ll 





2 


i 












Arthrotome. 











Tracer. 
























































nil 






























































FIG. 985.—Some of the Instruments Useful in the Removal or Dissection of the Brain. All of actual size. 
The two upper are eye-knives ; the syringotome is commonly called canaliculus knife ; 
(“foramen of Monro’) and the metapore (‘foramen of Magendie”’), 


prominent edge might do injury ; it has been my 


of air may be utilized by using the larger half of the metal pipe, 
handle continuous with the blade, 
curved forceps represented have t 


favorite instrument since 1866. Th 
more costly syringotome, but its chief use is in isolating nerves and vessels b 
soon tire the hand or hinder delicacy of manipulation ; the coarse ‘* Coxeter 
lighter than usual. The flexible blowpipe is most readily made by attaching to a piece of rubber tubing, 
of the metal blowpipe commonly sold with dissecting instruments. The length of the tube enables the 
venient distance from the eye ; since inflation is temporary injection, 


the advantages of witnessing the effects are obvious. 
and glass cannulas of any size may be employed. The arthrotome has the 
and one edge of the blade is rounded, excepting near the tip; it is practically a cartilage knife. The fine 
he points simply serrated ; but for the removal of the pia from the brain surfaces, 





Fine Curved Forceps. 


(From ** Anatomical Technology.’’) 
it is of great use for exploring orifices, the porta 
and for dealing with membranes and plexuses where a point or a 
e tracer may be employed sometimes in place of the 
y tearing the connective tissue. Most forceps are too stiff and 
” forceps represented have the blades excavated so as to be 
30 to 40 em. long, the smaller half 
object inflated to be held at a con- 
A larger volume 


and especially from the 


depths of fissures, a pair with interlocking teeth, like those of artery forceps, will be found very useful. 


384 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





stage, such as I have framed for the brains of the cat 
(W. and G.) and sheep (“ Physiology Practicums ”). 


§ 187. Instru- 
( . 


th , 


ments.—The instru- 

ments employed in 

the removal or dis- 

section of the brain 

($$ 50, 186) should, 

as a rule, be re- 

served for that pur- 

iy pose. If used in 

" ordinary dissection 

their points and 

edges should be at- 

tended to without 

delay. Some of the 

less familiar instru- 

ments are shown in 
Fig. 985. 

§ 188. Probe- 
Pointed Curved Bis- 
toury.—This is 
practically a longer 
and stronger syr- 
ingotome (Fig. 
985), the cutting 
edge being about 5 
cm. (2 in.) long, 
ending in a probe 
point. The curve 
is less than that of 
the syringotome. It 
replaces the latter 
in the dissection of 
the entire human 
brain, and it is par- 
ticularly applicable 
to transecting the 
brain through the 
mesencephal, to 
tracing the medi- 
cornu, and to slit- 
ting the arachnoid 
in following the 
Sylvian or other 
deep fissures. 

§ 139. Besides the instruments shown in Figs. 985 to 
987, the following, more familiar, are indispensable : 
Scalpels of three sizes: large for sections; medium for 
ordinary dissection; small (“ Charriére”) for finer dissec- 
tion. Scissors, curved flatwise, three sizes. A hand 
lens, tripod magnifier or “linen tester.” A bone- 
chisel, or ordinary chisel of moderate width, or even 
a screw-driver sharpened slightly. A syringe, 
metal, or rubber bulb. Absorbent cotton; if com- 
mon cotton is used it must be first thoroughly wet 
in alcohol or water. Cannulas, rubber tubing, and 





























Fig. 986.—Diagonal Side-Cutting Nippers. 
A little less than actual size. From 
** Anatomical Technology.’”’ This is the 
smallest size of the English make 
(Stubs’), and for most purposes should 
have the handles lengthened by pieces 
brazed on. The German and Swiss in- 
struments (for sale by large hardware 
dealers) are less highly finished and 
costly, but answer nearly as well. Of 
these, seven sizes are made, ranging in 
length from 10-20 em. (4-8 inches), and 
in price from 60c. to $1.50. Surgical 
bone forceps and dental wedge-cutters 
have a spring between the handles and 
are more expensive. The nippers are 
most serviceable for removing the calva 
of infants and fetuses and of small 
animals. In use they must cut or 
squarely break the bone; the pulling 
and tearing to which one naturally re- 
sorts will inevitably tear the brain or 
its meninges. 


the Y-tubes or T-tubes for branching of injection . 


tubes may be had of dealers. The smaller end of a 
straight “medicine dropper” makes a fair cannula. 


aE 


Fic. 987.—Steel-Handled Spatula. x 0.5. 
of Whitall, Tatum & Co.) This (ora palette-knife, or round- 
ended shoe-knife, ground thin so as to be flexible) is indis- 
pensable for detaching the dura when the calva is to be 

removed. 











The methods of making and securing cannulas, 
and of making injections, are detailed in “ Ana- 
tomical Technology,” pp. 137-148. Cheap and 
efficient pinch- cocks may be had in the form of 
the wooden, spring clothes- pin, which may be 
variously attached to the wire cranes or used in- 
dependently upon the tubes. 

§ 140. Saws.—There is no special advantage of 
the expensive surgical or anatomical saw over 


Vou. I.—25 





Fic. 988.—Head-Rest for the Removal of the Brain. 
Stroud. A, Baseboard; B, upright board, hinged to A and secured by 
hooks. 





the ordinary carpenter’s instrument; it should be kept 
sharp and well-set, and used for no other purpose. For 
dividing the cranium any small saw will answer, but the 
edge should be rather wide so as to make a broad kerf. 
For medisection of the head, however, the saw should be 
very large, fine toothed, thin (7.e., make a narrow kerf), 
have a removable back, and be very sharp and free from 
rust. 

§ 141. Saw-Box.—This (which might be called a macro- 
tome) is a coverless box made of boards about 2.5 cm. (1 
in.) thick, and with the following inside dimensions: 
length, 30 cm. (12 in.); height, at middle, 25 cm. (10 
in.) sloping to 15 cm. (6 in.) at the ends; width, ac- 
cording to the length of the neck attached to the head, 
25-40 cm. All the parts must be accurately squared 
and put together with screws. The sides should go 
outside the bottom and ends, and the bottom have a 
cleat at each end. Each side is to be divided squarely 
at the middle of its length by a saw of the same thick- 
ness as that with which the head is to be cut; the bot- 
tom also is to be sawn to the depth of 1-2 mm. When 
finished the box should be thoroughly oiled, inside and 
out, with linseed or olive oil, to prevent warping when 
it is wet. 

§ 142. Head-Rest for the Removal of the Brain.—The 
following description and figures (988, 989, and 982) are 
from the paper of B. B. Stroud (1900, 5) who devoted 
much time to the device. The apparatus was shown at 
the meeting of the Association of American Anatomists in 
Washington, May 2d, 1900. 

“This apparatus was devised for the purpose of hold- 
ing the head firmly with the base of the cranium hori- 
zontal. This enables the base of the skull to serve as a 
shallow tray in which the brain is supported during its 
removal. The subject lies upon the belly, being sup- 
ported by adjustable clamps fitting into the auditory 
meatuses, and the head naturally assumes a position in 
which the long axis of the cerebrum is nearly horizontal. 
Repeated trials in the neurological laboratory at Cornell 
University this spring have shown that with a maxi- 
mum of convenience to the operator there is a minimum 
of danger of rupturing the cranial nerves and certain 
delicate structures of the brain itself, which are fre- 
quently torn when the usual methods are employed. 
Fig. 988 shows a general view of the apparatus. Fig. 
989 shows details of construction. In Fig. 982 it is rep- 
resented in use. 

“The device consists of a baseboard A to which is at- 
tached at right angles a second board B. Both are of 
seven-eighths-inch oak. Professor Wilder suggested that 
the upright board should be hinged to the base for con- 


Devised by B. B. 
(From Stroud’s paper, 1900, D; see Figs. 982 and 989.) 


385 


Brain. 
Brain, 


venience in storage and transportation. 
valuable improvement. 

“The upright B—Figs. 988 and 989, A—has a middle 
emargination and the sides are cut at an angle as shown 
in Fig. 989, A. Thechin-rest D is hollowed upon the top 
to fit the chin. It slides in a shallow groove 0.5 cm. (4 
in.) deep, cut in B, and is adjustable by means of the 
thumbscrew. Thetwo lateral bars # are of iron. They 
project 3.5 cm, (1} in.) above the board B, and serve to 
support the two jaws F’and G. 

“The two clamps for grasping the head, Fig. 982, shown 
in detail in Fig. 989, B, consist of the jaw /, the guides 


This is a very 





C 


Fic. 989.—Portions of the Head-Rest. A, the upright board, with its 
side irons, E. B, One of the two clamps for grasping the head. 
C, improved form of the jaw-piece, F’. 


I, and the screw J, which pierces F in the form of a 
spike H, 2 cm. (? in.) long, to enter the auditory meatus. 
A flat head J, Fig. 989, B, is more convenient for turning 
the screw than the round milled head shown in Fig. 988. 
The jaw /'is bent flatwise to fit the curve of the skull 
and grasp it dorsad of (posterior to) the mastoid process. 
The other end is curved downward, to fit under the 
zygoma and thus hold the head more firmly. The guides 
J are made from one piece of steel bent in the form of a 
rectangle and made to fit very closely to the top of the 
side iron #. They and the curved form of /’ prevent a 
disagreeable rocking motion of the head. F is firmly 
riveted to Z by means of four double-headed rivets. 
The upright B is held in position by the two hooks K 
avOl IL 


* For the convenience of those who may desire to construct the head- 
rest the detailed specifications are here reproduced: A and B are 
made of %-in. oak. A is30x40cem. (12x18in.). B is 30x26 cm. 
(12x104% in.). It is cut as indicated in Fig. 989, A. The middle cut 
is 15x13em. (6x5in.). The front side contains a groove 4 in. deep 
and 39 in. wide to receive the chin support D. Dis of oak 5x9x17 
em. (2x 34% x 634 in.). The top is hollowed out to fit the chin 4.5 em. 
One and seven-eighths in. from the top it is cut down so as to be only 
.5 in. thick. There is a slot in the middle to accommodate a set screw 
for fastening it at the different heights. H is an iron bar, 17x2x1 
cm. (634 x 34 x 34 in.), and is bent at a point 3.5 em (14% in.) from the 
top so as to be perpendicular to the base A. F' is of 3; in. steel, 9x3 
em. (314 x 114 in.) and formed as shown in Fig. 989, B and C; 1 is the 
front end shaped so as to fit under the zygoma; 2 is the rear end and 
grasps the temporo-occipital bone dorsad of the mastoid process. The 
clamps J are made of 3¢-in. steel 12 x 2.5 em. (434 x 1 in.) and bent as 
shown in Fig. 989, B. The screw J operates the jaw F. It is made of 
ye-in. iron 4 in. long. It has a shoulder which is received between 
and I. The spike H projects one inch beyond F to be inserted into 
the auditory meatus. A flat head is more convenient than the round 
one shown in Fig. 988. All sharp edges should be rounded and 
smoothed to avoid accidental injury to the operator’s hands. 


386 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


§ 143. Agate- Ware Pans.—The brain anatomist will find 
most convenient, and in the end most economical, one or’ 
two “nests” of iron pans, “enamelled,” so as not to rust, 
with plates of the same for covers. For the largest size- 
(11 x 4 in.) covers of glass or metal must be provided;. 
this size will accommo- 
date a half head. 

§ 144. Butter jars, 10 
< 10 cm., or 10 x 20 
cm., with tin screw-cap, 
parchment lined, are 
sold by the Excelsior 
Package Co., 49 Warren 
Street, New York. They 
are very convenient for 
temporary storage or for 
transportation. 

§ 145. Labelling Speci- 
mens.—Much of the real 
value of a specimen de- 
pends upon its identifi- 
cation as being a certain 
part of a certain brain, 
taken from an individ- 
ual of a certain age, sex, 
and nationality, and pre- 
served in a certain way. 
Even if the possessor 
has so few specimens 
that he feels sure of re- 
membering the entire his- 
tory of each, his death 
would abolish the source 
of information. I have 
observed surprising in- 
stances of carelessness in 
this regard, even upon 
the part of some who 
should set an example 
of scientific accuracy. 

Were the specimen 
never to be removed 
from the jar in which it 
alone is kept, the object 
could be accomplished 
by inserting the label in 
the jar or attaching it thereto; but this is rarely an: 
adequate precaution, neither is it often possible to state 
all the desirable data upon a label 
attached to the specimen itself. 
The most satisfactory plan tried is. 
the adoption of a serial number for 
each brain. 

§ 146. Ali Specimens are Num- 
bered.—As soon as received every 
brain is assigned a number which 
permanently designates it and all 
parts into which it may at any time 
be divided; the same number per- 
tains to all notes, photographs, and 
drawings of it. 

§ 147. Sometimes, as with entire: 
brains or half-brains, it is possible 
to attach with a cord a metal (sheet. 
block tin, stamped) number. But 
commonly the nymbers are written. 
with India ink* upon bits of parch- 
ment and attached by small (rib- 
bon) pins. + 

§ 148. For purposes of dissection, photographing, or 
drawing it may sometimes be necessary to remove the 
label, but ordinarily it should be affixed to some other re- 
gion, so that there may be no possibility of misplacement.. 























































































































































































































Fig. 990.—Specimen Jar, with Glass: 
Top, Rubber Ring, and Clamp. 
(Made by Whitall, Tatum & Co., New- 
York.) Fourteen sizes are made, 
ranging from three to nine inches im 
diameter, and of various lengths.. 
The size here shown is 6 X 12, and 
will receive a half brain or the two- 
halves of a medisected cerebrum 3; 
for undivided brains and for medi- 
sected heads the size 9 X 8 suffices. 
These two sizes cost, respectively, 
$10 and $18 a dozen. ‘The prices. 
given in the catalogue are subject. 
to a discount of fifty per cent. 





Fie. 991. — Landen- 
berger’s Specimen 
Jars. These have a 
rubber ring and a 
glass top retained by 
a wire. The smaller 
size is 3 X 3in., capac- 
ity 6 oz. (180 ¢.c.); the 
larger, 3X4 (high), 
capacity 10 oz. (300 
¢.c.). 25N. Thirteenth 
Street, Philadelphia. 


* Good pencil marks last a long time in alcohol, but ordinary black 
ink is speedily washed out. : 

+ In time ordinary pins corrode and may break the brain substance 
when withdrawn; pins of aluminum or silver should be available at 
a moderate cost. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





§ 149. Distinctive Labels.—The ready recognition of 
cerebrums belonging to groups may be provided for as 
follows: ; 

A. The sexes are distinguished by using quadrangular 
labels for males and circular ones for females. 

B. Presumed normal white brains have white labels; 
Africans (of all shades), gray; murderers and other crim- 
inals, red; insane and idiots, blue. 

§ 150. Immediate Records are Made.—No one’s memory 
is conceded to be infallible. All data concerning a brain 
not obtainable from the specimen itself are recorded 
without delay under the number 
assigned to it; eg., the sex, age, 
known, believed or estimated, race, 
known or supposed weight when 
fresh, donor, mode of initial pres- 
ervation, weight or bodily condition 
of the individual, and his character 
or mental state. 

§ 151. Card Catalogue.—The basis 
of the records of each brain is a card 
bearing the number of the specimen 
at an upper corner. Upon the face 
of the card are written the data men- 
tioned in § 150; also, or continued 
upon the back, the numbers of neg- 
atives, and references to published 
figures or descriptions; suggestions 
of points to be elucidated are com- 
monly put on paper slips.* 

§ 152. Drawing is insisted upon.t 
These drawings should be, primarily 
at least, in outline only; shading, 
like charity, “covereth a multitude 
of sins.” 

§ 153. In beginning the study of 
a difficult region, the student is ad- 
vised to determine at once some 
prominent feature as a landmark, 
as a “base,” so to speak, “of intel- 
lectual supplies,” from which he 
may explore in any direction, and 
to which he may return when doubts 
arise. 

§ 154. No observation involving 
either complex manipulation or 
novel results is published until it has been submitted 
to at least one other trained observer. 

§ 155. It is freely admitted that rarely, if ever, is all 
possible information gained from a specimen at one ex- 
amination or by a single observer; hence specimens are 
preserved. ¢ 

§ 156. Methods of Representing the Brain.—The follow- 
ing considerations and suggestions apply more or less 
directly to all natural history illustrations, but with 
especial force to the human brain, on account of its soft- 
ness when fresh, the difficulty of preserving it, the great 
size of the entire organ, the minuteness of certain por- 
tions, the large number of recognizable parts within a 












































Fig. 992.—Tall, Round, 
Screw - Capped Jar, 
with Nickel- Plated 
Caps, Cork-Lined. 
Three sizes, viz.: four 
ounces, eight ounces, 
and sixteen ounces. 
(Whitall, Tatum & Co., 
New York.) Answers 
well for dry or non- 
volatile contents or for 
the temporary storage 
of alcoholic  speci- 
mens. 


* My own use of slips of convenient size for notes and drawings and 
descriptions began in 1867 while I was assistant in comparative anato- 
my at the (Agassiz) Museum of Comparative Zoology at Cambridge, 
Mass. The slips were about three by five inches. When the first 
United States postal card was issued that size (13.5 < 7.6 em., 5.25 x 
3in.) was adopted. But the subsequent introduction of other sizes 
has invalidated that standard, and the common and increasing em- 
ployment of the catalogue card of the Library Bureau (7.5 * 12.5 cm. 
or 3 X 5 in.) may render it desirable to adopt that size for notes as 
well. Brief accounts of the ‘‘slip system of notes” are given in 
Science, January 16th, 1885. and in Wilder and Gage. 

+ Every student of any branch of natural history should compel him- 
self to learn to draw, however slight may be his inherited artistic ca- 
pacity. Not merely the laboratory students in Cornell University, but 
the members of the large general classes in physiology and zoology 
are required to make drawings of entire animals, and of the parts ex- 
posed in their dissections. 

+ The time has not yet come, and indeed shows no signs of ap- 
proach, when I can look at even a familiar brain preparation without 
learning a new fact, gaining a better insight into what was already 
known, or receiving an impulse toward some special inquiry. <A good 
example of the desirability of preserving specimens for later scrutiny 
is furnished in my last paper, 1900, a (see p. 196). 








.figures of the extremity of the filum terminale. 





small area, the continuity of all, the contiguity of some 
which are otherwise associated but remotely, the inter- 
mixture of two differently colored substances, the com- 
plicated relations of the meninges to each other, to the 
vessels, and to the cavities, and the preponderance of 
curved and oblique contours over straight lines and 
planes. 

§ 157. Importance of Orientation.—With all organs, 
but especially with the brain, it is essential that the lo- 
cation of the region represented be easily recognized; 
otherwise details may be unappreciated or even misap- 
prehended. So far as possible, therefore, less familiar 
parts should be accompanied by such as are unmistak- 
able. It might seem that useless expense was incurred 
by the publishers of Bourgery and Jacob’s magnificent 
plates in the introduction of faces artistically drawn 
and colored; but even the expert neurologist is guided 
in the comprehension of the relative position of brain 
parts by reference to the apparently superfluous facial 
outlines. 

§ 158. Enlargement of Complex Regions.—It often hap- 
pens that the same section or dissection includes regions 
that are comparatively simple, and others that are very 
complex; shown upon a single scale, either the complex 
parts are unintelligible, or the total is undesirably and 
needlessly large. Hence, just as the histologist aims 
first to obtain a general view of all the parts in their gross 
relations, and then focuses a higher power upona selected 
region, so the delineator of encephalic structures should 
give first a view of the whole, if only an outline, and 
then an enlargement of complex parts to any extent re- 
quired for their complete elucidation; he can hardly 
make this enlargement excessive. Compare, é.g., Quain’s 
figures, 258 and 290, and Figs. 669, 670, 671, and 695 in 
this volume. 

§ 159. Terminal and limiting parts, membranes, and 
apparently atelic (functionless) parts and conditions 
should be distinctly shown, or the insufficiency of their 
representation admitted. “The little things of the 
brain” might well form the subject of an entire article. 
From the standpoints of physiology and medical practice 
such parts as the terma, valvula, crista, epiphysis, hy- 
pophysis, and habena, and such conditions as the reflec- 
tion of the endyma upon the plexuses, and the dorsal 
limitation of the porta, are of comparatively slight im- 
portance. But their morphological significance is, at least 
in some cases, inversely to their functional activity, and 
they cannot be ignored without endangering the success 
of any attempt to understand or explain the structure of 
the brain. 

§ 160. Anatomical figures should be something more 
than pictures conveying a general and vague idea. 
Where is there an adequate representation of the relation 
of the diatela to the habena, and of the cephalic end of 
the latter? From the published figures could any stu- 
dent be expected to comprehend the locations and bound- 
aries of the “foramina of Monro” or of “Magendie”? 
The tenia is easily enough shown as a white band 
throughout most of its course, but where are its extremi- 
ties accurately delineated? Any one can see the caudate 
prolongation of the striatum, but representations of its 
termination at the tip of the medicornu are as rare as are 
Even so 
considerable a part as the flocculus is seldom figured in 
such a way as to display either its form or its attach- 
ment. 

§ 161. The avoidance of the morphological incongrui- 
ties and deficiencies which are to be detected in nearly 
every portrayal of encephalic anatomy demands the ad- 
mission of three propositions, which are mere truisms in 
themselves, but radical affirmations when contrasted with 
their almost universal’ non-recognition in’ anatomical 
works: 

1. Every part, organ, membrane,* or surface is either 








*So essential is the exemplification of celian circumscription and 
endymal continuity that the endyma should be represented by a dis- 
tinct and rather heavy line, continuous excepting at the metapore : 
see p. 152, Fig. 687. 


387 


Brain, 
Brain. 





limited or continuous with some other part. If limited, 
its limits must be defined; if not, its extension must be 
indicated. 

2. Every cavity is either open or closed. If closed, 
the continuity of its parietes must be demonstrated; if 
open, its communications must be shown. 

3. Every elongated part has a middle and two extrem- 
ities; not only the former, but the latter must be repre- 
sented. 

§ 162. Figures—original ones especially—should be 
multiplied and descriptions reduced. In descriptive an- 
atomy, whether human or comparative, the text should 
be subordinate to the illustrations. Some treatises (Charles 
Bell, Meckel, Milne-Edwards, etc.) seem to have been 
prepared upon the idea that the description is essential 
and the figures merely supplementary; on the contrary, 
words should be employed only when pictures will not 
suffice—that is, for explanation, commentary, generaliza- 
tion, hypothesis, and manipulative directions. 

The arguments for the multiplication of figures may 
be summarized as follows: 

1. A figure is usually a guaranty that something like 
the object represented has been seen, at least by the artist, 
and that a certain amount of time has been devoted to its 
contemplation. 

2. The information conveyed by a figure is more real, 
and likely to be more lasting, than that which is expressed 
in words. In respect to reality and impressiveness, the 
sources of knowledge may be ranked as follows, in an 
ascending scale: (1) Description; (2) picture; (3) model; 
(4) object seen; (5) object handled; (6) object personally 
prepared. The picture is thus intermediate in value be- 
tween the thing itself and a description of it. 

3. A figure, if clear and properly placed, is more read- 
ily understood than a description, and a saving of time 
is thus effected. It may be easier for the author to write 
than to draw, or even than to supervise a drawing, but 
his personal inconvenience or loss of time should not out- 
weigh the gain to his readers. This applies particularly 
to dictionaries, cyclopedias, and journals, which are 
commonly read or consulted in haste. Editors and pub- 
lishers would find eventual profit in offering to authors 
the fullest encouragement to employ illustrations so far 
as possible and curtail their descriptions in proportion. 
That it is rather the exception than the rule for such en- 
couragement to be offered is probably due to several 
causes: (@) Publishing houses have usually a staff of 
printers who must be employed, whereas the various 
processes involved in the making of pictures are com- 
monly done outside at extra expense; (0) authors too often 
content themselves with carelessly made copies of “stock 
figures” instead of insisting upon original representations 
of objects prepared by themselves. Hence, on the one 
hand, the exceptionally liberal publisher is liable to get 
a poor return for any allowance made for drawings, and, 
on the other, the exceptionally painstaking author is apt 
to be told that, at best, the engraving will be done if he 
will furnish the drawings; and, if he cannot draw him- 
self, their cost is likely to deter him from their introduc- 
tion. In short, all the existing conditions work to the 
disadvantage of the reader, who gets but a “ pennyworth 
of [pictorial] bread to a monstrous deal of [verbal] sack.” 

Before this state of things can be amended the authors 
of books and papers must see clearly the importance of il- 
lustration; to paraphrase an epigram as to the making 
of an index, the drawings should be made or personally 
superintended by the author, even if some one else has 
to write the text. 

4, Figures usually occupy less space than descriptions 
conveying an equal amount of information. This means 
condensation, convenience, and economy in the present, 
and a due consideration for our successors in the not far 
distant future. Exact data are not accessible, but no 
thoughtful and public-spirited person (unless he be a 
publisher or printer) can contemplate without concern 
the logical results of the present rate of book-making 
activity. 

§ 163. Borrowed figures should be fully credited, and 


388 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


all modifications, whether of size or features, explicitly 
stated. To copy is to compliment, but unacknowledged 
copying is theft, and unspecified change is misrepresen- 
tation. 

The ill effects of omitting to state the source of a figure 
are two: (1) The originator loses credit to which he is 
justly entitled; (2) the reader may be seriously misled by 
the apparent duplication of some really unique feature 
or the confirmation of an error. For example, in the 
representations of the meson of the cat’s brain by Leuret 
(Leuret et Gratiolet, Pl. V., Fig. 2), the pseudocele 
(“fifth ventricle”) is made even more extensive than in 
man, reaching almost to the splenium. The figure is re- 
produced, without credit or correction, in Mivart’s “The 
Cat” (Fig. 129). Whoever remarks the coincidence in 
respect to the pseudocele, but fails to note that one figure 
is simply a copy of the other, may naturally infer that 
the feature in question is normal, or at least not anomalous. 

On the other hand, if informed that three of Mivart’s 
figures (125, 126, 129) were copied from Leuret, the stu- 
dent might conclude that the representation of the base 
of the brain (Fig. 128) was derived from the same source. 
This would be most injurious to the reputation of Leuret, 
for the figure in question displays several features (the 
size and direction of the hypophysis, the disconnected 
fissure on the temporal lobe, the relations of the pons to 
the trifacial and abducens nerves) which it is safe to say 
never were observed in a feline brain. 

Nor is it enough to give the sources of figures in a list, 
or in the preface, as in Huxley’s “ Vertebrated Animals” ; 
so great is the labor of preparing an original figure that 
the acknowledgment of it should be equally as explicit 
as that of a verbal quotation. 

Finally, in the case of modified figures, it needs but a 
moment’s reflection to see that nothing short of an accu- 
rate statement of the nature and extent of the alteration 
can insure full justice to the originator. 

§ 164. Drawings should be made as notes. In many 
cases an outline* drawing, even if hastily made, would 
convey to the maker, or any one else, at a future time 
more prompt and complete information than could be 
embodied in writing covering the same space. But the 
general employment of sketches, in addition to words, 
or in place of them, can hardly be looked for until chil- 
dren are taught to draw the intelligible objects about 
them before they are drilled in the making of the—to 
them—unmeaning pot-hooks of the alphabet. 

§ 165. Figures should be more frequently employed 
in preliminary or incomplete publication. Probably one 
of the reasons for the comparative infrequency of pictorial 
representations of normal, abnormal, and pathological 
structures, especially in journals, is the difficulty, often 
the impossibility, of preparing a detailed figure in time 
for publication. But this need not prevent the early ap- 
pearance of a figure, if only in outline, illustrating one 
or more points of greatest importance. 

§ 166. Figures should be based upon photographs. 
Photography enables the anatomist to (a) record the ap- 
pearances of perishable specimens, or of such as are in 
course of dissection; (0) insure the proper perspective; 
(c) save time and labor upon the part of the draughtsman, 
and thus either reduce the cost of the drawings or render 
a larger number attainable. 

It is seldom that a single anatomical preparation is so 
perfect as to display all that is needed, and yet present 
no superfluous parts; often, too, certain points are to be 
brought out with “diagrammatic clearness,” others being 
subordinated or omitted altogether. Hence, as a rule, 
the photograph forms rather the basis for the completed 
figure, and two or more similar preparations may be re- 
quired for the elucidation of all the desired features. + 


*There is a general and almost unconquerable predilection for 
shaded drawings. However advantageous shading may be in ordinary 
art as an element of finished pictures, and when merely a general 
effect is desired, in anatomical figures correct outlines‘are essential, 
and shading should be deferred until the last. 

+ A chief obstacle to the employment of photographs as a basis for 
figures of brains and embryos has been the difficulty of supporting 
such delicate objects within range of the camera in its usual horizon- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





§ 167. Figures should be placed so as to be most 
readily understood and instructively compared. In 
comparing pictures of two or more houses, ships, or 
stoves, the architect, ship-builder, or dealer places them 
in such positions with regard to one another and his own 
eyes as may minimize the effort at mental transposition. 
_ If asked the principle on which he acts, he will probably 
say that no principle is needed, that he simply follows 
nature, experience, and common sense. 

With few exceptions it seems to be reserved for those 
whose business is the contemplation of natural objects, 
who are credited with more than the average degree of 
intelligence, and who have at command the recorded ex- 
perience of centuries, to disregard a matter whose sim- 
plicity is equalled only by its importance. In most 
works there is an utter absence of system. Seldom, in- 
deed, are symmetrical figures placed otherwise than with 
the meson coinciding with that of the observer; but even 
this would be less likely to confuse than the apposition 
of transections of a subcylindrical mass like the myel 
with the dorsum above in one case and below in another.* 

The prevalent carelessness in this regard may be as- 
cribed to three sources: (a) The still too common idea that 
illustrations are of secondary importance; (0) the fact that 
most figures have been copied and thus placed without 
regularity, as in the original; (c) some time and trouble 
are required to reverse them. 

§ 168. General Rules for the Placing of Figures.—These 
rules are based upon a consideration of the whole subject. 
There is probably no one of them to which exceptions 
may not exist; but such exceptions should always have 
a well-defined reason and not occur through inadvertence. 

1. Figures should be coadjusted so as to facilitate 
comparison with one another and with typical structures 
in normal positions. 

2. The dorsal side should be uppermost. 

3. Direct views are to be preferred to oblique, though 
the latter are at times indispensable; e.g., Figs. 720, 769, 
and 775. 

4. Symmetrical figures, or parts thereof, should be so 
placed that the meson is vertical, e.g., Figs. 664, 672, and 
682. 

5. When there is no choice between the right and left 
sides, the latter should be represented. 

6. Of medisected organs, unless there is special reason 
for choice, the mesal aspect of the right half is to be 
shown.+ 

§ 169. Designation of Parts upon Figures.—The full 
technical names of parts should be given if possible. 
From the purely artistic point of view, of course, any 
extraneous line upon a picture isa disfigurement. But 
if it be once admitted that the primary object of an ana- 
tomical drawing is to convey accurate information, then, 
unless the shaded figure can be duplicated in an outline 
(as in Tiedemann, Vicq d’Azyr, and Dalton), there should 
be no sacrifice of the essential to the accessory. 

It may be a question whether the names should be 
upon the parts (as in Gray), or at the sides of the figure 
and connected with the parts by lines (Gegenbaur). Upon 
the whole the latter method seems preferable, especially 
if the technical names are used. 

§ 170. Abbreviations should represent technical terms; 
they should be uniform throughout the work, and be 
placed at the sides of the figure. 

Four methods of designating parts by abbreviations 





tal, or nearly horizontal, position. This obstacle is wholly removed 
by the photographic table devised by Professor Gage and used by us 
in Cornell University since 1873. With this the camera may be readily 
adjusted to any angle, and brought into a vertical position so as to 
cover an object lying upon cotton, or in alcohol, or even alive in water. 
The apparatus is described and figured in Science, April 11th, 1884. 

* The common disregard of uniformity in this respect was made the 
subject of a communication by a medical professor to the Association 
of American Anatomists at its meeting in December, 1892. 

+ If the fuller discussion of this subject in the New York Medical 
Journal, August 2d, 1884, be consulted, the following corrections 
should be made : 

Explanation of Fig. 57, last line, iranspose antimesal and symmesal. 

Fig. 59, for antimesal read symmesal. f 

Fig. 64, for symmesal read antimesat. 


have been employed: 1, By numbers and non-significant 
and ununiform letters, which may or may not be explained 
in the text (Owen); 2, by non-significant characters, 
uniform only in part, and explained at a distance from 
the figure (Reichert); 38, by uniform and significant, but 
partly vernacular, abbreviations (Parker); 4, by uniform 
technical abbreviations (W. and G.). 

The advantages of uniformity in the use of abbrevia- 
tions are obvious, but it is by no means easy to avoid the 
charge of ambiguity. Where uniformity is not at- 
tempted, care should at least be taken to avoid the use 
of the same abbreviation for the names of parts which 
are liable to be taken for one another. For example, in 
Schwalbe’s two representations of the lateral aspect of 
the cruraand adjacent parts (Figs. 280, 281), not only are 
opposite sides shown for no good reason, with some dif- 
ferences of detail which are puzzling rather than instruc- 
tive; not only is the pons designated in one by p and in 
the other by po, and the tractus opticus by ¢o in one and 
tr.oin the other; but the letters tp stand for the tenia 
pontis in Fig. 280, and in Fig. 281 for the tractus pedun- 
cularis transversus [cimbia]. Since these parts are similar 
in general appearance and direction, and only one appears 
in each figure, it is doubtful whether any but the most 
expert anatomist, thoroughly familiar with this somewhat 
obscure region, could escape at least a temporary misap- 
prehension. 

§ 171. Abbreviations should be explained in alphabet- 
icalorder. The “ practical” business man would exclaim, 
“Of course, how else should they be?” An “unscientific” 
child would adopt the alphabetical order with letters as 
he would the order of notation with numbers. But the 
super-scientific writer, especially if he be a German, 
scruples not to save a few moments of his own time at 
the expense of others, by giving the verbal equivalents 
of ten (Huxley, Fig. 19), fifteen (Balfour, ii., Fig. 271), 
twenty (Quain, Fig. 263), twenty-five (Schwalbe, Fig. 
279), forty (Meynert [Stricker], Fig. 253), or even fifty- 
eight (Marchand, Arch. f. mik. Anat., xxxvii., 331, 332) 
abbreviations, either in no recognizable order at all or 
as they occur upon the figure.* The time wasted by each 
consulter of the figure (not to mention the effect of just 
indignation) would nearly equal what it would have cost 
the author to place the abbreviations in alphabetical se- 
quence. Burt G. Wilder. 


BIBLIOGRAPHY. 


Donaldson, H. H., 1894: Preliminary Observations on Some Changes 
Caused in Nerve Tissue by the Reagents Commonly Employed to 
Harden Them. Journ. of Morphology, 1894, pp. 122-126. 

Fish, P. A., 1893: Brain Preservation, with a Résumé of Some Old 
and New Methods. The Wilder Quarter-Century Book, pp. 385- 
402, 1 plate. 

, 1894: Abstract of the Foregoing. Journ. Nery. and Mental 

Disease, February, 1894, pp. 101-103, plate. 

, 1895, a: Formalin for the Preservation of Brains. 

Note. Journ. Comp. Neurology, v., 125-128, July, 1895. 

> , Db: The Use of Formalin in Neurology. 

Micros. Society, xvii., 319-830. 

, 1897 : The Mummification of Small Anatomical and Zoological 
Specimens. Proc. Ass’n Amer. Anat., December, 1897, pp. 59-61. 
Stroud, B. B., 1897: On Brain Preservation. Proc. Ass’n Amer. 

Anat., 1897, pp. 30-82. 

A 1900: A New Head-Rest for the Removal of the Human Brain. 
Proc. Ass’n Amer. Anat., May, 1900, pp. 10-i4, 5 figures. 

Wilder and Gage, 1892: Anatomical Technology as Applied to the 
Domestic Cat, third edition, from the second revised, O., pp. 600, 130 
figures, and 4 lithographic plates. 








Preliminary 





Proc. Amer. 








’ Wilder, B. G., 1896, g: The Desirability and the Feasibility of the Ac- 


quisition of Some Real and Accurate Knowledge of the Brain by 
Precollegiate Scholars. Amer. Soc. Naturalists, December, 1896. 
Science, vi., 902-908, December 17th, 1897, 3 figures. 


BRAIN: PACCHIONIAN BODIES.—These granula- 
tions, once falsely called glands, were perhaps first men- 
tioned by Willis (1676), then by Méry (1701), and almost 
simultaneously described by A. Pacchioni. They start 
as minute spheroidal, partially vesicular outgrowths 
(villi of Luschka) from the arachnoidal layer of the pia— 
where it bridges fissures as well as where it rests on the 
gyres,—retaining its epithelial covering. They must not 





* Even more objectionable is the omission of the original pagina- 
tion upon the reprints of papers. The printer does not always realize 
the conditions and the author often remembers when it is too late. 


389 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





be confounded with granulations of the choroid or epen- 
dyma, with vegetations notably in the cavernous sinus 
(Hyrtl, 1862), nor with granular (aciniform) conditions of 
the meninges seen in inflammations. They are often 
clustered, become pedunculated, penetrate the opposed 
dura, and finally project into the overlying venous 
channels, and even excavate (in part repel) the bone. 
They are usually most abundant opposite the middle of 
the falcial sinus—more correctly opposite the largest 
parasinual spaces—but may occur on both sides, along 
nearly the whole length of this sinus, beside the trans- 
verse and tentorial sinuses, and even beneath the latter, 
also in the temporal fossa opposite the trunks of the 
medidural vessels and the frequently present temporal 
sinus. They occur not rarely 3 cm., and even farther, 
from the long sinus along the line of large incoming veins 
after the latter have left the pia, and also farther out at 
one point near the frontal border of the parietal bone, 
probably where a medidural artery bends to connect 
through the skull with temporal vessels. Hence, in gen- 
eral, they occur opposite intradural blood channels of 
some size, and especially those subject to continual varia- 
tions in calibre (pulsation, ebb and flow). Their preva- 
lent growth toward and into venous spaces has led to the 
assumption that the granulations themselves were venous 
structures, or opened into such (Key and Retzius, Koll- 
mann, and others; it is not true that Trolard claimed 
this). But it is now generally thought that the in- 
jection of the spaces through the granulations must have 
been effected by the rupture of granulation vesicles.* 
From the intimate connection of the older granulations 
with the spaces, they become darker colored; or, on 
tearing the two structures apart, flecked with blood. 
But the younger free corpuscles are pale, whitish. 

The parasinual spaces are said rather to diminish with 
age, while the granulations certainly increase. Up to 
the twentieth year they are rarely developed to any ex- 
tent. In congenital defect of the heart, they appear 
early and excessive (case of Lambl, 1860; one of the 
writer). However, at all ages continuous or intermittent 
compression of the brain space, of whatever origin, is 
the most frequent cause of their over-development. 
Under this head fall intracranial tumors of any kind or 
seat. Repeated congestion, as in chronic alcoholism, is 
also an accepted factor, doubtless acting mechanically. 
Various systemic troubles, as nephritis and diabetes, 
favor the enlargement of these bodies, possibly by un- 
usual variations in the encranial pressure. 

In view of all the facts—viz., that while these cor- 
puscles regularly occur opposite intradural (extra-arach- 
noidal) blood channels not necessarily venous, their 
growth is especially favored on the one hand by venous 
stasis, on the other by pressure from the side of the 
cranial space—it is evident that they result from the oft- 
repeated local oscillation of the arachnoid. As the cere- 
bro-spinal fluid is subarachnoidal, it, especially when 
under pressure, forces that membrane at its weakest 
points into any depression, as that beside a dilated vessel 
—the granulations always grow away from the cranial 
cavity, never toward tt. When, then, the favoring condi- 
tion—be that even negative instead of positive—relaxes, 
the granulations, to the extent that they have formed, 
press against and penetrate superimposed structures, 
the continuous alternation of the conditions as continu- 
ally favoring the process. This, as we believe, clear and 
simple explanation suffices for all the main features of 
these little growths. 

PaTHoLoGy, Cuinical History, ETc.—(a@) Like the 
wrinkling of the skin, the turning gray and falling out 
of the hair, and many other processes, the granulations 
themselves should be considered pathological only when 
they become excessive or develop prematurely. (0) 
Calcification or ossification of these bodies is not un- 


* This is a matter of interest in connection with the theory of brain 
pressure (Hirndruck). Bergmann lays much stress on the continu- 
ous (or intermittent) discharge of cerebro-spinal fluid through the 
granulations into the venous spaces; while Adamkiewicz ignores or 
argues against the existence of such discharge. 


390 


usual, They may contain deposits of so-called brain sand 
and even fat globules. (c) Where they penetrate into 
blood spaces and even a sinus, they so far interfere with 
the return current, and also favor thrombosis (only one 
case of the latter, Férster’s, has been attributed to this 
cause). (d@) Fovere glandulares, sharp depressions or ex- 
cavations in the inside of the skull (preceding e and /), 
quite analogous to that seen in aneurism of a dural 
artery, are sometimes found. From their more or less 
intimate relations with the sinus walls, Allen advises 
avoidance of the middle line in all operations upon the 
skull cap. However, the diploé itself is never opened 
by these growths as a new layer of bone always forms 
around the fovex. (e) Small flat elevations of the ex- 
ternal plate of the skull, opposite the fovez, and hence 
near the superior median line, are mentioned by many. 
(f) Very rarely complete perforation of the cranium oc- 
curs. 

1. Case of Weber-Ribes (1819; v. Pozzi); hole small, 
and covered by ligamentous membrane. 2. Luschka (p. 
116); perforation of squamous portion of temporal bone. 
3. Lecat (v. Heincke in Pitha-Billroth); pneumatocele 
capitis; skull at some points perforated by granulations 
of the dura. 4. Demme (1862; v. Mastin, “Venous 
Blood Tumors of the Cranium.” Reprint, 1886). “On 
the left of the sagittal suture (posteriorly) was a sharp- 
edged opening the size of a cherry stone, through which 
protruded a Pacchionian granulation.” 5. The writer’s 
observation. Man of forty; had suffered over three 
years from a tumor of the brain; autopsy, August, 1887. 
At the favorite spot near the frontal border of the parietal, 
somewhat removed from the sagittal suture, there was a 
clean-cut, complete perforation of the skull by Pacchion- 
ian granulations. This was circular, fully 0.5 cm. across, 
surrounded even in the diploic portion by smooth con- 
tinuous bone, and covered by periosteal membrane. At 
the border there was a very trifling over-projection of 
the outer bone plate. 

It is recognized that such perforations—even when in- 
complete—may, from local injury, lead to the formation 
of epicranial blood cysts, inasmuch as the causative 
granulations usually traverse some blood channel. 

(g) In a few cases growths of this class have pressed 
on passing nerves, causing local neuralgic or paretic 
symptoms. Though it has been claimed that at times 
these growths induce headache, it is probable that they 
are then but co-effects of some other cause. () In ani- 
mals generally these corpuscles are not present (brains 
of sheep, calf, rabbit, dog, and cat examined). Luschka 
found them only in the horse. William Browning. 


BIBLIOGRAPHY (MODERN). 


Luschka: Virchow’s Archiv, xviii. 

L. Meyer: Ibid., xix., 1860. 

H. C. Bastian: Quarterly Journal of Microscopical Science, 1866. 

Key and Retzius: Studien, ete., 1875, I. Halfte, Stockholm. 

Labbé: Archives de physiologie, 1879. 

H. Lahr: Dissertation, Berlin, 1880. 

Kollmann : Correspondenz-Blatt fiir Schweitzer Aerzte, 1880, No. 18. 
Browning: American Journal of the Medical Sciences, October, 1882. 


BRAIN: SIMPLE MENINGITIS.—(Pachymeningitis, 
mayvc, thick; leptomeningitis, Aettéc, thin; simple, as 
distinguished from cerebro-spinal and tuberculous menin- 
gitis; meningitis of the convexity as distinguished from 
basilar meningitis.) Meningitis, in general, was first 
recognized as an affection separate from disease of the 
brain by Morgagni, 1760. Epidemic cerebro-spinal 
meningitis first attracted the attention of Vieusseux, of 
Geneva, 1805, and of Strong, North, Fish, Hale, Miner, 
and Williams, of our own country, 1806-1814, and was 
at that early period easily differentiated from affec- 
tions limited to the membranes of the brain. Parent- 
Duchatelet and Martinet, 1821, first distinguished inflam- 
mation of the dura and pia mater, and Guérin and Guer- 
sant, 1827-1839, first distinctly recognized and set apart 
the tuberculous, granular, or basilar form of the disease. 
The first clear descriptions of the exclusively “simple” 
meningitis, from a pathological standpoint, are to be 
found in the works of Cruveilhier, 1880, and from a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





clinical standpoint, in those of Andral, 1834, and of 
Rilliet and Barthez, 1848. The recognition of the fact 
that simple meningitis is always a secondary affection is 
the result of the more accurate post-mortem observations 
‘of the last two decades, in the light of the recent in- 
‘vestigations concerning infections, and the contributions 
from rhinology and otology. 

That the various forms of meningitis are caused by 
specific micro-organisms was pointed out by the work- 
ers in bacteriology, especially by Koch, 1882, who demon- 
strated the tubercle bacillus in tuberculous meningitis; 
by Leyden, 1883, who found a diplococcus in the cerebro- 
spinal fluid and the pia, which Fraenkel and later Hauser 
showed to be identical with the pneumococcus; by 
Weichselbaum, 1887, who showed the presence of the 
diplococcus intracellularis meningitidis in epidemic cer- 
ebrospinal meningitis; and by Foa and by Bordoni-Uffre- 
duzzi, who described a third and a fourth variety of the 
meningococcus. 

Weichselbaum in Germany and Adenot in France, 
1884, showed that meningitis occurring during or after 
an attack of pneumonia depended as a rule upon the 
same micro-organism that caused the pneumonia. Later 
observers have found meningitis frequently due to the 
pneumococcus in the absence of pneumonia. Thus the 
pneumococcus was found by Grasset in cases of menin- 
gitis occurring with inflammatory rheumatism; by Gabbi 
and Puritz in cases of meningitis associated with periar- 
thritis and endocarditis; and by Ellehorst in a case of 
meningitis apparently due to fracture of the base of the 
skull. 

The diplococcus intracellularis meningitidis is believed 
by some observers to be a variety of the pneumococcus, 
while others hold that it is quite a different crganism. 
The latter view is held by Jaeger, who believes that 
the dipiococcus intracellularis meningitidis is the cause 
of epidemic cases, while sporadic cases may be due to 
the pneumococcus. Jaeger proposes the name tetracoc- 
cus intracellularis for the micro-organism described by 
Weichselbaum as the diplococcus intracellularis, since 
this organism frequently appears in the form of tetrads. 

In 25 cases of suppurative meningitis reported by 
Netter the pneumococcus was found in 18, the strepto- 
coccus pyogenes in 4, the diplococcus intracellularis in 
‘2, and the typhoid bacillus in 1 case. 

Next to the tubercle bacillus, the typhoid bacillus is 
most prone to cause purulent meningitis. Cases have 
been reported by Roux, Adenot, Kamen, Honl, Hintze, 
Fernet, Monsi and Carbone, Stiihlen, Tietine, and other 
observers. 

Next in the order of frequency, after the typhoid 
bacillus, is the bacillus coli communis, which has been 
found by Howard, Biggs, Sestre, Scherer, and others. 

A role in etiology has been ascribed to the bacillus 
pyocyaneus by Kossel, Pesina, and Honl. 

Among the pleomorphic bacteria that have been de- 
scribed in the exudates of meningitis are the cladothrix 
asteroides of Eppinger, and the actinomyces described 
by Moosbrugger, by Honl, and by Lenzine. 


Pachymeningitis, inflammation of the dura mater, pre- 
sents itself in two forms, external and internal, purulent 
and hemorrhagic, representing entirely different disease 
processes. 
form, is really the result of a degeneration rather than 
of an inflammation; but in theabsence of definite knowl- 
edge regarding the genesis of this disease, the two forms 
may be best studied together. 

PACHYMENINGITIS ExTERNA.—Accidents or injuries 
which directly expose the dura, or effect its separation 
’ from the bones of the skull, with consequent extravasa- 
tion of blood, whereby is implied, at least, a “hidden 
crevice” or some communication of the dura with the 
air, lead at once to inflammation of the outer lamella 
which may extend so as to involve all the rest of the 
membranes of the brain. Carious processes of the ear 
constitute an even more frequent cause of this condition. 
A mere microscopic breach in the thin wall of bone that 


Pachymeningitis externa, the hemorrhagic — 


forms the upper covering of the tympanic cavity will 
bring pus from the tympanum to the dura. So, also, 
caries of the ethmoid bone (ozzna) or other bones of the 
cranium (syphilis, carbuncle) may excite this form of 
meningitis; and even without caries, purulent inflam- 
mation of the mucose in the ethmoid and frontal sinuses 
may extend to the dura through the natural openings of 
communicating vessels. This complication has been 
noticed more especially in erysipelas after “mixed infec- 
tion,” whose nature it is to spread. As purulent pachy- 
meningitis rarely remains confined to the dura, but ex- 
tends, as a rule, to involve the pia mater, the symptoms, 
pathology, and treatment of this condition will be further 
discussed with leptomeningitis. 

PACHYMENINGITIS INTERNA (Consult Plate XV., Fig. 
1).—The disease of the dura which merits most con- 
sideration, from its frequency, limitation, and recogniz- 
ability in life, is that affection of the inner layer which is 
characterized by the extravasation of blood and subse- 
quent development of an adventitious membrane, com- 
monly known as hematoma dure matris, and technically 
described as pachymeningitis interna hemorrhagica. 
With these characteristics it is plain that internal pachy- 
meningitis does not supply the requisite conditions, nor 
rise to the nosological dignity of an inflammation in the 
modern sense of the term. It develops oftenest independ- 
ently of all infection, and should properly be discussed 
as a subvariety of cerebral hemorrhage. 

The pathology of this affection remains as yet obscure. 
The early anatomists and clinicians were fain content 
with descriptions of the condition without venturing to 
express opinions concerning the nature of the disease. 
It was commonly held and taught that the disease con- 
sisted in the extravasation of blood, and the only ques- 
tion discussed regarded its situation. Thus Abercrombie 
and Andral, 1807, maintained that the blood was effused 
between the dura and the parietal layer of the arachnoid 
so called; while Houssard, 1817, located the extravasa- 
tion in what was then, and for the sake of convenience 
is still, known as the cavity of the arachnoid. The 
hemorrhagic nature of the affection was nearly lost sight 
of when Bayle, 1848, considered the hematoma as an in- 
flammatory product of the dura, but it was again restored 
by Durand-Fardel, 1854, who believed in the develop- 
ment and organization of a flat blood clot. Heschl, 1855, 
regarded the membrane as a highly vascular connective 
tissue, a view which Virchow, 1856, with his predilec- 
tions for cellular pathology, elaborated into a hemor- 
rhagic inflammation of the dura as the first process, and 
a subsequent infiltration of blood as the second. The 
authority of these pioneers carried their views with al- 
most undisputed conviction up to our own times, when 
the studies concerning the nature and processes of in- 
flammation and infection naturally diverted attention to 
the condition of the blood and blood-vessels as prime 
factors in the production of the disease. 

That hemorrhagic pachymeningitis is not the expres- 
sion of an ordinary inflammation is shown by the fact that 
no amount of irritation of the dura will produce it. In- 
jections of ordinary irritants into and beneath the mem- 
branes of the brain of lower animals may be followed by 
purulent, but never by hemorrhagic, pachymeningitis. 
On the other hand, the injection of blood with all its 
constituents sufficed, in the experiments of Sperling, to 
produce the typical signs and lesions of the disease. The 
role of the fibrin in these cases is evidenced by the fact 
that a membrane was not developed after injections of 
defibrinated blood. 

Internal pachymeningitis consists, then, in the extrav- 
asation of blood, the formation of a blood clot which, 
when the effusion is not too great or rapid, is flattened 
by pressure, to become subsequently organized into a 
membrane. In the first stage of the disease process, the 
thin layer of coagulated blood soon begins to show, in 
the separation of its fibrin, a meshwork which contains 
multitudinous blood corpuscles. At this time there is 
no apparent connection with the dura, whose epithelium 
remains intact. In the consolidation which continues, 


391 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





the clot assumes the appearance and density of a mem- 
brane, which now in reality develops, from the trans- 
formation of white blood corpuscles into spindle-shaped 
connective-tissue cells, whence the synonym, P. fibrinosa. 
The red corpuscles now gradually lose their coloring 
matter, which collects in spots on the surface, and in the 
texture of the membrane (P. pigmentosa) lose their 
regular contours, and finally become transformed into 
masses of protoplasm. Young vessels now connect the 
dura with the membrane, which becomes gradually more 
dense, thick, and adherent. In the mean time new layers 
of blood may be effused into the membrane already in 
process of formation, which consists thus of superim- 
posed lamellzee—Virchow has seen as many as twenty,— 
for a time separable from one another. The effusion 
takes place chiefly upon the convexity of the brain, 
limited, in fifty-four of sixty-five cases collected by 
Kremiansky, quite precisely to the region covered by 
the parietal bones. It is rather more frequently bilateral 
than unilateral, being confined to one hemisphere in but 
forty-four per cent. of cases. 

The source of the hemorrhage still remains a matter of 
dispute and doubt. Kremiansky thought it came from 
the middle meningeal artery, an origin which comports 
well with the situation of the clot; but Huguenin de- 
clares that he has never seen this vessel affected in any 
of his observations. This author is inclined to find the 
lesion in the veins which run from the cortex to the 
longitudinal sinus along the falx cerebri; and Pacchion- 
ian vessels have likewise been accused, but all alike 
without as yet satisfactory anatomical proof. 

The chief danger of these effusions is pressure upon 
the brain, which shows itself in proportion to the amount 
of the extravasation. Huguenin has seen a hemisphere 
flattened by a large unilateral hematoma, which may 
be as large as a hen’s egg—Hichhorst mentions effusions 
of 500 gm.,—and in some cases a lateral ventricle has been 
reduced by pressure to half its size. The great evil of 
pressure is obviated in many cases by the latitude allowed 
by atrophy of the brain substance, a condition rather, as 
a rule, coincident with hematoma of the dura. In fact, 
the greatest contingent of cases is found in connection 
with paralytic dementia, and cases independent of some 
degree of atrophy are comparatively rare. 

When, from any cause, a real inflammation is en- 
grafted upon this hemorrhagic degeneration, serum or 
pus may be found in connection with the blood which 
forms the hematoma. As curiosities in this direction, 
Virchow describes a hydrocephalus externus pachymen- 
ingiticus, and Weber saw, in a lamellated hematoma, 
blood in one cavity and yellow-green pus in another. 

Various changes in the skull, membranes and brain 
have been observed in connection with pachymeningitis, 
but none so frequently as to belong to it of necessity. 
Thus the bones have been found thickened or thinned, 
with an agglutinated dura at times, the pia anemic, 
hyperemic and swollen, or cloudy and opaque, separable 
from or adherent to the dura, etc. The frequency with 
which general atheroma of the cerebral vessels is seen, 
with thromboses, softenings, apoplexies, scleroses, etc., 
of the brain, bespeaks the intimate relation of these proc- 
esses to the development of the disease, in connection 
more especially with general paralysis, alcoholism, insan- 
ity, senile atrophy, etc. 

Pachymeningitis is a much more frequent affection 
than is commonly believed. Savage records its presence 
in three per cent. of the autopsies made at the asylum at 
Bethlehem, and when it is remembered that there are 
more cases of dementia and insanity, not to mention al- 
coholism, out of than in asylums, it is seen that this per- 
centage is far too low. It is safe to say that most of the 
cases remain undiagnosticated during life; and death, 
when it occurs, though perhaps caused by this affection, 
is ascribed to the disease in the course of which this ac- 
cident develops. All authors agree in noting three- 
fourths of all the cases in the male sex, a proportion 
which corresponds to the relation of the sexes to the 
affections which produce the disease. For the same 


392 


reason hemorrhagic pachymeningitis is a disease of ad- 
vanced life. Exceptional cases at early periods of life— 
six months to eight years—have been recorded by Weber, 
Moses, Steffen, and others, mostly in connection with the 
venous stases from the strain of asthma, pertussis, etc., 
or the impoverished nutrition of blood-vessels from 
scurvy, leukemia, and more especially pernicious ane- 
mia; and cases have been more abundantly reported dur- 
ing adolescence and maturity in connection with tuber- 
culosis, empyema, valvular lesions of the heart, the 
various forms of Bright’s disease, the various infections 
(variola, scarlatina, acute articular rheumatism, and 
typhoid fever), and more especially local injuries of the 
dura (seventeen of seventy-four cases described by 
Schneider); but aside from these accidents, pachymenin- 
gitis remains a disease of age. The largest number of 
cases, twenty-two per cent., in the collection of Hugue- 
nin, occurred between the ages of seventy and eighty. 

Symptomatology.—Internal pachymeningitis exists at 
times without a symptom to mark its presence. Moses 
reports such a case in a child, aged seven months, who 
died of catarrhal pneumonia. At the autopsy there was 
found a pachymeningitic cyst which covered the ante- 
rior half of the right hemisphere, though no sign of brain 
disease had ever been manifest in life. Slight extravasa- 
tions often show no sign because of absence of pressure, 
or, if slowly effused, because of tolerance, which the 
brain acquires often in astonishing degree. In other 
cases the accident is overshadowed by symptoms per- 
taining to the original disease. These are, however, all 
exceptional cases. As a rule, the disease may be diag- 
nosticated during life by signs which are not so valuable 
in themselves as in their etiological relations. 

In the majority of cases the disease announces itself 
suddenly and violently. The patient is stricken with 
apoplexy. The hemorrhage may be so great as to cause 
death by compression of the brain within forty-eight 
hours. The nature of the disease, or more strictly, the 
localization of the hemorrhage, is, as a rule, in such 
cases impossible to determine. The first attack is not, 
however, usually fatal. In exceptional cases the patient 
may recover fully, but as a rule a train of symptoms 
ensues which more or less distinctly characterize the dis- 
ease. These symptoms vary greatly in individual cases, 
vary according to the locality and extent of the effusion, 
as well as according to the nature of the original disease; 
but they do not differ in essential characters from the 
symptoms of meningitis from any cause. Headache, 
stupor, which may at any time deepen to coma, mono- 
plegias, hemiplegias, or, in the irritant stage, unilateral 
twitchings and convulsions, limited at times to one ex- 
tremity, or confined to the area of distribution of the 
facial nerve; aphasia, when the region of the language 
centre is compressed—these symptoms, together with 
an irregular or retarded pulse, vomiting, and more 
especially contracted or dilated pupils irresponsive to 
light, with little or no disturbance of general sensation, 
make up a group which as a rule distinguishes the disease. 

But, as already intimated, it is not so much the symp- 
tomatology of the affection as its etiological relations 
which strictly define the disease. The general signs of 
meningitis refer especially to hematoma only when they 
occur in the course of general paralysis, chronic psy- 
choses, alcoholism, chronic Bright’s disease, pernicious 
anemia, traumata, the affections mentioned in the dis- 
cussion of the etiology of the disease. 

Another distinguishing, but by no means so distinc- 
tive, feature to indicate the nature of the affection, is the 
recurrence of the symptoms. Total or partial recovery 
from all the general manifestations of meningitis is fol- 
lowed in pachymeningitis, as a rule, by repeated attacks, 
and though the special symptoms may show great variety 
in relapses or recurrent attacks, the general character of 
the new signs is definitely sustained. 

The Diagnosis of pachymeningitis is based upon these 
two cardinal points: the existence of an underlying con- 
dition or causative disease, and the more or less rapid 
recurrence of the attacks. Cases are further character- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





ized by suddenness of onset and rapidity of recovery. 
Dr. Whittaker had at one time under observation an in- 
dividual affected with chronic alcoholism who was sud- 
denly stricken with apoplexy on the streets. The pa- 
tient was carried comatose to the hospital. The coma 


subsided in the course of a few hours, to leave a com-- 


plete right-sided hemiplegia, which entirely disappeared 
in three days, leaving the individual in better physical 
and mental condition than for ten years. Many of the 
cases of so-called “serous” apoplexy, characterized by 
sudden onset, and more especially by speedy recovery, 
are really cases of pachymeningitis. 

The predominance of symptoms indicating cortical 
lesion is another feature of diagnostic importance. Thus 
localized convulsions and contractions, monoplegias, 
contracted pupils, following an apoplectic attack in an 
individual predisposed to the disease by the factors al- 
ready emphasized, point almost certainly to pachymen- 
ingitis. 

Considerable diagnostic importance has been attached 
to rigidity of an extremity, which often develops as an 
expression of irritation of the motor centre of the ex- 
tremity, to become later manifest by convulsion or pa- 
ralysis. 

Collins considers it rather characteristic that the cranial 
nerves always remain free. 

A point of differentiation from other forms of intra- 
cranial hemorrhages is that the symptoms come on grad- 
ually and the stage of irritation is prolonged. 

The age and sex of the patient must not be overlooked. 

Basilar meningitis is differentiated by the youth of the 
patient, the family history, the presence of tuberculosis 
elsewhere, by its long prodromes, its insidious approach, 
its general and special hyperesthesia, opisthotonos, boat- 
shaped abdomen, etc. 

Cerebro-spinal meningitis prefers winter, soldiers, and 
children, occurs at times in endemic proportions, shows 
opisthotonos, herpes, and sometimes petechie, extreme 
hyperesthesia, spinal lesions, and does not recur. 

The Prognosis is always grave. Recovery without 
recurrence is possible, but not probable. The patient 
succumbs, as a rule, in a subsequent attack, if he does 
not fall a victim in the mean time to the original disease. 
The immediate prognosis is best established, as after any 
cerebral hemorrhage, by frequent observations of the 
temperature, whereby the degree of the rise after the 
initial depression incident to the shock would receive 
proper interpretation. A sudden or gradual elevation to 
a high grade (105° F.) at any time thereafter, independent 
of the original disease, is a sign of most ominous sig- 
nificance. 

T herapy.—The treatment of pachymeningitis does not 
differ materially from that of any form of meningitis or 
cerebral hemorrhage. The application of an ice bag to 
the head, the local abstraction of blood by leeches or 
cups behind the ears or over the temples, “derivation ” 
by purgatives (calomel, senna, croton oil), constitute the 
routine plan, which is sanctioned more by time and use 
than by benefit based upon demonstrable proof. Tran- 
quillity of surroundings, with all the measures which 
make up a more or less perfect hygiene, is the most 
effective agent in prophylaxis in the chronic psychoses; 


while abstention from alcohol addresses the “ causa indi-. 


cationis ” in cases dependent upon its abuse. Bright’s 
disease, heart disease, pernicious anemia, etc., in short, 
the underlying condition, calls for appropriate treatment, 
and paralyses, convulsive manifestations, persistent head- 
aches, whatever symptoms may be left, are to be met 
with symptomatic treatment. 

PACHYMENINGITIS CERVICALIS HYPERTROPHICA is a 
peculiar subvariety of meningitis, produced by great 
thickening of the meninges in the cervical cord, ‘and 
marked by severe pains in the back of the neck and both 
arms, with atrophy of the muscles of the neck and 
flexors of the hands, and final spastic paraparesis. 

LEPTOMENINGITIS.—It is possible, as already stated, 
that a real inflammation may limit itself to the dura 
mater alone, but such a distinct circumscription is very 


rare. Inflammation of the dura extends, as a rule, so as 
to involve the pia mater. The same qualification applies 
to the pia mater, though a strict limitation to the pia 
mater is more frequently observed. The subsequent re- 
marks apply more especially to inflammation of the pia 
mater, with which the dura is, or may be, secondarily 
affected in greater or less degree, It is taken for granted 
that cerebro-spinal meningitis and tuberculous menin- 
gitis, diseases due to special causes, are not included 
under the title leptomeningitis, which embraces all other 
kinds of simple meningitis of known or unknown cause. 

Leptomeningitis is always a secondary affection. The 
cases considered idiopathic become, under closer obser- 
vation, so much fewer every year that it is more safe 
to appeal to unknown primary affections than to. sub- 
scribe to the possibility of a spontaneous or idiopathic 
meningitis of any kind. A thorough conviction in this 
regard will alone lead to the searching investigation nec- 
essary in many cases to discover the original disease. 

Affections of the nose, accessory sinuses, and ear con- 
stitute by far the most fruitful causes of leptomeningitis. 

Chronic suppurative inflammations of the tympanic 
cavity, which constitute over twenty per cent. of all dis- 
eases of the ear, frequently lead to meningitis through 
caries of the osseous roof of the tympanum. The roof 
of the tympanum is composed of an excessively thin 
plate of bone, which is indeed at times congenitally de- 
fective, so that the way lies open to invasion of the 
cranial contents. 

A more or less openavenue is also offered in the course 
of, or along the sheaths of, the facial and auditory nerves, 
and the vessels which penetrate the petrosal fissure. 
Communication by caries may be also directly estab- 
lished between the cavity of the cranium and the mastoid 
cells; while indirect involvement of the meninges may 
follow phlebitis and thrombosis of the cavernous, trans- 
verse, and superior petrosal sinuses, as revealed by dila- 
tation of the veins and local cedema in the region of the 
mastoid process. Tuberculosis plays a prominent roéle 
as a special cause in the production of all these processes, 
while syphilis furnishes a small contingent of cases 
through caries of the upper meatus of the nose. 

Every meningitis whose cause is not obvious should 
excite suspicion of disease of the nose, accessory sinuses, 
or of the ear. So, also, diseases of the nose, especially 
those involving the accessory sinuses; and every case of 
otorrhea, which may sometimes reveal itself to the sense 
of smell in an offensive odor, before or in the absence of 
visible discharge, should excite the fear of possible men- 
ingitis. 

Trauma or injury to the cranial bones constitutes a 
not infrequent cause of simple meningitis. When com- 
pound fracture has occurred, or direct penetration has 
been effected, the sequence is sufficiently simple. In 
other cases the meninges, though not directly exposed, 
become affected through phlebitis, thrombosis, or sup- 
purations occurring in the patulous veins of the diploé, 
whereby is implied, as previously intimated, some hidden 
crevice or pre-existent communication with the air. A 
far more infrequent involvement of the meninges occurs 
at times when an abscess in the interior of the brain 
reaches its periphery, or bursts into a lateral ventricle to 
come in contact with inflections of the pia mater at the 
base of the brain. So-called brain “softenings,” which 
consist simply of brain and tissue débris, and simple 
hyperemias, the so-called “congestions” of the brain, 
including sunstroke, could not, with our present knowl- 
edge of the nature of infections, produce a leptomenin- 

itis. 
; Next in frequency to the direct invasion of the me- 
ninges from disease of the nose, accessory sinuses, and ear 
are the metastatic processes from distant ,depdts of in- 
fection. Any one of the acute infectious diseases may 
be thus attended or followed by meningitis, which is 
justly regarded as the most serious complication which 
can occur—which, indeed, imparts a sudden gravity to 
an otherwise mild case of disease. Of all the acute in- 
fections, pneumonia is the disease in which this complica- 


393 


Brain. 
Brain. 





tion most frequently occurs. The intimate relations of 
tuberculosis of the lung and brain in the frequent se- 
quence of basilar meningitis upon tuberculosis pulmo- 
num, prepare us in a measure for the frequent superven- 
tion of meningitis in the course of croupous pneumonia. 
The same connection or relation has been ob- 
served also in cerebro-spinal meningitis, and 
bacteriologists have pointed out the striking 
resemblance of the micro-organisms found in 
these two affections. Pyzemia and septicemia 
may be said to vie with pneumonia in the pro- 
duction of metastatic meningitis, while endo- 
carditis, empyema, acute articular rheumatism, 
the exanthematous diseases—more especially 
variola and scarlet fever (aside from ear dis- 
ease), and very rarely typhoid fever—diseases 
mentioned in the 
order of fre- 






quency, furnish WATTS x 
exceptional cases. © : ee 
Hinsdale reports 7 

a fatal case of 

purulent menin- 


gitis in a new- 
born child, due to 
a bacillus belong- 
ing to the colon 
group, which had 
apparently gained entrance to the body through the um- 
bilicus. As curiosities equally illustrative, however, of 
the nature of the process may be mentioned the cases 
of meningitis which have followed such trivial infec- 
tions as vaccinia and mumps. 

In a few reported cases, a paradoxical pupil reaction 
has been noted, the pupils being contracted to the size of 
a pinhead in the dark, and widely dilated in the light. 
The condition is rare and no satisfactory explanation of 
it has been given. 

The morbid anatomy and symptomatology of leptomen- 
ingitis do not differ—aside from the fact that the convex- 
ity is more often involved than the base, when the inflam- 
mation is due to metastatic and traumatic causes—from 
the morbid anatomy and symptomatology of cerebro- 
spinal meningitis (to be described farther on, in this vol- 
ume). 

The Diagnosis of meningitis in connection with disease 
of the nose, of the accessory sinuses, or of the ear, or 
with a trauma of the bones of the cranium, is very easy, 
as a rule, but the diagnosis of metastatic meningitis is 
oftentimes exceedingly difficult. High fever and blood- 
poisoning may be productive of symptoms which so 
closely simulate the signs of meningitis as to render an ab- 
solute diagnosis impossible, at least for atime. The per- 
sistence of these signs after subsidence of hyperpyrexia 
sometimes declares the disease. Tuberculosis, pymia, 
scarlatina, variola, erysipelas, and typhoid fever are the 
affections which oftenest create doubts as to the diag- 
nosis. But if close scrutiny be made of the etiological 
factors, and close at- 
tention be paid to the 
course of the disease, 
the diagnosis, as a 
general rule, soon be- 
comes clear. In dis- 
tinction from tuber- 
culosis and typhoid 
fever, it may be said 
that meningitis develops quickly, almost suddenly, 
with violent pain in the head, active delirium, and often 
with stiffness of the muscles of the neck, or retraction 
of the head. 

The Kernig Sign.—In meningitis, according to Kernig, 
of St. Petersburg, if the hip be flexed so that the thigh 
is at a right angle to the body, the knee may not, with- 
out undue force, be extended in some cases beyond 90° 
(Fig. 993, A), never to the point of full extension (Fig. 
993, B), and not farther than about 185° or 140° in any 
case (Fig. 994, (). With the hip extended, the knee may 


394 


cast Ph aN 


Ye 1 Anma= name nn neces ganeretnn, 
4, 


FIG. 993.—The Kernig Sign. 





Fig. 994.—The Kernig Sign 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





be readily straightened (Fig. 994, D). Thus, the ability 
readily to extend the knee, when the hip is flexed at a 
right angle (Fig. 993, B), would speak strongly against 
the presence of meningitis. 

Netter believes that the sign described by Kernig de- 
pends upon inflammation of the meninges and conse- 
quent irritability of the nerves, which is increased by the 
stretching of the lumbar and sacral roots when the indi- 
vidual is in the sitting posture, so that the attempt to 
extend the knee is sufficient to 
provoke reflex contracture of the 
flexures of the leg. Such reflex 
contracture is not produced by 
extension of the knee when the 
thighs are extended upon the 
pelvis. The sign is not pathog- 
nomonic, as was at first claimed, 
although it is of great value in 
diagnosis. Netter 
has observed it in 
forty - five out of 
fifty cases of men- 
ingitis. Cipollina 
was unable to find 
it in some severe 
cases of menin- 
gitis, and did find 
it in other affec- 
tions without the symptoms or lesions of meningitis. 
Packard has reported three cases of meningitis in in- 
fants, with the diagnosis confirmed by autopsy, in which 
the Kernig sign had been persistently absent. The ab- 
sence of the sign was ascribed by Packard to a diminu- 
tion of normal muscular hypertonia in infants. In an- 
other case the sign was present but no anatomical cause 
for death was found. 

Lumbar Puncture (Quincke).—Puncture of the ver- 
tebral canal, which was originally used as a therapeutic 
measure, has proven of great value in diagnosis. At 
first the method was used in the study of diseases of the 
vertebral canal; but with the knowledge of the com- 
munication between the subarachnoid spaces of the brain 
and those of the spinal cord, the method has come into 
much more general use in the diagnosis of diseases of the 
interior of the skull. 

Method.—The trunk should be 
well flexed, preferably with the 
patient lying upon the right side 
and the legs drawn up, or with 
the patient sitting up and bending 
the body well forward. The punc- 
ture is then made, under aseptic 
precautions, with a clean needle. 
An aspirating needle with an in- 
ternal measurement of 1 mm. 
should be used in adults; in chil- 
dren, the ordinary hypodermic 
needle is sufficiently large. With 
the object of reach- 
ing the subarachnoid 
space at the begin- 
ning of the cauda 
equina, the needle is 
introduced between 
the second and third 
or third and fourth 
lumbar vertebra. 
The puncture is made in the median line in children; 
in adults it is better to make the puncture close to 
the spinous process a little to one side of the middle 
line, in order to avoid the strong supraspinous ligament. 
The needle is introduced inward and slightly upward, 
to a maximum depth of from 2 cm. for children to 6 cm. 
for adults. When the needle enters the subarachnoid 
space, a varying amount of cerebro-spinal fluid will usu- 
ally flow out, either in drops or ina stream. Occasion- 
ally the fluid will not escape or the flow will suddenly 
cease, probably through the occlusion of the needle by a 











nA 


tore 










REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





flake of fibrin or in consequence of an obstructing fila- 
ment of the caudaequina. To avoid injury to the spinal 
cord, it is better to detach the aspirator from the needle, 
and thus withdraw the fluid without force. Any fluid 
that is withdrawn should be examined macroscopically, 
microscopically, and bacteriologically. Thus may be 
determined, first, whether the fluid be clear, turbid, 
purulent, or bloody; and second, the micro-organisms 
that may be present either as the primary cause of the 
meningitis or as a secondary infection. 

Osler confirmed the diagnosis in this way in thirteen 
out of seventeen cases. (See also p. 248 of the present 
volume.) 

Tuberculosis and typhoid fever show typical tem- 
perature curves, with lung symptoms in tuberculosis, 
and abdominal symptoms in typhoid fever. In scarla- 
tina, variola, and erysipelas it is rather a question of 
detecting a complication, as each disease shows charac- 
teristic eruptions upon the surface. Here, too, the per- 
sistence of cerebral signs after subsidence of the high 
temperature is of value. Septicand pyzmic diseases fol- 
low wounds, are attended with chills, and show joint affec- 
tions and internal metastases. Ulcerative endocarditis, 
a septic process, has the same history. Uremia is recog- 
nized by the dropsy, the condition of the urine, and, so 
far as the nervous symptoms are concerned, by the pre- 
dominance of convulsions. 

Cerebro-spinal meningitis is differentiated by the more 
prominent disturbances of sensation, by herpes, and by 
the occurrence of other cases. Basilar meningitis occurs 
more especially in children affected with tuberculosis 
elsewhere, or who come of tuberculous stock. It has 
long prodromes, and a longer duration. Its symptoms 
are less acute and intense. It more frequently implicates 
the membranes of the spinal cord. Pachymeningitis is a 
disease of age. It occurs in drunkards, and in cases of 
dementia paralytica, chronic insanity, etc. It shows a 
more fluctuating course. It must be repeated again and 
again that the various forms of meningitis are to be sep- 
arated and recognized more by the etiological relations 
of the disease than by any difference in symptomatology. 

The Prognosis is far more grave than that of cerebro- 
spinal, but not so absolutely fatal as that of basilar menin- 
gitis. The great majority of cases terminate fatally, in 
coma or convulsions, in the course of from two to ten 
days. 

The Treatment of leptomeningitis does not differ in any 
way from that of any other form of meningitis; what 
little may be accomplished for the relief of symptoms will 
be mentioned under Cerebro-Spinal Meningitis, Hpidemic. 

The physician who is thoroughly indoctrinated as to 
the dangers of disease of the nose, of the accessory sinuses, 
and of the ear, and who is thoroughly familiar with the 
researches regarding the nature of infection, will prevent 
many cases of meningitis by timely treatment of the nose 
and ear, and by maintaining scrupulous asepsis in the 
management of all wounds of the skull. 

James T, Whittaker. 
George H. Malsbary. 


BRAIN, SOFTENING OF.—The brain is said to be 
softened when its consistency is less than that taken as a 


normal standard. Diminution of consistence, however, . 


shows but a part of the morbid work of an affection in 
which this phenomenon is only a circumstance quite ac- 
cessory to the more important cerebromalacia, and the 
term in its literal acceptation could apply only to a 
diminution of the cohesion of the brain tissues, while their 
other properties remained intact. Softening, being a 
symptomatic word with a pathological meaning, like the 
‘word apoplexy, is rather a survival of a former belief, 
and its use is perhaps for this reason undesirable; but 
the name having been retained amid the fluctuations of 
opinions of writers on the subject, and in spite of its in- 
congruity and the fact that it is often applied to cases in 
which there is really no softening, it is now employed to 
designate a necrobiotic process that occurs in the elements 
of the brain tissues and that is consequent upon nutritive 














changes ordinarily attended by sensory, motor, and men- 
tal disturbances, which may vary according as the lesion 
is circumscribed or general in character. 

PATHOLOGICAL ANATOMy—Descriptions of the patho- 
logical changes accompanying occlusion of the cerebral 
arteries and the so-called encephalomalacia are compara- 
tively new. Their discussion is limited to contemporary 
authors, who have definitely settled certain points in- 
volved in the development of a new subject, notwith- 
standing diversity of opinica touching the nature and 
character of softening. 

In determining the question whether the diminished 
consistence or diffluence of cerebral substance be of 
pathological origin, two sources of deception should be 
guarded against; for this condition may be the result 
either of cadaveric decomposition or of accident happen- 
ing during the extraction of the brain from the skull. 
The genuine morbid appearances are then to be distin- 
guished from the artefacta produced by the investigator, 
and from the spontaneous changes occurring after death. 
Nor should the condition be confounded with diminished 
density or specific gravity. Normal white matter gives 
a specific gravity of 1.040, but when softened it is from 
six to eight degrees of the hydrometer scale lower than 
the normal condition; and the consistency of the brain is 
the same in individuals of all ages excepting the new- 
born and very young children. Season, temperature, 
and the disease to which the patient has succumbed 
affect this consistence. An epileptic, dying during a 
paroxysm, in the month of June, by asphyxia from the 
penetration of food into the respiratory ways, has been 
known to present at the necropsy, twenty-four hours 
afterward, a completely diffluent encephalon. In a 
second instance, forty hours after "death, with the same 
temperature, and in marasmus and an organic affection 
of the liver without cerebral symptoms, the brain was 
found to be in such a softened state that when it was 
placed on the hand the fingers penetrated by reason of 
its weight alone; while that of another cadaver, ex- 
amined seventy hours after death and twenty-four hours 
after the necropsy, was far from this state of softening. 

Though most frequent in old age, softening spares no 
period of life, its occurrence having been noted in the 
new-born and even in the feetus. That form peculiar to 
the senile condition appears to have served as a type in 
all the descriptions given by the best writers, who seem 
to have overlooked the pathological conformity shown 
in the failure of the nutrition as the primary and com- 
mon cause of cerebral softening at the two extremes of 
life. In the new-born the profound disturbance of nu- 
trition which, through the intermediary of the blood, 
disintegrates an organ whose softness has not yet been 


effaced by age, is essentially the same as that which in 


the senile state prepares for arterial and cardiac lesions, 
the formation of embolism or thrombosis, and the con- 
sequent incomplete irrigation of the cerebral substance 
by the blood. This starvation of the brain consequent 
upon diminished supply of arterial blood is now spoken 
of as necrobiotic and non-inflammatory in its nature. 
Such terms, however, as cerebral infarction and necro- 
biosis, though establishing facts, do not explain the 
phenomena of cerebral disintegration. 

Certain observers recognize in brain softening inflam- 
mation of an absolute kind; some regard it as a morbid 
state analogous to senile gangrene; others see a vital 
lesion affecting the nutritive integrity of the brain; while 
still others consider it asa lesion of nutrition owing to local 
ischemia, provoked by arrest or diminution of circula- 
tion either in one of the cerebral arteries or in the capil- 
laries of the brain. 

This profound trouble of nutrition, the essence of 
which is unknown, may occur as a primitiye necrobiosis 
of the brain substance, or this necrobiosis may be pre- 
ceded by a vascular lesion that causes a want of supply 
of blood effected through embolism, the local formation 
of a thrombus, or by compression of the vessels. If a 
cerebral vessel be stopped, that part of the brain supplied 
by the vessel is suddenly deprived of nourishment, and 


395 


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Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


$s 


this will be definitely the case if the embolism remains in 
place. When the vessel in question is a terminal artery, 
which does not exchange blood with other arteries, there 
will be immediate stoppage of cerebral function, followed 
by rapid changes of the brain elements, into fat and 
eventually into the liquescent state. 

The anatomical characters and circumstances that pre- 
side at the evolution of cerebral softening have been fairly 
made out. Observations in this direction warrant the 
statement that the arteria fosse Sylvit sinistre is most 
exposed to embolic occlusion, which circumstance may 
be explained anatomically by the difference in the angles 
at which the left carotid and the innominate arteries are 
given off by the aorta. For this reason the left carotid 
is liable to catch an embolus coming from the heart, and 
the left Sylvian artery being the terminal artery in ques- 
tion, the regions provided by this vessel are consequently 
most in danger of being affected by the embolic process. 
These regions are the nucleus lenticularis, the terminal 
nuclei in part, the external capsule, and part of the in- 
ternal capsule. The terminal branches of this vessel 
supply the second and third frontal convolutions, the 
island of Reil, and proximal surroundings, these being 
the portions of the brain most likely to suffer from the 
necrobiotic process. Further anatomical changes in the 
cerebral substance may result from the formation of an 
autochthonous coagulation, in consequence of degenera- 
tion of the intracranial vessels. Circumstances favoring 
the rapid formation of the thrombus are diminished 
motor force of the heart, roughening of the inner walls, 
narrowing and loss of force and elasticity of the vessels. 
Tumors of rapid growth, and inflammatory processes 
and their surroundings, which compress the vessels to 
such an extent as to lead to softening, are phenomena 
often observed in connection with softening. Occasion- 
ally the affected vessel is discovered entirely empty at 
the post-mortem examination, and for this reason it is 
supposed that the occluding mass has been reabsorbed. 

The first fact of importance in connection with the 
pathological details of softening is the infrequency of 
anatomical changes in the cerebral substance when the 
seat of obstruction is on the cardiac side of the circle of 
Willis, which permits the prompt re-establishment of the 
circulation on account of its free anastomosis. If, how- 
ever, the embolus is lodged in one of the terminal arteries 
of the basal arterial system, and a large region be thereby 
deprived of the necessary supply of fresh blood, there 
will be flowing back from the veins, and the tissues will 
become hyperemic and cedematous, and filled with 
small extravasations known as hemorrhagic infarctions. 
In this simple necrobiotic change, the blood and coloring 
matter pass through the ordinary metamorphosis, the 
tissue of the brain swells and decays, leading to the rapid 
development of masses of granular cells, and finally to 
fatty emulsion. Later, the diseased focus may become 
reabsorbed and a cyst remain in the place of the soften- 
ing, but this is rare; in fact, such a result may never 
occur except in the case of a small focus of inflammation. 
The process is more often followed by red sanguineous 
infiltration and yellow softening. The color, depending 
merely upon the amount of blood in the tissues, is, how- 
ever, not an essential point, nor is sanguineous infiltra- 
tion always present, and yellow softening is sometimes 
observed without its presence. 

ErroLogy.—Although the etiology of the large group 
of clinical symptoms popularly known as brain softening 
touches one of the most delicate points of medicine, but 
little satisfactory is to be said regarding its remote causes. 
Among those which predispose more or less are old age 
(from fifty to eighty) or agedness, chronic alcoholism, 
syphilis, sexual excesses and fast life, Bright’s disease, 
acute rheumatism, the dartrous diathesis, chorea, scarlet 
fever, insolation, intense cold, intense and long-continued 
intellectual exertion, severe and protracted emotional dis- 
turbance, misery, fright, overwork and responsibility, 
the abuse of opium, menstrual troubles, and, according 
to some authorities, the puerperal state. The cachexias 
and the inopectic diathesis (that is, a tendency to embo- 


396 


lism, to thrombosis, and to coagulation of fibrin) are 
adjuvant causes, the importance of which should not be 
overlooked. Among negroes, the intertropical races, and 
the inferior races generally, softening and other forms of 
brain disease are infrequent, but the aptitude for such 
disease grows with the degree of perfection of the species. 
Women are less subject than men, principally for the 
reason that, being women, they do not undergo the strain 
and exhaustion of high brain energy and severe muscular 
labor, and are not so exposed as men to the poison and 
excitement of alcohol, syphilis, and tobacco. 

Brain softening is the pathological sequence of many 
different conditions; but the more important causes that 
bring about the results in question may be stated as fol- 
lows, when brought concisely together: endocarditis, 
through the production of movable products; myocar- 
ditis, through the formation of thrombosis in the heart; 
all processes in the lungs leading to coagulation or to 
the reception of septic material into the veins of the 
lungs; aneurism of the aortic arch; atheroma of the cere- 
bral arteries; tumors of the brain, and even encephalitic 
foci; syphilis of the brain; the accumulation of pigment 
and pigmentous flakes in the blood, in connection with 
severe cases of malarial intermittent fever; and capillary 
occlusion through drops of fat. Other sources are in- 
juries and inflammations of the bone, the occlusion 
brought about by pus cells or white corpuscles, and the 
blocking of the vessels by lime metastasis. 

Of the phenomena of the occlusion of the intracranial 
vessels usually preceding the encephalomalacia, it is im- 
possible to present a clinical picture in definite terms 
without going into the details of embolism, thrombosis, 
and hemorrhage, for full particulars of which the reader 
is referred to their respective headings. Although 
spoken of in the same connection, cerebral softening and 
occlusion of the cerebral vessels are not necessarily in- 
terdependent, since softening does not always follow 
occlusion, and for this reason there is a tendency among 
some to consider softening as a distinct pathological con- 
dition. 

SymptToms.—Softening of embolic origin always begins 
by the symptoms peculiar to encephalic effusion of 
blood, or to those of apoplexy, the word being taken in 
its traditional sense. In fact, the symptomsare so similar 
to each other that their differentiation may be a matter 
of great difficulty to the most experienced. The symp- 
toms that characterize the early period of Hmbolism are 
sudden. Without premonition the patient is seized with 
a sudden dizziness, or a momentary headache, and with 
an involuntary cry falls consciousless; motion and sensa- 
tion appear to be extinguished, and unilateral paralysis, 
generally of the right side, follows. The only apparent 
difference between the symptoms occasioned by em- 
bolism of a cerebral artery and those of hemorrhage is 
the more transient state of the unconsciousness. For 
this reason part of the symptoms are often spoken of as 
apoplectic. In some cases, when the symptoms are less 
distinct, the unilateral paralysis forms a prominent 
feature. Other cases are prominently marked by more 
or less dizziness, by the absence of coma, by convulsions, 
and. by unilateral symptoms. This seems chiefly the 
case when embolism occurs in a circumscribed smaller 
cortical region, or when the embolus is reabsorbed and 
the circulation restored. Vomiting sometimes attends 
the onset of the attack; at other times delirium of a 
transitory character occurs; and in many cases sudden 
aphasia results from the anemia produced in the speech 
centre by the embolic occlusion of the artery supplying 
that region. There seems to be diversity of opinion 
among observers regarding the state of the pupils during 
the onset of the attack; it is probable, however, that they 
vary in different cases. At the fundus of the eye there 
may be found papillary or retinal cedema. It is only in 
chronic senile cases that papillary atrophy occurs. 

Thrombosis of the cerebral vessels is usually attended 
by premonitory symptoms, as persistent headache, either 
diffused or localized, slight dizziness, a sense of general 
confusion, unilateral disturbances of sensation, and even 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





violent transient paresis. Further development of the 
trouble gives rise to excitement and active delirium, 
causing the patient to get out of bed at night and to 
commmit other unreasonable acts. Symptoms of de- 
pression may follow this period of excitement, the pa- 
tient becoming apathetic and answering questions with 
difficulty. His movements are slow; there is tendency 
to somnolency; and a notable decrease occurs in the 
psychic functions, this decrease being characterized 
mainly by failures of the reasoning process, and by a 
more or less compromised memory, both of which are 
shown in verbal amnesia and other dysphasic affections. 
The humor is changing and emotional, and later the 
mental and other symptoms may become those of local- 
ized cerebral disease generally. As the patient goes into 
greater decline there may be bed-sores, and he may die 
from these; from an intercurrent malady, as a cardiac, 
renal,or splenic complication, ora pulmonary phlegmasia ; 
or a new attack or some new lesion of the encephalon 
may carry him off. Generally the patient dies in a state 
of profound adynamia. The size and physiological im- 
portance of the occluded vessels determine the difference 
in the extent and duration of the symptoms. In freshand 
vigorous subjects the occlusion of a small vessel may be 
followed by recovery, if the collateral circulation be es- 
tablished before the stage of necrobiosis begins. How- 
ever, in most cases of autochthonous thrombosis that 
survive, the subsequent history is that of chronic local- 
ized brain disease, and of the motor, sensory, and intel- 
lectual disturbances that follow. The same may be said 
of embolic softening. Actual softening being fully estab- 
lished, the most prominent symptoms are permanent 
weakness, often persistent hemiplegia accompanied by 
athetoid spasms, and progressive mental weakness end- 
ing in paretic dementia. With the exception of the dis- 
turbances of vision, the affections of the special senses 
are the same as those that occur in connection with cere- 
bral hemorrhage. The same is true of the sensory, 
trophic, and vaso-motor disturbances. Sudden amaurosis 
from occlusion of the arteria centralis retinse has been 
observed to occur in some cases of embolism. Anzemia 
of the fundus has also been found; and certain observers 
attach much diagnostic importance to the arterial and 
venous hyperemia of the retinal vessels and to conges- 
tion of the optic disc. 

The paralyzed limbs are generally those of the right 
side, for the simple reason that the left Sylvian artery is 
oftener occluded than the right. Bilateral paralysis 
may, however, follow bilateral vascular occlusion. Since 
we are unable to offer any satisfactory explanation of 
either the presence or the absence of contractures of the 
paralyzed limbs, they can scarcely be regarded as of 
pathognomonic significance. Motor restlessness, though 
characteristic of the worst cases, is greatly influenced by 
heredity. A patient of bad nervous antecedents, with a 
spot of progressive softening in one of the corpora striata, 
may become noisy and restless and suffer from insomnia, 
while another, with no nervous heredity and under the 
same conditions, is quiet and manageable. As enfeeble- 
ment progresses, the motor symptoms are particularly 
noticeable in the paretic walk and aphasic speech, the 
latter resulting from a disturbance of the secondary co- 
ordination consequent upon a lesion of the basal motor 
ganglia. (See Aphasia.) 

A brain affected by softening being on the verge of 
dissolution, the most prominent and troublesome symp- 
tom is the disturbance of the mental functions. The 
faculty most prone to failismemory. The vesicular neu- 
rin not being susceptible to the impression of events, the 
patient is unable to recall recent experiences and impres- 
sions with distinctness. The destructive metamorphosis 
of the convolutional structure is further shown in the 
impairment of the reflective faculty or power of judg- 
ment; and as the cerebromalacia progresses the patient 
may become whimsical and peevish, or his affective power 
may be deadened, and the intellectual faculties may de- 
cline into childishness or gatism and finally become ex- 
tinct. 


The occurrence of these mental changes in connection 
with the situation of the brain lesion may be further 
studied under other headings (see Brain Diseases : Diag- 
nosis of Local Lesions, and Brain: Functions of the 
Cerebral Cortez). 

DraGenosis.—The diagnosis of cerebral softening should 
be based upon the history of the case and the proving of 
such fundamental conditions as may produce hemorrhage 
and embolism or thrombosis. Hemorrhage cannot be 
distinguished from thrombosis by any absolute means, 
notwithstanding the various diagnostic signs that have 
been proposed at various times; but the condition of 
softening may be established with a probability border- 
ing on certainty when the associated symptoms are taken 
into account. When the premonitory symptoms have 
continued for a long time, the so-called apoplectic ac- 
cidents point to cerebral hemorrhage rather than to em- 
bolism, but the symptoms in all probability may be 
owing to thrombosis. Gradual march of the paralysis 
indicates thrombosis rather than cerebral hemorrhage. 
The rapid appearance or disappearance of the attack, 
and the situation of a centre of softening in the left 
hemisphere, point rather to embolism than to thrombosis. 
It can also be affirmed with almost entire certainty that 
the encephalic foyer is of embolic origin when the pres- 
ence of the symptoms permits us to suspect the forma- 
tion of splenic or of renal infarction. Such symptoms 
would be likely to occur aftera sudden attack in a young 
subject with an active bruit de souffle and enlargement 
of the spleen, pains in the lumbar region, and the pres- 
ence of blood in the urine. Cerebral softening may be 
confounded with hemorrhage, encephalitis, hematoma 
of the dura, and with tumors. In tumors the speech 
and intellect are generally unaffected, and there is pain 
with convulsions, vomiting, double optic neuritis, and 
choked disc; in hematoma the history of the case is the 
main reliance in making out a correct diagnosis; while 
in encephalitis there is a considerable rise in temperature 
and the evidence of tissue action in the respective region 
of the brain, which is notably absent in softening. The 
lowering of temperature, almost constant at the outset 
of cerebral hemorrhage, is absent in softening; aphasia 
is more frequent; paralysis of a mobile character in- 
creases by abrupt stages, and death may occur during 
the initial coma. The signs of arterial atheroma are of 
no value. 

PRoGNoOsIS.—Softening of the brain, more or less grave 
according to the extent and intensity of the functional 
troubles, is a disease that ends in death after a certain 
time, varying from a few days to several months or 
years. More die of the acute than of the chronic form. 
Some think the malady curable, but it leaves ineffaceable 
marks in the most favorable cases, and the reported re- 
coveries are to be looked upon with a great deal of 
doubt. They are said to have occurred in young and 
vigorous subjects; and when it is taken into considera- 
tion that the symptoms may have been incorrectly ob- 
served, or that they may have been those following vari- 
ous depraved states of the nervous system, the statement 
becomes more problematical. When not carried off by 
the initial symptoms, the patient is left with an incurable 
infirmity, in one of the most unfavorable conditions 
known. With the gradual enfeeblement of the intellect 
he is constantly threatened with new symptoms, and the 
reproduction of the original causes that produced the 
centre of softening. In fact, these causes greatly influ- 
ence any forecast that it is possible to make concerning 
the march and duration of the malady. As a rule, it 
may be said that the indications are the more favorable 
in simple circumscribed embolism, and most unfavorable 
in cases of autochthonous thrombosis. The prognosis is 
worse when there is slight impairment of the intellect, 
sensibility, and motility taken together than it is when 
any one of these singly is profoundly impaired. A case 
may be regarded as hopeless as long as the underlying 
cause of the attack remains, and extreme gravity is to 
be attached to such symptoms as rise of temperature and 
bed-sores. 


397 


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TREATMENT.—The causes that produce softening are 
difficult to remove and the therapeutical treatment of 
their effects is generally barren in results, notwithstand- 
ing correctness of diagnosis and the most judicious efforts 
to meet symptoms as they occur. Once established, 
senile softening is not amenable to treatment, Preven- 
tive measures being out of the question, except when 
the premonitory symptoms have continued for a long 
time, a consideration of the causes becomes fundamental 
matter, and the state of the heart and its action the 
main question. A declivous position of the head and 
perfect rest in a uniform temperature are advisable dur- 
ing an acute attack, while the body should be kept 
warm by artificial heat, warm clothing, and the cautious 
administration of stimulants. The caution in regard to 
stimulation is the more to be observed if there be the 
least suspicion of hemorrhage. In such a contingency 
it is deemed wise to act as if the case were one of cere- 
bral hemorrhage, since hemorrhage is more likely to 
oecur than occlusion, and the harm following stimula- 
tion in such a case seems to justify the diagnostic doubt. 
Symptoms pointing to a severe collateral hyperemia 
may be treated with large doses of the bromides, sina- 
pisms, dry-cupping, and mild purgation. The actual 
cautery and bleeding are to be avoided; but when there 
is general vascular irritation, leeches may be applied to 
the anus and behind the ears, in connection with intestinal 
revulsives and cold applications to the head. Digitalis, 
or strophanthus with glonoin, and amyl nitrite, are in- 
dicated, if the arterial tension be weak. Their use is, 
however, inadvisable in old persons. Recourse may be 
had to nervine tonics and to mild forms of slow deriva- 
tion after the attack has passed. The diet should be 
strictly regulated, all intellectual effort should be inter- 
dicted, the integrity of the nutritive functions should be 
maintained as much as possible, and the methods of 
treatment applicable to the chronic symptoms of circum- 
scribed cerebral disease should be generally observed. 

Irving C. Rosse. 


BRAIN, SURGERY OF THE.—History.—AlIthough in 
1871 Broca located a cerebral abscess in the speech centre, 
and greatly relieved the patient by trephining, modern 
brain surgery begins properly with a modest report of a 
case by Macewen in the Glasgow Medical Journal for 1879, 
xii., 210, and a later more elaborate paper, by the same 
author, in The Lancet for 1881, ii., p. 541. In these 
papers he narrates three cases, occurring in 1876 and 1879, 
in which cerebral disease was located by focal symptoms. 
The first was a case of convulsions of the face, arm, and 
leg, in the order named, following a fall on the right 
side of the head. A trephine opening of the dura evacu- 
ated two ounces of blood, and the boy recovered without 
any febrile movement. 

In the second case the symptoms pointed to a lesion of 
the frontal lobe, and, after trephining, a tumor of the 
dura mater was dissected out. The patient died eight 
years subsequently from Bright’s disease. 

The third was a case of cerebral abscess, existing not 
at the site of a prior injury marked by a distinct cicatrix, 
but correctly diagnosticated in a totally distinct position, 
that is, in Broca’s convolution, by the focal symptoms. 
The parents declined an operation, and the child died. 
After death an operation was done precisely as it would 
have been done during life, and an abscess was found, 
the size of a pigeon’s egg, at the spot indicated by the 
localizing symptoms. 

In spite, however, of. this remarkable paper, the sur- 
gical world seemed blind to its opportunity. But in The 
Lancet for December 20, 1884, Dr. Hughes Bennett and 
Mr. Godlee narrated a case of subcortical tumor of the 
brain, diagnosticated by the localizing symptoms alone 
and before operation. When the dura was opened no 
tumor was visible: but so certain were they that a tumor 
existed that an incision was made in the apparently 
healthy brain tissue, and a morbid growth the size of a 
walnut was found one-fourth of an inch below the sur- 
face. This case, though ultimately unsuccessful because 


398 











of suppurative meningitis, instantly arrested the atten- 
tion of the surgical world by the precision of the diag- 
nosis, the success of the operative technique, and the 
evidence it afforded that we could successfully cope with 
heretofore hopeless cases. Its very failure, like the fail- 
ure of the first Atlantic cable, but pointed the way to 
success. 

The first American paper on cerebral tumor, by Hirsch- 
felder and Morse, of San Francisco, appeared in the 
Pacific Medical and Surgical Journal for April, 1886. 
The case was that of the successful localization, but un- 
successful removal, of a brain tumor. Two most remark- 
able papers on brain surgery, however, were published 
soon afterward by Mr. Victor Horsley, in the British 
Medical Journal for October 9, 1886, and April 23, 1887. 
In these papers ten cases were related, all of which were 
correctly localized; only one died, and the remainder 
were either benefited or cured. These were in part cases. 
of removal of brain tumor and of portions of diseased 
brain tissue the cause of epilepsy, and in part cases of 
trephining for relief of intense headache, ete. 

In this country, besides many excellent publications 
that I have not space or time to enumerate, the most 
noteworthy early papers published have been those by 
John B. Roberts, read before the American Surgical As- 
sociation in 1885; two by R. W. Amidon, in the Medical 
News for January 21, 1884, and the Annals of Surgery, 
vol. i., 1885, both of these authors making strong pleas for 
early and more heroic surgical interference in affections 
of the brain; and one by Seguinand Weir, in the Ameri- 
can Journal of the Medical Sciences for July, August, and 
September, 1888. I have also published several papers 
to which I may allude; the earliest two appeared in the 
American Journal of the Medical Sciences for October and 





Fic. 995.—Skull Showing Points Named by Broca. IV, Nasion (junction 
of the nasal and frontal sutures); G, ophryon (on a level with the 
superior border of the eyebrows, and corresponding nearly to the 
glabella, the smooth swelling between the eyebrows); B, bregma. 
(junction of the sagittal and coronal sutures); Ob, obelion (the 
sagittal suture between the parietal foramina) ; L, lambda (junction 
of the sagittal and lambdoidal sutures) ; J, inion (external occipital 
protuberance) ; the basion is the middle of anterior wall of foramen 
magnum; As, asterion (junction of the occipital, parietal, and tem- 
poral bones). g, gonion (angle of the lower jaw) ; S, stephanion (or, 
better, the superior stephanion, intersection of ridge for temporal 
fascia and coronal suture); S’, inferior stephanion (intersection of 
ridge for temporal muscle and coronal suture); P, pterion (point 
of junction of great wing of sphenoid and the frontal, parietal, 
and squamous bones). This may be H-shaped, or K-shaped, or 
“retourné,” in which the frontal and temporal just touch. 


November, 1888, and in the Medical News for December 
1, 1888. In Germany perhaps the most elaborate and 
important publication is von Bergmann’s Hirnchirurgie. 
In addition to these, Mr. Horsley published, in the 
British Medical Journal for June 16, 1888, an account of 
the removal of a tumor from the spinal cord, and Dr. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





Macewen (British Medical Journal, August 11, 1888) 
published six cases in which the posterior arches of the 
vertebra had been removed for tumor and compression 
of the cord, and for an abscess in the posterior medias- 
tinum, two of which (paraplegia from Pott’s disease and 
fractured spine) had been published as early as 1886 
(Glasgow Medical Journal, xxv., 210.) (See article on 
Spine, Surgery of the.) I shall refer in the course 
of this paper to a number of other publications, but I 
have thought it right to sketch thus briefly 
the early historical development of the sub- 
ject. 

; Two things have made such brain surgery 
possible. First, the accurate localization of 
the functions (especially the motor centres) 
by Ferrier, Horsley, Fritsch, Hitzig, and 
others, by means of which we can with fair 
accuracy determine the site of a tumor, ab- 
scess, cyst, etc., by the focal symptoms. 
Secondly, the impunity with which we can 
trephine and open the dura mater, and inter- 
fere with the brain tissue itself, due almost 
entirely to the introduction of antiseptic 
surgery. To Horsley more than to any one 
else we owe the formulation of rules for suc- 
cessful brain surgery—rules which will be 
given at length hereafter. 

The Danger of Trephining.—For the tech- 
nique of trephining I refer the reader to the 
paper under that head in a later volume. But 
it is important further to consider the ques- 
tion of the danger involved in this opera- 
tion. In St. Bartholomew’s Hospital Reports 
for 1882, Dr. Walsham published a paper en- 
titled “Is Trephining of the Skull a Dangerous Operation 
per se?” In this article he analyzes 686 cases, of which 
417 survived, the mortality, therefore, being 39.3 per cent. 
Dividing these large numbers into classes: first, those in 
which preventive trephining was used (nearly all for frac- 
ture), there being no cerebral symptoms, the mortality was 
21.9 per cent. ; second, trephining in which severe cerebral 
symptoms existed, the mortality was 48.4 per cent. ; third, 
trephining in which moderate cerebral symptoms were 
present, the mortality was 27 per cent.; fourth, late 
trephining, mostly after inflammation had set in, the 
mortality was 58.5 per cent.; fifth, secondary trephin- 
ing showed a mortality of 22 per cent. 

Walsham showed that in 122 cases of late trephining, 
in which there was no condition endangering life, only 
10.6 per cent. died. Amidon, in the paper referred to, 
analyzes 100 cases of trephining reported since 1879, in 
most of which antiseptics were employed. Of these 100 
cases 26 died, but of these 23 presented at the time of 
operation symptoms already endangering life. He there- 
fore concluded (and most later writers practically concur 
in his conclusions) that the mortality of trephining per se 
is but 3 per cent., a conclusion which would seem to 
be confirmed by Pruniéres and Robert Fletcher, by their 
investigations, which show the frequency of recovery in 
cases of prehistoric trephining. Seydel (“ Antiseptie 
und Trepanation”) even estimates the mortality as only 
1.6 per cent. 

Not only have antiseptics thus diminished the danger 


of simply opening the cranium, but the numerous cases’ 


which have been reported of opening the dura, even when 
followed by removal of tumor or of some brain sub- 
stance, clearly show that only moderate danger is add- 
ed in any case by such surgical procedures. “ Hereto- 
fore,” says Amidon, “the reluctance of the surgeon to 
open the cranium seems avidity as compared with his 
hesitation in piercing the dura mater. The cerebral cor- 
tex seems to be a ‘dead line’ inside the prison walls of 
conservative surgery, across which even the most daring 
are tempted or the most unwilling are dragged only by 
sure indications or desperate chances.” 

The future danger seems to be, however, that temerity 
may take the place of timidity, and that many patients 
will either die or go about with multilated brains that 


on 





ought never to have been touched. This word of cau- 

tion, therefore, at the outset may not be out of place. 
TOPOGRAPHY OF THE BRAIN IN Its SuRGICAL RELA: 

TIons.—The relation of the chief fissures and convolu- 















Fic. 996.—View of the Brain from Above. fF’, Frontal lobe; P, parie- 
tal lobe; O, occipital lobe; S, end of the horizontal branch of the 
fissure of Sylvius; c, central fissure or fissure of Rolando ; _A, an- 
terior central or ascending frontal convolution ; B, posterior central 
or ascending parietal convolution; F, upper, #2, middle, F'3, lower 
frontal convolution ; f;, superior frontal sulcus; fo, inferior frontal 
sulcus ; f3, vertical fissure (sulcus preecentralis) ; P,, upper or pos- 
tero-parietal lobule ; P2, lower parietal lobule, constituted by Po, 
supramarginal gyrus ; P2’, angular gyrus; tp, intraparietal sulcus ; 
cm, calloso-marginal sulcus ; po, parieto-occipital fissure ; t,;, upper 
temporal sulcus; 0, first occipital convolution; 0, transverse occip- 
ital sulcus. (Ecker.) 


tions of the brain to the surface of the skull is of the 
greatest possible importance. It is essential that we 
shall be able, from fixed landmarks on the skull, to locate 
the various fissures and convolutions, and by them the: 
various cortical centres. The subject has been studied 
by Reid, Horsley and Hare, Krénlein and others, each of 
whose methods of research has its own merit. 

I shall give a brief outline of the four methods, and in 
doing so I must take it for granted that the reader is 
fairly well acquainted with the chief outlines of the 
cerebral cortex. In order, however, to facilitate the 
study of the external topography of the brain, I have 
introduced cuts. 

First: Fig. 995, from Broca, giving the points named 
upon the skull. 

Secondly: Figs. 996-998, from Ecker, giving the names 
of the principal sulci and convolutions. 

I have also appended two figures from Ferrier’s “ Func- 
tions of the Brain” (Figs. 999 and 1000) in order to fix as 
nearly as possible the relations of the various centres, so. 
far as known at present. The figures in these two cuts 
are placed as follows: 

1, On the postero-parietal lobule (precuneus), the 
centres for movements of the opposite leg and foot in 
locomotion. 2, 3, 4, At the upper end of the fissure of 
Rolando, and hinder part of the first frontal convolu- 
tion, the centres for various complex movements of the 


399 


Brain. 
Brain, 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


arms and legs, as in climbing, swimming, etc. In this | the centre for hearing. a, b, ¢, d, On the ascending 
area Horsley states that the arm and leg of the same side | parietal (post-Rolandic) convolution, indicate the cen- 
are involved together. 5, At the posterior part of the | tres for movements of the fingers and wrist. The cen- 


c 


7 cm 
F : vw” 
z ; 
‘ 





Fic. 997.—Outer Surface of the Left Hemisphere. F’, Frontal lobe; P, parietal lobe; O, occipital 
lobe ; 7, temporo-sphenoidal lobe; S, fissure of Sylvius; S’, horizontal, S", ascending ramus of the 
same ; ¢, central sulcus or fissure of Rolando; A, anterior central or ascending frontal convolu- 
tion ; B, posterior central, or ascending parietal convolution ; F'1, superior, F’?, middle, and F'3, 
inferior frontal convyolutions ; f!, superior, f?, inferior frontal sulcus ; £3, preecentral sulcus; P?, 
superior parietal or postero-parietal lobule ; P?, P%, inferior parietal lobule, viz. : P?, supramar- 
ginal gyrus; P®, angular gyrus; ip, intraparietal sulcus ; em, termination of the calloso-marginal 
fissure ; O}, first, O?, second, O%, third occipital convolutions ; po, parieto-occipital fissure ; 0}, 
transverse occipital sulcus; 02, inferior longitudinal occipital sulcus; 7"), first, 7'2, second, T3, 
third temporo-sphenoidal convolutions ; t’, first, t?, second temporo-sphenoidal sulci. (EcKer.) 


tre for smell is situated in the 
hook of the hippocampal region 
(Fig. 998, U). In close proxim- 
ity, but not exactly defined as 
to limits, is the centre for taste. 
The centre for touch is situated 
in the hippocampal region (Fig. 
998, H) and gyrus fornicatus 
(Gf). 

To these I also add Figs. 1001 
to 1009 from Horsley’s article 
(Amer. Jour. of the Med. Sciences, 
April, 1887) for the same pur- 
pose. I also add a figure from 
Gowers (Fig. 1010) to show the 
relations of the convolutions to 
the skull. 

The reader desirous of further 
information will find it briefly 
stated in the American edition 
of Gray’s “ Anatomy,” for 1887, 
p. 681, or very fully in the works 
of the authors already referred 
to, together with Ferrier’s 
“Functions of the Brain.” (See 
also article Skull, etc.) 

It must be borne in mind that, 
as pointed out by Stokes, the 
relations between the brain and 
the skull vary at different ages, 
a fact reinforced by Cunning- 
ham’s models of the brain hard- 
ened 77 sttw, and then exposed 
by removing the bones of the 
skull, leaving bridges at the sut- 
ures. Symington points out that 
the Sylvian fissure lies much 
higher above the squamo-pari- 
etal suture in the child than in 
the adult, and is from half an 


superior frontal convolution—extension forward of the | inch to even an inch above it. He thinks that they at- 
arm and hand, as in putting forth the hand to touch | tain the adult relations at about the eighth or ninth year. 


something in front. 6, On the 
ascending frontal (pre-Rolandic) 
convolution, just behind the up- 
per and hinder end of the mid- 
dle frontal convolution—move- 
ments of the hand and forearm 
in which the biceps is particu- 
larly engaged, viz., supination 
of the hand and flexion of the 
forearm. 7 and 8, Respect- 
ively for the elevators and de- 
pressors of the angle of the 
mouth. 9 and 10, As one, 
mark the centre for movements 
of the lips and tongue, as in 
speech. This especially occu- 
pies the posterior portion of the 
inferior frontal (generally known 
as Broca’s) convolution. Dis- 
ease of this region on the left 
side produces aphasia. i1, The 
centre for the platysma, retrac- 
tion of the angle of the mouth. 
12, A centre for the lateral 
movements of the head and 
eyes, with elevation of the eye- 


A @ 





lids and dilatation of the pupils. Frc. 998.—Inner Surface of the Right Hemisphere. CO, Corpus callosum, longitudinally divided ; 


18 and 13’, On the supramar- Gt, gyrus formes Hy, gyrus Py pea A) 0s ripe hippocarint or yrinces fissure ; U, unci- 

. Se nate gyrus; cm, calloso-marginal sulcus ; , Median aspect of the first frontal convolution ; ¢, 
ginal lobule and angular syrus, terminal portion of the central sulcus, or fissure of Rolando; A, ascending frontal, B, ascending 
including also the occipital lobe, parietal convolution; Pe, paracentral lobule; Pl’, precuneus; Oz, cuneus; po, parieto-occipital 
indicate the centre for vision. fissure; 0, transverse occipital sulcus; 0c, calcarine fissure; oc’, superior, oc", inferior ramus of 


14, On the superior temporo- 
sphenoidal convolution, indicates Ecker.) 


400 


the same; D, gyrus descendens; 74, gyrus occipito-temporalis lateralis (lobulis fusiformis) ; 75, 
yrus occipito-temporalis medialis (lobulus lingualis) ; cf, collateral or occipito-temporal fissure. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain. 





The fissure of Rolando is also much more oblique in 
its direction (52°, Hamy) in the child, and lies farther 
forward on account of the imperfect development of the 





Fig. 999.—Side View of the Brainof Man. (ferrier.) 
see pp. 399, 400). 


(For references 


frontal lobes. Gradually as these are developed, espe- 
cially the third frontal convolution, the lower end of the 
fissure is pushed back and assumes its adult angle and 
position. 

First: Landmarks on the Skull. Most of these are 
readily determined by reference to the foregoing figures, 





Fic. 1000.—'rop View of the Brain of grin ‘ Ferrier.) (For references 


see pp. 399, 4! 


but there are some which must be more minutely de- 
scribed. 

The temporal ridges (Fig. 995) are two in number: the 
upper for the temporal fascia, the lower for the upper 
border of the temporal muscle. The upper is the better 
marked, and can be easily followed by the finger from 
the external angular process backward. It marks the 
sudden change in the slope of the skull, from the curve 
of the upper surface to the more vertical direction of the 


Vou. II.—26 


' 





side. ‘The lower one is best made out by closing and re- 
laxing the jaw, when the upper edge of the tempora! 
muscle can be located by the finger. Like the upper, it 
begins at the external angular process, but runs at a 
lower level than the fascial ridge. Its middle is about 
two-fifths of an inch below it. The points where the 





Fig. 1001.—Representation of the Centre for the Upper Face and Angle 
of the Mouth. (Horsley.) 


coronal suture crosses these two ridges are called re- 
spectively the upper and the lower stephanion (Fig. 995, 
Sand S’). 
The coronal suture starts at the bregma (Fig. 995, B). 
Drawing the bi-auricular line (Fig. 995), measurements 
on 185 skulls have given me as a mean result, that in the 
adult the bregma lies 0.875 of an inch in front of this line. 





Fig. 1002.—Representation of the Centre for the Vocal Chords (Adduc- 
tion). (Horsley.) 


The greatest distance was1.2 inch. In 16of these skulls, 
the bregma coincided with the point where the bi-auricu- 
lar line crosses the sagittal suture. In only 7 did it lie 
behind it, the maximum being 0.9 inch. Starting from 
the bregma, by shoving the scalp backward and forward, 
the finger can perceive (but with some difficulty, espe- 
cially in the aged) the irregularities of the coronal suture, 





Fig. 1003.—Representation of the Centre for the Lower Face and Floor 
of the Mouth. (Horsley.) 


but toward the stephanion they become more marked and 
can be pretty well appreciated. The parieto-sguamosal 


401 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





suture lies beneath the temporal muscle. The highest 
point of its curved line is at the junction of the upper 
and middle thirds of a vertical line drawn from the upper 





Fic. 1004.—Representation of the Centre for the Shoulder. CHorsley.) 


border of the zygoma to the ridge for the temporal 
muscle in front of the temporo-maxillary articulation. 
The point of junction of the great wing of the sphenoid, 
frontal, parietal, and squamous bones is called the pterion 
(Fig. 995), and is about half-way between the superior 
stephanion and the zygoma. It is usually H-shaped. 
The Relation of the Fissures and Convolutions to the 





Fig. 1005.—Representation of the Centre for the Elbow and Wrist. 
(Horsley.) 


Landmarks on the Skull.—There are five great fissures of 
the brain to be localized: 

First, the great longitudinal fissure separates the two 
hemispheres of the cerebrum. This does not lie precisely 
in the middle line, but in consequence of the slightly 
larger size of the left hemisphere, it lies about an eighth 
of an inch to the right of the middle line. 

Second, the great transverse fissure, or the fissure of 





Fic. 1006.—Representation of the Centre for the Thumb. (Horsley.) 
Bichat, between the cerebrum and the cerebellum. This 
lies in a line from the external auditory meatus to the 
tnion (or external occipital protuberance). This marks 
also the position of the tentorium and of the lateral sinuses. 
The other three great fissures (viz., the fisswre of Sylvius, 
the fissure of Rolando, and the parieto-occipital fisswre) 
may be located by the following rules, 


402 


Horsley’s Method.—The fissure of Rolando, in relation 
to the motor region, is the most important in the whole 
brain. As will be seen by reference to Figs. 996 and 997, 





Fic. 1007.— Representation of the Centre for the Combined Synchron- 
ous Action of Both Limbs. (Horsley.) 


almost all the motor centres lie clustered about it. As 
Thane has shown, it runs downward and forward from 
a point half an inch behind the middle of the distance 
from the glabella to the inion. This point being fixed, 
if a line be drawn laterally at an angle of 67° (as shown 





THT 


Fig. 1008.—Representation of the Centre for the Lower Limb. H, Fo- 
cus of representation of the hallux. (Beevor and Horsley.) 


by Hare) for a distance of three and three-eighths inches, 
it will indicate the fissure of Rolando; the lower third of 
the fissure, however, changes to a somewhat more verti- 
cal direction, thus forming a knee-like bend. To fix this 
important fissure, Horsley uses a strip of metal or of 
parchment paper, say fourteen inches long, with a sec- 
ond strip firmly fixed to it at an angle of 67° (Fig. 1011). 





Fa. 1009.—Representation of the Centre for the Head and Neck, to- 
gether with Conjugate Deviation of the Eyes. (Horsley.) 


The zero point of the scale of the longer piece (as sug- 
gested by Dr. Morris J. Lewis, of Philadelphia) is placed 
half an inch in front of the angle formed by the two 
arms. From this zero point the scale (in quarter inches) . 
leads both forward and backward. The longer arm is 
placed in the middle line of the shaven head, in such a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





position that the reading of the two scales at the glabella 
and at the inion shall be identical. The lateral strip will 
then mark the fissure of Rolando (three and three-eighths 
inches); the direction of the lower third being slightly 
changed, as above indicated. 

The fissure of Sylvius commences at the pterion, the 
anterior branch running upward and forward, continu- 





Fic. 1010.—Diagram of the Relations of the Convolutions to the Skull. 
2, and 3, Upper, middle, and lower frontal convolutions; A F, A P, 
ascending frontal and parietal convolutions ; S P, superior parietal lobule ; 
Ang, angular gyrus; OcL, occipital lobe; 7'1, 2, 3, the temporal convo- 
lutions; P O F, parieto-occipital fissure; F' Sy and F' Sy P, tissure of 


Sylvius and its posterior limb; F’. Ro, fissure of Kolando. 


ing the line of the squamo-sphenoidal suture, but one or 
two millimetres in front of it. The posterior branch 
passes upward and backward half a millimetre above the 
squamo-parietal suture, as far as its highest point, and 
from there curves slightly upward toward the centre of 
the parietal eminence, which it nearly reaches. This 
fissure limits the motor region anteriorly by its anterior 
limb, and postero-inferiorly by its posterior limb. 

The precentral or vertical suleus is of great importance 
also, as it divides two convolutions of very different 
functions, and on each side of it has convolutions of 
great motor importance. It runs parallel to and just 
behind the coronal suture, and is al- 


most vertical to a horizontal tangent (74 #1, la Plea Pll a A 


at the bregma; hence its second 

name. Its upper end reaches to the 

level of the middle of the fissure of Rolando. From it, 
about ona level with the superior stephanion, the inferior 
Frontal sulcus runs forward. Above the origin of this 
latter sulcus, the precentral sulcus continues vertically 
half-way across the root of the middle frontal convolu- 
tion. Its lower end is separated from the fissure of Syl- 
vius by a horseshoe-shaped convolution of great im- 
portance (the operculum), which is nearly always one 
centimetre wide, and overlies the island of Reil. 

The superior frontal sulcus starts from the ascending 
frontal (pre-Rolandic) convolution midway between the 
fissure of Rolando and the line of the precentral sulcus. 
Its posterior end, therefore, lies behind the precentral 
sulcus. The superior and inferior frontal sulci run for- 
ward and slightly downward, practically parallel with 
the great longitudinal fissure. 

The intraparietal sulcus lies behind the fissure of Ro- 
lando, and bounds the motor area posteriorly. It begins 
opposite the knee-like bend at the junction of the middle 
and lower thirds of the fissure of Rolando. As it goes 
upward it lies about midway between the line of the Ro- 
landic fissure and the parietal eminence. It then sepa- 
rates farther from the fissure of Rolando, and so widens 


HY, 


(Gowers. ) 





Brain, 
Brain, 








the area of the ascending parietal (post-Rolandic) con- 
volution that its upper end is known as the superior 
parietal lobule. In the middle of its course it runs about 
parallel to the great longitudinal fissure, and midway 
between it and the parietal eminence. Farther on, it 
passes by the external end of the parieto-occipital fissure 
and goes downward and backward into the occipital lobe. 

The parieto-occipital fissure on the upper surface 
of the cerebrum is a short fissure about an inch 
long, at right angles with the great longitudinal 
fissure, and two or three inches in front of the 
lambda (the junction of the lambdoidal and sagittal 
sutures) (Fig. 995, Z). This fissure, on the median 
surface of the cerebrum (Fig. 998, po), is a long fis- 
sure running downward and forward. It is joined 
at its middle by the calcarine fissure (Fig. 998, oc). 
Between these two fissures is the cwneus (02, Fig. 
998), in which lies the cortical centre for sight. In- 
jury to the cuneus, therefore, produces blindness 
in the half of each retina on the side corresponding 
to the injury (hemianopsia). 

In front of the parieto-occipital fissure, on the 
middle surface of the hemisphere, lies the precuneus 
or quadrate lobule (Fig. 998, P;'), bounded in front 
by the upper end of the calloso-marginal fissure (em). 

In front of and behind the fissure of Rolando 
(Figs. 997 and 998) are two most important convolu- 
tions. The one in front is chiefly known as the 
ascending frontal or precentral, or, as I prefer to 
term it, the pre-Rolandic convolution. The one be- 
hind the fissure of Rolando is known as the as- 
cending parietal or postcentral, or, as I prefer to 
term it, the post-Rolandic convolution. At their up- 
per ends they fuse into the paracentral lobule, and 
at their lower into the operculum. The two frontal 
sulci divide the frontal lobe horizontally into three 
convolutions, viz., the first, second, and third, or 
respectively the superior, middle, and inferior frontal 
convolutions. The third or inferior convolution is 
frequently known as Broca’s convolution. On the left 
side the centre for speech is located (in left-handed per- 
sons this speech centre lies in Broca’s convolution on the 
right side). For the location of other centres in these 
various convolutions the reader is referred to Figs. 999- 
1009. 

Below the intraparietal sulcus, between its beginning 
and the posterior limb of the fissure of Syivius, lies the 
supramarginal convolution (Fig. 997, P*). Below the 
posterior portion of the intraparietaly and behind the 
superior extremity of the horizontal limb of the Sylvian 
fissure, lies the angular gyrus (Fig. 997, P®). 


uj 


The temporo-sphenoidal lobe 
is divided horizontally, by the 
supertor and inferior temporal 
sulci, into three convolutions, 
first, second, and third, or sw- 
perior, middle, and inferior tem- 
poro - sphenoidal convolutions. 
On the median aspect of the 
hemispheres the calloso-mar- 
ginal fissure (Fig. 997) has 
above it the marginal convolu- 
tion; below it, and immedi- 
ately above the corpus cal- 
losum, lies the gyrus fornicatus. 

Reid’s Method.—Reid’s “ base 
line” (Fig. 1012) is a line run- 
ning backward from the infra- 
orbital ridge through the mid- 
dle of the external auditory meatus, and prolonged to 
the middle line of the head posteriorly. The fisswre of 
Sylvius runs from a point an inch and a quarter behind 
the external angular process of the frontal bone to a 
point three-fourths of an inch below the most promi- 





Fig. 1011.—Horsley’s Instru- 
ment for Fixing the Fis- 
sure of Rolando, as Modi- 
fled by Dr. Morris J. 
Lewis. 


403 


Re< 


Brain. 
Brain. 





nent point of the parietal eminence. Measuring from 
above backward, the first three-fourths of an inch will 
represent the main fissure; the rest indicates the hori- 
zontal limb. The ascending limb starts at a point three 
fourths of an inch back of the anterior extremity, that 
is, two inches behind and slightly above the external 
angular process, and runs vertically upward and forward 
about one-fourth of an inch. 

To find the fissure of Rolando, draw the base line and 
the lines for the great longitudinal fissure and the fissure 
of Sylvius. Then draw two lines perpendicular to the 
base line: one from the depression in front of the external 
meatus (Fig. 1012, D E) and the other (F G) from the 
posterior border of the mastoid process at its root. We 
shall thus have on the surface of the head a four-sided 
figure, bounded above and below by the lines for the 
longitudinal fissure and the horizontal limb of the fissure 
of Sylvius, respectively, and in front and behind by the 
two perpendicular lines just described. Next draw a 
diagonal line (F H) from the posterior superior angle to 
the anterior inferior angle. This corresponds to the 
fissure of Rolando, which, however, as a rule, does not 
quite join the fissure of Sylvius. 

Cunningham states, however, that this (Reid’s) mode 
of locating the fissure of Rolando is not reliable, and I 
much prefer Horsley’s, Krénlein’s, or Hare’s, both as 
more accurate and much more easily applied. 

To find the parteto-occipital fissure continue the line for 
the horizontal limb of the fissure of Sylvius (Fig. 1012, 
Sy.h.fis.) to the line of the longitudinal fissure. The por- 
tion of this line, about an inch long, next to the longi- 
tudinal fissure, will usually approximately correspond to 
it. The position of the various convolutions can now 
be readily indicated by reference to Fig. 1010. 

Hare's Method.—Mr. A. W. Hare has pointed out that 
neither the cranial sutures nor the prominences of the 





Fic. 1012.—A, Glabella; B, external occipital protuberance; e.a.p., 
external angular process of frontal bone; B C, transverse fissure ; 
A B, longitudinal fissure; Sy.fis., Sylvian fissure ; Sy.h.jis., horizon- 
tal limb of fissure of Sylvius; Sy.a.fis., ascending limb of fissure of 
Sylvius ; D, E, perpendicular line from depression in front of exter- 
nal auditory meatus to middle line of top of head; F, G, perpendic- 
ular line from posterior end of base of mastoid process to middle 
line of top of head ; F, H, fissure of Rolando ; .o.fis., parieto-occipi- 
tal fissure ; +, most prominent part of parietal eminence. (Reid.) 


face are available for mapping out the brain; the former, 
because they are too indistinct or obliterated, the latter, 
because they have no direct relation to the cranium as a 
whole on account of the unequal development. The 
same observation, he points out, is true of the bony land- 


404 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





marks on the lower portion of the skull. If the external 
auditory meatus or the mastoid process has lines drawn 
from it over the convexity of the skull, they will give 
inconstant results according as the anterior or posterior 
portions of the head are more or less developed. Four 


Ton gitud fis. 


Sore meee 1c, 





4 
ya 
on 


‘} 


) 


Fic. 1018.— +, Most prominent part of parietal eminence; a, convex 
line bounding parietal lobe below ; b, convex line bounding temporo- 
sphenoidal lobe behind; 1.fr.c., first frontal convolution ; 1.f7r.f., 
first frontal sulcus; f.R, fissure of Rolando; Sy.f., Sylvian fissure; 
Sy.h.f., horizontal limb of Sylvian fissure; Sy.a.f., ascending limb 
of Sylvian fissure; p.o.f., parieto-occipital fissure; i.par.f., intra- 
parietal sulcus; ang.g., angular gyrus; 8.m.c., supramarginal con- 
volution ; 1.t.s.¢., first temporo-sphenoidal convolution ; 1.t.s.f., first 
temporo-sphenoidal sulcus; 1.0.c., first occipital convolution ; p.p.l., 
postero-parietal lobule. (Reid.) 


points, however, are of value, viz., (1) the glabella, which 
corresponds to the base of the anterior lobe of the brain; 
(2) the inion, which corresponds to the base of the pos- 
terior lobe of the brain, and also to the junction of the falx 
with the tentorium; (3) the third constant landmark is the 
external angular process of the frontal bone which limits 
the cerebrum laterally and has also a uniform relation to 
the fissure of Sylvius; (4) finally, the parietal eminence is 
valuable, since it marks the greatest lateral expansion of 
the brain and bears a special relation to the supramarginal 
convolution. While its cranial relations vary consider- 
ably, its cerebral relations are much more constant. The 
distance from the glabella to the upper end of the fissure 
of Rolando will be 55.7 per cent. of the total distance 
from the glabella to the inion. For instance: 


The distance from the glabella to 
the upper end of the Rolandic 
fissure will be— 


If the distance from the glabella 
to the inion is— 


11 inches. 6.1 inches. 
113° (Gk 
12 6.6 sas 
10h cae i. Oem 
13 La 7 


In other words, however the proportions of a head may 
differ, the pre-Rolandic and post-Rolandic regions of the 
brain are uniformly proportionate to each other, the 
pre-Rolandic being 55.7 per cent. and the post-Rolandic 
44.38. Moreover, the fissure of Rolando runs downward 
and forward at an angle of 67°, and its average length is 
32 inches. 

Dr. Claude Wilson, of Tunbridge Wells, has con- . 
structed a cyrtometer (Fig. 1014) consisting of two strips 
of flexible metal forming a letter T, with a tape to secure 
the short horizontal limb in place; the mode of using 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


which is shown in Fig. 1015. On the antero-posterior arm 
it will be noticed that there are two scales. The posterior 
scale is lettered in capitals from A to Q. The anterior 
scale is lettered in small letters from a to g, and they are 
so placed that when in position the distance from the 
glabella to small a, 0, c, etc., is 55.7 per cent. of the dis- 
tance from the glabella to capital A, B, C, etc. The 
horizontal limb being placed on the forehead, so that its 
inferior border corresponds to the glabella, if the capital 
letter A falls over the inion, then the small a will corre- 
spond to the beginning of the fissure of Rolando, and so 
on for the other letters. The small strip for marking 
the fissure of Rolando is movable on the antero-posterior 
limb, and is also reversible to suit both sides. This is 
now slid along until it corresponds for instance to the 
small @, when its anterior border marks the line of the 
fissure of Rolando. Similarly, if the inion corresponds 
to B or C, the Rolandic strip is slid to 0 or ¢, ete. 

The Fissure of Sylwius.—To locate this fissure a line 
is drawn from the external angular process backward to 
the occipital protuberance (Fig. 1018, EAP to OPr) by 
the shortest route between these 
points. This line droops a 
little toward the external au- 
ditory meatus in avoiding the 
great convexity of the skull, 
which convexity lies in the 
course of the direct horizontal 
line between these two bony 
prominences. It usually passes 
about half an inch above the 
meatus, and thus closely cor- 
responds to the floor of the 
middle fossa at this point. In 
front of the me- 
atus it lies above 
the level of the 
floor of the mid- 
dle fossa; behind 
it, it runs parallel 
to, and nearly co- 


incident with, the attachment of the tentorium and the - 


posterior half of the lateral sinus. A point one inch 
and a half posterior to the external angular process on 
this line marks the commencement of the fissure of Syl- 





BY! 
Fig. 1015.—Wilson’s Cyrtometer in situ. G, Glabella; EAP, external 
angular process; R, fissure of Rolando, its position and direction 
marked by the lateral strip of metal. 


































Fig. 1014.—Wilson’s Cyrtometer. 


Brain, 
Brain, 


vius. Even in heads of the most varied shapes and 
sizes this measurement remains constant. From 
this point a straight line to the centre of the parietal 
eminence marks accurately the course of the pos- 
terior limb of the fissure and nearly corresponds in 
part with the squamo-parietal fissure (Fig. 1018, SF). 
The ascending limb of the fissure corresponds closely 
with the squamo-sphenoidal suture in its entire 
length, and is continued upward in the same line for 
half an inch (A). The middle meningeal artery is 
also shown in Fig. 1018 in its relation to the Sylvian 
and Rolandic fissures. To expose the tip of the 
temporo-sphenoidal lobe, trephine behind the upper 
extremity of the great wing of the sphenoid (TS). 
To expose Broca’s convolution, trephine immedi- 
ately in front of the great wing of the sphenoid (B). 

iroenlein’s Method.—K. has recently proposed this 
simple and accurate method of locating the fissures 
(Fig. 1016): (1) The base 
line, ZM, runs horizontally 
at the lower border of the 
orbit and the upper border 
of the auditory meatus.* 
(2) Parallel with this, on a 
level with the supraorbital 
ridge, another horizontal 
line (KK’)is drawn. (3) An 
anterior vertical line (ZK) is drawn from the middle 
of the zygoma to the supra-orbital line. (4) A mid- 
dle vertical line is drawn from the. articulation on 
the lower jaw A, and prolonged to R. (5) A pos- 
terior vertical line is drawn from the posterior bor- 
der of the base of the mastoid (MK’) and prolonged 
to P, the middle line of the skull. (6) Draw a line 
from K toP. Be- 
tween the points 
R and P’ it cor- 
responds to the fis- 
sure of Rolando. 
(7) Bisect the 
angle PKK’ by 
the line KS. This line corresponds to the fissure of Syl- 
vius from its bifurcation to its posterior end. The point 
K is over the bifurcation of the fissure of Sylvius. K 
and K’ are the points for trephining to reach the anterior 
and posterior branches of the middle meningeal artery. 
The method applies equally to all varieties in the shape 
of the head, both brachi- and dolicho-cephalic. 

Chiene’s Method.—Mr. John Chiene, of Edinburgh, has 
proposed a method of fixing the position and length of 
the Rolandic fissure which is at once simple, ingenious, 





Fig. 1016. 


and always available. He folds a square piece of paper 
once (Fig. 1017, A, B, C, D), on the diagonal line A, C. 
The angle B A C is then evidently 45°. The angle DAC 
(45°) is then halved (22.5°) by folding the paper again on 
the line A E. The sum of the angles B A CandC A E° 





* I perhaps ought to state here that in different parts of this article 
I have utilized to a small extent portions of the text contributed to 
other publications. 


405 


Brain, 
Brain, 


is evidently 67.5°, which is near enough for all practical 
purposes to the angle of the fissure of Rolando. The side 
A Bis then applied to the middle line of the head, the 
point A being placed half an inch behind the midpoint 
between the glabella 
and the inion, when 
the line A E will cor- 
respond to the fissure 
of Rolando. 

But it must be re- 
membered that how- 
ever exact our cerebral 
localization may be, 
there are exceptional 
cases that setat naught 
all our present knowl- 
edge on this subject. 
Thus Cunningham re- 
ports a case of subar- 
achnoid cyst extend- 
ing from the fissure of 
Rolando to the occip- 
ital lobe with neither 
motor nor sensory dis- 
turbance, and Bramwell reports a case of sarcoma of the 
dura destroying the greater part of the motor centre with- 
out any paralysis. These and a number of other such 
cases should make us careful not to be too dogmatic 
until we learn much more. 

Percussion of the Skull.—Here, perhaps, as well as else- 
where, may be noted a point to which Macewen has 
called attention, viz., that percussion of the skull may 
afford valuable evidence not only of the condition of its 
contents, and, as I have pointed out, of that of the skull 
itself, but also, as I have observed in one case, of the 
condition of the overlying tissues. 

Macewen does not state the character of the percussion 
note, but presumably it is that, when an abscess or tumor 
exists, there will be a local, increased dulness on per- 
cussion, with a lower tone. He states that it has been 
verified post mortem, and that it will probably be of 
especial value in early life in the diagnosis of tumors 
of the cerebellum. In a case of hydrocephalus I have 
observed a markedly increased dulness of one side on per- 
cussion, and the autopsy showed that the ventricular 
distention was far more marked on this side. 

In simple fracture of the skull, hydrocephalus, and 
large tumors, the “cracked-pot ” sound described on page 
421 of this paper may be of service, and I would urge 
that it be tested and reported on in future cases. 

In a case of syphilitic necrosis of the skull above the 
left ear, with a Jacksonian epilepsy in the left arm and 
leg, and therefore a presumable lesion (gumma?) on 
the right side of the brain, I have tested the percus- 
sion note. Over the necrosed bone the tissues were 
somewhat thickened, but not to any excessive degree. 
The percussion note was so much duller on the left side, 
half-way between the sagittal suture and the ear, that 
two of my assistants with their backs turned to the pa- 
tient correctly stated which side was percussed, and the 
same difference was noted as between the same site and 
the forehead well above the frontal sinus. In a paper 
published in 1884, I have pointed out the similar value 
of percussion in the so-called abscess in the frontal sinus 
and the antrum. 

GENERAL TECHNIQUE OF OPERATIONS ON THE BRAIN. 
—This has been carefully formulated by Horsley. In 
a few minor points I have added to it from my own 
personal experience, as well as from that of others. 

I. Shaving the Head.—This is not only important for 
the operation, but should always precede a definite diag- 
nosis, and, in fact, be one of the means of making it. 
So important do I regard this that I should consider no 
diagnosis as assured, and no operation warranted, that 
had not been preceded by shaving. The unexpected and 
the unknown scars found have surprised me in several 
cases. Besides this, no reliable mapping on the head of 
the fissures and convolutions can otherwise be made. 





Ur-------—----------------<sps 


Fic. 1017.—Chiene’s Method of Locating 
the Fissure of Rolando. 


406 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


These should always be marked on the skull by an ani- 
line pencil. 

II. Antiseptie Preparation of the Patient.—The day be- 
fore the operation the patient’s head should again be 
shaved, scrubbed by a nail-brush with soap and water, 
next with ether, and then be covered with a wet subli- 
mate dressing (1: 2,000), retained in place by a bandage 
till the time of operation. Formerly I used, as Horsley 
advises, a solution of 1 to 1,000, but I have found that the 
recently shaved scalp is so tender that pustulation was 
‘often caused by it. This scrubbing must be gentle, but 
thorough. The operation room should be uncarpeted 
and should contain only necessary furniture, the walls 
and ceiling should be carefully wiped the day before, 
and all the woodwork and furniture scrubbed with car- 
bolic solution. Aseptic gauze sponges should be used. 
The instruments may be disinfected either by boiling for 
fifteen minutes, or by lying for an equal length of time in 
a carbolic solution (1 to 20), and then transferred to boiled 
water sufficiently cooled to permit of their being handled. 
The head should be washed with soap and water, ether, - 
and sublimate solution, a second time just before the 
operation. The hands, and especially the finger nails, of 
the operator and of every one of the assistants should be 
most carefully cleaned and then disinfected. 

III. Anesthetic.—Horsley specially advises the use of 
chloroform, but I have often used ether and found no 
reason to regret it. Horsley cautions us that when the 
dura is opened there is a special sensitiveness to the action 
of an anesthetic (chloroform only ?), and that special care 
should therefore be used not to give too much. 

As a preliminary Horsley advises that a quarter of a 
grain of morphine be injected under the skin from a half- 








ER 








Fig. 1018.—Head, Skull, and Cerebral Fis- 
sures (adapted from Marshall, by Hare). 
OPr, occipital protuberance: EAP, ex- 
ternal angular process; SF, Sylvian fis- 
sure; A,its ascending limb; FR, fissure 
of Rolando; PE, parietal eminence; 
MMA, middle meningeal artery; TS, tip 
of temporo-sphenoidal lobe; B, Bro¢éa’s 
convolution; IF, inferior frontal sulcus; 
POF, parieto-occipital fissure; IPF, intraparietal sulcus. The pte- 
rion is the region where three sutures meet; those bounding the 
great wing of the sphenoid where it joins the frontal, parietal, and 
temporal bones. 


hour to an hour before the operation, both because a 
smaller quantity of anzesthetic will be required, and also 
because it produces contraction of the arterioles, and 
consequently diminishes hemorrhage. As Nancrede has. 
pointed out, however, the use of opium, at least in cases 
in which a small definite cortical centre is to be removed 
and but little hemorrhage is anticipated, is not advisable. 
Horsley states that it is dangerous to operate upon pa- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





tients under the influence of drugs, and especially the 
bromide of potassium; why, I do not know; but I should 
be inclined to follow so high an authority. 

IV. Marking the Bone.—This can be done in two ways: 
1. The site of the scar or other lesion is easily marked by 
making a small incision down to the bone and then mark- 
ing it by an aniline pencil as done by Weir; or, better, I 
think, as I have proposed, by nicking the bone by a 
gouge. To mark the Rolandic and other fissures of the 
brain, the same method may be employed by means of 





Fic. 1019.—Hopkins’ Rongeur Forceps, as Modified by Weir. 


two or more small nicks. These nicks may also be use- 
ful in other ways. In my first case (tumor), as I was not 
able to replace the button of bone, I utilized the nick to 
fix accurately the location of the tumor. There was a 
sear, the situation of which was exactly determined by 
measurements. A nick on the button of bone was made 
at the site of the scar. After the operation the button of 
bone was fitted to the tumor, and the dimensions of the 
tumor measured from the nick. These measurements 
were afterward transferred to another skull, upon which 
the site of the scar was accurately fixed, and upon which, 
- also, the fissures of the brain had been marked. I was 
thus able to locate, with great accuracy, the position of 
the tumor. 2. Another method of marking the fissures 
(especially the Rolandic) is by drawing them on the scalp 
with an aniline pencil, and prolonging the lines above 
and below the limits of the intended flap. When the 
flap is raised all the other external landmarks are prac- 
tically lost; but a nick in the bone, or an imaginary line 
adjoining the aniline lines of the Rolandic fissure beyond 
the limits of the flap, will give us this important land- 
mark. 

V. Access to the Brain.—Instead of the old crucial in- 
cision Horsley has recommended a large horseshoe- 
shaped flap, which will usually be about three inches or 
more in diameter. This incision must be carried verti- 
cally down to the skull, and must be so made, first, as 
to favor drainage in the supine position; secondly, its 
base should be so placed as to retain the most favorable 
blood supply to the flap. Horsley has recommended 
that the periosteum be not raised with the flap, but re- 
flected by a later crucial incision. I have, however, al- 
ways reflected the periosteum with the flap, and have 
found no ill results. It is a cardinal principle in the new 
cerebral surgery that both the flap in the scalp and the 
opening in the bone shall be ample. The mode of deal- 
ing with the bone will be mentioned later; but let it once 
for all be stated thata large opening in the bone has been 






































Fig. 1020.—Pyle’s Chisel, as Modified by Keen. 


amply proved to be no more dangerous than a small one, 
and an immense advantage can be gained in locating the 
fissures and the convolutions (and therefore the lesions), 
and, so to speak, in the amount of “elbow-room” for 
operative procedure. This is of the greatest possible 
service. Jonnesco and Doyen have gone so far as to re- 
flect nearly the whole side of the skull (hemicraniotomy). 
As a rule this is a needlessly large opening and certainly 
increases the danger. 








Brain, 
Brain, 





Different methods may be adopted for making the 
opening in the bone. A large trephine, one and one- 
half, two, or even two and one-half inches in diameter, 
may be used. If the smallest of these sizes be used, it 
may necessitate the removal of two adjacent buttons, 
and even then the opening may have to be enlarged in 
any given direction for access to the lesion. This is best 
done by the ordinary rongeur forceps, or by Hopkins’ 
modification of them. These forceps have been further 
modified (and I think with advantage) by Weir, by mak- 
ing the bend at right angles to the 
handles of the forceps instead of in 
their plane (Fig. 1019). 

Another method is one that Mr. 
Horsley has used, and which has the 
advantage of abridging the time re- 
quired for the operation. He makes 
a one-inch opening with a trephine, 
and by this determines the thickness 
of the skull. He then outlines the 
piece of bone to be removed, by Bon- 
will’s surgical engine, cutting almost 
through the bone. Complete division 
of the bone is then effected by stout bone forceps. 
Devilbiss’ forceps are also very useful. 

The German surgeons frequently use the chisel and 
hammer. In most of my recent operations I have used 
this method and have found no evil consequences from 
their use. Pyle chisels, as modified by myself, I have 
found the most useful (Fig. 1020). The thick handles 
add greatly to the convenience of their use. 

Oteoplastic Resection.—In 1889 Wagner, following an 
earlier suggestion of Wolff, proposed to make a tempo- 
rary osteoplastic resection by 
chiselling loose the piece of 
bone to be removed, except 
at one portion where it was 
fractured and turned back 
using the scalp as a hinge. 
The scalp is incised down to 
the bone, the flap not being 
loosened from the bone. By 
mallet and chisel the bone is 
then nearly cut through at 
every point, the separation 
being completed by an osteo- 
tome, excepting at its base. 
It is then lifted by means of 
elevators, the base being frac- 
tured, a window, so to speak, 
being opened by turning back 
the flap (Fig. 1021). By this 
means access can be had toa 
very large area of the brain 
cortex; one of even three, 
four, or five inches has been 
thus exposed. When the operation is terminated the 
opening is closed by replacing the flap, which is sutured in 
place as usual. In chiselling such a piece loose, it is best 
to chisel it obliquely, so that the opening in the inner table 
will be a little smaller than that in the outer, the inner 
table thus forming a shelf on which the flap rests. The 
base of the flap which serves as a hinge should always 
be in that part of the flap having the largest blood supply. 

The surgical engine with a special drill, an electrical 
motor with a saw, and the Gigli wire saw have been also 
used in place of the chisel. 

“Trephining,” in the remainder of this paper, will be 
used in the sense of opening the skull to obtain access to 
its interior, irrespective of whether the opening is made 
by the trephine, the chisel, or any other means. 

Of course, in trephining for abscess only a three-fourth- 
inch trephine would be necessary, and the opening can 
be enlarged, if necessary, by the rongeur forceps. For 
tapping the ventricles a half-inch opening isample. Von 
Bergmann has declared himself opposed to operative in- 
terference with a cerebral tumor which would require a 
large opening in the bone, on account of the probable 





Fig. 1021. 


407 


Brain, 
Brain, 


consequent cedema. The best answer to this is that suc- 
cess has practically followed operations in which large 
openings have been made and no cedema has followed. 
Horsley has thus successfully removed a tumor of four 
and a half ounces, and I have done the same in a case of 
a tumor weighing over three. Bramann has successfully 
removed a tumor weighing nine ounces, the largest on 
record (Centrailbl. f. Chir., 1892, Beilage, p. 66). Indeed, 
in some cases pre-existing cedema has been relieved. 

It is quite surprising how far beyond the limit of the 
opening in the bone and dura we can feel and see. The 
brain allows gentle pressure very readily. A finger can 
be inserted for nearly an inch all 
round the opening, and the eye 
can reach as far if the brain be 
gently depressed by any flat in- 
strument. 

Before enlarging the opening 
the dura mater must be sepa- 
rated from the bone. This can 
be done with a bent probe, but 
the best instrument is one de- 
vised by Horsley (Fig. 1002). By 
it also the under surface of the 
surrounding bone can be exam- 
ined for any inequalities, etc. 

The dura, as a rule, should be 
opened. Unless this is done im- 
portant information may be lost, 
and the case be improperly treat- 
ed. Occasionally it may be al- 
lowed to remain intact, when, 
for instance, a sufficient lesion 
has been discovered. But it is 
a rule, with rare exceptions, that, if we tre 
phine at all, the brain itself should be ex- 
amined. The opening in the dura should 
not be by a crucial incision (except in case 
of a small opening for abscess of the brain 
or draining the ventricles), but by a horse- 
shoe-shaped incision at about a quarter of 
an inch away from the margin of the bony 
opening. The dura should first be lifted by 
a tenaculum and slightly opened by a scal- 
pel, and the incision then be completed by a 
pair of blunt-pointed curved scissors. The 
dura should be carefully lifted by forceps 
so as not to wound the veins beneath, and 
the same caution applies to the scissors. 
Should it be necessary to cut across the 
trunk or any branches of the meningeal ar- 
teries, they should be secured by ligatures 
passed through the dura mater by a small 
curved Hagedorn needle, and tied before 
the vessel is cut across, the dura being well 
lifted meantime, lest the needle wound the 
large veins in the brain. When the opera- 
tion is terminated, if the dura has not been 
removed, it should be replaced and secured 
by catgut. 

VI. Hemorrhage.—Hemorrhage from the 
scalp will be very free. To a large extent 
it can be prevented in many cases by the use 
of the narrow band furnished with Es- 
march’s bandage, as has been suggested by Dr. M. Allen 
Starr. Hemostatic forceps, however, can with safety 
grasp the entire thickness of the scalp and quickly con- 
trol any large vessels. Such as need it, of course, should 
be ligated at the end of the operation. The control of hem- 
orrhage from the vessels of the brain itself, is one of the 
most difficult of all the operative questions. [ have already 
alluded to the use of morphine. I have also used a solu- 
tion of cocaine applied directly to the brain. I have also 
suggested the use of antipyrin, which has been employed 
by Park with advantage. Such solutions, together with 
the corks and the bottles, should be sterilized. These 
applications have certainly proved advantageous in 
checking hemorrhage from the smaller vessels, nor could 



















































NOS 8 SIYNA9 


Fig. 1022.— 
Horsley’s In- 
strument, to 
Separate the 
Dura from 
the Skull. 


408 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


I see any harm resulting from them when I have used 
them. The cocaine should be a ten-per-cent. solution. 
Another means is boiling water cooled to 115° or 120° F. 
This I have used very lfberally and have found no dis- 
advantage from the comparatively high temperature. 
Pressure is another means which can be constantly and 
successfully applied by sponges, or by iodoform or other 
gauze. 

But, after all, the chief reliance is to be placed on liga- 
tures of catgut. They should not be chromicized, but are 
best prepared after the Jefferson method * by bichloride of 
palladium. The method of applying them is very im- 
portant. While the larger arteries in the brain can be 
ligated in the usual way, the veins, which are very large, 
very full, and very fragile, are a much more troublesome 
source of hemorrhage, and require much more delicate 
manipulation. The greatest gentleness must be used 
during traction; and in tying, the traction on the two 
ends of the ligature must be exactly even or the vessel 
will be torn. In addition, the knot must be drawn only 
tightly enough to stop the hemorrhage, for if drawn too 
tightly it will easily cut through the fragile vessel. Weir 
has suggested in some cases the application of clamps to 
the vessels for twenty-four hours; very exceptionally they 
may be used, especially to the dura. Of course they must: 
be included in the dressing. 

It is occasionally necessary to trephine very near, or 
even over, one of the great sinuses of the brain, and in 
doing so it might easily be wounded. The sinus, how- 
ever, may be avoided if due care be used. The trephine 
should be applied far enough from the sinus to be ina 
region of absolute safety. The opening can be enlarged 
later toward, or even over, the sinus with safety. Ina 
recent case [recognized when I was near the lateral sinus 
by feeling the bony groove in which it is lodged by my 
finger introduced through the trephine opening. Icould 
then separate the duraand sinus from the bone and could 
have trephined safely over the sinus, had it been neces- 
sary. In addition to this we may have to deal witha 
primary wound of a sinus itself. If the opening in the 
sinus is small, lateral suture of the sinus may be practised. 
If large and it cannot be closed by sutures, clamps may 
be used with advantage. 

Pressure by a tampon of iodoform or other gauze has 
controlled it in a number of instances. In some cases the 
sinus has been tied by two ligatures, one in front and 
one behind, thus cutting off all possible hemorrhage, and 
the sinus excised as by von Bergmann and Kiister. Barr 
has even suggested that in cases of thrombosis of the 
lateral sinus we may purposely open it after ligation, 
clean out the clot and remove this portion of the sinus. 
Care should be taken that no air enters the sinus lest. 
sudden death should follow, as in Volkmann’s case. In 
the same volume aseries of nine experiments are reported 
on dogs by Genzmer, in which there was aspiration of 
air in six. (See also Senn’s experiments. ) 

VII. Treatment of the Brain.—The first practical point 
to notice, after the dura is opened and hemorrhage con- 
trolled, is whether the brain bulges into the trephine 
opening. If it does so, it indicates a pathological in- 
crease of the intracrania] pressure, a fact of the highest. 
importance, since it will indicate either a tumor, abscess, 
blood clot, or dropsy of the ventricles. Bulging of the 
dura before opening it is, of course, equally significant. 

Next, the color of the brain should be observed. A 
yellow tinge or lividity will probably indicate a tumor 
beneath the cortex. If the brain tissue be the seat of an 
old laceration its color will be altered, usually to a dirty 
yellowish brown. Next, the condition of the vessels and 
of the perivascular lymphatics must be observed, and par- 
ticular notice should be taken whether there are yellow- 
white patches on them that may indicate any old mis- 
chief. Sometimes the membranes and convolutions will 
be densely matted into a yellowish cicatrix. In anum. 
ber of cases I have seen wdema of the membranes sometimes. 





* Annals of Surgery, January, 1898; Journal of Nervous and Men- 
tal Disease, 1894, xxi., p. 486. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


so great as to obscure the sulci and convolutions to a 
marked extent. Precisely what is its significance, how 
far it is normal and how far pathological, I do not yet 
know. Nicking or snipping the membrane allows the 
serum to escape, and the sulci and convolutions to be 
recognized. 

Next, the density of the brain must be appreciated by 
the touch. If there be an abscess or dropsy of the ven- 
tricles the elastic tension will be increased, but, at least 
in dropsy, it will be very soft. If there be a large tumor 
the brain substance will be more resistant and dense 
than normal except in the case of soft sarcomata, etc. 
But it must be remembered that a small cerebral tumor 
at any distance beneath the cortex can scarcely be 
detected by this means. Should any hardness be de- 
tected, the brain substance must be incised and careful 
search instituted by the finger for the tumor or other 
pathological condition. If the finger be used it should 
be the little finger by preference, and great gentleness 
should be employed, or serious laceration of the brain 
substance will be produced. If abscess or dropsy be 
suspected the brain may be explored by a needle, knife, 
or grooved director. (For their comparative value, see 
page 414.) Wright, after trephining over the occipital 
lobe, even thrust a trocar through the tentorium down 
into the cerebellum and evacuated an abscess—a procedure 
Ishould not employ ; trephining over the cerebellum itself 
would have been safer and better. 

Next, the presence or absence of pulsation in the brain 
is to be noted. Ifa large tumor, abscess, or cyst exist it 
will be absent, but if a small tumor, cyst, or abscess be 
separated from the surface by any considerable layer of 
normal brain tissue, pulsation may be present. Altered 
brain tissue from old lacerations, etc., will generally 
pulsate. 

In incising the brain, the knife should be carried down 
vertically into the corona radiata in such a manner as to 
avoid damage to the fibres coming from adjacent portions 
of the cortex, and the incision should run as nearly as 
possible parallel with the cerebral vessels which are “ ter- 
minal.” 

Should the brain tissue be abnormal, the whole ab- 
normal portion must be removed. It is important in 
doing this to remember that, while we should guard 
against producing any needless paralysis by removing 
healthy brain tissue, yet it is of prime importance that 
all of the diseased portion should be removed. If there 
be a cortical tumor (unless it is encapsulated or otherwise 
definitely limited), the necessity of removing a portion 
of adjacent and apparently healthy brain tissue, so as to 
get beyond the limits of infiltration, is of the greatest 
importance. If the tumor be subcortical, it can be 
sought for by the finger with great gentleness, and be 
removed either by a sharp spoon or other similar means, 
together with a suitable adjacent zone of healthy brain 
tissue. In all this removal of tissue adjacent to the 
tumor we can cut much more freely antero-posteriorly 
than vertically upward or downward. In the vertical 
direction we encroach far more quickly upon adjacent 
additional centres than we do in the antero-posterior 
direction. 

VIIL. Recognition of the Brain Centre Sought for.—In 


certain cases of Jacksonian epilepsy the object sought. 


for is the removal of the centre whence the discharging 
lesion starts. In this case it will be necessary to recog- 
nize such centres by definite methods. In some cases the 
membranes and the convolutions are so matted together, 
and the brain substance so altered, that it will be im- 
possible to recognize the sulci and the convolutions. 
But in these cases it is scarcely necessary to do so, inas- 
much as all the damaged tissue should be removed, and, 
as before stated, we must even encroach to some degree 
upon apparently healthy brain tissue. In other cases, 
however, it is important and also possible to recognize 
the individual sulci and the convolutions, and to deter- 
mine the precise part of the brain that is the seat of the 
discharging lesion, and therefore to be removed. The 
prolonged aniline lines on the undisturbed portion of the 


+ 


Brain, 
Brain, 








scalp, indicating the position of the fissure of Rolando, 
or the reapplication of the cyrtometer will here assist us 
very materially. 

The determination of the brain centre by electricity has 
now been done in many cases most satisfactorily and with- 
out damage to the brain. The earliest four cases were 
those of Horsley, Keen, Deaver and Lloyd, and Nancrede. 
This is best accomplished by means of an ordinary faradic 






Fia. 1023.—The Author’s Cerebral Electrode. 


battery. In order more handily to use this means of 
diagnosis, I have had made a little rubber handle with 
two insulated points, the stems of which, being flexible, 
can be bent toward each other or separated as far as de- 
sired (Fig. 1028). 

A very important point in this relation is stated by 
Horsley as the result of his experiments on animals. The 
cortex of the brain soon loses its excitability for electrical 
stimuli when bathed with antiseptic solutions. In any 
such case, therefore, it is desirable that the search for 
such cortical centres, by means of electrical stimuli, 
should be done immediately after the opening of the dura, 
and before any antiseptics have been applied. Usually 
none are now used. When once recognized, I have sug- 
gested, in order to prevent the need for repeated and 
possibly injurious applications of electricity, that the de- 
sired centre be marked by an aniline pencil or a nick. If 
the centre is to be removed the latter would do no harm. 

IX. Drainage.—Drainage of the brain should be con- 
ducted on precisely the same principle as drainage for 
other parts of the body. Usually it may be entirely dis- 
pensed with. If itisused, however, it must be dispensed 
with as soon as possible.. Generally I employ a gauze 
wick and remove it at the end of twenty-four hours. If 
not employed there is usually a considerable bulging of 
the flap during the first few days after the operation. 
This bulging, if it does not become too great, is not to 
be interfered with. If, however, it is more than a moder- 
ate bulging showing a considerable collection of wound 
fluids, a stitch may be cut and the flap gently and slightly 
opened. This will give egress to the retained fluids and 
the opening may be kept patent for twenty-four hours 
by a very small bit of gauze inserted for about half an 
inch. Primary union will follow the removal of this 
gauze, 

In cases of abscess, gunshot wounds, hemorrhage, etc., 
or in cases in which there is danger of infection, the drain- 
age must be more prolonged, and is best accomplished 
by rubber tubing. For the method of drainage in these 
conditions the reader is referred to other portions of this 
paper under the headings mentioned. 

X. Replacement of the Bone.—Mr. Macewen first showed 
the possibility of replacing the bone by mincing it up 
into small pieces and spreading it over the surface of the 
reunited dura. Clark, of Glasgow, was the first, I be- 
lieve, to replace the entire trephine button with success. 
In the case of replacement the utmost care, however, 
must be given to the button from the.moment it is re- 
moved to the time of itsreplacement. The instant that it 
is removed it should be placed in a cup containing a warm 
solution of bichloride (1 to 2,000), or warm salt solution, 
0.7 per cent. This cup should be placed in a large basin 
in which lies a thermometer, and hot water should be 
poured into the outer basin from time to time to keep the 
temperature always between 105° and 100° F. It should 
be the duty of one assistant to attend to nothing else but 
to the water in this basin. All small fragments are also 
placed in this cup, and when the dura has been sutured 
the large discs of bone may be replaced, together with a 
suitable number of the small fragments bitten away by 
the rongeur forceps. If there be more than one large 
button, the triangular spur or spurs between the trephine 
holes should not be removed unless it is absolutely neces- 


409 


Brain, 
Brain, 








sary in order to get more room, as they assist materially 
in keeping the buttons in their proper places. Should the 
membrane be removed, the bone cannot be thus replaced. 
In one case I successfully adopted the following expedi- 
ent: I bored the centre-pin hole completely through the 
bone, and at the margin of the disc made another hole, 
also by the centre pin of the trephine. The two ends of 





Cag PEN Fey 
3 ips 


Fig. 1024.—Replaced Button of Bone. Inner surface. 


a chromic catgut ligature were passed through these 
openings, and by needles these two ends were passed 
through the scalp and tied on the outside. The union to 
the scalp was complete, and the aperture in the skull 
was almost entirely closed by the callus. If the opening, 
after removing the disc of bone, has been enlarged by 
the rongeur forceps, the small fragments may be scat-- 
tered closely wether over the dura. 

XI. Substitute for the Dura.—tIn three cases in which 
the dura was necessarily removed, I have made an effi- 
cient new dura by stripping off a large piece of the peri- 
cranium, trimming it to fit the opening and then fixing 
it in place (with the osteogenetic surface outward) by a 
few sutures. Bone chips may then be sprinkled over the 
surface freely... These have united and formed a firm 
skull. Figs. 1024 and 1025, in the so far unique case of 
Burrell, show how complete the union may be after re- 
placement of a trephine button. In case the bone is not 
replaced it will be well for the patient to wear a skull cap 
into which is sewed a metal plate somewhat larger than 
the opening, as a protection against blows and falls. If 
a drain tube has to be placed under the bone, a piece 
should be bitten out of its edge by the rongeur forceps to 
allow for the passage of the tube. 

XII. Closure and Later Treatment of the Wound.— 
Hemorrhage having been checked, the dura sutured as de- 
scribed on page 408, and the bone replaced with provision 
for drainage if deemed useful, the scalp should now be 
replaced and secured with sutures. An abundant dress- 
ing is to be applied and retained in place by suitable 
bandages. The dressing will most probably be saturated 
with blood and serum at the end of a few hours. If so, 
the wound should be redressed. At the end of twenty- 
four hours the wound should always be redressed, when, 
as already directed, the drainage is to be removed, or 
slight drainage provided by a bit of gauze if the wound 
fluids necessitate the slight opening of the scalp wound. 
The next dressing should not be done until the wound 
fluids have saturated the dressing tu its margin. By the 
fifth day, it is my rule then to redress the wound for the 
purpose of removing any stitches that may be no longer 
needed. In operations on the brain in which the bulg- 
ing above referred to has produced some tension on the 
stitches, it is best not to remove them too early; but usu- 
ally all of them may be taken out by the seventh or 
eighth day,.and some of them by the fifth. If by the 


fifth day primary union has been secured, a mere protec- * 


tive dressing may be applied. In a few days this may 
be dispensed with, but the patient, on account of his 
shaven head, should wear a skull cap, or some other 
means of protection against taking cold. 

XIII. After-Treatment.—If the case be not one with 
active inflammation, and if union by first intention has 
been secured, the patient should be well within a week 


410 NN 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


or ten days, without an elevation of temperature much 
above 100° F., and possibly not even up to that point. 
The bowelsand the diet should receive the ordinary care. 

One thing is of the greatest moment after such opera- . 
tions: no excitement, study, business, household cares, 
or mental worry should be permitted for several weeks, 
or, better, for several months, after the operation. 

XIV. Secondary Operations.—A number of these have 
been done. Mr. Horsley has referred to some in his 
paper. Nancrede has reported one, and Stokes another 
by Franks, and I have done several. The membranes 
will commonly be found to be quite adherent to each 
other and to the brain tissue, and if it be necessary to 
dissect them off the latter, it is almost inevitable that 
some portion of the outer layer of the cortex will be re- 
moved along with them, producing paresis in the centres 
thus encroached upon; hence it should be done with the 
greatest. gentleness and care. After removal of a motor 
centre there is, of course, entire paralysis of the part sup- 
plied by this centre; and the pressure caused by the 
blood clot which accumulates and the later cell prolifera- 
tion is apt to cause widespread paralysis, amounting even 
to a hemiplegia. After some weeks this invariably dis- 
appears to a greater or lesser extent, leaving, however, 
the affected muscles, it may be, somewhat paretic. The 
cicatricial tissue between the brain and the bone very 
likely will be quite vascular, and, possibly, traversed by 
large veins. Should the dura not have been opened at 
the first operation, it will still be adherent to the brain 
itself, and probably covered by a layer of granulation and 
cicatricial tissue, which must be dealt with according to 
the needs of each case. 

“XV. The Limits of Operative Interference with the 
Brain.—Over twenty years ago I perforated the squa- 
mous bone and passed a probe between the dura and along 
the petrous bone to a depth of two inches, in a search 
for an abscess. I found no pus, but the search did 
neither good nor harm. Weir has proposed, in a case of 
aural disease with subsequent cerebral mischief, in a 
similar manner to lift the dura to a point corresponding 
to the roof of the tympanum; and if need be, in sup- 
purative meningitis of the middle fossa, to open the dura 
and drain the fossa. He has well likened the petrous 
bone to the appendix vermiformis, as a focus of inflam- 
mation followed by suppurative processes in the dura or - 
arachnoid, either local or general. It is followed, there- 
fore, by external pachymeningitis and extra-dural abscess, 
internal suppurative meningitis, or cerebral or cerebellar 





Fig. 1025.—Outer Surface of the Same Button. 


abscess, all of which he suggests may be similarly re- 
lieved by operation. The same excellent surgeon has 
shown (and I have verified the procedures partly on the 
living subject and partly on the cadaver) that the cerebel- 
lum can be lifted sufficiently to obtain a view as far as to 
the foramen magnum; the same foramen can be reached 
by the finger on the inside, and from the outside by both 
the eye and the finger; the longitudinal and lateral sinuses 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





can be safely uncovered and separated from the skull; 
and the frontal lobe can be lifted far enough to expose 
the anterior clinoid processes. 

Horsley has reached an exostosis of the orbit almost 
at the optic foramen, and has stated that the tumor of 
the auditory nerve, reported to the Neurological Society 
of London by Dr. Sharkey, could have been removed by 
incision of the tentorium and ligature of the lateral sinus. 

Other cases, referred to in this paper and elsewhere, 
show that the sinuses may be tied and exsected; a very 
large part of the surface of the skull, up to even the 
size of the palm, or even more, may be taken out; large 
tumors, up to over nine ounces, may be successfully re- 
moved, and considerable areas of brain tissue may be cut 
away with safety and advantage. 

A large portion of the base of the brain can be ex- 
plored by the finger, the eye, and the probe or director, 
and the substance of the brain can be punctured almost 
with impunity, repeatedly and to a depth of two inches 
and more, without leaving any injurious trace behind. 

I have shown also that the lateral ventricles can be 
safely reached. In many cases, especially since my pa- 
per was published, the ventricles have been tapped with 
success. Even a wound involving them is not neces- 
sarily fatal. 

MENINGOCELE, ENCEPHALOCELE, AND HYDRENCEPHA- 
LOCELE.—For the more detailed account of symptoms 
and physical signs of these diseases, see the article enti- 
tled Brain: Cephalocele in the present volume. In this 
article I shall consider them only briefly and from the 
surgical point of view. 

Meningocele, encephalocele, and hydrencephalocele are 
allied malformations of the brain which are fortunately 
not common. 

1. MENINGOCELE consists in the protrusion of the 
membranes of the brain through an aperture in the 
bones of the skull, the sac formed by the membranes 
being distended to a greater or lesser extent by fluid 
which is extra-cerebral. 

2. ENCEPHALOCELE consists in the protrusion of a 
portion of the brain itself, as well as of the membranes, 
usually with a smaller amount of fluid within them, the 
fluid again being external to the brain substance. 

3. HyDRENCEPHALOCELE consists in the protrusion of 
the brain substance itself as well as of the membranes, 
but in this case the interior of the mass communicates 
directly with the ventricles, and is often filled with a 
large amount of the ventricular fluid, so large in some 
cases that the layer of brain substance enclosing the 
fluid is reduced to a very thin film. 

All three forms of the disease arise in intra-uterine 
life, and are therefore congenital. The most frequent is 
unfortunately the gravest form—viz., hydrencephalocele 
—and the least frequent is meningocele. As a rule, 
they are apt to be fatal early in life. Their commonest 
situation is, first, in the median line, especially in the 
occipital region; next, in the fronto-nasal region, and 
lastly, at the sides of the skull or about the base. Of 93 
cases collected by Houel, 68 were occipital, 16 fronto- 
nasal, and 9 at the sides and base. 

Diagnosis.—They have been mistaken for abscesses, 
nevi, sebaceous cysts, etc. The following points of 


‘diagnosis will generally enable the surgeon to reach a __ 


proper conclusion: 

All of them are congenital, commonly median, and 
especially occipital in position. Meningocele is usually 
cystic in its feel, is translucent, fluctuates, rarely pul- 
sates, is more or less pedunculated, generally becomes 
tense in forced expiration and is easily reducible. En- 
cephalocele is usually small, is opaque, does not fluctu- 
ate, pulsates distinctly, has a wide base, becomes more 
tense in forced expiration, and symptoms of pressure 
are produced on attempting to reduce it. Hydrenceph- 
alocele is generally large, is lobulated, is partially trans- 
lucent, fluctuates distinctly, pulsates but rarely, is usu- 
ally pedunculated, is made only slightly more tense in 
forced expiration, and is not reducible. 

_ All three forms are apt to be combined with other de- 


Brain, 
Brain, 





formities, and paralysis often accompanies hydrenceph- 
alocele. 

Treatment.—As a rule, hydrencephalocele is not amen- 
able to treatment. The child fortunately dies early. 
The other two forms hold out more hope, especially if 
they are small. Sometimes an encephalocele by retro- 
grade development may be changed into a meningocele, 
and occasionally by gradual concentric ossification, re- 
sembling that of the fontanelles, the bony aperture is 
lessened and may even close. The intracranial com- 
munication with the interior of the sac may be narrowed 
and finally obliterated, thus partially or completely 
effecting a spontaneous cure. Until the late improve- 
ments in cerebral surgery, nothing was usually recom- 
mended in the way of treatment, certainly not unless 
there was danger of rupture. A number of successful 
cases of excision, however, have been recently reported, 
and, unless the size of the tumor or the condition of the 
patient forbid, this should be attempted, of course with 
all the antiseptic care bestowed on other brain operations. 
Enough scalp should be preserved to make sufficient 
flaps to close the opening. If operation be felt inadvis- 
able, electrolysis may be used as a substitute. Pressure 
and the injection of Morton’s fluid (iodine, gr. x.; potas- 
sium iodide, gr. xxx.; glycerin, 3i.) may be tried, but 
with little prospect of benefit. 

INTRACRANIAL ABSCESS. —Oauses.—Nearly one-half of 
the cases of abscess of the brain arise from a suppurative 
processin the ear. Occasionally they arise from an acute 
inflammation of the ear; but much more frequently they 
are a sequel of chronic ear disease. Occasionally they will 
follow even a few weeks after suppuration, but they 
are far more commonly a sequel years after scarlet fever, 
or some other exanthem, has set up a discharge from the 
ear. The situation of such abscesses is most frequently 
in the temporo-sphenoidal lobe. 

Barr, in 76 cases of cerebral abscess following disease 
of the ear, found 55 in the temporo-sphenoidal lobe, 13 
in the cerebellum, 4in both the cerebrum and cerebellum, 
2 in the pons, and 1 in the peduncle. When situated in 
the temporo-sphenoidal lobe they are not necessarily 
directly in contact with the petrous bone, but may be 
separated from it by even an inch of apparently healthy 
brain tissue. They reach the cerebellum usually by the 
track of the lateral sinus, in which very often thrombosis 
occurs. The mastoid cells are very frequently, but not 
always, involved. The discharge is almost always fetid. 

The next most frequent cause is injury. Frequently 
this injury has not been very severe, but even a small 
scalp wound, if it becomes septic, may involve the bone, 
the veins, or the lymphatics, and then the encephalon. 
Moreover, if recovery apparently takes place, the patient 
is by no means safe, as a number of instances are on 
record in which several weeks or months, and in some in- 
stances even a number of years, have elapsed between 
the infliction of the injury and the development of the 
abscess. A most remarkable case of late development 
of abscess, and of its correct localization, is given by Mr. 
Damer Harrisson in the British Medical Journal, April 21, 
1888. A boy, aged fifteen, had received a severe blow 
on the /eft side of the head when fowr or five years of age. 
No severe symptoms followed the wound, but nine or 
ten years later, for about a year before his admission, 
twitching and flexion of the wrist, biceps, and deltoid 
had been observed. Eight days before his admission he 
had received a blow on the right side of the head from 
a pair of tongs. Three days after this accident a con- 
vulsion on the right side of the body suddenly set in, 
beginning in the arm, then spreading to the face and leg, 
and followed by paralysis of the right side of the body. 
Repeated convulsions followed his admission. Mr. Har- 
risson trephined the boy, not at the site of, the last, but 
at the cicatrix of the first, injury, and eventually evacu- 
ated four drachms of fetid pus, and the boy made an 
uninterrupted recovery. Macewen (loc. cit.) reports a 
remarkable case in which an acute abscess developed later 
in the periphery of an old encysted abscess. After 
evacuating several ounces of pus, the old abscess ap- 


411 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





peared “like a tennis-ball floating in a sea of pus.” 
Wagner (loc. cit.) gives two cases of abscess, arising 
seven and nine years respectively after falls, without 
any external wound; and Souques reports one of abscess 
arising eleven years after a fracture of the skull. 

If the injury is followed by meningitis, this will usu- 
ally develop within three or four days; but should it re- 
sult in abscess rather than in meningitis, it will not usu- 
ally form earlier than at the end of the first week. The 
situation of an abscess after a blow or fall is almost 
invariably under the site of the injury, but, as is shown 
by Macewen’s earliest case, Harrisson’s, and others, the 
location of the abscess must be fixed by considering not 
only the site of the injury, but the focal symptoms as 
shown by cerebral localization—e.g., in Macewen’s case 
the abscess was in Broca’s lobe, but the cicatrix was on 
the forehead. 

Still another occasional cause is localized meningitis. 
Of this, perhaps the most instructive case yet recorded 
is that found in the very able paper of Mr. A. E. Barker, 
in which the pus, accumulating undoubtedly between 
the island of Reil and the operculum, produced upward 
pressure on the motor centres for the face and arm. 
Complete recovery followed the operation. 

Metastatic abscess occurs not infrequently in the brain 
as a result of various conditions, even in distant organs, 
such as gangrene of the lung, fetid bronchitis, and bron- 
chiectasis. Tuberculous abscesses also are sometimes 
seen, but in both these cases the abscesses are usually 
multiple, and hold out but little hope for any successful 
surgical treatment. Wernicke and Hahn and Frinkel 
have reported two cases of tuberculous abscess which 
were single. 

Symptoms.—The symptoms of cerebral abscess may be 
arranged in three categories: 1, those due to the sup- 
purative process itself; 2, symptoms arising from gen- 
eral pressure; 8, focal symptoms. 

1. Among the symptoms arising from the suppurative 
process itself, usually the most important is fever, and 
it is especially noteworthy that in intracranial abscess 
the temperature is either normal or subnormal most of 
the time, even when the gravest general symptoms exist. 
The temperature, however, does sometimes rise, espe- 
cially toward the end, and is often attended by delirium, 
but will generally subside quickly, only to rise again af- 
ter an interval if the patient survive long enough. Von 
Bergmann and others state, however, that the local cra- 
nial temperature in abscess willrise. If, therefore, symp- 
toms of serious intracranial pressure exist, if the general 
temperature is normal or subnormal, while the local tem- 
perature shows a rise and the pulse is slow, the first 
thought of the surgeon should be to seek for evidence of 
abscess of the brain. A chill not uncommonly occurs, 
but may be absent. Of course there will be loss of appe- 
tite, vomiting, general malaise, etc. Somerville has stated 
that when pus is present in the brain, the chlorides in the 
urine will be below the norm and the phosphates above; 
but I know of no confirmatory examinations of this im- 
portant assertion. 

2. Among the pressure symptoms, headache holds an 
important place. It is almost invariably present, and 
not uncommonly of an extreme and severe type, so that 
the patient will constantly moan; and if he be suffi- 
ciently intelligent, this will be the one thing of which 
he will complain. It is apt to become worse, and when 
the temperature occasionally rises it is often located 
distinctly at the focus of the lesion, but sometimes is 
general. It does not, therefore, always serve as a guide 
to the situation of the abscess. The pulse is almost al- 
ways slow, and may even fall to thirty or forty in the 
minute. Respiration is often of the Cheyne-Stokes type. 
The mental condition is very soon impaired, and gradu- 
ally, as the pressure increases, becomes worse and worse 
until the patient may become comatose. Not seldom the 
bowels and bladder will be evacuated involuntarily. 
Convulsions of an epileptic type often occur, but not 
usually when the abscess is situated in the temporo- 
sphenoidal lobe. Sometimes: convulsions will be the 


412 





very first acute symptom. Muscular twitchings may 
occur, and if so, their occurrence will often point to the 
cortical centre involved. Sensation is not usually much 
impaired. 

The presence or absence of choked disc does not seem 
to be pathognomonic, as it is sometimes present and 
sometimes absent. When present, even if bilateral, it is 
almost always more marked on the side of the lesion, 
though this is sometimes reversed. Not uncommonly 
there will be ptosis, and sometimes paralysis of the entire 
third nerve, while the sixth may escape; though some- 
times the reverse is the case. The pupil of the same 
side is generally dilated, and more or less immobile. 
Almost all the symptoms of pressure vary from time to 
time, and the patient’s general condition fluctuates in a 
remarkable degree, sometimes simulating recovery, soon 
to relapse again into a worse state than before. Theo- 
retically, there should probably be deafness of the op- 
posite ear if the first or second temporal convolution is 
involved; but this symptom is very uncertain. 

When the abscess is situated in the cerebellum, the 
diagnosis is apt to be very obscure. Occipital headache 
and rigidity of the neck muscles often exist. Inco-ordi- 
nation of movement, and especially an unsteady, drunken 
gait, indicates pressure upon the middle lobe. Vomit- 
ing and vertigo are frequent and persistent. If these 
symptoms exist with tenderness on pressure and pain on 
percussion over the cerebellum, they may point definitely 
to the cerebellum. Optic neuritis is not frequent in 
cerebellar abscess. But here, above all other localities, 
the remark of von Bergmann eminently applies: “The 
technique of the evacuation of brain abscess no longer 
deters us from operating. All progress in treatment 
must depend chiefly upon diagnosis.” It is, therefore, 
especially important that all cases of brain abscess should 
be observed and reported with the minutest and most 
exact detail, especially if there is any suspicion of the 
cerebellum being involved, in order that we may learn 
how to make a more exact diagnosis. 

At present the condition of the reflexes is not known 
with sufficient accuracy to be of much value in diagnosis, 
though they are probably increased on the side of the 
lesion. Their study is therefore all the more important, 
not only in abscess, but in all other cranial lesions. 

3. The symptoms by which the locality of an ab- 
scess may be inferred are chiefly those which are so 
admirably described in general by Dr. M. Allen Starr, in 
his article on Brain Diseases : Diagnosis of Local Lesions, 
in the present volume. I need, therefore, only briefly 
recall a few leading facts. The left temporo-sphenoidal 
lobe being adjacent to Broca’s convolution, a very 
common result of abscess in this lobe would be motor 
aphasia. If the abscess is of such size as to-press upon 
the inferior centres of the motor region, paralysis or 
paresis of the opposite side of the face would probably 
be first induced, followed by paralysis of the arm, and 
occasionally even by complete hemiplegia of the opposite 
side. If the ear disease has implicated the seventh nerve 
in its passage from the petrous bone, there will be, of 
course, palsy of the same side of the face. Sometimes 
there will bea distinct squint from paralysis of the sixth 
nerve. Especially are all localizing symptoms valuable 
in those cases, which are not altogether rare, in which 
there is a suppurative discharge from both ears. 

Mr. Barker has suggested that at the operation the 
mastoid foramen, through which passes a small vein to 
the lateral sinus, should be laid bare and an examination 
for pus be made. Should pus be found exuding from this 
foramen, it would certainly be a most valuable sign; 
but thus far I do not know that its examination has 
proved to be of positive value. The foramen (Figs. 1026 
and 1027, 2) lies one and one-fourth inches behind, and 
about one-fourth inch below, the external meatus, at the 
base of the mastoid process. 

Should the abscess exist in the frontal lobe, as is some- 
times the case from nasal disease, but little information 
can be derived from localizing symptoms, this lobe be- 
ing a “latent” region. In the occipital lobe the same is 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


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Brain, 








true, unless the cuneus is involved, when hemianopsia 
on the same side of each retina would certainly follow. 
Should the angular or supramarginal gyrus be involved 
in the lesion, the state of the pupil may possibly give 
valuable information. In the American Journal of the 
Medical Sciences for October, 1888, pp. 349 and 355, Dr. 
Oliver has described a species of monocular Argyll- 
Robertson pupil, which seems to promise to be of value 
in lesions of this region. 

The temperature of the two sides of the head should 
always be carefully taken, and in doing so it should be 
remembered that the left side is normally hotter than the 
right (Gray and Seguin, Arch. of Med., December, 1879). 
Should abnormal variation of the local temperature be 
observed, it would be a valuable indication, but one that 
as yet is not sufficient to localize an abscess with absolute 
certainty. 

Percussion and pressure on the head are also valuable, 
but alone are not to be relied onabsolutely. Taken with 
other symptoms, they may assist materially in the local- 
ization of an abscess. Hulke records an instance of a 
tender spot above the ear in a case of abscess in the cere- 
bellum; and another of a tender spot over the occiput 
with an abscess in the temporo-sphenoidal lobe. Pain 
on percussion, but not spontaneously complained of, in the 
opinion of Ferrier, is of greater value than mere tender- 
ness on pressure. Pressure and percussion are of value, 
in many cases, in diagnosticating cerebellar abscess from 
cerebral. Should the abscess, as occasionally happens, 
be extra-dural, its locality would almost certainly be in- 
dicated by cedema of the overlying scalp. This, there- 
fore, should always be looked for. 

Differential Diagnosis.—First, meningitis : Thisis often 
avery difficult differential diagnosis. In meningitis there 
will usually be delirium, delusions, photophobia, con- 
traction of the pupils, convulsive facial twitchings, high 
general temperature, and marked rigidity of the neck 
muscles, all developing rapidly after an injury or from 
disease of the ear, or in a strumous patient. 

Secondly, mastoid disease, following purulent otitis 
media, sometimes gives rise to serious cerebral disturb- 
ance. Trephining the mastoid—which in nearly all cases 
of cerebral abscess, at least from ear disease, will pre- 
cede the opening of the skull—will, in general, quickly 
differentiate this from intracranial abscess. As a rule, 
the mastoid region will be swollen, cedematous, and 
painful; in other words, will present the usual evidences 
of mastoid disease. For the diagnosis from extra-dural 
abscess arising from mastoid disease, see page 415. 

Thirdly, thrombosis of the lateral sinuses and pyemia 
would most likely involve the internal jugular vein, into 
which, most probably, the thrombus would extend. It 
would be hard, cord-like, and painful, and the veins of 
the face would almost. certainly be turgid and swollen. 
Besides this, very probably, there would be general 
symptoms of pyxmia, such as involvement of the joints, 
lungs, liver, etc. The temperature also would never, as 
in abscess, be near or below the normal, but of the pyzemic 
or “pump-handle” type. There would almost certainly 
be rigors, profuse sweating, and great general prostra- 
tion, without such marked dulling of the intellect as exists 
in abscess. 


Fourthly, twmor. While in most cases the diagnosis 


between abscess and tumor can be pretty clearly made, 


yet, in not a few cases, the diagnosis is difficult and 
sometimes impossible. Usually the development of a 
tumor is very slow, and is attended with distinct focal 
symptoms from the time when its existence is first mani- 
fested. While the development of abscess may be de- 
ferred in its outbreak, yet once started, it usually runs 
a much more rapid course than a tumor. Moreover, 
abscess has usually some evident cause, as either injury, 
aural or nasal disease, etc. 'Tumor sometimes develops 
as aresult of injury, but more commonly without. In 
tumor the optic neuritis is almost always double, and 
usually more intense than in the case of abscess. In 
abscess, also, choked disc is much rarer, and if present, 
it is not rarely unilateral instead of bilateral, and may 





be on the side opposite to the abscess rather than on the 
same side (Ferrier and Horsley’s, Barker and Gowers’ 
cases). 

While tumor sometimes exists in the temporo-sphe- 
noidal lobe or in the cerebellum, yet abscess is far more 
common in these situations. In other parts of the brain 
tumor is far more common thanabscess. If syphilis exist 
as a cause, it is far more likely to give rise to tumor than 
to abscess. The temperature is not apt to rise in either 
case. Rapid and sharp fluctuations in the general con- 
dition of the patient would be more suggestive of abscess 
than of tumor; slow fluctuations are more common in 
tumor. Emaciation without sufficient cause sometimes 
attends abscess. 

Surgical Treatment.—The almost uniform mortality 
that attends abscess of the brain, if not relieved, renders 
any means that holds out a reasonable prospect of relief 
a necessity. Very many such cases of abscess have been 
operated upon successfully by trephining, even so long 
ago as when Dupuytren and others boldly punctured 
the brain. So early as August, 1849, Detmold even 
punctured the ventricle itself and evacuated an abscess, 
and Dr. George R. Morehouse, of Philadelphia, informs 
me that he did the same during the Civil War. All this 
was done with boldness, it is true, but we must also add 
that in the majority of cases it was rather the result of 
happy chance than of scientific precision. 

The operation has entered upon an entirely new career 
since the establishment of the doctrines of cerebral local- 
ization. Abscesses in the brain, in the last few years, 
have been frequently and accurately localized, and suc- 
cessfully operated upon, by a large number of surgeons. 

When abscess from ear disease is suspected, the mas- 
toid should in most cases first be trephined and care- 
fully washed out. Should this operation not give relief, 
then we must proceed further and trephine the skull. 
But before this is done, the ear and the mastoid should 
be most carefully cleansed with a borated solution and 
filled with powdered boric acid, in order to prevent any 
possible infection of the brain. The head should be 
shaved, certainly over a /arge area, or better, entirely, 
and the scalp cleaned and disinfected in accordance with 
the method already described. 

The question as to where the trephining shall be done 
is an important point. As already related, even in case 
of abscesses arising from injury, the scar is not always 
over the point at which the abscess exists. It must be 
located by cerebral localization quite as much as by the 
site of the external lesions. Moreover, tenderness on 
pressure is not always a reliable indication of the site at 
which the trephining should be done, though tenderness 
on percussion is a more reliable sign. 

Tn order to attack an abscess in the temporo-sphenoidal 
lobe two points are advocated. Mr. Caird, who oper- 
ated on Greenfield’s case, applied the centre pin of the 
trephine one inch and a quarter behind the external 
angular process, and nearly one inch above the zygoma. 
This seems to me a very undesirable point, because it 
would generally strike the middle meningeal artery at, 
or just below, the antero-inferior angle of the parietal 
bone, where the artery not infrequently passes through 
a bony canal, and might give rise to hemorrhage which 
at least would be troublesome. 

A’point three-fourths of an inch in front of the meatus 
and an inch and a half above Reid’s “base line” was 
the spot I selected in a case of trephining for supposed 
cerebral abscess, for reasons there given. It is better 
than Mr. Caird’s, I think, as it avoids the artery and 
even its posterior branch, and gives access to the tem- 
poro-sphenoidal lobe at about its middle; but the danger 
of wounding the middle cerebral artery, if the brain is 
incised or punctured, is possibly even a more serious 
objection. In certain other cases in which the symptoms 
seem clearly to point to sucha location, this point might, 
however, be selected with advantage. , 

In the majority of cases, however, I should agree with 
Mr. Barker that the best place for trephining is one 
inch and a quarter behind the external auditory meatus, 


413 


Brain, 
Brain, 





and the same distance above Reid’s “base line” (Figs. 
1026, c, and 1027). This is just above and behind the 
junction of the petrous with the remaining portions of 
the temporal bone. Even in children the distance above 
Reid’s “base line” should be the same, I find, for at a 
lower point the upper border of the petrous bone would 





Fic. 1026.—From a Photograph of a Dissection of the Skull Before Ex- 
posing the Brain. a,a, Reid’s “base line,”’ running from the lower 
border of the orbit through the centre of the auditory meatus ; ¢, the 
exact point at which the pin of the trephine was applied to open the 
cerebral abscess, just behind the squamosal suture; x, the point at 
which the mastoid antrum was opened; 7, the foramen for the mas- 
toid vein; 0, on the point below the inferior curved line at which 
the cerebellum should be explored if abscess arises in it. (Barker.) 


greatly and suddenly thicken the inferior edge of the 
button of bone and might give some trouble in its re- 
moval. A director thrust downward, forward, and in- 
ward in the direction of the opposite ala of the nose 
would pass through the axis of the temporo-sphenoidal 
lobe, and be almost certain to strike an abscess of any 
size. Should it fail to do so, punctures may be made in 
various other allied directions, in order to reach possible 
small abscesses. As pointed out later, this same trephine 
opening can also be utilized for tapping the lateral ven- 
tricles, if necessary. 

In the report of the operation above alluded to, I have 
shown that repeated punctures may be made with a 
grooved director or hypodermic needle without any seri- 
ous damage to the brain substance. I have there stated 
at some length my reasons for preferring the grooved 
director to either the knife or needle for exploration 
alone. A needle sucks up healthy brain tissue, even 
when the suction power does not exceed seven to ten 
minims, and the danger of wounding the vessel is not 
an imaginary one. With the director we feel much more 
safe, and will, therefore, be proportionally bolder and 
more thorough in our explorations. Such boldness and 
thoroughness, combined with safety, will often result in 
success, when timidity from possible danger would re- 
sult in failure. In a recent case I punctured the frontal 
lobe four times with a director, and to the depth of two 
and one-half inches, without any evil symptoms as a 
result. Rivington, in 1881, was, I believe, the first to 
use the director boldly in thismanner. He thrust it two 
inches into the brain. The remarkable paper of Spitzka 
shows how freely we may puncture the brain without 
evil result. In many cases no trace of the puncture 
could be found, and where it existed there was only usu- 
ally a trace of blood. Even the filthiest mud was in- 
jected into animals’ brains, with but little damage asa 
rule. 

For ¢ncision, however, as distinguished from eaplora- 
tion, the knife is certainly to be preferred. As soon, 
therefore, as the abscess cavity is reached the knife 
should be used, and then a pair of hxemostatic forceps 
be introduced, closed, and drawn out expanded to a 
reasonable degree, in order to afford free vent for the 
pus. Should the wall of the abscess cavity be lined with 
granulation tissue, it should be removed by the sharp 


414 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





spoon or otherwise, just as in case of an abscess in other 
parts of the body, care being taken not to encroach on 
any important neighboring centre or vessel. The abscess 
cavity may now be very gently washed out with normal 
salt solution, and a rubber drainage tube then be in- 
serted. This should be passed through a good-sized 
buttonhole opening in the flap, and secured to the scalp 
by a long silk thread tied in a bow knot. The bone 
should not be replaced. If the first trephine opening 
does not afford good drainage a second should always 
be made in the proper place. An ample dressing should 
then be applied. The drainage tube should be kept in 
place, but gradually shortened until the discharge has 
diminished to such an extent that it is safe to remove it. 
The silk thread may be untied, secured to the tube, and 
retied at will. Even with the greatest care it will happen 
every now and then that the wound, after apparent heal- 
ing, will have to be reopened to give vent to a reac- 
cumulation of pus, as in a number of cases already re- 
ported. Thus McCutcheon trephined his patient five 
times for as many different objects: (1) after the accident ; 
(2) for compression; (8) for epilepsy; (4) for atrocious 
headaches; (5) for necrosed bone; each operation being 
followed by benefit, and the final one by recovery. 
Fengerand Lee operated three times, Rivington operated 
four times, and Schede operated five times. All of these 
cases recovered. In Westmoreland’s case the blow was 
received in 1879, and repeated attacks of suppuration 
occurred in 1881, 18838, and 1886. In each case reopen- 
ing the wound and redraining resulted in recovery. 

Of course, if a fistula be discovered, even a small one, 
as in the case reported by Truckenbrodt, and operated 
on by Schede, the trephine opening would be made at the 
site of the fistula rather than at any of the points above 
described, and would lead to the abscess. Weir has sug- 
gested the injection of an aniline solution to discover 
the route and extent of the sinus. 

If the abscess is in the cerebellum the proper place to 
trephine is well below the superior curved line, so as to 
avoid the lateral sinus, the centre pin being placed mid- 
way between the tip of the mastoid process and the inion. 
A three-quarter-inch trephine or the chisel or a gouge 
should be used. It must be remembered that the skull 
is quite thin and easily penetrated at this point. The 
opening can be enlarged later if necessary. 

The flap in the dura should have its base upward. Of 
course, the occipital artery will have to be ligated. As 





Fig. 1027.—Photographed from the Same Skull, with the Brain Exposed 
in situ. The lettering is the same as in Fig. 1026. The point at 
which the opening was made in the central cortex (¢) is observed 
to lie on the posterior part of the second temporo-sphenoidal conyo- 
lution. (Barker.) 


pointed out by Weir, “with the use of a spatula to lift 
it up slightly, the cerebellum can, if necessary, be viewed 
with an electric light nearly to the foramen magnum.” 
With a grooved director or other appropriate means, the 
cerebellum can now be punctured and the abscess evac- 
uated in a favorable position for drainage. Even should 
the abscess be upon the opposite side of the cerebellum, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





it would be easy, as I have shown, to reach it obliquely 
through such an opening. In making any puncture, 
however, care should be taken not to injure the superior 
vermiform process. A drainage tube should be used 
and the abscess treated as before described. 

If anabscess exists in any other place than in the tem- 
poro-sphenoidal lobe or in the cerebellum, the trephining 
should be done immediately over the site, as determined 
by cerebral localization, and the cavity treated as above 
described. , 

Should no abscess be found at the first trephine open- 
ing, and there be a possibility of its existence at another 
point, there is no objection to a second trephine opening, 
and even a third, should the necessity arise. The danger 
from an additional trephining is so slight, and the dan- 
ger from abscess, if it exist, so great, that we should 
seek for it at a second or even a third point, if not found 
at the first. It is, however, scarcely necessary to add 
that this additional trephining should not be done with- 
out good and sufficient reasons. In-such cases, when 
the abscess is found to be encysted and encapsulated by 
a thick membrane, the membrane should, of course, be 
removed, as was done by Bergmann. 

Extra-DurAL ABscEesses.—Besides the abscesses in 
the substance of the brain, another variety exists that it 
is very important to recognize; that is, an abscess be- 
tween the dura and the bones of the skull. These almost 
always arise from ear disease by involvement of the bone 
and subsequent pachymeningitis externa followed by 
suppuration, The pus may accumulate in an abscess, or 
may be diffused between the dura and the skull. 

Symptoms and Diagnosis.—They cannot be distin- 
guished from cerebral abscesses proper, or from lepto- 
meningitis or thrombosis of the lateral sinus, by the eye 
symptoms or headache, but other means may enable us 
to do so. The temperature, in marked contrast to cere- 
bral abscess, will rise to 102°-104° F. The pain in extra- 
dural abscess is usually fixed either above or behind the 
ear, and is increased by percussion or by pressure. The 
mastoid, of course, will be involved, but the tenderness 
on pressure or percussion will extend both farther back 
and higher up than the mastoid. Usually there will be 
cedema of the overlying scalp. If the mastoid has al- 
ready been opened and no improvement has followed, 
and no marked symptoms of the other cerebral diseases 
mentioned above be present—such as the pronounced 
cerebral irritative lesions of leptomeningitis, the localiz- 
ing or focal symptoms and low temperature of cerebral 
abscess, or those of thrombosis of the internal jugular, 
and other signs of pyzemia in plugging of the lateral sinus 
—we should suspect extra-dural abscess. Pressure symp- 
toms are rarely seen in extra-dural abscess, especially if 
it arise from aural trouble. If evidence exist of caries of 
the bone, extra-dural abscess should be suspected, and 
especially if the pus well up through such a sinus and 
show any pulsation communicated from the brain. Not 
seldom a sequestrum or carious bone will be found. 

Treatment.—The ordinary operation for trephining 
the mastoid will usually have been done for the earlier 
symptoms. If not, itshould be done at once, and further 
operative interference be carried out, if so indicated. If 
the operation be limited to opening of the mastoid, and 
this does not speedily bring relief, the skull itself should 
be opened either by the trephine or by the rongeur for- 
ceps. The probe orescaping pus will indicate to us any 
fistula, and this must be followed up till the carious or 
necrosed bone is discovered and the dura laid bare. This 
last can usually easily be recognized by its texture, its re- 
lation to the bone, and its pulsation. Should the lateral 
sinus be exposed, care must be taken not to wound 
it. Should a thrombus exist, it must be treated as in- 
dicated under that heading later. That recovery may 
take place after thrombosis of the sinus and without in- 
terfering with it, is shown by a case of Hoffmann. The 
abscess cavity having been reached, it should be cleaned 
out, the granulations from its walls removed, and free 
drainage provided, all carious or necrosed bone having, 
of course, been first removed. Unless such efficient 


operative measures be taken, the case is almost sure to 
prove fatal. Hoffmann, whose paper (loc. cit.) is the 
best study of the subject I have found, gives a ghastly 
table of 102 fatal cases in which the diagnosis was estab- 
lished by a post-mortem examination, and its impressive 
lesson is but reinforced by the 10 additional cases diag- 
nosticated during life. Four of these were observed by 
others, of which 3 recovered after operation; 6 are re- 
ported by himself, of which 5 recovered after operation, 
one dying six weeks later from bronchitis. No other 
commentary as to the absolute necessity for an operation 
can be needed. The causes of death were mostly menin- 
gitis, cerebral abscess, and pysemia, with, and probably 
from, thrombosis of the lateral sinus. 

PYMIA AND THROMBOSIS OF THE CEREBRAL SINUSES. 
—Under the title Har: Intracranial Complications, etc., 
in Volume III. of the present work, Dr. Orne Green con- 
siders this matter very much more fully, especially from 
the point of view of the otologist. A few words, how- 
ever, ought to be said about it from the view of the gen- 
eral surgeon. ‘This is all the more true, because nearly 
all the cases until within the last few years have passed 
unrecognized and unoperated on, while the results of 
operation have been extraordinarily good. 

In a table which I published in Ashhurst’s “ Interna- 
tional Encyclopedia of Surgery,” (supplementary vol- 
ume), I collected 84 cases, of which 56 recovered—66.7 
per cent. Since that time a large number of cases have 
been reported, but no later complete tabulation to my 
knowledge has been made. I have no doubt that a con- 
siderably larger percentage of recoveries would be shown 
in the later cases. 

The cause of the thrombus may be infected fractures, 
erysipelas, decayed teeth, etc., but by far the larger 
proportion of the cases arise from chronic otitis media. 
The thrombus, being an infected one, gives rise to a 
pyemia with all of its ordinary symptoms. The in- 
fected clot softens and suppurates. Very frequently it 
extends into the jugular vein, whence fragments of it 
will eventually reach the lungs unless the progress of 
the disease is stayed. While the thrombus takes place 
in the vast majority of cases in the sigmoid portion of 
the lateral sinus (the curved portion of the sinus oc- 
cupying the groove in the mastoid portion of the tem- 
poral bone), yet there are a fair number of instances re- 
ported in which the superior longitudinal sinus, the 
cavernous and other cerebral sinuses have been involved. 
The symptoms will be detailed fully in Dr. Green’s arti- 
cle. 

The only treatment to be considered for a moment is 
the surgical, and this must be prompt and thorough in 
order to be effective. The mastoid operation, if not al- 
ready done, should immediately be carried out. If the 
internal jugular is involved, this should be exposed in 
the neck and tied below the thrombus, in order to pre- 
vent infection of the lungs. Ordinarily this thrombus 
can be readily recognized by touch, but sometimes, as 
in one of my own cases, the vein is so completely de- 
stroyed by suppuration that it is difficult to recognize it. 
Next, the sigmoid sinus should be exposed and deliber- 
ately opened. It should be cleaned as far as the clot 
extends; if need be, even to the torcular Herophili. If 
serious hemorrhage occurs, it can readily be controlled 
by plugging with strips of iodoform gauze. The vein 
and the sinus should be washed out both from above and 
from below.. The petrosal and the cavernous sinuses 
cannot be reached by surgical operation. 

Up to the present time, the symptoms of thrombosis 
of the superior longitudinal sinus have not been suffi- 
ciently clear to enable the surgeon to make a positive 
diagnosis of the location of the disease. Whenever we 
can do this, a similar operation to that on the sigmoid 
sinus should be done. 

INTRACRANIAL Tumors.—The causes of intracranial 
growths are various, but in the majority of cases the 
cause can scarcely be ascertained. Injury occasionally 
plays an important role, but much more frequently they 
arise without any apparent local cause. The statistics 


415 


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Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 








of Hale White, and Bernhart, quoted by Seguin and 
Weir, give a sufficient number of cases from which to 
draw a reasonably correct conclusion. They number 
580, and are as follows: 


Number. Per cent. 





NALUTe OL LUIOOr NOt SEALE cimicaeisieiveetesielalrsioleiele 133 22.9 
MT TDOLCUIOUS: HULTLOUS ee wth ote oye lnleleiscerslevarelafoteietninier erste 137 23.0 
GOMIAtA erence sci ete te wletticiatstale vie invale afatareamseretes 76 13.0 
Sarcomata Cineluding cysto- SACOM) is s'cieicleiereerd 75 13.0 
Hydatids, eysticerci, and echinococci . Lae) ROU 5.0 
OV SES irlstelaloya le are’avelelr(osalols!s <ierescle rele) sta lepeielelM sfotnleutonsts 27 4.6 
AY CLOTIAL ee erate aon oracle crcreai anion 24 4.0 
fetthiseneh Ch oa ereinream aie doo anon borers Se amitooc. 21 3.6 
CeLiG-SATCONTALA seta care scceataiaraelds eetalel tote aleurone enter. 14 2.2 
Myxomata (including myxo-sarcomata)........ 12 2.0 
Osteomata...... Seithtale pntaigie Ge elscare cera eise Galeton eetant 6 1.0+ 
INGLITOMIAtH IO) ee ae eres cletentots lelenctnis ste ates iomeieteh iain oe cists 4 —1.0 
Pe NITION A A lavctaley evel uayare otovetadetearmoc aneia stan ebeierste 4 —1.0 
Pep ilLOma sibel <prisii> e/aielors orebelaysloyave el-elelels!aialels /acola/ elie Meas 4 —1.0 
PIDTOUMI ACs ora k ce ecltiinie eiaiel veletotets eraicreleisteretcversiaisce 3 
Cholestestomiata soci meiislereteeissteete eer ietaeera aie ciske 2 

TiO OMAP oss orarvis stelle clove lansrateistalele eksic  eterelst= ree: 

Erectile or vascular tumors. 2 

Dermoid cysts.. 2 
Enchondromata . 3 1 
Lymphomata...--....... 1 





This shows that tuberculosis is nearly twice as common 
as any other one known cause. Tuberculous tumors are 
most frequent in early life, three-fourths of them occur- 
ring before twenty, and one-half before ten, years of 
age (Gowers). The various forms of malignant tumors 
exceed in number even those which are of a tuberculous 
nature. They are most common from twenty to forty. 
Other varieties, excepting hydatids and cysts, furnish 
each but asmallnumber. The small percentage of syph- 
ilitic gummata is rather surprising. Dr. Gowers states 
that of 637 intracranial tumors the distribution was as 
follows: Cerebral hemispheres (excluding the central 
ganglia), 297; cerebellum, 179; pons, 59; central ganglia, 
48; medulla, 31; corpora quadrigemina, 13; crura cere- 
bri, 10. Starr, in a valuable paper on 300 cases of intra- 
cranial tumors in children, found 96 in the cerebellum. 

The Symptoms have been so carefully studied and so 
fully treated by Dr. Mary Putnam-Jacobi, in the present 
volume of this HANDBOOK (article on Brain, Tumors of), 
and by Dr. M. Allen Starr, in his article on Brain: Diag- 
nosis of Local Lesions (see p. 282), that it would be but a 
repetition here for me to consider them. Three points, 
however, ought to be more fully noticed, viz., disturb- 
ance of language, eye symptoms, and local tempera- 
tures. 

A most important paper in connection with disturb- 
ance of language is that by Dr. M. Allen Starr. Words 
in ordinary use have a complex mental substratum, 
made up of a number of mental pictures. These are, 
first, memory of the sound of a word as spoken; if this 
be lost we have “word deafness.” Second, memory of 
the appearance of a word as printed or written, if this 
be lost we have “word blindness.” Third, memory of 
the muscular movements made in writing a word; if 
this be lost the result is “agraphia,” or inability to write. 
Fourth, memory of the muscular movements made in 
pronouncing a word; if this be lost, although the vocal 
apparatus is perfect, it is known as “motor aphasia. ” 
Fifth, the word-hearing and word-uttering processes 
may be perfect, and the patient can understand what 
is said to him, and can pronounce words well, but the 
connection between the word-hearing and the word- 
uttering processes is broken, and the patient misplaces 
words or uses one word for another—for instance, call- 
ing the “four of spades” the “five of telephone.” This 
is known as “ paraphasia,” or the aphasia of conduction 
of Wernicke. The lesion in these cases usually involves 
the island of Reil, and severs the fibres beneath it, the 
great association tract joining the temporal and frontal 
lobes with one another. Sixth, the mind may not 
recognize the use, odor, color, taste, etc., of any object 
presented to it. This general symptom is termed 
“apraxia.” It has, of necessity, as many varieties as 
there are avenues by which the mind may be reached; 


416 





for instance, by sight, smell, taste, hearing (not only 
hearing for language, but also for music), either of which 
may be lost separately, thus producing “ mind blindness,” 
“mind deafness,” etc. The patient, however, though 
unable to recognize any object when seen, may be able 
to do so when felt. These symptoms (according to Starr) 
are found only when the lesion is in the left hemisphere 
in a right-handed person, and in the right hemisphere in 
a left-handed person. Hence, in examining an aphasic 
thoroughly, Starr states that it is necessary to test, first, 
the power to recall the spoken or written name of an 
object, seen, heard, handled, tasted, or smelled. Second, 
the power to understand speech, andalsomusic. Third, 
the power to understand printed or written words. 
Fourth, the power to speak voluntarily. Does he talk 
clearly? Does he mispronounce words or talk jargon? 
Fifth, the power to repeat words when dictated. Sixth, 
the power to read aloud. Does he understand what he 
reads? Seventh, the power to write voluntarily. Can 
he read what he has written? Highth, the power to 
write at dictation. Ninth, the power to copy. Tenth, 
the power to recognize the use of objects seen, felt, 
heard, tasted, or smelled. One illustration, and only 
one, so far.as I know, exists of the diagnosis of a lesion 
by the existence of “mind blindness,” and this was fol- 
lowed by a brilliant and successful treatment. This is 
recorded by Macewen, and is briefly quoted on page 425 
of this article. 

When it is remembered that the second, the third, the 
fourth, and the sixth nerves, in their entirety, are solely 
intended for innervation and specializing function of the 
organ of vision, it will be readily understood how im- 
portant this apparatus becomes as an index of intra- 
cranial disturbance. 

The methods may be briefly given in a series of short 
captions, as follows: 

1. Always, if possible, get central vision in each eye 
separately, not only for form but for color, as this prac- 
tically gives the physiological power of the most highly 
evolutionized fibres of each retina. To do this, cards of 
known sizes of types or symbols, and graded areas of 
definite colors, such as green, red, rose, blue, and yellow, 
should be placed at certain distances in good light, and 
the results compared with the normal standards for such 
distances. Should the patient be unable to designate 
types, symbols, or colors, then keys, coins, etc., of the 
same size as certain test letters can be held at the related 
distances, or less if necessary, and attempts made for 
similar selection among duplicates held in the lap. 

2. Power and range of accommodation should be tried 
separately and combinedly for the smallest type visible, 
with or without helping lenses, at the nearest, furthest, 
and best points possible. Retinoscopy may be useful 
in quite a number of cases. Tonic and clonic spasm 
must be sought for. 

3. Visual fields must be most carefully studied in ref- 
erence to comparative sizes and areas for white, yellow, 
blue, red, and green; blind spots and points of feeble color 
saturation must also be diligently sought for and noted. 

4. More complete study of central color perception 
should now be made with graded intensities of Holm- 
gren’s wools, and the results should be recorded upon 
suitable blanks. 

5. The pupils should be examined and re-examined 
separately and in associated action, until definite an- - 
swers can be given as to their comparative sizes and 
shapes. 

6. Careful attention must be paid to monocular and 
binocular action of the trides to light stimulus thrown 
from all parts of the visual field; to associated action 
with the ciliary muscles, as in accommodative efforts; 
and to the combined and associated action with the ciliary 
muscles and internal recti muscles, as in convergence, 
and these tests must be repeated over and over until un- 
equivocal results are obtained. Spasmodic action of the 
irides must be carefully looked for. 

7. Hxtra-ocular muscle balance, when the organs are in 
a state of rest, should be obtained as correctly as possible. 


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Brain, 
Brain, 





8. Combined and disassociated action of the attached 
extra-ocular muscles in convergence, conjugate deviation, 
extreme separate and combined excursions in all direc- 
tions, must be gone over with special study of the vary- 
ing degrees of change from the slightest loss of innerva- 
tion up to total paralysis. Search for clonic and tonic 
spasms should also be carefully made. 

9. Combined and associated action of the muscular ap- 
paratus of the ocular appendages should now follow, in 
reference both to paretic and to spasmodic changes. 

10. Sensibility of the entire ocular superficies, both to 
touch and pain, should be studied. 

11. In cases in which a difference of temperatures is 
suspected, comparative surface thermometry should be 
made, although it is really best not to omit it in any in- 
stance. 

12. Accurate ophthalmoscopic study of the media and 
the fundus of each eye should be repeatedly made, until 
adequate dataas to the comparative condition of the two 
organs are correctly obtained. 

Having thus obtained this grouping of ocular condi- 
tions in association with the history and concomitant 
symptoms, determinations can often be made of sufficient 
accuracy to point out at least not only the probable 
character of the lesion, but even its possible situation. 
Negative signs may oftentimes prove themselves of great 
value in the diagnosis of the position of the supposed 
growth; and no case can be said to be complete and 
ready for surgical procedure until all the ocular changes 
have been properly and carefully studied. 

For the purposes of help in differential diagnosis the 
few following general observations may be of use: 

Optic neuritis is very usual in some stage of intra- 
cranial tumor, and indicates more rapid progress of the 
growth. It is of no definite value in the diagnosis of 
the position, the character, and the size of the mass. 

If the so-called monocular type be met with in such 
cases, the neoplasm is most probably situated in the op- 
posite hemisphere; and should the neuritis be double 
(which is most probably always the case), it is almost cer- 
tain that the side of the lesser optic nerve swelling is the 
one in which to look for the growth. The occurrence of 
this symptom is less frequent in abscess, and may be 
more ordinarily found upon the same side as that of the 
lesion than in tumor. It seldom occurs, if at all, in cor- 
tical lesions with irritative symptoms. 

Primary optic-nerve atrophy with or without retinal 
change, as shown by the ophthalmoscope, is generally 
found in connection with basilar disease or trunkal in- 
flammation, from trauma, new growths, general dys- 
crasia, and the introduction of toxic agents into the sys- 
tem. In epilepsy it is seldom decidedly marked, being 
usually found in its incipient form, and seemingly de- 
pendent upon the number and severity of the seizures. 
It is not apt to occur in abscess, except in those rare 
cases of the encysted and slowly growing varieties. 

Weakening of any single muscle or any group of 
muscles generally indicates either pressure from a coarse 
lesion, external to any portion of the related outgoing 
fibres, or true infiltration of pathogenic material into 
the neural meshes themselves. Unassociated with other 
symptoms it is of little value in questions of the position 
of the lesion, and must be used in conjunction with 
other data to be of any determining use. Being, how- 
ever, more of a fixed quantity than muscle irritation, it 
is of greater importance in such instances than the latter, 
as it better shows the probable position of the lesion. 
Localized spasm in itself is probably more apt to be 
caused by lesions in the motor zones and in the centres 
devoted to the action of the involved group or groups 
of muscles. It thus often offers itself of special diag- 
nostic value in the localization of the initial point of the 
epileptic spasm. 

In acute and subacute meningitis, irritative symptoms 
of both motor and sensory varieties appear, whereas in 
the chronic form degenerative changes are more prone 
to occur. 

Hemianopsia is of paramount importance, more so 


Vou. II.—27 


than aphasia and agraphia. Each variety, carefully 
considered in conjunction with ophthalmoscopic study, 
experiments with pupillary responses, and other motor 
and sensory disturbances, can hardly fail to serve as 
most important data for indicating the probable situa- 
tion of the lesion. 

It must be remembered, however, that each ocular 
symptom in itself is not etiologically self-answerable. 
Careful study must be made of all the conditions, so 
that, by the process of exclusion, adequate data can be 
obtained upon which to base answers as to the character, 
ne type, and the situation of the supposed intracranial 
esion. 

Surface Temperature of the Head.—Mills and Lloyd, in 
Pepper’s “System of Medicine,” vol. v., p. 1036, have 
given the record of four cases of tumor of the cerebrum 
and one of the cerebellum. Seguin and Weir (loc. cit.) 
have recorded the temperatures in their case, and I have 
done the same in the case of tumor in my first paper al- 
ready referred to. The general conclusion seems to be 
that the average temperature of the whole head is ele- 
vated somewhat above the normal, and that the elevation 
of temperature is usually greatest at the station nearest 
to the site of the growth. But a much larger number of 
observations must be made in order to reach a definite 
conclusion as to this symptom; therefore, every case of 
supposed tumor, and, in fact, every other lesion in the 
skull, should have the surface temperatures carefully 
noted both before and after the operation, if any be done. 
In the second case in my paper the temperature certainly 
seemed to be elevated by the irritation of the lesion pres- 
ent. The elevation immediately disappeared after the 
operation, coincidently with the cessation of the epileptic 
attacks. In the third case in which the fits were relieved, 
but not cured, the temperature did not fall. Our sur- 
face thermometers also are as yet much lacking in ac- 
curacy, as they are used in practice. 

Diagnosis.—While in many cases the diagnosis is suf- 
ficiently clear, in others we are, of necessity, in the 
greatest doubt, until the operation, it may be, reveals 
the correctness or the incorrectness of our conclusions. 
Hence, as already quoted with approval from von Berg- 
mann, the great necessity of a correct diagnosis on the 
part of the neurologist, so that the surgeon may be sure 
that his attempt to remove a supposed tumor will not 
cause chagrin to both by finding none. This has oc- 
curred in numerous instances. 

In the careful and elaborate paper of Seguin and Weir, 
already referred to, it is pointed out that the diagnosis 
before operation must be worked out in five lines of in- 
quiry. (1) The existence of tumor; (2) its exact loca- 
tion; (3) whether it is cortical or subcortical; (4) 
whether solitary or multiple; (5) its nature; to which 
I would add (6) if possible, its size. 

1. Diagnosis of the Existence of a Tuwmor.—When the 
symptoms referred to by Dr. Jacobi, in her article, are 
present—such, é.g., as headache, cerebral vomiting, grad- 
ually developing stupor, convulsions either general or lo- 
calized, paralysis in varying degrees, choked disc, some- 
times hemianopsia, slow pulse, probable localized rise of 
temperature with aphasia and apraxia, and in some 
cases with but little anzesthesia—it is almost certain that 


.we have a tumor to deal with. The most difficult diag- 


nosis is often between tumor and abscess, and for their 
differential diagnosis I must refer the reader to the article 
on Brain: Abscess of, on p. 218. 

2. Diagnosis of the Location of the Tumor.—This must 
be done chiefly by the localizing symptoms. In certain 
parts of the brain a tumor may exist and give rise to no 
localizing symptoms, but only to general headache, 
choked disc, convulsions, etc. This is more particularly 
in the anterior portion of the frontal lobes,’in the tem- 
poro-sphenoidal lobes, especially on the right side, and 
in parts of the parietal and occipital lobes. But gradu- 
ally these “latent zones” are being narrowed progres- 
sively to smaller and smaller portions of the cerebrum. 
It is not too much to hope that eventually there may be 
no “latent zones.” The reader must refer to that portion 


417 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of this article which treats of Topography of the Brain, 
and to Dr. Jacobi’s and Dr. Starr’s papers in the pres- 
ent volume, for the details of the methods of localization, 
whether in the motor or in the sensory zones. One point 
must be regarded in following the history of a case. If 
a tumor increase in size, centres adjacent to the first. one 
involved will also be affected; hence a succession of addi- 
tional spasms and of pareses will develop in different 
parts of the body, and they are very important to study. 
The first limited spasm or paresis Seguin has proposed 
to call the “signal symptom ”—a happy name for an im- 
portant symptom in diagnosis. Rapidly produced blind- 
ness, as pointed out by Zenner and others, is usually due 
to tumors (especially in the cerebellum) which obstruct 
the veins of Galen or the straight sinus, and so produce 
internal (ventricular) hydrocephalus and pressure on the 
optic tracts, followed by choked disc and hemorrhages. 

3. The Diagnosis of the Depth at which a Tumor Lies, 
7.e., whether Cortical or Subcortical.—Seguin, in the article 
already quoted, concludes that a tumor of the cortex 
cannot be distinguished from a subcortical tumor by the 
character of the convulsions, or by the: presence or ab- 
sence of localized headache, or by the cranial tempera- 
ture. But tenderness on percussion rather than on press- 
ure may very possibly be of some service. In this as in 
the question of local temperatures, it must be urged that 
more exact and detailed clinical histories may hereafter 
give us the means of making such a diagnosis. How 
near one may come to removing a tumor and yet miss it, 
is well shown in a case of Sands, in which he recognized 
unusual resistance in two punctures by the needle, yet 
did not remove the growth, which was found at the 
autopsy just below the surface. Surgery had not then 
reached its present boldness and success. 

4. Is the Tumor Solitary or Multiple ?—If solitary it 
may be successfully attacked by operation, but if multi- 
ple such an attempt would be clearly inadvisable in most 
cases, unless the multiple tumors are grouped within a 
limited area. If the tumor is single, the localizing symp- 
toms will probably point to one area alone, if the tumor 
be small; or if large, several areas may be involved, but 
these areas will be adjacent to the primary one. If, how- 
ever, localizing symptoms give two or more centres, far 
apart, without any intervening centres being involved, 
then the multiplicity of the growth is probable. 

5. The Diagnosis of the Nature of the Tumor.—In some 
cases this may be made with fair approach to accuracy. 
For example, if the patient has cancer, tuberculosis, or 
syphilis in other organs, and shows characteristic symp- 
toms of intracranial tumor, it will most likely be of the 
same type as the disease in the other part of the body. 
Beyond these three classes of tumor I do not think it 
possible to make other than a guess at its nature. 

Hale White and von Bergmann are both opposed to 
operation in case the nature of the tumor is probably 
syphilitic. I quite agree with Seguin, however, that, 
provided thorough antisyphilitic treatment has been in- 
effectual, including the American method of the admin- 
istration of large and increasing doses of iodides, if pos- 
sible up to half an ounce a day, the probable gummatous 
character of the tumor or a syphilitic disease of the 
bones or membranes is not a bar to operation. 
gumma has become organized and permanently devel- 
oped, and has resisted vigorous specific treatment for six 
weeks, it should be attacked precisely as any other tumor 
would be dealt with, surgically, unless contraindicated 
by special symptoms, such as multiplicity, etc. 

6. The Size of the Tumor.—This in a few cases can be 
probably diagnosticated. The diagnosis of a small tumor 
will be based upon its involving a restricted area of rep- 
resentation in the brain, as shown by the limited por- 
tion of the body involved; by the non-progressive in- 
volvement of neighboring centres; and by the absence 
of marked pressure symptoms. A large tumor will in- 
volve a large number of neighboring centres and would 
show marked pressure symptoms. Until the parts are 
exposed by operation, however, it is impossible to make 
any accurate diagnosis of the size of atumor. Itis prob- 





418 








Once a: 


able, however, that a few of them will be so large as to 
prohibit surgical interference, before the general symp- 
toms will be so grave as to make such interference quite 
inadvisable. 

Surgical Treatment of Intracranial Tumors.—I have 
already referred to the historical case of Bennett and 
Godlee, which was the first really to arouse the attention 
of the surgical world to the possible diagnostication and 
removal of a brain tumor, of which there were no ex- 
ternal local symptoms. I have also referred to some 
later cases which have been operated upon. The num- 


_ber of intracranial tumors operated upon has now reached 


such proportions (vide infra) that we can assume it as 
conceded that in all suitable cases operation should be 
at least attempted. 

As to operative technique I have already considered 
the various steps under that head. The only point neces- 
sary to be’ insisted upon here is, that in cases of tumor 
which are not encapsulated, it is important that not only 
the entire tumor shall be removed, but also the zone of 
apparently healthy but probably infiltrated brain tissue 
in its immediate vicinity, so that we may be sure, so far 
as it is possible, that we have removed the entire neo- 
plasm. In doing so the surgeon must remember that he 
can excise with greater impunity a larger area in the 
antero-posterior direction than in the vertical, for reasons 
already given. 

Prognosis.—lf the tumor is malignant, its return is only 
a question of time in the majority of cases. In tubercu- 
lous and syphilitic tumors the prognosis is, of course, a 
a much more favorable one; while in cases of benign 
growths, such as fibroma, recurrence is not to be ex- 
pected. 

The prognosis as to death or recovery from such opera- 
tion cannot be made in any individual case, for up to 
the time of the operation we cannot be certain of the 
size and the relations of such tumor, nor of the surgical 
complications that may arise during its removal. 

The percentage of recoveries in cases of operation on in- 
tracranial tumors has been, for a new operation, unex- 
pectedly large. Of course, in any individual case, it will 
depend largely on the size, position, complications, ete. 

When the first edition of the REFERENCE HANDBOOK 
was published, I could gather only 17 cases of tumor 
which had been operated on, of which 8 were in the cere- 
bellum and all 3 died. 

In 1898 von Bergmann published the most recent sta- 
tistics, which cover 273 operations for intracranial tumors. 
of all kinds, of which 169 (61.9 per cent.) recovered and 
104 (38.1 per cent.) died. One hundred and fifty-seven 
were exploratory or palliative operations, of which 82 
(538.5 per cent.) recovered and 75 (46.5 per cent.) died. 
The chief reason for the fatality in exploratory or pallia- 
tive operations has been either too extensive exploration 
in search of the tumor or for its removal, or that many of 
the cases were inoperable from the size or location of the 
growth and only relief from intracranial pressure was 
sought. If no tumor is found after cautious search by 
the knife, grooved director, and the gentlest use of the lit- 
tle finger, or if, being found, it is not removable, the op- 
eration should be terminated at once, especially if there is 
much bulging, indicating a large tumor. In fact, in 
cases of great increase in the intracranial pressure, until I 
have determined the fact that the tumor can be removed, 
Iam very cautious about making a large opening in the 
dura, since the pressure will force out a large amount of 
brain substance which cannot possibly be replaced with- 
out extensive laceration, which invites fungus cerebri. 
Of fourteen cases in which trephining was done for the 
relief of increased intracranial pressure, all recovered. 

Another important cause for the high mortality of the 
whole series has been the delay in operating. Physicians, 
who almost always see these cases first, postpone con- 
sulting the surgeon for an unreasonably long time in the 
vain hope of improvement. It cannot be too strongly 
insisted upon that tumors of the brain should be treated 
precisely like tumors in other parts of the body, by re- 
moval at the earliest practicable moment. In fact, in 


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Brain, 
Brain, 





the brain the reasons for early operation are even more 
cogent than elsewhere: its soft tissues are more easily 
injured; it cannot escape from pressure as do the soft 
parts, since the bony case in which it lies prevents this; 
and the growth of the tumor within the skull is insidi- 
ous and not easily perceived, as it is when accessible to 
touch and sight. Progressive growth can be inferred 
only from progressive symptoms. As soon, therefore, 
as drugs have had a fair trial an operation should imme- 
diately be done, if the tumor can be located with reason- 
able certainty and if there is a fair prospect of success by 
operation. The limit of the “fair trial” Horsley places, 
and I think rightly, at six weeks. After that, time is 
wasted and life imperilled by longer waiting, since time 
only allows of increase in the size of the tumor with 
wider infiltration of brain tissue and the wider destruc- 
. tion by pressure, and the operative difficulties and dangers 
rapidly increase with each week or month of delay. 

In the case of irremovable tumors, the opening in the 
skull should not be closed by replacing the bone. This 
partial operation will often be an immense comfort, and 
Ihave had the same experience that Horsley has had 
—namely, that the patient found so much relief from one 
operation that he requested a second. 

Operations upon cerebellar tumors—by reason of their 
proximity to the fourth ventricle, the tubercula quadri- 
gemina, and the pons with their important and vital cen- 
tres—are more hazardous than those performed in any 
other less vital regions of the brain. Out of 23 cases, 
15 died. 

Epiteprsy.—From a surgical point of view cases of 
epilepsy may be sharply divided into the traumatic and 
the non-traumatic varieties. The cases arising from 
traumatism can again be subdivided into (1) those in 
which the scar, old depression, etc., arising from injury, 
lies over well-recognized centres, motor or otherwise, 
and (2) those in which the evidences of injury lie over the 
so-called “latent zones” in the brain. 

In those cases in which the lesion lies over well-known 
centres, and the epileptic fits affect only the muscles 
corresponding to the motor centres (monospasm or hemi- 
spasm), there can be no question at present as to the pro- 
priety of surgical interference, and the excision of the 
epileptogenous centre so involved. In cases in which 
the injury lies over a portion of the “latent zones,” I 
believe that here also it is often proper to operate. 

It is true, time has cooled our earliest enthusiasm, but 
epilepsy is such a terrible disease that I find most parents 
are of my own opinion, viz., that no risk, even of death, 
still less of the probability of failure, is to be weighed 
against the possibility of benefit orcure. The danger of 
death is not very great, the number of failures is large, 
the number of cases benefited is considerable, the num- 
ber of cures is limited but encouraging. If we could 
operate early, before the “epileptic habit” is formed, 
the number of cures would be much greater. 

In these traumatic cases it is always possible that the 
scalp may be the site of irritation, and should there at 
least be no evidence of depression of the skull, it would 
always be wise, therefore, to excise the scar first of all, 
especially if it be tender, or if pressure upon it produces 
pain or an epileptic fit, or if the epileptic aura starts 
from the scar. Even should none of these symptoms be 


present, and if the bone be not fractured, I should deem. 


it right first to excise the scar and then to wait in order 
to see whether this would cut short the epileptic seizures. 
Thus Briggs reports five such cases and Mears one in 
which such a happy result followed mere excision of the 
scars. I also have had two cases in which the attacks 
have not returned for several years after merely ex- 
cising the scar. In one case the immunity has reached 
nine years. Any other source of peripheral irritation 
must also be eliminated, as has long since been ob- 
served. Briggsrelates a case in point in the same paper, 
in which a girl had both a depressed cranial fracture and 
necrosis of the tibia. He wisely operated on the tibia 
first to eliminate this as a source of irritation, and the 
fits had not recurred when the case was reported five 





years later, thus disproving their origin from the fracture 
of the skull, which was prima facie the most probable 
cause. It must be remembered also that any operation 
is apt to cause a cessation of the fits for some time; 
hence, before deciding that the epilepsy has been cured 
by removal of the scar or other source of irritation, at 
least two or three years of immunity should elapse. 
Should excision of the scar not cure the patient, or 
should there be a depression of the skull, with fits cor- 
responding in their distribution to the motor centre or 
centres over which the scar lies, the patient should be 
trephined. The operator may find a splintering of the 
inner table. Sometimes a cyst will have been developed 
under the site of the injury. Sometimes, as a result of 
laceration of the brain tissue at the time of the injury, a 
brain scar will be found. The dura also wili have been 
ruptured in some cases, and a scar will be found in it; or 
mere eburnation of the bones, as a result of osteitis from 
the traumatism, may be the only lesion. The skull hav- 
ing been trephined and the dura opened, the damaged 
brain tissue should be removed; and if there be a scar or 
thickening of the dura, the dura itself should be removed. 
In removing the damaged brain tissue, care must be 
taken to see that it is a// removed, even to the extent of 
trenching upon apparently healthy brain tissue, and the 
directions heretofore given that freer excision may be 
made in the antero-posterior direction than in the vertical 
(for reasons already mentioned) must be remembered. 
The bone should not be replaced in a large piece, if by 
its shape, or for any other reason, it would cause press- 
ure on the brain. [t may sometimes be replaced to ad- 
vantage after dividing it into small pieces by the chisel 
or rongeur forceps. 

In those cases in which the lesion lies over the “latent 
zones,” the same rule as that given above would apply to 
the excision of the cutaneous scar. Should this not effect 
a cure, then it would be proper to operate. What should 
be done would depend upon what was found to exist in 
the brain, and any damaged brain tissue or cyst should be 
excised as already advised. Occasionally, after accidents, 
primary trephining will have been done, yet epilepsy will 
develop at a longer or shorter time after healing. In 
such cases, no matter where the scar is situated, it is some- 
times wise to raise the flap over the site of the primary 
trephining and round off the edges of the bone, and to ex- 
cise any scar in the dura or in the brain which may have 
resulted from the primary traumatism, or from any 
operation done at that time. Occasionally some benefit 
will follow, but generally the result will only be a tem- 
porary cessation of the attacks. 

Non-Traumatic Epilepsy.—First, of the Jacksonian 
type. So far as our limited experience goes, it seems 
probable that in cases of distinct Jacksonian epilepsy it 
is proper to operate, and to excise the centre correspond- 
ing to that portion of the body which is involved. The 
experience of Horsley and Macewen, as well as quite a 
number of other operators, at present would seem to 
show that such operations at least do no harm, and in 
not a few cases they have resulted in apparent recovery 
both from the epilepsy and from the operation. It isa 
matter of some importance also that if we operate at all, 
it shall be as early as possible, before the “epileptic 
habit” has been established. But both in thisand in the 
non-Jacksonian type, 7 7s of the utmost importance that 
the fits shall have been always observed by a competent, and, 
if possible, w trained observer. Ihave had brought to me 
for operation a large number of cases of alleged Jack- 
sonian epilepsy, and others of ordinary epileptic type, in 
which the fits were said to be limited and uniform in the 
point of beginning. These statements have been in 
some cases the result of the patient’s knowledge, but. 
more commonly of that of members of the family only. 
It is very evident that persons not trained to exact ob- 
servation, and especially those persons whose affections 
are involved, and whose first motive would be to aid the: 
patient rather than to observe the fit, are, as a rule, in- 
competent observers. Frequently, after placing such 
persons under observation in hospital, I have found that 


419 


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the fits had not been at all correctly described. There- 
fore it cannot be too strongly insisted upon that accurate 
observations shall be made the foundation of knowledge 
before we proceed to excise any brain centre. In mak- 
ing these observations, not only should the observer note 
all the phenomena in detail, and especially the muscles in- 
volved—particularly the muscle or muscles first involved 
(Seguin’s “signal symptom”)—and the “march” of the 
fit (that is, the progressive involvement of one muscle or 
set of muscles after another), but the dynamometer 
should be used as soon as possible after the fit to deter- 
mine whether the muscles involved in the fit be paretic. 

Such operations have been seriously objected to on the 
ground of subsequent paralysis. This seems to me not 
to be a valid objection. To exchange epilepsy for 
paralysis would, I think, be a choice at which few pa- 
tients would hesitate. It must also be remembered that 
the excision of a centre for an ordinary group of mus- 
cles, though it be followed by paralysis which may even 
be complete, has resulted eventually in so great a restora- 
tion of power as to convert the paralysisinto only moder- 
ate paresis, probably through the compensative action of 
the centre on the opposite side. Thus, in the third case 
related in my first paper already referred to, in which 
excision of the wrist centre was done, the patient was 
entirely paralyzed from May 30, 1888, till early in July. 
Motion began to return at this time, and when I last saw 
him, in the middle of September, 1888, he had so far re- 
gained control of his hand as to be able to play baseball. 
The fits, however, had persisted, though changed in 
type, there being now but few severe convulsions, and 
only a moderate number of attacks of petit mal. In an- 
other case in which I excised the thumb centre the hand 
and arm became paralyzed to the elbow. This rapidly 
disappeared, and in a few weeks the patient could again 
sew perfectly well and the dynamometer showed no dif- 
ference in the muscular power of the two thumbs. 

As to operative procedure in these cases, it is impor- 
tant, first of all, to obtain a view of the brain sufficiently 
large for the operator to be able to recognize the con- 
volutions. Once the convolutions are exposed, no anti- 
septic solution should be allowed to touch them until the 
centre sought for shall have been well defined by the 
battery. Hot water, however, may be used to check the 
bleeding. As soon as the brain is uncovered the faradic 
current should be employed by means of my double 
electrode (Fig. 10238, page 409). 

The remainder of the operative procedure is as de- 
scribed in the section on the technique. 

Secondly, in cases of general or “essential” epilepsy 
experience has shown that it is better to refrain from 
operation as a rule. 

INJURIES OF THE HEAD.—Contusion.—In any case of 
serious contusion, the patient should at once be put to 
bed on light diet, and the bowels and general hygiene 
carefully looked to. The patient should then be closely 
watched, and, if any serious symptoms arise indicating 
intracranial mischief, a semicircular flap of the scalp 
should be raised and the bone inspected. If a fracture 
of the bone be discovered and the symptoms are at all 
serious, showing that inflammation of the meninges or 
of the brain substance has set in, or is impending, ex- 
ploratory trephining must be done at once, and the dura 
be opened. Even if no fracture exists, if the symptoms 
are those of encephalitis, trephining should be done. It 
is possible, in such a case, either that a piece of the inner 
table has been separated, with or without external frac- 
ture, or that the dura has been ruptured or the brain 
Jacerated, and that inflammation with exudation has be- 
gun. Once inflammation with its attending proliferation 
has set in, it is essential that a means of escape for the 
exudate be provided for, or for the escape of pus if the 
inflammation shall have proceeded so far. In other 
words, we should treat contusions followed by serious 
symptoms of mischief in precisely the same manner that 
we would treat them in any other part of the body, al- 
ways remembering that in the brain it is impossible for 
any exudate or hemorrhage to find its way to the sur- 





420 


face without surgical assistance, by reason of the bony 
case in which it is retained. Trephining of the skull, 
therefore, is equivalent only to incision through the soft 
parts down to the seat of injury in any other part of the 
body. In many cases of very severe contusion, it would 
be proper immediately to make a horsehoe flap in order 
to determine the question of fracture. The swelling of 
the scalp is often so thick and so dense that in some 
cases it is extremely difficult to ascertain whether a frac- 
ture exists or not without such an incision. It is all-im- 
portant to know this fact, and especially if there be de- 
pression or not, so that the proper treatment shall be 
adopted. Preventive trephining, in many of these cases, 
is not only justifiable but demanded. A simple incision 
through the scalp is of itself unattended with danger in 
these days of antiseptic surgery. It may be objected 
that if a simple fracture exists, by such an incision we 
convert it into a compound one; but the position taken 
by Roberts in 1885 is certainly the correct one, that such 
an incision, with modern surgical methods, adds nothing 
to the danger, and is the only method by which we can 
make an absolutely certain diagnosis in any serious case, 
and so enable us to pursue a course of treatment which 
will diminish or avoid the danger. 

Should there be motor paralysis without any decided 
loss of sensation, there is almost certainly a lesion of the 
cortex; but, as Ferrier has pointed out, if sensation is 
impaired to any extent, there is probably a lesion of the 
sensory tracts of the internal capsule, or of the centres to 
which they are distributed. 

Even after recovery from a severe contusion of the 
head, the patient should be carefully watched for some 
months, as in not a few instances abscesses, cysts, or 
epilepsy has developed after a long time. One case in 
which I trephined, a month after an exploratory incision 
of the scalp alone had been made, was most instructive 
as to the intracranial effects of a very slight extracranial 
traumatism. Inenlarging the trephine opening, I found 
that the dura suddenly became remarkably adherent to 
the bone. Inspection showed me that the area of ad- 
hesion was precisely under the flap of the first operation. 
This had been simply the raising of a flap of scalp, had 
been conducted with the utmost antiseptic care, and had 
healed without incident in a few days; yet the simple 
lifting of this flap had been felt instantly within the 
cranium, and exhibited itself by the strong adhesion be- 
tween the dura and the bone. A severe contusion, 
therefore, it can easily be understood, even without 
fracture of the bone, might set up such inflammation as 
would ultimately lead to suppuration, to the formation 
of a cyst or a tumor, or to such organic changes as would 
be followed by epilepsy. Williams has reported an un- 
usual case in which a blow on the forehead produced an 
abscess which discharged through the nose. 

Compression of the Brain.—In 1885, in a paper read 
before the American Surgical Association, Roberts in- 
sisted that the complexus of symptoms passing under 
the title of “compression of the brain” was due not so 
much to compression as to brain laceration and inflam- 
mation. In cases of encephalic hemorrhage, we cer- 
tainly have an example of compression. Apart from 
this cause, and probably from tumor and from effusion, 
in both of which, however, inflammation has a large 
share, I certainly would agree with the position taken 
by him. A blow which is followed by symptoms of 
compression, when it is sufficiently serious to produce 
violence to the membranes, or laceration of the brain 
tissues, is, as a rule, one which has been followed by in- 
flammation; and it is this inflammation with its exudate 
and swelling that causes the mischief. We are apt to 
think of increased intracranial pressure as a result to be 
looked for only from tumor, abscess, or effusion into the 
ventricles. But it is certainly reasonable to believe that 
mere inflammation of the cranial contents will be at- 
tended by swelling as in other tissues, and that thereby 
the intracranial pressure will be increased. 

An experiment by Felizet is full of instruction. He 
filled a skull with melted paraffin, and after this had 


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Brain, 
Brain. 





cooled, he let the skull fall from a moderate height to the 
floor. The calvarium was then removed. No fracture 
existed, but the surface of the paraffin was flattened at 
the point corresponding to the blow. The skull had 
been momentarily depressed, and had returned again to 
its former shape by its elastic resiliency. Undoubtedly 
the same occurs in the brain, and no such momentary 
changes of form from violence, even though followed by 
a restoration of the organ to its original place, can have 
been produced without more or less laceration of the brain 
tissue. What is to be feared is that inflammation will 
take place, and that the products of inflammation will 
produce symptoms of pressure. Hence, in such cases, 
I would trephine for the same reasons as are given under 
the last heading, if similar symptoms arise. 

Scalp. Wounds and Injuries of the Head.—In every case 
of scalp wound, the head should be shaved over a large 
area, and scrubbed with a nail brushand soap and water, 
followed by an application of ether, and then of a sub- 
limate solution. The scalp should, of course, by this 
process be thoroughly cleansed from all dirt and foreign 
substances, and if need be the edges of the wound should 
be trimmed in order entirely to get rid of the dust and 
dirt. The wound may now, and not until now, be ex- 
amined by a probe and the finger, both of which must be 
entirely aseptic. Should the injury be limited to the 
scalp and the periosteum, after providing for drainage, 
the wound should be closed and dressed antiseptically. 
But should the skull be fractured, it should be treated as 
described below. In wounds which produce a crushing 
or sloughing of the scalp, the late Dr. William Hunt called 
my attention to the fact that the depressed scar result- 
ing from loss of scalp tissue only, not seldom may be mis- 
taken for an old depressed fracture of the skull—an error 
he had known to be made by more than one good surgeon. 

Simple Fracture of the Skull without Depression.—This 
is often exceedingly difficult to diagnosticate. One of 
my patients, a bright, intelligent fellow, experimented 
on his own head the morning after a fall of nine feet, by 
tapping on his head on the injured side. He elicited a 
“cracked-pot” sound which did not exist on the unin- 
jured side. It is possible that this may be sometimes of 
great value in diagnosticating simple fracture without 
depression. If the fracture be simple and without de- 
pression, and without cerebral symptoms, it should be 
treated expectantly, but the moment that there are any 
symptoms of encephalitis the trephine should be used 
for the reasons previously stated. Two most instructive 
cases of such trephining are reported by Heusner. 

Simple Fracture with Depression.—In simple fracture 
with depression I should certainly advise immediate 
preventive trephining, even if there be no sign of en- 
cephalic mischief present, although I am quite aware 
that many conservative surgeons are opposed to such 
radical treatment. As already stated, the conversion of 
a simple fracture into a compound one is at present at- 
tended with no serious risk. It must be remembered 
that any violence sufficient to break a bone and to de- 
press it will unquestionably have produced some lacera- 
tion of the brain substance, and possibly of the dura. 
In addition to this, as the inner table is so much more 
easily fractured than the outer, occasionally a fragment 
may have been detached and driven into the brain. The 
immediate dangers arising from such a fragment of bone 


and laceration of the cerebral tissues and membranes are _ 


those of serious inflammation, and if the products of in- 
flammation are confined within the skull, without possi- 
bility of escape by drainage, the danger is a serious one. 
Even should the patient recover, as is undoubtedly often 
the case, the numerous instances of epilepsy arising from 
irritation of a scar, from a cyst, or from secondary de- 
generation are so great, and the danger of trephining so 
small, that but little choice would seem to exist. 
Compound Fractures of the Skull.—The rule in such 
cases should be always to explore by a large incision 
in the scalp. Should there be no depression, no 
strong probability of separation of the inner table, or of 
serious laceration of the brain, or of hemorrhage, the 





wound ‘should be most scrupulously disinfected, and, 
after careful antiseptic dressing, the expectant plan 
should be pursued. Should the fracture bea mere linear 
fissure, after careful disinfection, if the fissure be at all 
impregnated with hair, dirt, etc., the soiled edges should 
be carefully chiselledk away so as to make sure that we 
have cleaned them of all infective material; for it is in 
the probable infection more than in the mere fissured 
fracture (apart from the violence of the accident) that 
the danger of encephalic mischief lies. In doing this 
only the outer table need be cut away. An antiseptic 
dressing should then be applied. 

But if depression exists, and there are symptoms which 
lead us to believe that serious injury to the brain, or 
fracture of the inner table, or hemorrhage is present, 
preventive trephining should be done at once. It goes 
without saying that a large area of the scalp should be 
shaved and most rigidly disinfected in all these cases. 

Mr. Mayo Robson has reported an excellent illustra- 
tion of the value of comparatively early trephining in 
such cases. A man received a blow on the left side of 
the head directly over the arm centre, the scalp showing 
a small lacerated wound. The right arm was paralyzed, 
this condition being attributed by the surgeon who first 
saw him only to bruising. Later rhythmic epileptiform 
spasms began in this hand, followed by facial paresis, 
cedema of the left optic disc, and exaggerated reflexes 
on the right side. Exploration showed a depressed frac- 
ture, and trephining saved his life. The twitchings dis- 
appeared in six days after the operation. Even had he 
recovered without operation he would probably have 
suffered from a Jacksonian epilepsy. 

Ina case of extensive compound fracture of the oc- 
ciput, so early as 1810, Hutchison boldly anticipated 
modern surgery with the happiest results. The patient 
had fallen thirty feet and fractured the occiput, the frac- 
ture extending into the foramen magnum, as proved at 
the operation. He was trephined at once, and, to the 
embarrassment of the surgeon, the dura bulged beyond 
the outer surface of the bone, and by its elasticity showed 
that there was an extravasation of blood beneathit. The 
next day this was incised, the blood evacuated, and, after 
a tedious illness from a suppuration that would now hap- 
pily be conspicuous by its absence, the patient recovered. 

In Punctured Wounds of the Brain, which are of course 
always compound fractures of the most dangerous char- 
acter, the rule should be adsolute to trephine at once, 
whether there be brain symptoms or not. The almost 
certain danger of septic inflammation, and the need both 
for immediate provision for drainage and for antiseptic 
cleansing of the wound, render immediate trephining 
imperative, just as incision, cleansing, and drainage of 
a similar wound in the soft tissues isthe rule. No better 
illustration could be given than that of a case reported 
by Ball in which a man was struck on the left temple 
with a pen-knife. The wound was not considered serious 
enough to warrant ‘his admission to the hospital where 
he first applied. Ten days later aphasia, word blindness, 
and word deafness set in, without paralysis. Five days 
later he was trephined. The knife blade had penetrated 
the dura and wounded the brain. <A clot was removed 
and drainage provided for. The next day his aphasia 
recurred, but disappeared after the blocked drainage 
tube was made perviousand further clots removed. An 
excellent recovery followed. 

Wagner states that in 81 cases of complicated various 
fractures of the skull freshly treated as above advocated, 
the death rate was only 1.23 per cent.; whereas in 12 
such, treated secondarily, the mortality was 33.5 per cent. 
No better commentary could be made. 

GunsHotT Wounps.—The experience of the last fifteen 
years in cerebral surgery has revolutionized the treat- 
ment of gunshot wounds of the brain. The application 
of antiseptic methods to the treatment of brain injuries, 
the consequent boldness with which we operate on the 
brain and its membranes, the introduction of the gravity 
probe and the making of counter openings by the tre- 
phine, both to search for the bullet and for drainage, 


491 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





are the chief points in which recent practice 
differs from the old. 

The cardinal principles to be applied to gun- 
shot wounds may be stated as follows: First, 
the scalp should be shaved over a large area 
around the wound or wounds, or, better still, 
over the whole head. 

Secondly, the entire wound should be disin- 
fected, from the wound of entrance all the way 
to the wound of exit, or to the site of the ball, 
if the missile has not escaped. 

Thirdly, if hemorrhage has taken place, 
either the wound of entrance or the wound of 
exit, or both, should be freely enlarged by the 
bone forceps or by the trephine, and the ves- 
sels secured by catgut ligatures, or, in rare 
cases, be controlled by pressure or by hemo- 
static forceps. 

Fourthly, the bullet or other missile should, 
if possible, be removed, if need be, by a sec- 
ond trephine opening. 

Fifthly, absolute free drainage should be 
secured, again, if need be, by a counter tre- 
phine opening, even if the drainage tube 
should have to traverse the entire brain. 

Sixthly, antiseptic or aseptic dressings should 
be applied, and the subsequent treatment of the 
case be conducted on general principles. 

The admirable cases of Fenger and Lee, 
Fluhrer, Nancrede, Bryant, and many others 
since have proved conclusively the truth of 
the above maxims, and future wars will tell as 
different a story in cases of penetrating wounds 
of the head as they will in penetrating wounds 
of the abdomen. 

Of the above points several have already 
been considered. The removal of the ball has 
always been one of the chief difficulties in cases 
of gunshot wounds. Fluhrer, in the brilliant 
article alluded to, however, showed a new 
method, which is of great importance. The 
wound having been suitably disinfected, to- 
gether with, of course, the hands of the opera- 
tor and the instruments, etc., the head of the 
patient is so placed that the probable direction 
of the ball will be vertical. The gravity probe 
of Fluhrer, made of aluminum, with large con- 
































Fig. 1028.—Fluhrer’s Aluminum Gravity Probe (full size, except length, which is twelve inches). 











Fie. 1029.—a, The extra-cerebral portion of the probe ; 8, the line taken 
by the probe through the brain; ¢, ¢, ¢, c, lines placed in the direc- 
tion of the probe with the aid of a string. 


422 


ical ends, is now introduced by its larger end. This 
probe is so light that it will not force its large end into 
the brain substance, and so produce a false passage, but 
by its own weight will follow the track of the ball, if 
this be made vertical. If the ball be within easy reach 
it may be extracted by the ordinary methods; if, how- 





Fia. 1030.—e, ¢c, C, c, Lines converging on the opposite side of the head ; 
d, point at which to trephine. 


ever, as shown by the probe, it has penetrated so far as 
to be more accessible from the opposite side of the skull, 
unless important centres lie in the way a counter open- 
ing should be made on the opposite side of the skull at 
the point at which the probe would emerge if pushed 
through. The proper point for the counter opening can 
be best located by the point of intersection of the lines 
determined in various planes by the method described by 
Bryant. Figs. 1029 and 1030 show the method plainly. 
Before the probe has been introduced in the search for 
the ball its length should be measured. If, then, it im- 
pinges against the ball, by measuring the protruding 
part of the probe the difference in the two measurements 
will give the depth at which the ball lies. Pushing the 
probe through to the counter opening, and again meas- 
uring the part protruding from the original opening, 
we ascertain the depth at which the ball lies from the 
counter opening. The probe is now to be carried en- 
tirely through the counter opening and two strands of 
antiseptic silk are attached to its extremity, and on with- 
drawal of the probe the strands of silk will lie in the 
track of the wound. To one of these is now attached a 
No. 9 (French) gum catheter, which should be new and 
carefully disinfected, especially in its interior, 
and within it should be a disinfected straight 
stylet in order to give it rigidity. The stylet 
being ensheathed by the catheter will not mis- 
lead by its metallic sound or feel in the search 
for the metal ball. A pair of forceps is now 
tethered to the catheter by a loop of silk round one of 
its arms, and the ball is searched for at its known depth, 
above, then below, then to the right, and lastly, to the 
left of the catheter guide. Between searching in any 
one direction and the following one the forceps should 
be entirely withdrawn and reintroduced so as not to 
swing around the catheter and thereby, perhaps, injure 
the brain substance unnecessarily. In case the ball has 
struck the opposite side of the cranium, as in Fluhrer’s 
case, it will have rebounded in the direction determined 
by two influences: first, the natural angle of reflection, 
which will probably be about equal to the angle of in- 
cidence; and secondly, the influence exerted by gravity. 
A counter opening having been made, the wound in the 
meninges made by the ball in impinging on the opposite 
wall of the skull should be sought for, and from this, as 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





a new point of departure, a new search may be made in 
the same manner as above with the gravity probe. An- 
other instrument may be used, also, in determining the 
site of the ball. It is the very ingenious invention of 
Dr. Girdner. The “telephonic probe,” if it touch the 
ball, will indicate it by a grating sound, a sound which 
is not produced if it touch any other than a metallic 
substance. 

By the second strand of silk a drainage tube may now 
be drawn entirely through the wound. 

Until recently missiles that lodged in the brain were 
allowed to remain there unless easily accessible, under 
the impression that meddling with the brain with a view 
of removing anything that may have lodged was entirely 
unwarrantable. This, we now know, isan error. The 
missile should in all cases be removed if accessible. Dr. 
Wharton has presented the analyses of 316 cases in which 
foreign bodies were lodged in the brain. Asa result of 
this investigation, in 106 cases in which removal was 
effected, 34 (32 per cent.) died. Of the much larger 
number, 210, in which the missile was not removed, 122 
(58.1 per cent.) died, and of those who lived 10 died from 
the ultimate effects of the ball, and many of the others 
suffered from epilepsy and physical and mental deteri- 
oration. 

Arnold, at the request of Bryant (loc. cit.), investigated 
very carefully 140 cases, and found that of the 85 cases 
in which the missiles escaped primarily, or were re- 
moved, 38 (44.7 per cent.) died. Of the 55 in which the 
missile was not removed, 382 (58.2 per cent.) died, giving 
nearly the same result as Wharton’s tables. 

If the bullet has not escaped, and cannot be found or 
removed directly, or by a counter opening, the wound 
should be carefully disinfected and thorough drainage 
should be secured by a rubber tube carried to the entire 
depth of the wound. If, however, a second opening 
has been made, the drainage tube should be carried en- 
tirely through the track of the wound. 

Drainage should be kept free and thorough, and anti- 
sepsis secured by gentle syringing with sterile salt 
solution, but it should be done with great gentleness. 

FRACTURE OF THE BASE OF THE SKULL.—Besides the 
ordinary dangers from fracture of the vault of the skull, 
we have at the base another danger of great importance, 
that does not at first glance seem to be present, viz., 
probable and insidious communication with the external 
air, and, as a result of it, septic infection that is apt to 
be overlooked. This communication with the outer air 
may take place through the ear, the nose, the mouth, or 
the roof of the orbit. 

Fracture of the occipital bone, involving the base of 
the skull, should be dealt with, of course, as in the case 
of fracture of the vault. 

Heretofore fracture of the base has been excessively 
fatal, and it is a remarkable fact in cerebral surgery that 
Wagner, in the lecture already referred to (page 421), 
states that in twenty-three cases of fracture of the base 
that survived the first forty-eight hours (that is to say, 
those which did not die from the severe primary vio- 
lence), every one of them recovered.* 

If the communication with the air be through the ear, 
as shown by escape of the cerebro-spinal fluid, the first 
thing to do is most carefully to disinfect the ear, after 
having removed all of the wax, dirt, etc., within it. 
This disinfection should extend to all the hollows in the 


external ear and the surrounding scalp, which last should © 


be shaved. The ear should next be well washed out 
with boric acid solution, and the ear and scalp should 
then be covered with sublimate gauze. 

Should the fracture of the base involve the roof of the 
orbit and not communicate with the external air, of 
course it should be treated as a simple fracture without 
operative measures, unless the subsequent history should 
demand it. But should such a fracture be caused by an 
umbrella rib, a splinter of wood, a pair of scissors, or 








*It is impossible, however, on the mere ipse dixit of Wagner, to 
accept the diagnosis of all these cases as undoubted fractures of the 
base. without detailed histories. 


other such vulnerating body, then the whole region 
about the orbit should be carefully disinfected. After 
disinfection by bichloride solution (1 to 1,000) the normal 
salt solution should be used. An incision should then 
be made in the line of the eyebrow, in order to hide the 
subsequent scar, the lid drawn down, the track of the 
wound carefully disinfected, and a considerable opening 
made in the roof of the orbit by a gouge or chisel, rather 
than byatrephine. If the brain itself has been injured, 
the dura should be opened, and the track of the wound 
again disinfected. Thorough free drainage should be 
provided for, and the wound treated as usual. 

Should the fracture involve the nose, the same prin- 
ciple would apply, viz., thorough disinfection and free 
drainage. Trephining here should be through the track 
of the exterior wound, if it involve the base of the nose 
or lower forehead. If the vulnerating body has passed 
through one nostril, of course the nostril should be first 
washed clean and then disinfected with boric acid and 
salt solution, and, after trephining, the same acid should 
be thoroughly insufflated .into the nostril, both from be- 
low and by way of the trephine opening. The trephin- 
ing would probably be done best just above the root of 
the nose, and would, unfortunately, involve the frontal 
sinus, which should always be avoided if possible. But 
the great danger from want of drainage must overcome 
every objection of a minor character. The frontal sinus, 
as well as the wound, should be disinfected, therefore, 
with great care, and the same drainage and dressing be 
applied as heretofore recommended. In order to prevent 
the passage of infective air through the nose, both from 
without and from the lungs, it would be well to plug 
up both anterior nares with a moderate tampon of steril- 
ized cotton for the first three days at least. A tampon 
in the anterior nares would nearly prevent any current 
of air through the nose, even from behind. In children 
it is to be remembered that the frontal sinus is very 
small and ill developed. 

INTRACRANIAL HEMORRHAGE, ESPECIALLY FROM THE 
MimpiE MENINGEAL ARTERY.—Three papers published 
some years ago practically settled the question of the 
treatment of hemorrhage from the middle meningeal ar- 
tery (Wiesmann, Deutsche Zeitschr. f. Chir., Bd. xxi..and 
xxii., 1885; Jacobson, “Guy’s Hospital Reports,” 1886, 
vol. xliii.; and Krénlein in the first journal, Bd. xxiii., 
Heft 3 and 4, 1886). 

The violence that may rupture the middle meningeal 
is but slight in some cases: so slight, indeed, as even to 
leave no mark. <A fracture may exist, but it may be so 
small as not to be recognizable by the touch, and barely 
by sight. Iv a number of cases there will be no frac- 
ture whatever. Stokes reports a case which is a model 
of diagnusis and treatment, in which, after only a bruise, 
trephining evacuated a clot an inch and a half thick, 
followed by immediate relief to the paralysis, and speedy 
recovery. Jacobson (loc. cit.) reports four cases out of 
seventy, of such hemorrhage, in which no fracture ex- 
isted. Anumber of other cases have since been reported. 
In some, of course, the fracture will be both visible and 
palpable, not only over the vault but also at the base of 
the skull. Either the trunk or the branches may be 
ruptured. Of the seventy cases tabulated by Jacobson, 
in two certainly, and in four others probably, the trunk 
was injured; but the divisions beyond the trunk are the 
site of the lesion more commonly than is the main trunk 
itself. 

The adhesions of the dura to the skull, it should be 
remembered, while in general very strong, are very 
slight in the area of the middle meningeal, as pointed 
out by Tillaux, and so favor hemorrhage. 

The symptoms of the greatest value are: First, an 
interval of consciousness between the accident and the 
appearance of serious symptoms. This interval of con- 
sciousness is of the greatest importance, and probably is 
worth all of the other symptoms put together. It is due 
to the fact that it takes a certain amount of time for 
sufficient blood to escape to produce unconsciousness 
from pressure. It was present in two-thirds of Jacob- 


423 


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son’s cases. If the main trunk be injured, or one of its 
larger branches, and the blood poured out rapidly, this 
interval will be very brief, and coma and death will 
quickly supervene. It may even be absent, the second- 
ary coma setting in before the primary unconsciousness 
has disappeared. But not uncommonly it will last for 





Fiq. 1031.—Clot in Hemorrhage from the Middle Meningeal Artery. 
(Jacobson.) ~ 


some hours, or occasionally even for days. But even if 
brief, its possible existence should always be inquired 
into, and if present the other signs of intracranial hemor- 
rhage should be looked for with care. Secondly, there 
is hemiplegia on the side opposite to the hemorrhage. 
This may be progressive, the hemiplegia extending from 
one portion of the body to another, as the extending clot 
presses upon one cortical centre after another; as, for 
example, if the clot be effused over the face centre, the 
face muscles will be paralyzed first, and as the blood 
clot extends upward over the arm centre, paralysis of 
the arm will follow. Such extension is extremely sig- 
nificant. The paralysis, however, may exist on the 
same side as the injury, if the artery has been ruptured 
on the side opposite to the injury, as has not infrequently 
happened. Clark, in just such a case, trephined on the 
same side as the injury and the paralysis, and lost his 
patient, who had a clot in the side opposite to that of 
the injury. Sometimes, though rarely, both arteries 
may be ruptured, as in the remarkable cases of Hill 
(Cases 18 and 19, Jacobson’s paper). If there be no 
paralysis, the dilated and immobile pupil on the side of 
the clot may assist the diagnosis. This was the only 
diagnostic sign in one of my cases. Thirdly, the pulse 
becomes frequent. Fourthly, the respiration becomes 
slow and stertorous. Fifthly, if the clot extends toward 
the base, the pupil on the side of the clot will be dilated 
and immobile, and if the clot be on the left side, aphasia 
also will take place. Sixthly, the temperature will 
probably rise, it may be quite rapidly, and up to 101°- 
103°, or even 104° F., especially on the side opposite to 
that of the clot, according to Horsley. 

The importance of operative treatment is best shown 
by Wiesmann. Of 147 cases treated expectantly, 131 
died (89.1 per cent.); of 110 cases treated actively, only 
36 died (32.7 per cent.)! Besides this, in the majority of 
these cases ending fatally after operation, the extrava- 
sation was not reached, and the clot therefore was not re- 
moved. When, therefore, any of the above symptoms 
are present in a case showing a reasonable ground for 
believing that the middle meningeal or its branches 
have been ruptured, even though some doubt exist, the 
skull should be trephined. 

As to which side of the skull should be operated upon, 
we should be guided by the localizing symptoms rather 
than by the site of the injury. Kronlein (Fig. 1032) tre- 
phined four cases of rupture of the middle meningeal, 
and in two of them removed the clot, and the patients 
recovered. In the other two he failed to find it, and 
both patients died. He states that in by far the greatest 
number of cases the clot will be best reached by trephin- 


424 


ing at a point one inch behind the external angular proc- 
ess of the frontal bone, at the level of the upper border 
of the orbit. Should this not reach the clot, he strongly 
urges that another trephine opening be made just below 
the parietal boss on the same level as the former. By 
not making this last opening he lost the two patients 
alluded to. By the anterior opening access is had to the 
main trunk and the anterior branch of the middle menin- 
geal, and by the posterior to its posterior branch. As 
in not a few cases there will be doubt as to whether 
the rupture is in the anterior branch or trunk, or, on the 
other hand, in the posterior branch, the need for 


.the second opening, in case the first does not disclose 


the clot, is apparent. Having made one or both of these 
openings, the clot should be removed, and either open- 
ing, if necessary, enlarged by the rongeur forceps in 
order to obtain access to it. If the pupil be widely 
dilated, showing that the clot has extended downward 
toward the base, the trephine should be applied about 
half an inch below the level of the upper border of the 
orbit, rather than at its level. 

Should the middle cerebral artery be wounded, it must 
be secured by ligature. The differential diagnosis can- 
not be made at present between hemorrhage from the 
middle meningeal and that from the middle cerebral; 
hence the discovery that the middle cerebral is wounded 
would follow a trephining at the point already indicated 
for the meningeal—viz., an inch behind the external an- 
gular process. If the bleeding point on the middle cere- 
bral be not accessible here, as the artery lies in the fis- 
sure of Sylvius, the trephine opening should be enlarged 
by the rongeur forceps, upward and backward, in the 
line of the fissure, z7.e., in the direction of the parietal 
eminence. 

The clot cavity should be washed out, after the hemor- 
rhage has been controlled, by normal salt solution. 
Drainage should be carefully provided for, and the 
wound dressed in the usual way. Weir, in May, 1885, 
was the first, I believe, to propose that in case the first 
trephine opening would not answer well for drainage, 





Fig. 1032.—Site of Trephine Opening to Reach Clot in Hemorrhage 
from Middle Meningeal Artery. (After Krénlein.) a, b, Horizontal 
line through the auditory meatus; c,d, line passing through the 
eyebrows; ¢é, f, vertical line 8 or 4cem. behind the external angu- 
jar process; g, h, line passing through the posterior border of the 
mastoid process; A, the point where the anterior branch of the mid- 
dle meningeal artery can be reached; and B, the point where the 
posterior branch of the same artery can be reached. (Esmarch and 
Kowalzig.) 


a second one should immediately be made. In doing so, 
not only must the position of the clot be remembered, 
but the second trephine opening should be made also in 
such a position as to favor drainage in the recumbent 
posture. As a secondary measure, it was done by Noyes 
as early as 1882, and later by many others. 

Under the head of hemorrhage should, be mentioned, 
also, a remarkable and instructive case, reported by Dr. 
T. Grainger Stewart and Mr. Annandale, of traumatic 
pachymeningitis interna, accompanied by hemorrhage. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





In consequence of a fall on the occiput, without visible 
lesion of the skull or scalp, in two months there were 
gradually developing vertigo and frontal pain, increas- 
ing optic neuritis, gradually developing stupor, right 
hemiplegia and aphasia, with subsequent normal tem- 
perature. Annandale trephined over Broca’s convolu- 
tion, and found under the dura a space extending three 
inches behind and two inches in front of the trephine 
opening, which was filled with brownish-red fluid. 
Temporary improvement occurred, but the patient died 
five days later. The autopsy showed inflammation of 
the cerebellum, diffused lepto- and pachymeningitis, 
with hemorrhage of the cerebrum on both sides and red 
softening on the left side. This was evidently of inflam- 
matory origin, and it is not improbable that in sucha 
case as this, and in those of serous apoplexy, very early 
trephining might result far differently. 

Ceci (quoted by von Bergmann, loc. cit., p. 112) also has 
reported a case of chronic hemorrhagic paclymeningitis, 
the result of a blow, in which palsy, incontinence, and 
coma were present. Hetrephined over two months after 
the accident, evacuated the blood, and his patient re- 
covered and regained all the motor functions except 
those of the left hand (slight paresis). 

In the British Medical Journal, March 2d, 1889, Spencer 
and Horsley report some remarkable experiments on the 
possibility of controlling hemorrhage from the middle 
cerebral artery and its branches by pressure on the caro- 
tid. The ingravescent form of apoplexy from such a 
rupture, impending apoplexy from intense cerebral con- 
gestion, and some of the severer congestive headaches 
may possibly prove capable of relief by this means. The 
reader must consult the original paper for the grounds 
upon which their conclusions are based. I have operated 
on two such cases and saved one. 

INVETERATE HeADACcHE.—Horsley (Case 7 of his table) 
and von Bergmann (loc. c7t., p. 118) have published two 
cases of relief of fixed and excessively severe localized 
headache by operative interference. In Horsley’s case 
he trephined at the seat of pain and removed a piece of 
the parietal bone, the inner table of which had been per- 
forated and was being eroded by a Pacchionian body. 
Relief from pain had continued for five months after the 
operation. 

In von Bergmann’s case, after all ordinary means had 
been exhausted, the bone was exposed. Its color was 
dark and purplish, as if extravasated blood were seen 
through it. It was greatly thinned, so that he was able 
to cut it with his scalpel. A quantity of tea-like dark 
blood escaped, and the pulsating dura was seen beneath. 
Six months before the operation a stone had struck the 
patient on the head, without, however, wounding the 
skin. This had been followed by considerable localized 
swelling, and the headaches began some weeks after the 
injury. As soon as he recovered from the effects of the 
anesthetic his headache was gone, and the relief had 
continued for certainly three years. I have operated on 
four such cases with resulting cure in three. 

Such operations seem, therefore, to be entirely justifi- 
able in view of the very small risk to life from trephin- 
ing; provided, of course, that the headache be really so 
constant and severe as to justify a reasonable risk, and 
that all suitable medical means have been faithfully and 
ineffectually tried. Very probably simple trephining 
without opening the dura may be all that is necessary 
to effect the cure. In cases of suspected syphilis, the 
iodides should be pushed on the American plan, if 
necessary, up to half an ounce a day, before a decision 
in favor of operation can properly be made. Just such 
a persistent, severe headache (of syphilitic origin) has 
recently been under my care, and has in this way been 
cured, and an operation avoided; less than three drachms 
a day, it was found, did absolutely no good. 

MENTAL DistTURBANCES.—Macewen has reported a re- 
markable case of this kind. The man had received an 
injury a year previously. and was suffering from melan- 
cholia, with homicidal tendencies. These were attended 
by paroxysms of pain, which were not well located. 


. hallucinations and melancholia. 


Brain, 
Brain, 





There were no motor phenomena, but it was discovered 
that immediately after the accident, for two weeks, he 
had suffered from psychical blindness. He could see, 
but what he saw conveyed no impression to him. He 
recognized his New Testament by touching its smooth 
leather cover with the deep indented letters on the back, 
but on opening it the printed words were unknown 
symbols to him. At the operation the angular gyrus 
was exposed, and it was found that a portion of the inner 
table had been detached and had produced pressure on 
the posterior portion of the supramarginal convolution, 
while a corner of it lay embedded in the anterior portion 
of the angular gyrus. The bone was removed from the 
brain and replaced in its proper position. He was 
greatly relieved from his mental state, though still ex- 
citable. He was at work when the case was reported, 
and had made no further allusion to his homicidal ten- 
dencies. This localization of a single mental process is 
of great importance. The fact that Macewen was able, 
by a careful and shrewd examination, to elicit so impor- 
tant a localizing symptom from a case which was obscure 
both in its history and in its visible lesions, is a source 
of great encouragement. 

Besides the case just alluded to, in which psychical 
symptoms led to the localization of the lesion, there are 
a number of cases on record in which insanity has fol- 
lowed injury and has been cured by operation involving 
the brain. One is reported by Hoffman: A man, fifty 
years of age, was made unconscious by a blow on the 
head, which, however, produced neither fracture, con- 
vulsion, nor paralysis, but was followed by pain in the 
head and aphasia, and a tender spot above and in front 
of theright ear. Insanity developed after healing. The 
cranium was opened by a chisel over the tender spot. 
The dura bulged but did not pulsate. An incision 
evacuated a half-ounce of cerebro-spinal fluid. The 
brain tissue had been lacerated by the blow. The pa- 
tient recovered both from the operation and from his 
mental alienation. 

McDonald reports a case of insanity following a pistol 
wound. The wound was three-eighths of an inch to the 
right of the middle line, and at the junction of the an- 
terior and middle thirds of the first frontal convolution. 
The skull was opened eighteen months after the injury. 
There was no bone, but only fibrous tissue, at the point 
of injury. At the fourth puncture by a hypodermatic 
needle, two drachms of serum were removed. On re- 
covery from the anesthetic the patient had regained his 
sanity. 

Bennett and Gould report the case of a man who re- 
ceived a severe blow two and three-fourths inches be- 
hind the meatus, and three and one-half inches to the 
right of the middle line. Six weeks afterward epilepsy 
developed, followed by mania, so that he was placed in 
anasylum. Trephining was done and the brain explored, 
in three or four different directions, to the depth of one 
inch, but nothing was found. The patient recovered 
both from his epilepsy and from his insanity. 

Rannie reports the case of a woman who had tertiary 
syphilis. For eighteen months she had suffered with 
frontal and parietal pain on the right side, with tender- 
ness of the scalp and discharge from the right ear, all of 
an intermittent character. There was no evidence of dis- 
ease of the middle ear. She also suffered from visual 
Her disease finally cul- 
minated in epilepsy affecting chiefly the left side, includ- 
ing the face. The attacks were followed by marked 
paresis on the left side. She was trephined over the 
right pre-Rolandic convolution. Theskull and the dura 
were thickened. On opening the dura a small quantity 
of purulent fluid ran out which was found to come from 
a small degenerating gumma in the dura. Very slight 
opacity of the membranes existed. Three weeks later 
she was walking without any droop, and the motor 
power of the left arm was steadily improving. The 
headache and tenderness of the scalp had disappeared, 
and her mental condition was very much improved. 

A large number of similar instances have been since 


425 


Brain, 
Brain. 


reported. While there have been many failures, the suc- 
cesses have been considerable, quite enough to warrant 
surgical interference in suitable cases. 

TREPHINING FOR ARRESTED DEVELOPMENT.—AS a 
rule it is better to leave these cases alone. Extravagant 
claims and promises have been made by some surgeons, 
but they have not been realized in practice. 

TAPPING OF THE LATERAL VENTRICLES AS A DEFINITE 
SureicaAL ProcepuRE.—In November, 1888-89, I first 


R 





Fic. 1033.—(Drawn by Dr. John M. Taylor.) Antero-Posterior Section 
of the Head One-Half Inch from the Middle Line. R, Fissure of 
Rolando; I, inion; A and B (solid), the lines of puncture, the 
dotted lines showing their imaginary continuation to the opposite 
fixed points. 


proposed the tapping of the lateral ventricles as a definite 
surgical procedure. Since then it has been done scores 
of times and as a rule with benefit. I had hoped that it 
would serve the same purpose as cceliotomy for tubercu- 
lous peritonitis. The few cases in which this fatal disease 
has been thus treated have proved that it is of little use. 
But it has been of great use asa palliative measure for the 
relief of the intense headache accompanying especially 
tumors pressing on the veins of Galen and the straight 
sinus. Moreover, the operation has dispelled the idea 
that opening the lateral ventricles is necessarily fatal. 
In a paper read at the International Medical Congress in 
Berlin in 1890 (Lancet, September 13th, 1890, New York 
Medical Record, September 20th, 1890), but unfortunately 
published only in abstract, as the original was lost by the 
secretary, I quoted many cases of such a lesion followed 
by recovery. 

Operative Technique.—In doing the operation it is clear 
that we must avoid the motor zone, Broca’s centre for 
speech, and any other well-defined centres for the special 
senses, and also the regions of the large blood-vessels of 
the brain, the middle meningeal, and the middle cerebral 
arteries. A number of experiments on the cadaver led 
me to point out three practicable routes for the pur- 
pose. They are all, of course, only provisional, until 
experience shall show us a better one. 

First, from a point from one-half to three-fourths of 
an inch on either side of the median line, and one-third 
of the distance from the glabella to the upper end of the 
Rolandic fissure. This is high enough to avoid the 
frontal sinuses, and is in advance of the motor area. A 
three-quarter-inch trephine opening having been made 
and the dura having been incised crucially, a grooved 
director should be thrust slowly into the brain tissue in 
the direction of the inion. The director will traverse 
the first frontal convolution. Ata depth of two to two 
and one-fourth inches the normal ventricle will be 
reached. Should it be distended, it would be reached at 
a less depth. 

Secondly, trephine, ete., as before, "midway between 
the inion and the upper end of the Rolandic fissure, one- 


426 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ° 


half or three-fourths of an inch from the median line. 
This is high enough to avoid the cuneus, the wounding 
of which would produce hemianopsia. The director 
should now be slowly thrust into the brain toward the 
inner end of the supraorbital ridge on the same side. 
The director will traverse the precuneus, and the normal 
lateral ventricle will be reached at a depth of two and 
one-fourth to two and three-fourths inches from the 
scalp. A distended ventricle will, of course, be reached 
at a shorter distance. 

Thirdly, trephine, etc., as before, at a point an inch and 
a quarter behind the external anditory meatus, and one 
inch and a quarter above Reid’s “base line.” This will 
expose the second temporal convolution. It is possible 
that this may be the site for hearing of the opposite ear, 
but it has been punctured ina number of cases of abscess 
in the temporo-sphenoidal lobe without apparent injury 
to hearing. The director should be carefully thrust into 
the brain in the direction of a point vertically over the 
opposite meatus, and two and one-half or three inches 
above it; when at a depth of two or two and one-fourth 
inches the normal lateral ventricle would be reached, 
either at the beginning or in the course of the descending 
cornu. I have advised the use of the director rather 
than the hypodermatic needle, for the reasons already . 
stated in the section on abscess of the brain. The fluid 
having been found, a bundle of horse hairs or a drain- 
age tube should be inserted for a suitable length of time. 
In order to prevent possible loss of the drainage tube in 
the cranial cavity, it may be passed through a button- 
hole opening in the flap, and, if necessary, be secured to 
the flap by a stitch. To regulate the amount of drain- 
age through the tube it may be closed by a disinfected 
wooden plug. In this a V-shaped slot may be cut, and 
the size of the slot will regulate the rapidity of the drain- 
age. Whether the drainage shall be continued for more 
than twenty-four hours, a longer experience must decide, 

Of the three proposed routes my preference is for the 
lateral opening. This route has a great advantage in 
that by it we can explore for abscess of the temporo- 
sphenoidal lobe, and also for effusion into the ventricles, 
by the same trephine opening. The drainage could be 





Transverse Section ot 


Fig. 1034.—(Drawn by Dr. John M. Taylor.) 


the Head One Inch and a Quarter Behind the Meatus. The contin- 


uous line shows the line of puncture, the dotted line its imaginary 
continuation to the opposite side of the skull. 


either favored or hindered by the patient lying with the 
operated side down or up. Should prolonged drainage 
prove to be wisest, the posterior route might be the 
best one. The anterior route would hinder drainage, 
and as an additional disadvantage there would be a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








visible scar. As to a choice of which side it is best to 
operate on, we should select the side of the diseased ear, 
if there be such disease, or if not, then that side which 
is tender to either pressure or percussion, or both. 

After the above was written my attention was called 
to the fact that Wernicke, so long ago as 1881, proposed 
to tap the ventricles, and that Zenner renewed the pro- 
posal. At the time of writing my paper I was wholly 
unaware of their propositions, and in referring to them 
I find that, while I must disclaim priority for the sug- 
gestion, I may claim that I have established exact rules 
for the operation and described its precise technique. 

January 11th, 1889, in my clinic at the Woman’s Hospi- 
tal, I first performed the operation. I found it easy, and 
the rules I laid down proved to be correct. The patient 
was a fat and hearty boy, of four, suffering, it was 
thought probable, either from tumor or chronic menin- 
‘gitis with effusion, most likely a tumor of the cerebellum 
pressing on the straight sinus or the veins of Galen. 
‘There were no symptoms by which it could be more ac- 
curately located. His head had begun to enlarge about 
the early part of December, 1888, and measured twenty- 
one and three-eighths inches in circumference (exactly 
the measurement of my own head), with a biparietal di- 
ameter of six and one-fourth inches. At Christmas he 
became blind. For this he was brought to Prof. George 
Strawbridge, to whose courtesy I owe the case. There 
was great choking of both discs and threatened blind- 
ness. The general health was good, and the tempera- 
ture was normal. As the approaching blindness from 
the increased intracranial pressure was the immediate 
danger, I decided, with Dr. Strawbridge’s assent, to tap 
the ventricles, and selected the lateral route. I removed 
a one-half inch button of bone, one inch and a quarter 
behind the left meatus and one inch and a quarter above 
Reid’s base line. The dura pulsated and bulged. In 
the dura as in the skin, I made a small crucial incision. 
I then slowly introduced a hollow needle (of the size of 
No. 5 of the French catheter scale), into which I had al- 
ready pushed three doubled horse hairs nearly to the 
end. I introduced it toward a point two and one-half 
inches above the right meatus. At adepth of an inch 
and three quarters from the dura I suddenly felt a marked 
diminution of the pressure, and said to the class that I be- 
lieved I had entered the ventricle, and in a moment the 
fluid began to escape. This fluid was found to contain 
sugar and albumin. It was slightly turbid, with small 
flakes in it. ; 

The horse hairs were now pushed in as the tube was 
pulled:out. About three ounces of fluid escaped during 
the operation. Anample sublimate dressing was applied. 
During the first week from two to four ounces escaped 
daily, and the choking of the discs diminished from 2.30 
to 1.09 mm. in each eye, the decrease being measurable 
From day to day. At the end of the first week I explored 
for a possible tumor by thrusting a probe in two direc- 
tions into the left occipital lobe to the depth of three and 
a half inches. Finding no tumor Imadeasmall opening, 
by asimple gouge, in the occipital bone, below and to 
the left of the inion. Through this I probed the left 
lobe of the cerebellum to a depth of two inches, and 
then obliquely across into the right lobe two and a half 
inches, but found notumor. There was no reaction from 
these procedures, and the wound healed promptly. At 
the end of the second week the choking was reduced to 
0.96 mm, As in spite of the drainage the swelling was 
subsiding very slowly, and Dr. Amy 8. Barton, who 
kindly examined the eyes for me, reported that there 
was beginning atrophy of the nerves, I removed the 
horse hairs and introduced a small rubber tube into the 
ventricles. For a week this gave vent to from four to 
eight ounces of fluid daily. Except a temporary rise of 
temperature, no reaction followed. At the end of four 
weeks, as the boy’s general condition had deteriorated, 
especially when from choking of the tube the drainage 
was poor, I removed another similar half-inch button 
at a corresponding point above and behind the right ear. 
I then explored the right occipital lobe as far as to the 


Brain, 
Brain. 








tentorium and falx, but found no tumor. I therefore 
tapped the ventricles from the right side by a drainage 
tube. Following this, there was a brief but sharp rise 
of temperature to 104° F., which, however, quickly 
subsided. Four days later I washed out the ventricles 
from side to side by eight ounces of a warm boric acid so- 
lution (gr. iv. to 31.), evidently to the boy’s comfort, and 
with no results of a deleterious character. The boy died 
fifty-two days after the first operation. The autopsy 
showed that at the site of the drainage tubes, even after 
so long a time, there was not the slightest trace of in- 
flammation either on the cortex or in the ventricular 
cavities, and the cerebro-spinal fluid evacuated at the 
autopsy was less turbid than that evacuated at the 
operation. There was not any perceptible trace of the 
various punctures. The cayse of death was a tumor of 
the cerebellum. The probe had penetrated it, but as its 
density was about the same as that of the brain, its pres- 
ence could not be appreciated. 

The case showed clearly that the rules which I formu- 
lated for the operation are exact; that the procedure is 
easy and safe; and that the ventricies may not only be 
drained, but even irrigated, without causing any deleteri- 
ous results. (For bibliography see Note at end of 
volume.) W. W. Keen. 


BRAIN: SYPHILIS.—Syphilis of the brain may de- 
velop as the result of inherited syphilis, or during the 
secondary or tertiary stage of the acquired disease. 

In hereditary syphilis the evidences of an affection of 
the brain are manifested, as a rule, during childhood. 
According to Fournier the disease begins generally be- 
tween the ages of three and eighteen years. In rare cases, 
however, it is observed in early childhood. Forexample, 
marked arterial changes were presented by a girl of fif- 
teen months suffering from hereditary syphilis. In this 
case the dura mater was smooth and pale, the pia mater 
presented numerous circumscribed patches of thickening 
over the cerebral lobes. There was slight thickening 
around the large arteries at the base of the brain, and 
most of these vessels were thickened and hard. The bas- 
ilar artery was completely plugged, and the upper part 
of the vertebral arteries contained tolerably soft thrombi. 

On the other hand Ljunggren reports a case, beginning 
at the age of thirty-three years, which he attributed to 
hereditary syphilis. 

In any event, however, hereditary syphilis is a com- 
paratively rare source of cerebral disease. It was for- 
merly held that, in acquired syphilis, nervous mani- 
festations were observed almost exclusively among the 
very late symptoms. Many neurologists now hold 
the very opposite opinion, and this view is also gain- 
ing ground among syphilidologists. So far as our 
knowledge goes, the earliest development of cerebral 
symptoms was observed by Brasch, who reported the 
following case: The patient, aged forty-three years, was 
infected with syphilis in the early part of August, 1893. 
In the middle of September, 1898, he had an attack of 
right facial paralysis and headache. In the beginning of 
November, 1898, he suffered from dizziness and headache 
and the paralysis was unchanged. In the beginning of 
December there was difficulty of hearing on both sides, 
and examination showed that this was probably due to 
labyrinthine disease. On February 19th, 1894, he was 
discharged, free from symptoms. In March, 1894, there 


‘was a return of the headache, vertigo, and difficulty of 


hearing. May 380th, left hemiplegia developed, but im- 
proved under antisyphilitic treatment. Then the condi- 
tion grew worse, bulbar symptoms set in and the patient 
died on October 30th, 1894. 

The autopsy showed purely vascular disease most 
marked at the base, but also present in other vessels. 
The hemiplegia was due to softening in the anterior part 
of the right half of the pons. The microscope showed 
advanced endarteritis sy philitica; secondary degeneration 
of the right pyramid from the pons lesion down to the 
cord; degeneration of both acoustic nerves in their extra- 
cerebral course, and disease of both ventral nuclei; both 


497 


Brain. 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








facial nuclei and roots were intact, but the right root ex- 
hibited, a short distance before its exit from the brain, 
an abundant development of spindle cells, while the per- 
ipheral nerve showed parenchymatous and interstitial 
changes. 

While this case and other similar but less striking 
ones prove conclusively that cerebral lesions may de- 
velop among the very earliest manifestations of the con- 
stitutional disease, we still adhere to the older view that 
in the majority of cases syphilis of the brain is a late 
manifestation. Indeed, the symptoms of secondary 
syphilis very often are entirely or almost entirely absent, 
so that we may be compelled to rely upon the grouping 
of the cerebral symptoms in arriving at a diagnosis of 
the previous infection. Numerous cases have been re- 
ported in which twenty, thirty years or more have 
elapsed between the initial lesion and the outbreak of the 
cerebral symptoms. 

In addition to the direct etiological significance of 
syphilis in the production of brain disease, it also seems 
to exert a malign influence after the constitutional dis- 
ease has run its course (parasyphilitic affections of Four- 
nier). This is seen particularly in dementia paralytica 
and locomotor ataxia. In the large majority of such 
cases a previous history of syphilis can be elicited, but 
the diseases are distinguished from syphilitic affections 
proper both by the character of the anatomical lesions 
(purely degenerative) and by the utter uselessness of 
antisyphilitic treatment. In these diseases we assume 
the existence of a primary degenerative process, resulting 
from a chemical poison which has been produced by the 
syphilitic germs (metasyphilis or parasyphilis). It is not 
true, however, that dementia paralytica is always the 
result of constitutional syphilis. 

Among the exciting causes which may lead to localiza- 
tion of the syphilitic virus in the brain may be mentioned 
mental overwork and prolonged worry, injury to the 
head, and alcoholism. 

PaTHoLoGiIcaAL ANATOMy.—Syphilis may attack the 
bones of the skull and all of the structures within the 
cranial cavity, the vessels, meninges, or brain tissue, 
either singly or in combination. The lesions are usually 
multiple in character. 

One of the most frequent forms of cerebral syphilis is 
a lesion of the vessels, which attacks usually the vessels 
at the base of the brain or their Jarge branches. The 
disease may begin independently in these vessels or it 
may spread from adjacent foci of disease in the meninges. 

Heubner, who was the first to call attention to specific 
lesions of the cerebral vessels, describes them in the fol- 
lowing words: The vessel becomes less transparent and 
somewhat whitish, finally grayish white; it then becomes 
cylindrical in shape and very rigid. Upon transverse 
section the lumen of the vessel is found narrowed by new- 
formed tissue which develops between the elastic lamella 
of the tunica intima and the endothelial layer. The new 
tissue consists at first of endothelium cells which con- 
tinue to proliferate and change into a firm connective 
tissue consisting of spindle and stellate cells into which 
round cells emigrate from the nutrient vessels of the 
artery. 

While this endarteritis of Heubner has also been ob- 
served by other writers, changes of a periarteritic and 
mesarteritic character have been frequently described. 

According to Baumgarten, the process begins, as a 
rule, in the outer layers of the vessels as a gummatous 
periarteritis, while the intima is only affected secondarily 
by proliferation of cells. 
tumors (from the size of a poppy seed to that of a cherry 
pit) upon the arteries, meninges, and cerebral nerves; 
they consisted of granulation tissue and were associated 
with endarteritic changes in the intima. Gummatous 
arteritis has also been observed by other writers. 

Koester claims that the process starts from the vasa 
vasorum of the external layers of the artery, and that 
the leucocytes emigrating therefrom form inflammatory 
foci in the muscular coat. The affection begins, there- 
fore, as a mesarteritis while the endarteritic prolifera- 


428 


He found little yellowish. 


tions develop secondarily by immigration of cells from 
without. 

According to Abramov, all three layers of the vessels 
are attacked independently of one another. Dilatation 
of the vessel may be produced by destruction of a cireum- 
scribed part of the vascular wall from proliferation start- 
ing either in the external or in the internal layer. If the 
proliferation starts in the tunica intima, a dense accumu- 
lation of elastic tissue is produced, due to splitting of the 
fenestrated membrane. Abramov came to the conclusion 
that the microscopical findings are insufficient to prove 
the syphilitic character of the vascular disease, unless 
gummy nodules are found in the walls of the vessels. 

Hyaline degeneration has also been described in the 
small vessels of the brain. 

Gummata’constitute another frequent form of syphilitic 
lesion of the brain. As a rule, these tumors start from 
the meninges or the prolongations of the latter into the 
brain substance. In exceptional cases, the gumma is 
located in the central ganglia or other parts within the 
brain, but it is probable that even in these cases they 
start from prolongations of the pia mater. 

In the large majority of cases the tumor is situated on 
the meninges of the convexity and at the base of the 
brain. They vary in size from that of a pin’s head to 
that of a walnut or even hen’s egg. The miliary form 
is rare and may be mistaken for miliary tubercles. 

Gummata belong to the class of infectious granulo- 
mata, 7.e., they are composed of granulation tissue or 
densely aggregated round cells. The connective-tissue 
stroma is very-scantily developed. The smaller tumors 
may exhibit a uniform grayish or grayish-red color, but 
the larger ones are speckled with yellowish foci. A few 
stellate and spindle-shaped ceils are found among the 
round cells. The yellowish foci are the result of simple 
necrosis of the round cells or caseation, and this is due 
to the relatively small number of vessels and the con- 
sequent poor nutrition of the parts. Some of the cells 
are also apt to be converted into firm connective tissue, 
which traverses the tumor in broad bands. 

In cerebral syphilis we also find a diffuse gummy in- 
flammation of the meninges, and this may or may not be 
associated with the presence of circumscribed gummata. 
This process is situated most frequently at the base of 
the brain and is often most marked over the optic chiasm. 
The pia mater in this locality is found thickened in vary- 
ing degrees; in places the thickening is quite soft, in 
other parts it is firm and dense. This process surrounds 
the nerves at the base and sometimes compresses them, 
or the round-cell infiltration may spread into the tissue 
of the nerves. The process may also extend into the 
vessels of the circle of Willis. Usually the cortex is 
adherent to the pia mater, and the former is torn when 
an attempt is made to detach the meninges. 

Gummy meningitis is also not uncommon at the con- 
vexity of the brain, but here it is more apt to start from 
the dura mater. This is perhaps owing to the fact that 
gummy tumors start not infrequently from the inner 
surface of the vault of the cranium. Apart from the 
specific lesions which we have just described, the brain 
may also exhibit secondary lesions, such as hemorrhage 
and spots of softening, varying in extent according to 
the character of the primary lesion. 

The heterogeneity of the lesions of cerebral syphilis is 
increased still further by the fact that the spinal cord 
may also be the site of syphilitic processes. 

Some writers also maintain that syphilis may give rise 
to ordinary, non-specific inflammatory processes in the 
brain, such as Virchow’s encephalitis of childhood, spots 
of softening, and chronic disseminated foci of inflamma- 
tion. None of the reported cases, however, seems to be 
entirely free from doubt. 

In quite a considerable number of cases it has been de- 
monstrated that syphilis has given rise to degenerative 
processes in the nuclei of various cerebral nerves (nuclei 
of the ocular muscle nerves, glosso-pharyngeal nucleus, 
trigeminal and acoustic nuclei). 

Symproms.—It is evident from our brief résumé of the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain. 





pathological anatomy of cerebral syphilis that the symp- 
toms must vary greatly in character. Nevertheless, there 
are certain prodromal symptoms which may be common 
to various forms and localizations of the disease. 

The most prominent prodrome is headache. This is 
always present when syphilis attacks the bones of the 
skull, but is also frequent when the osseous structures 
are unaffected. Formonths it may be the sole symptom. 
The pain is usually of a boring, pressing, often agoniz- 
ing character, with marked nocturnal exacerbations, as a 
rule, though it is not very infrequent to find the pain 
equally severe during the day. The pain is often so 
severe that it gives rise to persistent insomnia; but the 
latter symptom may also be present for a considerable 
period independently of the occurrence of pain. In not 
a few cases the headache is associated with attacks of 
dizziness and sometimes with vomiting. Sometimes the 
only prodrome noticeable for quite a while before the 
advent of other symptoms is an inexplicable fear “ that 
something is going to happen,” and this feeling some- 
times causes great mental depression. 

Paralysis of one or more of the ocular muscles may 
also be an early symptom. Sudden development and 
almost equally rapid disappearance of these paralyses 
are very characteristic of syphilis. Indeed, the sudden 
occurrence of ocular palsies inan adult, in the absence of 
other cerebral symptoms, should always lead the physi- 
cian to make a very thorough examination into the ques- 
tion of their syphilitic origin. 

Individual cases of syphilis of the brain present such 
a varied and heterogeneous history that it becomes ex- 
tremely difficult to give a general description which will 
be applicable to any considerable group of cases. A 

_tolerably well-defined symptomatology attaches to syph- 
ilis of the cerebral yessels, which we will first describe. 

This form of disease is often preceded by headache, 
of the variety described above, which may last for a 
variable period, sometimes even for months, before the 
special symptoms develop. When the vessels supply- 
ing the pons or medulla are implicated, glycosuria or 
albuminuria may be associated with the headache. A 
characteristic phenomenon of a small series of cases is a 
peculiar drowsiness which may continue for several 
months and may precede or follow other evidences of 
disease of the vessels. The patients go about as if “ina 
haze”; their movements, both mental and physical, are 
slow and deliberate, as if consciousness, before struggling 
to the surface, had to overcome some unusual resistance. 
In some cases, deep coma develops from which it may be 
impossible to arouse the patient for days and days, or 
this condition may alternate with periods of delirium. 

In a considerable proportion of cases the symptoms ref- 
erable to disease of the vessels develop quite suddenly 
(sometimes as rapidly as in cerebral embolism) or within 
one or two days. The clinical history is then the same 
as that of embolism or thrombosis from other causes. 
The patient often develops hemiplegia, associated quite 
frequently with aphasia, if the paralysis is on the right 
side of the body. Aphasia may also be the sole symptom 
of an attackof this kind. In the majority of cases under 
our observation consciousness was retained either entirely 
or partially during the attack. Sometimes the duration 
of the paralysis is very brief and the patient is rapidly 
restored to the status quo ante. The entire seizure may 
be represented by a feeling of weakness or a sensation 
of numbness and tingling on one side of the body. 

The hemiplegic attacks may be repeated from time to 
time. A patient under my observation had five attacks, 
in one of which both sides of the body were paralyzed in 
rapid succession. In cases of this kind, pseudo-bulbar 
symptoms are very apt to develop. 

As a rule, the patient eventually suffers from symp- 
toms indicative of other forms of syphilitic affections of 
the brain. 

Gummy meningitis of the base of the brain also merits 
separate consideration. In this form likewise headache 
is a prodromal symptom and resembles in character the 
form described above. The headache is attended not 


infrequently with vertigo, which may appear either in 
paroxysms—the usual course—or may be more constant. 
Morbid conditions of sleep alternating with periods of ex- 
citement are also not uncommon prior to the onset of 
those symptoms which point more directly to a basilar 
affection. These conditions may also persist after the 
later symptoms have been fully developed. Asa general 
thing they are manifested by semi-consciousness, from 
which the patient may be easily aroused or during which 
he performs various automatic actions. The return to 
complete consciousness may be quite rapid. At times 
the coma is quite complete and it is impossible to arouse 
the patient. In a case under our observation the patient 
remained completely unconscious for a week; this condi- 
tion was unattended by stertorous breathing and the pulse 
was normal. 

One of the most characteristic features of syphilitic 
basilar meningitis is the implication of the cerebral nerves, 
and chief among these is the motor oculi communis. In 
many cases both nerves are involved, and in the majority 
of cases a great part of the entire nerve supply is affected. 
As we have already stated, a single muscle alone may be 
paralyzed, and this is particularly apt to be the levator 
palpebree superioris. 

The trochlear and abducens nerves are attacked with 
much less frequency than the motor oculi. The pupils 
sometimes exhibit inequality; myosis or mydriasis may 
be present in one or both eyes. The Argyll-Robertson 
pupil has been observed frequently and is sometimes the 
sole indication, for a long period, of a cerebral affec- 
tion. In one case under our observation, the right pupil 
was normal while the left showed the Argyll-Robertson 
symptom, 

The optic nerve is not infrequently the site of disease 
and may exhibit the appearances of choked disc or simple 
optic atrophy. In the majority of cases these processes 
are due to an extension of the syphilitic lesion directly 
to the optic chiasm or nerves, or to compression of these 
parts. Ina considerable number of cases hemianopsia is 
observed. This may persist unchanged or there may be 
a gradual development of complete blindness, the latter 
being limited generally to one eye. Temporary amau- 
rosis, sometimes lasting only a day or two, is observed 
not so very rarely in this form of the disease. 

In comparatively rare cases the other cerebral nerves 
may be affected, either separately or, more frequently, 
in varying combinations. The olfactory and trigeminus 
nerves are especially apt to be involved. The paralyses 
due to lesion of these nerves are always peripheral in 
character, 

As we have already seen in the section on Pathological 
Anatomy, gummy meningitis is very apt to be associated 
with lesions of the vessels of the circle of Willis. When 
this happens, the clinical history is complicated by the 
symptoms described on page 244. The hemiplegia pro- 
duced under such circumstances is combined, more fre- 
quently than in paralysis due to other brain lesions, with 
hemianesthesia and hemianopsia. The morbid conditions 
of sleep and unconsciousness, to which we have already 
referred, are frequently present in this form of the dis- 
ease, and general impairment of the mental faculties is 
not uncommon. 

Gummy meningitis of the convexity of the brain is 


often found independently of lesions of other parts of 


the organ. This process starts with comparative fre- 
quency from the inner table of the skull or the dura 
mater, and may or may not complicate a well-defined 
gummy tumor. As in the other forms of cerebral 
syphilis, headache is a prominent prodromal symptom. 
In not a few cases the headache is attended with localized 
tenderness on percussion of the skull. The most signifi- 
cant symptom of this form of disease is cortical or Jack- 
sonian epilepsy. Thissymptom may begin with a sensory 
aura in the arm, leg, face, or tongue, which is soon fol- 
lowed by muscular twitchings. At the outset the con- 
vulsions are limited to one side of the body and for a con- 
siderable period may involve only one or more groups of 
muscles. Butafter they have lasted fora variable period 


429 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





they may become much more general and finally may 
extend over the entire body. Asa rule, it is found that 
the convulsion spreads in a definite manner from one 
group of muscles to another, and that the mode of pro- 
gression remains the same in subsequent attacks. Con- 
sciousness is often retained throughout the seizure, 
though it is generally lost when the convulsion extends 
to both sides of the body. After each attack slight 
paralysis may develop temporarily in the affected parts. 
It grows most pronounced after repeated attacks and 
finally may remain permanent. The convulsions some- 
times recur with such frequency that the status epilep- 
ticus develops. In not a few cases this condition is the 
immediate forerunner of death. 

Like other cerebral symptoms of syphilis, cortical 
epilepsy and paralysis may disappear suddenly and 
may remain absent for many months, even without anti- 
syphilitic treatment. 

The monoplegias due to meningitis of the convexity 
sometimes develop prior to the epileptic attacks. Further- 
more, the monoplegia may be converted suddenly into 
hemiplegia on account of extension of softening down- 
ward into the white matter of the hemispheres. 

The symptoms described above are due to localization 
of the lesion in the motor zone. Meningitis of other 
parts of the cortex will produce symptoms corresponding 
to the functions of those parts. The most frequent 
symptoms are aphasia and hemianopsia. The aphasia is 
often ephemeral in character and may even last only 
a few minutes at a time It is apt to be attended or 
preceded by convulsive twitchings on the right side of 
the body, starting usually from the muscles of the face 
and tongue. After a variable period the aphasia usually 
becomes permanent. 

Hemianopsia, due to an affection of the occipital lobes, 
is not very rare. This symptom is apt to be attended by 
visual hallucinations, which are referred to the blind side 
of the field of vision. When the meningitis is more dif- 
fuse and extends over a considerable part of the convex- 
ity of one or both sides, mental disturbances may be the 
chief feature in the clinical history. In such cases the 
first symptom noticeable may be a change in the char- 
acter of the patient, who becomes morose, peevish, irri- 
table, loses judgment in business affairs and exhibits de- 
cided lapses of memory. There may be a pronounced 
melancholy tinge at an early stage. In rarer cases, 
maniacal attacks, sometimes attended with destructive- 
ness, are observed very early. Ideas of grandeur may 
be noticed at times, but, as a rule, they are not very per- 
sistent or well defined, and they do not last as long as in 
general paresis. Headache may be a prominent symptom 
and usually exhibits the well-known syphilitic character- 
istics. Speech sometimes becomes slow and labored, and 
there may even be tremor of the tongue and twitchings 
of the lower facial muscles. The dominant symptom, 
however, is the mental failure, which usually progresses 
more or less rapidly, but sometimes shows very pro- 
nounced remissions. Paralysis of*various cerebral nerves 
is quite common, likewise sudden attacks of temporary 
aphasia. Convulsive or apoplectiform seizures are also 
frequently observed and serve to increase the resemblance 
to general paralysis of the insane. Indeed, the latter 
disease is found in such an immense proportion of cases 
among syphilitic subjects that it may be difficult or even 
impossible to distinguish it from cerebral syphilis. 

Gummy tumors, when solitary and uncomplicated 
with other lesions of the brain or vessels, present the 
same clinical history as do other varieties of tumor, except 
that» exacerbations and remissions of the sympéoms are 
much more frequent in the former (vide Brain, Tumors 
of, in the present volume). In addition, choked disc is 
comparatively rare in gummata, while it is a frequent 
attendant of other varieties of tumor. 

DraGenosis.—Of course, the first element in diagnosis is 
the recognition of previous infection with syphilis. In 
many cases this is a very simple matter, but in numerous 
instances the symptoms at the time of the original infec- 
tion were so slight, and such a long interval has elapsed 


430 





before the outbreak of cerebral symptoms, that it may 
be extremely difficult to make a positive diagnosis. 
Moreover, in negative cases we must not forget that 
many patients attempt to deceive the physician in regard 
to the contraction of venereal disease. In doubtful cases. 
careful search must be made throughout the entire body 
for any traces which may have been left over by the 
original disease. 

Headache is an important sign at the beginning of cere- 
bral syphilis, in whatever part of the brain tissues the 
lesion may be located. The pain exhibits the character- 


‘istics described in the previous section, but it must be 


remembered that the nocturnal exacerbations are some- 
times absent. 

The occurrence of cortical epilepsy in a syphilitic sub- 
ject is also very significant. It must not be forgotten 
that this may start with either convulsions or paralysis, 
although the former are a much more frequent initial 
symptom. Unlike ordinary epileptic attacks, these seiz- 
ures are often unattended with unconsciousness. 

Another important sign of cerebral syphilis is the 
heterogeneous character of the symptoms (paralysis of 
the cranial nerves, hemiplegia, aphasia, convulsions, etc.), 
a fact which is naturally due to the varied character of 
the lesions present in the brain. In many cases the 
secondary manifestations of the constitutional disease are 
very slightly marked, so that they may have been un- 
noticed by the patient, and, as the initial lesion is often 
disregarded, he may be unaware of his infection with the. 
specific virus. But so significant are the heterogeneity 
and anomalous distribution of the symptoms that the 
existence of syphilis should be suspected in every case of 
nervous disease in which the symptoms appear to be due 
to an organic affection but are grouped in an irregular 
and anomalous manner. Buzzard says: “I should not. 
take much account of this absence [of syphilitic symp- 
toms], if there were other reasons for strongly suspecting 
syphilis, for we are continually meeting with cases in 
which the symptoms caused by lesion of some part of the: 
nervous system constitute of themselves the only testi- 
mony to the specific nature of the disorder, and experi- 
ence shows these to be quite as pathognomonic as affec- 
tions of the skin.” The brilliant results which are often 
obtained by vigorous antisyphilitic treatment may also: 
prove a valuable aid in diagnosis. It is true that, in rare- 
cases, very favorable results are also obtained by such 
treatment in non-specific cases, but we can hardly ex- 
pect such pronounced changes as are seen in syphilitic: 
affections. 

Another very important characteristic of the symptoms. 
of cerebral syphilis is their remarkable changeableness. 
For example, an attack of aphasia may last only a few 
minutes or hours, or an attack of hemiplegia may disap- 
pear within a day or two. In no other disease, with the: 
exception of hysteria, is this ebb and flow of the symp- 
toms noticed in such a marked degree. 

In making a diagnosis of syphilis of the cerebral ves- 
sels, as distinguished from other syphilitic lesions of the- 
brain, special stress should be laid upon the absence of’ 
irritative symptoms. The localization of the lesion in 
the individual arteries will depend upon the same factors. 
as in ordinary cerebral embolism and thrombosis. The 
problem is frequently complicated, however, by the co- 
incident affection of several vessels, and perhaps by the: 
existence of other syphilitic lesions. 

The diagnosis of gummy basilar meningitis is based. 
chiefly on the prominence of paralyses of various cere- 
bral nerves, in addition to the other evidences of cerebral 
syphilis. It should be borne in mind, however, that in 
rare cases the syphilitic lesion appears to be confined to 
the cerebral nerves themselves (multiple neuritis). In 
basilar meningitis, however, the cerebral-nerve paralyses. 
are complicated sooner or later by other symptoms, such 
as hemiplegia, hemianzsthesia, etc. 

The most significant symptom of meningitis of the 
convexity is the development of cortical epilepsy. 
Hemianopsia, attended by visual hallucinations, is also a. 
very characteristic symptom. The occurrence of tem-- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





porary aphasia is also apt to be the result of syphilitic 
lesions of the convexity. In addition to these special 
focal symptoms, we usually find the general symptoms 
which have been described in the section on Symptoma- 
tology. ? 

Wien the syphilitic changes in the brain are very dif- 
fuse, especially when they involve a large part of the 
convexity of one or both hemispheres, mental symptoms 
are often prominent, and it may be difficult to distin- 
guish the condition from dementia paralytica. The latter 
affection runs a progressive course and ends fatally in a 
few years. In cases of cerebral syphilis proper treat- 
ment may result in very marked improvement and occa- 

‘sionally in recovery. Inequality of the pupils is much 
more common in dementia paralytica, but in rare cases of 
cerebral syphilis pupillary changes are found for years 
before the outbreak of other symptoms. In cerebral 
syphilis the focal symptoms are prominent and the de- 
mentia, while it is more stable in character, does not lead 
gradually to complete dementia. True ideas of grandeur 
are comparatively rare in syphilitic dementia, and are 
frequent in dementia paralytica. On the whole the 
evidences of an organic disease of the brain are much 
more decided in cases of cerebral syphilis than in de- 
mentia paralytica. 

Proenosts.—However mild the symptoms of cerebral 
syphilis may be at the outset of the disease, the prognosis 
is always serious. It is true that a considerable propor- 
tion of cases recover, but the danger of relapse is always 
to be kept in mind. There seems to be some ground for 
believing that when the original syphilitic infection runs 
a mild course, subsequent cerebral manifestations are 
apt to be severe in character. This may be owing to the 
fact that antisyphilitic treatment is not carried out very 
vigorously or persistently unless the symptoms are severe. 
Nungazzini, on the other hand, claims that malignity of 
the morbid process and early death are characteristic of 
many cases of early syphilis of the brain. 

Contrary to the opinion of many writers, we have not 
found that the general condition of the patient has much 
effect upon the course of the disease, except in those 
cases in which there is excessive indulgence in alcoholic 
stimulants. 

Among the various forms of cerebral syphilis the most 
unfavorable prognosis is presented by lesions of the blood- 
vessels. Even a lesion which is very slight in actual 
dimensions may be sufficient to interfere very seriously 
with the circulation in the brain. When a vessel is oc- 
cluded entirely, softening in its area of distribution de- 
velops very rapidly and the function of such parts is 
never restored. The most serious results are observed 
when the basilar artery is the site of disease. 

The most favorable results are seen in gummy tumors 
and gummy meningitis of the convexity. Symptoms 
which point very conclusively to gummy tumors may 
disappear completely under treatment. Gummy menin- 
gitis of the convexity also promises a more favorable 
prognosis than other localizations, but in these cases re- 
covery is usually incomplete. This is particularly true 
of cases in which mental disturbances have been promi- 
nent. 

Gummy meningitis at the base of the brain presents 
almost as unfavorable a prognosis as syphilis of the ves- 
sels, and indeed the two conditions are very apt to be 
associated. In many cases, however, the extent and 
rapidity of the improvement secured by antisyphilitic 
treatment are little less than marvellous. 

TREATMENT.—The treatment consists practically of 
the administration of antisyphilitic remedies, and the 
earlier we resort to these remedies the more assured is a 
successful result. Hence the extreme importance of an 
early diagnosis and the advisability of specific treatment 
in all doubtful cases. 

In our hands more benefit has been derived from the 
use of potassium iodide than from the preparations of 
mercury; but this opinion is not held by all writers. 
German authorities in particular usually lay more stress 
upon the exhibition of mercurial preparations. 


Unless the patient manifests an idiosyncrasy with re- 
gard to one or the other of these drugs, the mixed treat- 
ment should always be adopted. The dosage should de- 
pend solely upon the tolerance of the patient. In some 
cases the effect desired is not secured until enormous 
doses (an ounce or even more) of potassium iodide are 
given in the course of twenty-four hours. The notion is 
quite prevalent that such large doses are dangerous to 
the general condition of the patient, but this opinion is 
not justified by our own observation. For internal ad- 
ministration we usually rely upon bichloride of mercury, 
beginning with one-thirty-second of a grain, and increas- 
ing rapidly until the desired effect is obtained. The 
mercury is given in solution with potassium iodide, the 
initial dose of the latter being usually fifteen grains, un- 
less the symptoms are very urgent, when much larger 
doses may be given at once. This mixture is best given 
about two hours after meals and should always be largely 
diluted (one-half to one tumblerful of water, Vichy 
water, or milk). If we wish to increase the dose of the 
two drugs at varying rates, it is preferable to give the 
mercury in the shape of tablets. Sometimes it is neces- 
sary to give daily as much as one-eighth of a grain or even 
more, according to the indications in the individual case. 
It is a good plan to keep on increasing the dose.until the 
gums become a little tender, and then an amount slightly 
smaller than that necessary to produce such an effect 
may be continued foralong time. In grave cases, when 
we wish to overwhelm the patient with the drug, it is 
better to use inunctions of mercurial ointment regardless 
of its effect upon the gums. If the patient is uncon- 
scious, my plan has been to administer the mercury by 
inunction and the iodide of potassium by rectal injec- 
tions. As much as from 4 to 6 gm. of the iodide (diluted 
with water or milk) may be injected every four hours. 
When the patient recovers consciousness, the drug may 
again be administered in the usual way. 

During the entire period of treatment, the patient 
should devote extreme attention to the care of the teeth 
and mouth. The teeth should be very carefully brushed 
after each meal, and the mouth rinsed several times a 
day with a weak solution of listerine or some other mild 
antiseptic. 

After serious symptoms have subsided, the dose of the 
antisy philitic is gradually diminished to a certain extent, 
but should be continued persistently (if possible, without 
intermission) for at least one or two years after the dis- 
appearance of all evidences of the disease. 

I cannot express myself too strongly concerning the 
extreme importance of protracted treatment and the 
necessity of administering the remedies in sufficiently 
large doses. The dose is to be regulated solely by the 
amount requisite to control the symptoms in each indi- 
vidual case. 

Apart from the use of the strictly antisyphilitic 
remedies, very little can be done in the way of treatment. 
When the pains do not yield to these drugs, opium must 
be resorted to, and perhaps the repeated application of 
blisters to the back of the neck will prove useful. Re- 
peated convulsions are sometimes controlled by the ad- 
dition of bromide of potassium to the iodide mixture. 
The patients should be strictly warned against the use 
of alcoholic stimulants in any shape, and also against 
indulgence in sexual intercourse. They should be kept 
as free as possible from excitement and overwork, and 
regular, easy evacuations of the bowels should be secured 
daily. Leopold Putzel. 


BRAIN: TRAUMATIC AFFECTIONS. 
Diseases and Injuries of. 


BRAIN: TUBERCULOUS MENINGITIS.—(Synonyms: 
Acute Hydrocephalus, Granular Meningitis, Basilar Men- 
ingitis, Dropsy of the Brain.) 

DEFINITION.—Tuberculous meningitis is an acute in- 
flammation of the pia mater of the brain, due to infection 
by tubercle bacilli, and characterized by the deposit of 
miliary tubereles wid aa ebusion of pus and lymph. 


See Skull, 


431 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





GENERAL OBSERVATIONS.—In 1768 the attention of the 
profession was first particularly called to this disease 
by Dr. Robert Whytt, of Edinburgh. His remarkable 
monograph, entitled “Observations on the Dropsy of the 
Brain,” ranks to-day among the medical classics, and is 
highly commended by all recent writers for its accuracy 
of description and fulness of detail. 

Dr. Whytt, and the observers immediately succeeding 
him, framing their opinion as to the nature of the affec- 
tion from the very prominent anatomical lesion—the 
ventricular effusion—unavoidably included, under the 
term dropsy of the brain, several other diseases besides 
tuberculous inflammation of the meninges. No correct 
idea of its pathology could be attained until Géelis, in 
1815, pointed out that acute ventricular dropsy was nota 
primary condition, but was always dependent upon some 
antecedent affection of the cerebral vessels or nerves. 

Although the granular condition of the meninges had 
been previously noted by Guersant, it was reserved for 
Papavoine, in 1830, to establish the tuberculous nature of 
these granules, and to point out their pathological rela- 
tion to the meningeal inflammation. 

The name of tuberculous meningitis, which has won its 
way to universal acceptance, was suggested by Briche- 
teau. Dr. Gerhard, of Philadelphia, was the first to call 
attention to the disease in this country. His most valu- 
able paper, published in the American Journal of the 
Medical Sciences (1833-34), was based upon the reports of 
thirty-two cases, with autopsies (Minot). 

Tuberculous meningitis is not an independent affection, 
but is one of the most important phases of that protean 
malady, acute miliary tuberculosis. It rarely, if ever, 
occurs as the sole tuberculous lesion in the body. 

Two forms of the disease are recognized, a primary 
and a secondary form. In the former, although other 
organs besides the pia may be the seat of tubercles, the 
symptoms first noticed are those arising from the cerebral 
lesion, and these retain their prominence throughout the 
attack. In the secondary form, on the other hand, the 
brain symptoms are preceded by those arising from in- 
flammatory affections of other viscera, also dependent 
upon the diathetic influence, and are only manifested 
toward the close of the illness. 

Tuberculous meningitis is one of the most important 
and most fatal organic diseases of the cerebro-spinal 
system. The primary form is essentially a disease of 
early life, and occurs with special frequency between the 
ages of two and ten years. Infancy and adolescence do 
not confer entire immunity, but at these periods of life 
the disease is almost always secondary to advanced pul- 
monary tuberculosis. Statistics indicate that males are 
more susceptible to the disease than females; according 
to Huguenin, this preponderance is much oftener ob- 
served in children under fifteen years of age than in 
adults. 

ErroLtocy.—The essential factor in the causation of 
tuberculous meningitis is the infection of the pia mater 
with tubercle bacilli. They may reach the brain through 
the lymphatics or blood-vessels. Foremost among the 
predisposing causes must be placed the hereditary diath- 
esis. The badly nourished and physically ill-developed 
children of consumptive parents are the most susceptible, 
but the apparently rugged and robust are not exempt; 
in the latter, however, a careful search will almost cer- 
tainly disclose a taint in some collateral branch of the 
family, if not in the direct line of descent. 


That the disease is with rare exceptions dependent . 


upon foci of caseous degeneration in some remote gland or 
viscus, a suppurating joint, or tuberculous inflammation 
of bone, is now generally recognized by modern pathol- 
ogists. Seitz found such lesions in more than ninety- 
three per cent. of the cases tabulated by him. Holt 
states that “although it is not infrequent to see menin- 
gitis without symptoms of tuberculosis elsewhere, I have 
never failed at autopsy to find other tuberculous lesions 
in the body.” 

The exciting causes are obscure. Unpropitious ex- 
ternal conditions of all kinds, such as impure air, un- 


432 





wholesome food, exposure, bad drainage, may kindle 
into activity a slumbering predisposition. 

Blows upon the head, emotional excitement, exposure 
to the direct rays of the sun, and like causes exert a 
doubtful influence. Climate and seasons have no place 
among the etiological factors, although the disease is 
more prevalent in the changeable weather of winter and 
spring. 

It is not improbable that, in older children, excessive 
study and worry, or the high-pressure system of modern 
schools, may promote the disease in those predisposed 
by inheritance to tuberculous affections; and, in this 
connection, it may be stated that such children are, as a 
rule, precocious and ambitious to excel in their studies. - 

Morsip Anatomy.—The distinctive anatomical feature 
of tuberculous meningitis is a deposit of miliary tubercles 
in the pia mater of the brain. These granules are always 
found on the inner surface of the membrane, are grayish 
white, semi-transparent, and vary in size from an object 
just visible to the naked eye to that of a millet or hemp 
seed. “These are really the seats of activity of the 
bacilli” (Lloyd). The coalescence of several nodules may 
form tubercular masses as large as, or larger than, a pea. 
They are usually more numerous at the base, especially 
about the fissure of Sylvius and the optic chiasm, but in 
rare instances are formed in greater numbers on the con- 
vexity. The distribution is generally symmetrical in the 
two hemispheres, but may be limited to any particular 
portion, even to the narrow area fed by the branches of 
a Single artery. They are always developed within the 
perivascular canals, and adhere to the coats of the arteries, 
giving somewhat the appearance of a string of beads. 
They may be few in number or so abundant as to impair 
the integrity of the coats of the vessels and completely 
obstruct the circulation. 

Hektoen found tubercles in the intima, accompanied 
by extensive endarteritis. His investigations showed the 
intravascular lesion to be primary, due to the implanta- 
tion upon the intima of bacilli from the blood. The 
number of the nodules does not determine the intensity 
of the inflammation, which may be slight in the presence 
of a large deposit, or severe with a few widely scattered 
granules. 

The pia mater is thickened, opaque in appearance, 
more or less adherent to the surface of the brain, and 
often is studded with tubercles. 

Other changes may be noted which are to a certain 
extent common to all forms of meningeal inflammation. 
A sero-purulent exudation covers the pia, especially at 
the base, and extends along the course of the arteries. 
It may be so copious as to embed the cranial nerves and 
fill up the natural depressions at the base of the brain. 

The ventricles are almost invariably distended with 
fluid. The effusion into the ventricles, which was con- 
sidered by the early authors to be the essential anatomical 
lesion, furnishes the most common name for the disease. 
It varies largely in quantity, but is generally sufficient 
to distend the ventricles, flatten the convolutions, and 
render them dry and anemic. There is often bulging of 
the fontanel and sometimes even separation of the su- 
tures when they are not completely ossified. The fluid 
has a specific gravity of about 1.010, is usually turbid 
from the admixture of epithelium and leucocytes, and is 
sometimes, though rarely, tinged with blood. The por- 
tions of the brain adjacent to the ventricles are softened. 
The fornix and septum lucidum may be almost diffluent, 
and the basal ganglia so altered in consistence as to fall 
into a shapeless pulp on being removed from the skull 
(Fag ge). 

The choroid plexuses are hyperemic, and sometimes 
covered with purulent exudation. The convolutions are 
cedematous and injected when the ventricular effusion is 
small or wanting, but are dry, bloodless, and flattened 
when the effusion is large. Occasionally patches of red 
softening, punctiform hemorrhages, and, very rarely, 
large extravasations of blood are met with in the sub- 
stance of the brain. 

Changes similar in kind to those above described, but 

‘ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





less in degree, are sometimes found in the spinal cord 
and its membranes. 

In tuberculous meningitis the lesions are very rarely 
limited to the intracranial viscera. Tuberculous depos- 
its almost invariably occur in other organs of the body, 
most frequently in the lungs; or there are remote depots 
of caseating material or other evidences of the cachexia. 
Tubercles can often be demonstrated by means of the 
ophthalmoscope in the choroid coat of the eye. Dr. 
Money found the choroid affected in fourteen out of forty- 
two cases of tuberculous meningitis. In one instance 
tubercles were observed in the eye, but not in the brain 
or its membranes; in another, the meninges were free, 
but there was a mass of crude tubercles in the cerebellum 
(London Lancet, 1883). According to Oliver tuberculous 
meningitis is more prone than other forms of meningitis 
to cause changes in the optic nerves. 

Symptoms.—Tuberculous meningitis is nearly always 
preceded by premonitory symptoms which, if rightly 
interpreted, are of the highest value. In twenty-six 
eases collected by Dr. Gee there were only two in which 
prodromes were absent. These symptoms are usually so 
indefinite in character as to excite little attention at the 
time, and are rarely thoroughly appreciated until the de- 
veloped disease leads the parents carefully to review the 
past weeks of the child’s life. 

This period probably corresponds with the deposit of 
miliary tubercles in the pia mater before serious struc- 
tural changes have taken place. 

The symptoms met with during the prodromal stage 
relate chiefly to the nutritive and digestive processes. 
The appetite is capricious, the breath offensive, and the 
tongue furred. Vomiting isnot common. The bowels 
are slightly constipated, or diarrhcea and constipation 
alternate. The child tires easily and will often be found 
asleep on the floor surrounded by his playmates and toys. 
At night, sleep is restless and disturbed by dreams. 
Headache is not a prominent symptom, but is rarely 
wholly absent. Frequent complaints of dizziness are 
made. Very rarely double vision is observed. Along 
with these symptoms will be noted an alteration in the 
child’s character. This is one of the most important of 
the prodromes, and should never be overlooked in en- 
deavoring to make a diagnosis in a doubtful case. The 
patient, before precocious and vivacious, becomes dull 
and listless, indifferent to his books or plays, moody, 
and petulant. Many grow very emotional, bursting into 
tears on the slightest provocation, or dispensing their 
caresses with annoying lavishness. Before the close of 
the prodromal period the effect of imperfect nutrition is 
apparent. The patient grows thinner and paler. The 
muscles become soft and flabby, and he is day by day 
less inclined to exertion of any kind. The prodromal 
stage may last for from one week to three months. 

It is customary, for convenience of description, to di- 
vide the disease into distinct stages, based upon the 
predominance of certain symptoms at different periods 
in its course, viz., a stage of ¢nvasion, one of pressure, and 
one of paralysis. 'This arrangement is purely arbitrary, 
and is rarely fully justified by clinical observation. 

There are few diseases more irregular in the develop- 
ment or sequence of symptoms than tuberculous menin- 
gitis, and he who seeks at the bedside only the typical 
case of the books may long search in vain. 

Since the age of the patient impresses some minor dif- 
ferences upon its course, we will first describe the disease 
as seen in children. 

Stage of Invasion.—The onset is rarely announced by 
any sudden perturbation, like a chill or convulsion, but 
usually the symptoms of the prodromal stage are in- 
creased in severity and gradually reinforced by others 
characteristic of cerebral lesions. 

Headache, vomiting, and fever are the common initial 
symptoms. Of these, vomiting is perhaps the most con- 
stant. It varies greatly in frequency, is not usually 
troublesome after the first few days, though it may con- 
tinue during the entire illness, and seldom returns, after 
it has once ceased for twenty-four hours. It is especially 


Vote le 25 








provoked by the ingestion of food or drink, and by rising 
in bed, and, as a rule, is not preceded by nausea or ac- 
companied with severe retching. 

The headache is intense, and constitutes one of the 
most distressing features of the disease. It is usually 
referred to the frontal region. The pain is aggravated 
by sudden movement, bright light, or loud noises, and is 
subject to exacerbations without apparent cause. It at 
times compels the child to make outcries, hold his head 
with his hands, or bury his face in the pillow. Fortu- 
nately, remissions of variable duration are not infrequent. 
Vertigo is occasionally present, manifested by unsteadi- 
ness of gait, or a sensation of falling, even when lying in 
bed. The complaint of headache in a child, especially 
when associated with vomiting, should always awaken 
the gravest apprehensions. 

There is no distinctive temperature curve. The fever 
is moderate in intensity, irregularly remittent in type, 
and rarely measures more than 103° F. in the evening, 
and 100° F. or 99° F. in the morning. Constipation is 
very constant. It is usually marked from the beginning 
of the illness, and is rebellious to the action of laxatives; 
yet cases are recorded in which persistent diarrhoea has 
occurred without tuberculous or other disease of the gas- 
tro-intestinal mucous membrane (Huguenin). Anorexia 
and moderate thirst are present. The tongue may be 
clean, but is generally heavily coated. ; 

The pulse for the first few days is rapid and regular, 
but soon becomes slow, irregular, and variable. The 
variability is marked; the slightest exertion or excite- 
ment will cause an increase of twenty or more beats per 
minute, and a like effect may be often produced without 
known cause. 

The respiration is changed in like manner, and after 
three or four days becomes irregular and sighing. These 
alterations in the pulse and breathing are by no means 
constant in the early stages. They may be marked at 
one, and absent at several subsequent visits; in fact, 
fluctuations may be noted in the course of the same ob- 
servation. Repeated and lengthy examinations must 
therefore be made before they are declared absent. It is 
important to make the examination of the pulse when 
the child is at rest, since a pulse which is slow and irregu- 
lar during repose may be rapid and regular under excite- 
ment or after movement. 

Sleep is fitfuland disturbed. Mild delirium is observed 
at some period of the day or night. The pupils are con- 
tracted, and light is painful to the eyes. 

During the early part of this stage, both special and 
general sensibility are increased, so that the child often 
receives with dread even the gentle ministrations of its 
mother. Later on, he becomes more passive, and will 
without a murmur submit to the protracted examination 
of the physician. 

If the cranial bones are unossified, the anterior fonta- 
nel is distended. 

Strabismus, double vision, and ptosis sometimes ap- 
pear toward the end of the stage of invasion. . Convul- 
sions are not common, but muscular twitchings and rigid- 
ity of the muscles of the spine are occasionally noted. 

The child is dull, apathetic, and drowsy from the be- 
ginning. At first he can be easily aroused, and although 
his mental operations are sluggish, he notices his sur- 
roundings and may at times amuse himself with his 
playthings. The somnolence gradually increases until, 
toward the close of this period, he will, if undisturbed, 
lie for hours in a deep sleep, with eyelids half-open, 
grinding his teeth, and at times uttering a sharp, pierc- 
ing shriek—the hydrencephalic ery of Coindet. Some 
authors place great stress upon this cry, but Rilliet, Gee, 
and others hold that it is not special to nor frequent in 
tuberculous meningitis. 

The duration of this stage is from seven to fourteen 
days. 

Stage of Pressure.—The signs of irritation now give 
place to those of pressure or exudation upon the surface 
of the pia and into the ventricles of the brain. The 
transition takes place gradually; in fact, there is usually 


433 


Brain. 
Brain, 





a period of uncertain duration, which has been not in- 
aptly named the mized stage, in which the “symptoms 
of irritation still linger and the symptoms of depression 
are just manifesting themselves ” (Bartholow). 

Paroxysms of pain, great restlessness, irritability, and 
delirium are succeeded by periods of extreme drowsiness 
or even of profound stupor, out of which the child is 
aroused with difficulty, perhaps replies in monosyllables, 
or stares vacantly at the questioner through half-open 
lids, and again lapses into his former condition. 

The most characteristic feature of this stage when 
fully developed is loss of consciousness, 
mains in a state of complete insensibility, and at times 
moans or shrieks out wildly. He commonly lies on one 
side, with the knees drawn close to the abdomen, one 
hand pressing his head and the other grasping the genitals. 

The head is often retracted, and the muscles of the 
nape of the neck are rigid. The pulse becomes slow— 
from 40 to 80 beats in the minute. The irregularity 
of the pulse and respiration are more pronounced and 
more constant than before. Typical Cheyne-Stokes 
respiration is often observed. The temperature falls a 
degree or more and often becomes subnormal. Vomit- 
ing ceases, if it has not already done so, but constipa- 
tion persists. The abdomen is deeply hollowed. The 
common term “boat-shaped” very accurately describes 
the sunken belly bounded by the unduly prominent sym- 
physis, iliac crests, and ensiform cartilage. 

The pupils are dilated, often unequally, and some- 
times waver under light. The globe rolls from side to 
side, the sclerotic is suffused, a puriform secretion col- 
lects in the angles of the eyes or glues together the edges 
of the lids. The ophthalmoscope shows ischemia of 
the optic discs or beginning neuro-retinitis. In rare in- 
stances, miliary tubercles are seen in the choroid. Dr. 
Allbutt found retinal lesions in twenty-nine out of thirty- 
eight cases of tuberculous meningitis. 

The skin presents peculiar vaso-motor disturbances. 
Small patches or spots of congestion appear on the 
cheeks, forehead, or ears, and quickly fade away, their 
bright color making a vivid contrast with the general 
pallor. If the finger-nail be lightly drawn across the 
abdomen or inner surface of the thigh, a bright-red line 
comes out slowly, persists for a few moments, and then 
gradually fades—the tdche cérébrale of Trousseau. 

Paralyses, both local and general, are commonly met 
with at this period; as are also rigidity or pendulum-like 
movements of one or more of the extremities. 

The contents of the bladder and rectum are usually 
discharged involuntarily. 

Stage of Paralysis.—From twenty-four to forty-eight 
hours before death, some of the characteristic symptoms 
undergo a remarkable alteration. The period covered 
by these changes is known as the stage of paralysis. 
The child now lies completely comatose and irresponsive 
to external irritations. Only reflex movements can be 
excited, and these imperfectly. 

The constipation which has marked the whole progress 
of the illness is now often replaced by copious, involun- 
tary, liquid stools; the sunken abdomen becomes dis- 
tended with gas; the slow pulse becomes rapid and feeble, 
numbering 160 to 180 beats per minute, and the mercury 
registers a temperature of 104° to 107° F. This second 
rise in pulse and temperature is a certain forerunner of 
speedy dissolution. 

The capillary circulation is more and more interfered 
with, the respirations become less distinct, and death may 
occur quietly in deep coma or be ushered in by a con- 
vulsion. Death by coma is the more common mode. 

Sometimes the death agony is prolonged for several 
days, to the great grief of the parents. Death occurs in 
from sixteen to twenty-one days after the appearance of 
the initial symptoms. 

TUBERCULOUS MENINGITIS IN THE ADULT.—The course 
of tuberculous meningitis in adults varies sufficiently 
from that observed in children to deserve brief men- 
tion. 

The disease is more common in men than in women, 


434 


The patient re- . 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





and occurs at ali ages, but especially between the years 
of seventeen and thirty. It is almost invariably second- 
ary to advanced tuberculous disease in some remote part, 
the symptoms of which to a certain extent mask those of 
the meningeal affection. The primary form of the dis- 
ease is rarely met with in adult life. 

Premonitory symptoms are usually absent, and when 
present never obtain the same prominence as in early life. 
Persistent vomiting and convulsions rarely usher in the 
attack, but local paralyses, hemiplegia, and aphasia— 
very seldom seen in childhood—are not infrequently the 
first symptoms to direct attention to the cerebral com- 
plication. 

The disease ordinarily runs a much shorter course than 
in children. Death may occur within forty-eight hours 
after the appearance of brain symptoms, and is seldom 
delayed longer than fourteen days. 

Dracnosis.—The diagnosis of typical, fully developed 
tuberculous meningitis can scarcely give serious trouble, 
but in the prodromal period, or in those cases which 
pursue an irregular course or in which some of the 
prominent symptomsare absent altogether, it is proverbi- 
ally difficult. 

Since the disease is almost invariably engrafted upon a 
tuberculous diathesis, a careful investigation of the 
family record and personal history should be at once 
instituted. It is, however, only by the exercise of the 
most painstaking care, by closely observing the physi- 
ognomy and actions of the child, and by noting the 
hourly variations in the symptoms, that an early diag- 
nosis can be reached in doubtful cases. Tl-defined ailing 
in a scrofulous child which resists ordinary treatment, 
especially if accompanied with headache and causeless 
vomiting, should always awaken suspicion. 

The diseases for which tuberculous meningitis is most 
liable to be mistaken are acute simple meningitis, hy- 
drencephaloid disease, gastro-intestinal disturbances, and 
typhoid fever. 

Simple meningitis is ordinarily recognized by the 
sharper onset (without prodromes), more severe head- 
ache, more furious delirium, higher temperature—in 
short, the greater intensity of all the symptoms and its 
rapid course. The comparative rarity of the simple over 
the tuberculous form of the disease should be remem- 
bered. In exceptional cases the differentiation cannot 
be made. 

False hydrocephalus is usually readily known by the 
history of antecedent diarrhea or other exhausting 
malady, the prostration when the cerebral symptoms 
began, the rapid and feeble pulse, the depressed fonta- 
nel, the pallor, and the normal or even subnormal tem- 
perature. All authors speak of the resemblance which 
certain cases of typhoid fever bear to the disease under 
discussion. Theinfrequency of typhoid fever in patients 
of the age most prone to tuberculous meningitis, the 
regular temperature curve, the diarrhoea, the iliac gurg- 
ling, the rose-colored spots, and the splenic tumor will 
generally easily establish the nature of the disease. 

The subacute gastro-intestinal disturbances to which 
children, especially cachectic children, are so liable may 
lead to error. Feverishness, anorexia, vomiting, irrita- 
bility, and headache are common to each, and in many 
cases the development of the symptoms must be awaited 
to clear up the diagnosis. 

The more intense headache, the irregular pulse, the 
sighing respiration, the alterations in the pupils, and the 
graver aspect of the illness will generally speedily indi- 
cate its cerebral nature. 

The lumbar puncture of Quincke sometimes gives 
valuable information. It is especially valuable in the 
differentiation of meningitis from other diseases accom- 
panied by marked brain symptoms. 

The discovery of tubercle bacilli in the spinal fluid is 
positive evidence of the nature of the disease. They are, 
however, difficult of demonstration, and are not always 
present in undoubted cases of meningeal tuberculosis. 

Fiirbringer found bacilli in thirty out of thirty-seven 
examinations. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The changes which take place in the fundus of the eye 
are often among the early signs of meningeal inflamma- 
tion, and hence are valuable in diagnosis. However, too 
much reliance must not be put upon the ophthalmoscopic 
examination. Dr. Fagge remarks: “The clinical value 
of ophthalmoscopic changes in the optic discs is still 
somewhat doubtful. It is certain that a normal state of 
the retinze is no proof of the absence of tuberculous men- 
ingitis, but I believe the time has not yet arrived fora 
dogmatic expression of opinion as to the positive signifi- 
eance of ischemia (or even of retinitis) as between that 
disease and some less severe affection of. the brain, such 
as might be attended with great vascular congestion of 
its tissue. One appearance indeed is conclusive, namely, 
the presence of tubercles in the choroid. It is true that 
they belong not to the meningeal affection itself, but 
rather to a general acute tuberculosis, but this fact 
in no degree diminishes their diagnostic importance ” 
(“Practice of Medicine”). Dr. Minot says on this point 
that “choroidal tubercles are so rarely seen as to be of 
little avail in diagnosis. In fact, they are less frequent 
in this disease than in general tuberculosis without men- 
ingitis. In twenty-six cases of tuberculous meningitis 
examined by Garlick at the London Hospital for Sick 
Children they were found only once” (Pepper’s “System 
of Medicine”). 

Dr. Bastian (Quain’s “ Dictionary of Medicine”) places 
great reliance upon the microscopic examination of the 
blood in the diagnosis of tuberculous meningitis. He 
mentions the following alterations in the blood as pecul- 
iar to this affection: an increase in the number and ex- 
alted ameeboid activity of the white corpuscles; groups 
of protoplasmic particles of various sizes interspersed 
among the blood corpuscles, as well as here and there 
small pigment granules. The red corpuscles tend to run 
together into irregular masses rather than into definite 
rouleaux, but present no distinctive changes. 

Proenosts.—The prognosis is absolutely bad. When 
fully developed, tuberculous meningitis almost invaria- 
bly marches steadily on to a fatal termination. Delusive 
lulls not infrequently occur, however, even in the ad- 
vanced stages, when an unwary practitioner may doubt 
his diagnosis and raise hopes in the parents which are 
doomed to bitter disappointment. 

The possibility of recovery from the early stages of the 
disease cannot now be successfully denied, although it is 
not, perhaps, uncharitable to doubt the correctness of 
the diagnosis in many of the recorded recoveries.  Ril- 
liet, Rousseau, and other equally eminent clinicians re- 
port cases in which death occurred from a relapse some 
time after recovery from the first attack; and at the 
autopsy, old and recent tubercles of the pia could be 
clearly distinguished. Huguenin does not even accept 
the revelations of the post-mortem examination as con- 
clusive, and remarks that “pathological anatomy fur- 
nishes no information the correctness of which it would 
not be possible to doubt.” 

The isolated exceptions who do survive an attack of 
tuberculous meningitis are nearly always left with im- 
paired mental or physical powers, and sooner or later 
succumb to a recurrence of the disease. 

The writer has seen recovery in one case which was 
well advanced in the second stage, and in which there 
could scarcely be a doubt as to the tuberculous nature of 
the disease; but the patient never fully regained his 
mental faculties, and died in convulsions eighteen months 
afterward. 

TREATMENT.—Tuberculous meningitis is so universally 
fatal that but little benefit can be hoped for from the 
administration of remedies. There are no drugs that can 
control or retard the specific action of the tubercle bacilli 
on themembranes of the brain. The treatment is wholly 
symptomatic and palliative. Treatment should not, 
however, be abandoned too soon, as a positive diagnosis 
between the simple and the tuberculous form of menin- 
gitis is not always possible in the early stages. 

In the present stage of our knowledge, the greatest 
good must come from the adoption of measures to pre- 











Brain, 
Brain, 


vent the development of the cachexia in those so predis- 
posed. It is not necessary for us to detail here the special 
means to be employed; they are set forth at length in 
other chapters of this HANDBOOK. 

In general terms, however, we may say that, in the 
presence of the diathesis every influence which tends to 
develop the nervous system at the expense of the diges- 
tive and muscular systems will increase the liability to 
the disease. 

The violent antiphlogistic measures formerly employed 
in the treatment are now properly discarded. As soon 
as the nature of the disease is known or strongly sus- 
pected, the patient should be placed in a darkened room 
and all sources of cerebral excitement excluded. An ac- 
tive calomel purge should be at once administered. An 
ice-cap must be applied to the head and upper portion of 
the spine and warm applications to the extremities. 

Special symptoms must be met as they arise by the 
use of the customary remedies, but our chief reliance in 
arresting the disease lies in the use of the bromide and 
iodide of potash. The bromide may be omitted during 
the pressure stage, unless convulsions ensue, but the 
iodide must be given until treatment is abandoned. 

Sometimes, during the stage of excitement, opium 
may be advantageously combined with the bromide. 
Flattering reports have been published from the use of 
iodoform inunctions, and a Swedish physician, Dr. Warf- 
vinge, reports five successful cases. The method fol- 
lowed by Dr. Warfvinge consists in shaving the head 
and anointing it with an ointment consisting of iodoform, 
1 gm., in vaseline, 5 gm. This is applied twice daily, 
the head being afterward covered with an impermeable 
cap. This method has still a few advocates, but it never 
gained the confidence of the profession and is practically 
abandoned. Lumbar puncture has been recently prac- 
tised in a large number of cases, both as a curative and 
as a diagnostic measure, but the later reports are not 
such as to commend the practice. Rotchand Wentworth 
report alarming symptoms following its use in a two- 
year-old child. W. J. Conklin. 


BRAIN, TUMORS OF THE.—The symptoms caused 
by tumors of the brain are due, first, to irritation or de- 
struction of the portions of the nerve tissue in which 
they are embedded, or near to which they lie; second, to 
pressure exercised upon the entire contents of the cranium 
—nerve tissue, blood-vessels, and lymphatics. The first 
class of symptoms are common to tumor, and to all other 
circumscribed lesions of the same locality, thus especially 
patches of chronic softening. The second class are com- 
mon to all conditions in which the intracranial space is 
encroached upon; such are extra- as well as intra-cerebral 
tumors, morbid products within the brain, which differ 
considerably from neoplasms proper, and finally, ab- 
scesses and aneurisms. Thus, the investigation of the 
case of any patient exhibiting cerebral symptoms de- 
mands that we decide: first, whether these are caused 
by a new growth of any kind, which is encroaching upon 
the cranial cavity; second, this being admitted, what is 
the nature of the growth; third, what is its precise locality. 

The prognosis must then be framed according to the 
fact, the nature, and the seat of the growth; and, finally, 
the (very limited) indications for treatment must be con- 
sidered. 

Symptoms INDICATING THE EXISTENCE OF AN INTRA- 
CRANIAL GRowTH.—These are of two kinds: those be- 
longing to the perversion or abolition of cerebral function, 
and those indicating a rise of intracranial pressure. The 
first are the focal, the second the diffused symptoms 
(Griesinger). It is this second class of symptoms which 
are of the most importance in distinguishing between 
tumor and other cerebral lesions, and they may therefore 
be considered first. 

Diffused Symptoms.—These are headache, vertigo, vom- 
iting, general epileptiform convulsions, apoplectiform 
attacks, psychic disturbances, and choked disc. 

Headache is one of the earliest and most constant symp- 
toms of intracranial tumor. The intensity of the pain 


435 


Brain, 
Brain, 


is usually severe, has even led to suicide, but this very 
intensity may sometimes confuse the diagnosis with 
hemicrania. From this functional disease it is sufficiently 
distinguished by its persistence. It may, for some time, 
precede all other symptoms of tumor. Although it is on 
the whole persistent, there may, in a certain number of 
cases, be intervals of freedom of several hours, days, 
weeks, or even months in duration. Not unfrequently 
is the headache periodic, and it may then be mistaken 
for an apyretic malarial attack. Frontal headache may 
simulate brow ague, or occipital headache the cervico- 
occipital neuralgia of gout. The pain is apt to be ex- 
acerbated at night, or to grow worse in the early morn- 
ing hours, a fact probably due to stagnation of the 
intracranial lymph stream determined by the lowered 
blood pressure during sleep. The pain is also increased 
by every condition liable to cause congestion of the head; 
thus by psychical excitement, alcohol, straining at stool. 
The headache may be diffuse or localized, but the locali- 
zation of the pain does not assist much in the localizing 
diagnosis of the tumor. Frontal tumors frequently ex- 
cite occipital headache. _ Although so prominent a symp- 
tom when it exists, headache is by no means always 
present. It was absent in 148 out of 274 cases analyzed 
by Ball and Krishaber. By combining the tables of 
Ladame and of Bernhardt (the first summing up all cases 
published earlier than 1868, the second those between 
that date and 1880), we can construct the following table, 
showing the proportion of cases of headache with cere- 
bral tumors of different localities: 





TABLE I. 
Number | Number with 
Seat. of cases. headache. Per cent. 
Cerebral peduncle ........... 10 4 40 
Basal Panga ici ceteiee ite 41 19 48 
COOLIO sacs cieenewae cult eles 74 37 50 
Medulla aes chain daiteeio arts 28 16 60 
Cerebral lobes asua% skies + stents 196 129 66 
PONS! Se cranisissrsriawmoesimane ee 56 37 7 
Corpora quadrigemina ....... 18 9 69 
Cerebellumigactssassceestenesr 186 150 81 








This table confirms the inferences that might be drawn 
from what we know of the physiology of cerebral pain. 
It is rarely to be attributed to irritation of sensory cen- 
tres, but rather to stretching of the dura mater from 
effusion into the cavity of the arachnoid or into the in- 
ternal ventricles; hence irritation of the dural sensory 
nerve filaments supplied by the trigeminus. As some 
degree of stretching always takes place, no matter what 
the seat of the tumor, headache is always imminent, but 
it may not manifest itself if the tumor grows very slowly 
and makes way for itself by gradual compression of the 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ache with tumors of the corpora quadrigemina may per- 
haps be due to their intimate connections with the cere- 
bellum. In the cortex, only half the cases are attended 
by headache; this probably being due to the tendency 
of the tumor to grow downward, and thus to relieve the 
tension of the dura. The periodicity in the pain is un- 
doubtedly associated with fluctuations of the circulation, 
always liable to be diurnally periodic. An initial head- 
ache often disappears when paralysis sets in; probably 
because by that time a zone of softening has usually 
developed around the tumor. The intensity of the press- 
ure is at first either partially or entirely relieved; head- 
ache may set in if the tumor suddenly assume a more 
rapid rate of growth; it necessarily subsides at the ap- 
pearance of the terminal symptoms of drowsiness and 
comatose apathy, the pain being blunted, like other signs 
of irritation, in the general depression of the sensibility. 

Vertigo is a-much less frequent but still a prominent 
symptom of any organic brain disease, and although fre- 
quently present with tumor, is far from characteristic of 
it. It is probably always associated with direct or in- 
direct irritation of those portions of the brain which are 
concerned in equilibration; and it agrees well with this 
presumption that vertigo occurs so much more frequently 
with tumors of the cerebellum than with those of other 
parts of the brain. It is also frequently observed in 
tumors of the pons and medulla. Other space-encroach- 
ing lesions, ¢.g., abscesses, so situated as to affect the 
middle or internal ear, may cause vertigo by the same 
mechanism as that which is brought into play in ear dis- 
ease proper—namely, by excitation of the auditory nerve. 
As the central fibres of this nerve have been traced to the 
cerebellum, it seems probable that the sensation of ver- 
tigo, whether cerebral or aural in origin, is always finally 
produced by the same mechanism. From the connec- 
tion of the ocular muscles with the superior olive, and 
through that with the auditory nerve, paralysis of these 
muscles by a brain tumor may become an effective cause 
of vertigo (Bruns). 

The third diffused symptom, Vomiting, follows the 
same order of predominance as headache and vertigo, 
namely, it is much more frequent and severe in tumors 
of the cerebellum than in those involving some other 
portion of the brain, with the exception of the corpora 
quadrigemina, where the liability to vomiting is at the 
maximum, 

From the following table it appears that vomiting is a 
much less frequent symptom than headache, and occurs 
later, but follows exactly the same order of predominance, 
except in respect to the centrum ovale. This is because 
the vomiting is partly due to the same cause as the 
headache, namely, the tension of the dura mater and the 
tentorium. Extreme tension does not, however, always 
cause vomiting. 

















TABLES Is 
Seat of tumor. Headache. Vomiting. Convulsion. Choked dise (Bernhardt alone). 
-Amaurosis.— Vision intact.— Total. 

Cases. Per cent.|Cases. Per cent.|Cases. Percent.| Cases. Per cent. Cases. Percent. Cases. Percent. 
Cerebral peduncle ........... 4 40 ar ote 2 QD. | Calecein:eco.ccaeininte iD La MEIEs wrsle-c-e retreat een 
Cerebral lobes Seanicccacemice os 129 66 36 18.5 49 26 15 in 124 12 12 in 124 9 = 27 in 124 21 
Basal panglia hyo. ete neee 19 46 8 19.5 ff ED | sctege avis oe heae eke 2in 5= 2in 2 Vf 
GOrtex wie cats we a noeenen 7 50 18 - 23 20 25 5in 57 8 5in 57 9=10'in or ee 
POS sense cio iowaeceetenc 7 67 15 27 2 5 4in 30 18 2in 30 6= 6in 30 20 
MGGulla 5isc cre siee cise cacteanerers 16 60 12 40 2 6 Seles ceawoeiey Zin 21 re ici 9 
Cerebellum s.Nieacocecswee se 150 83 75 45 18 12 18 in 90 20 13 in 90 14=81lin 90 34 
Corpora quadrigemina....... 9 69 8 61 1 5in 11 45 Pane 10 = S6 ine 54 

STORM sos ae visisinvinsissie sevsiseiese 401 in 568 cases = |172 in 568 cases = |101 in 568 cases = + ons p=, 
70 per cent. 30 per cent. 17 per cent. 82 in 362 cases = 22 per cent. 
| 














brain substance and displacement of its fluids. On the 
other hand, the pain is most certain to occur, and also 
to be most violent, when the tumor grows in the cere- 
bellum under the tense fold of the tentorium; it is least 
likely to occur when room is left for the expansion of 
the growth at the interpeduncular space. In the pons 
and medulla, direct irritation of the trigeminus may add 
a special liability, to pain. The great liability to head- 


436 


Case, by King (Brain, October, 1882): Two tumors, 
one on right side of pons extending to left middle 
peduncle of the cerebellum, the second embedded in the 
left side of the floor of the fourth ventricle; convolutions 
flattened, much serum in ventricles, showing extreme in- 
tracranial pressure; but optic neuritis devéloped only 
after attacks of coma. Headache, but no vomiting. 

The immediate cause of vomiting is supposed to be al- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 


























Brain, 
TABLE III. 
INTELLIGENCE DISTURBED. 
Be amor, Mental depression tle eo 
’ a ; ORMAL. 
apathy, loss of Hallucination. Delirium or Drowsiness or Total. > 
memory, imbecility. ENE stupor. 
Cases. Per cent./Cases. Per cent.|Cases. Per cent.|Cases. Percent./Cases. Percent.||Cases. Percent. 
Medulla, 29 cases.........se08. 6 20 2 ii 2 i 1 3.0 11 38 18 62 
Cerebellum, 162 cases .......... 48 29 1 . 6 3 9 5 64 39 98 60 
DTEOR OT CASES vec cccs cee necice Ss aie ate re 66, ewe a aehte 28 49 ve wate 
PONS, 56 CASES 0... ccseeee 48 i : s 1 bias 29 51.5 27 48.5 
Basal ganglia, 40 cases . 45 1 oF 2 sats ae ASAE 21 52 19 47 
Lobes, 192 cases........ 46.5 9 4 11 5.5 5 2.5 115 60 77 40 
OCC IDA Es .  aru y aici ofere aie Sdcic er ae oe GAC ac Darcie ae: ahah i Sev 
ROTA ete ra/e ties ees sie 10% a i eect: 6 10 11 19 
AMICUS eC cciieniccees sels s 15.5 i 2 re 7 12 19 33 17 29.5 
SEPIO IATA cece ccapccs vase ress 3 ae 56 Rate ne Git ie ocr 
Corpora quadrigemina, 13 cases} 4 30 2 15 4 30 10 77 3 23 














ways the excitation of a vomiting centre in the medulla; 
and this can be brought about by pressure transmitted 
from any part of the brain. This pressure is, however, 
more direct when exercised from some point in the pos- 
terior cranial fossa; hence a second reason for the in- 
tensity of the symptom in cases of tumor of this locality. 

The vomiting is unattended by nausea and occurs on 
an empty stomach and with a clean tongue, and in these 
respects contrasts markedly with the vomiting of uremia. 
It is apt to follow the headache closely, and, as in mi- 
graine, to occur at the height of the paroxysm of pain, 
and also in the early morning. 

Epileptiform Convulsions constitute a fourth diffused 
symptom, which is very characteristic of tumors of the 
brain. Their causal relations to increased intracranial 
pressure have been strikingly shown by Leyden’s experi- 
ments. In these, pressure was directly applied to the 
brain of animals previously trepanned for the purpose. 
Convulsions occurred as soon as the pressure had risen 
to 180 mm. of mercury. Pressure, however, is only one 
of the mechanisms by which convulsions may be excited. 
Kussmaul’s experiments, made many years ago, showed 
that sudden anzemia of the brain, such as might be in- 
duced by copious hemorrhage, was invariably followed 
by convulsions. The predominance of convulsions in 
cases of brain tumor, according to the locality occupied 
by the latter, does not follow the law which is applicable 
to symptoms traceable to increased pressure, for convul- 
sions occur oftenest in cases of tumor of the cortex and 
cerebral lobes, presumably of the portions of the centrum 
ovale which lie immediately beneath the cortex. General 
convulsions, therefore, like local spasms, are rendered 
imminent by direct excitation of the motor tracts. Curi- 
ously enough, convulsions are almost excluded from the 
symptomatology of the pons, though this region, which 
is traversed in every direction by motor tracts, probably 
contains the convulsing centre. But apparently the 
properties of the centre become abolished before they can 
be effectually irritated. This absence of convulsions, 
when certain positive signs are present at the same time, 
is of real value in localizing a tumor in the pons. 

As the convulsion is not proportioned to the locality 
of greatest tension, so it stands in no relation to the time 
at which tension is greatest. It occurs as an initial 
symptom, or during the active period of the disease; but 
it usually disappears, with other irritative symptoms, in 
some other manner toward the close, when intracranial 
pressure is at its maximum. Sudden variations in such 
pressure, caused by fluctuations of the circulation, seem 
to be the essential proximate cause of the convulsions of 
brain tumors. The form of the convulsion does not 
differ from that observed in idiopathic epilepsy, and the 
diagnosis between tumor and epilepsy is often difficult. 

It can be made only by means of the concomitant 
symptoms. Convulsions occurring in adult life for the 
first time should at once excite suspicion of brain tumor 
and lead to an ophthalmoscopic examination for choked 
disc. According to Bruns, convulsions may occasionally 
precede for years, and with intermittences of years, all 
other symptoms of an intracranial growth. 


Apoplectiform Attacks occur with brain tumors, and 
may, though rarely, be the first symptom, and followed 
by paralysis or paresis. It is extremely difficult, then, 
to distinguish the case from one of ordinary cerebral 
hemorrhage. Hemorrhage into or around the tumor is a 
frequent cause of apoplexy, and thus may first reveal the 
existence of a tumor hitherto latent; or it may occur in- 
cidentally among phenomena already well defined and 
recognized. Finally, the apoplectic attack may usher 
in the terminal period; the patient never completely 
recovering, but passing into a soporose condition and 
finally into coma. The apoplectic ictus is not invariably 
associated with hemorrhage; it may be due to sudden 
alterations of intracranial pressure, by which the func- 
tions of brain tissue are temporarily suspended, as after 
concussion. 

Psychic Changes.—The earliest is usually an extreme 
irritability, which contrasts with the lachrymose emo- 
tionality characteristic of softening of the brain. Occa- 
sionally this culminates in attacks of maniacal excite- 
ment; oftener, however, the patient suffers from mel- 
ancholic depression, and gradually becomes more and 
more apathetic and taciturn. This taciturnity, which is 





a diffused symptom, must be distinguished from true 
aphasia. As in all mental disturbances, the memory 
fails. Dementia may precede death for some time, es- 
pecially if epileptic convulsions have been severe. The 
specific psychic symptom of brain tumor is drowsiness, 
from which it is often difficult to rouse the patient. 
When roused, however, his mind may seem unexpect- 
edly clear. The drowsiness is proportioned to the degree 
of general intracranial pressure. It is particularly 
marked in tumors of the frontal lobes, which may reach 
a considerable size without occasioning other symptoms. 
Table III. shows that the liability to psychic symp- 
toms other than drowsiness is not at its maximum when 
the tumor is seated at the cortex, nor when a cortical 
tumor is in the frontal lobes. Cortical tumors stand 
third from the bottom of the scale in this respect; the 
highest place is occupied by tumors of the corpora 
quadrigemina, seventy-seven per cent. A relative infre- 
quence of mental disturbances is observed in tumors of 
the medulla and pons. On the other hand, the high 
percentage of such disturbances in tumors of the centrum 
ovale may probably be, at least in part, attributed te 
. their influence upon the cortex. To such influence must, 
in last analysis, all psychic perversions be ascribed; and 
the high proportion of cases in which these are present 
with tumor in any locality of the brain is explained by 
the extreme sensitiveness of the cortical substance to dis- 
turbance of the intracranial pressure from whatever point 
diffused. Psychic symptoms, of one kind or another, are 
seen to be extremely frequent in tumors of the brain, 
being present in about half the cases. Their presence, 
therefore, materially aids in establishing the diagnosis. 
Certain specific psychoses, as paranoia and hysteria, are 
occasionally excited by the presence of a brain tumor. 
Choked Disc.—This symptom, when present, is more 
nearly pathognomonic than any other of brain tumor. 
According to Oppenheim, ninety per cent. of all cases of 


437 


Brain, 
Brain. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





choked disc are due to intracranial growths. The choked 
disc has been differently regarded as the expression of 
two different morbid processes: an inflammation of the 
optic nerve, “neuritis optica,” or a mechanical obstruc- 
tion to its circulation, which should be the choked disc 
proper. Oppenheim notes that in tumors of the base 
of the cranium, which are liable to obstruct the flow 
of lymph into the sheath of the optic nerve, the choked 
disc is usually lacking, and tumors of the optic nerve 
itself are apt to lead to direct atrophy of the nerve with- 
out any preliminary stage of choked disc. These facts 
are counted as an argument in support of the celebrated 
doctrine of von Graefe, who attributed the choked disc 
in all cases to an obstruction offered to the venous cir- 
culation of the optic nerve, from immediate or mediate 
pressure exercised upon the sinus cavernosus; hence a 
serous transudation from the veins, rendering the papilla 
swollen and edematous. As seen with the ophthalmo- 
scope the papilla appears engorged, tumefied, nebulous, 
irregular, and with ill-defined edges; a spirus of cloud 
covers both the centre and the circumference, rendering 
the whole surface opaque. The arteries are diminished 
in calibre, the veins appear interrupted at various points. 





papilla sometimes atrophies without passing through any 
stage of choked disc. Until atrophy sets in, vision is 
not necessarily impaired. Thus, out of a total of 82 
cases of choked disc, vision remained intact in 37, or 45 
per cent. In a great many cases no ophthalmoscopic 
examination is made, unless vision is impaired, and this 
explains why such examination is lacking to the history 
in 282 out of 485 observations analyzed by Bernhardt 
(47.8 per cent.). In many of these negative cases it is 
very possible that choked disc really existed, so that the 
real proportion of this lesion in brain tumor cannot be 
considered as known. 5 

The ten per cent. of cases of choked disc which are not 
caused by intracranial growths have a very diverse etiol- 
ogy. Thecondition has been seen in pernicious anzemia ; 
in a few cases of arteriosclerosis, when the arteries of the 
optic nerve are involved; inabscess; in multiple sclerosis. 

In a certain number of cases cerebral tumor manifests 
itself exclusively by one or more of the foregoing “ dif- 
fuse” symptoms. Among Bernhardt’s cases of tumors 
of the cortex, centrum ovale, cerebellum, and basal gan- 
glia, this limitation may be found 71 times out of a total 
of 297 cases, or 23.8 per cent. 


TABLE IV.—CASES OF DIFFUSED SYMPTOMS ALONE. 















































' 
. . Lan | eS 
gl | ee aa Bee by Je 
3 | 2H] oQ] coo l| gs ls else ssisss| » | gd | &9 
q 85/82) 85 |See¢@n ae¢slagdala sn] g ) a5 
S | 32/82 | 38 |S88/88 5/32 cls85| | 2 | Ss 
Seat. as S Sai we sae Sa SF bi cs Set 3 2 ‘2 | Psychic alteration. Total. 
$ | S85 | 88 | 83 |Sas|saaisaee(see| 51 & | x 
mo) Ry me | mS eRe Sim ER Smee > | So] Es 
= 5 = 5 I =) = FTE SS) iS) = CS) 
3 Ss ° ° © 
Cortex, 57 CaS€S ......eeeeees 4 3 1 5: re 1 is 1 1 | In 7 of these......- 11 = 19 per cent. 
Lobes, 124 CaS@S «0.0. swceeses 5 3 8 2 4 5 3 2 4 1 | In 22 of these...... 37 = 29 per cent. 
Basal ganglia, 26 cases ...... 2 1 we ; oe Ae « 5 2 1 alone, 1 besides.. 6 = 23 per cent. 
Cerebellum, 90 cases ........ 2 6 1 3 At % 4 1 In 4 of these....... 17 = 18.5 per cent. 
TPOUAL . s ccclessrevelesis ore eens 13 13 10 2 7 6 7 2 8 2 35 71 = 23.8 per cent. 














In one form the capillaries are increased in size, in the 
other they are effaced. 

Bruns considers these two forms simply gradations of 
each other, the neuritis optica being the incipient stage, 
the choked disc proper the advanced stage of the same 
process. When the arteries have almost ceased to be 
distinguishable, except at the periphery of the retina, 
small hemorrhages usually form in the retina, and spots 
of fatty degeneration are seen, the latter being a serious 
threat of speedy blindness. 

Against the doctrine of venous obstruction as a cause 
of choked disc, it has been urged that the free inoscula- 
tion of the ophthalmic vein with the angular branch of 
the facial suffices to avert complete venous obstruction, 
even when the circulation in the cavernous sinus has been 
retarded. Further, a free communication has been de- 
monstrated between the intervaginal lymphatic space of 
the optic nerve and the subarachnoid space of the brain. 
It has been shown that a rise of intracranial pressure 
suffices to force cerebro-spinal fluid into the intervaginal 
space of the nerve, thus causing compression of its cen- 
tral vessels, local obstruction, and swelling from transu- 
dation, apart from venous obstructions. 

Choked disc sometimes appears in cases in which the 
tumor is so small that much increase of intracranial 
pressure seems doubtful. It is then more probably due 
to inflammation of the optic nerve, first propagated from 
irritated brain tissue to the central terminations of the 
nerve, neuritis from diffused cerebritis (Mackenzie), or 
excited by direct pressure upon the optic tract. Such 
direct pressure is exercised by tumors of the corpora 
quadrigemina, the chiasma, the cerebral peduncles, or 
the interpeduncular space. 

Choked disc is found far more frequently (54 per cent.) 
in cases in which the tumor involves the corpora quadri- 
gemina, than in those in which it involves any other part 
of the brain. The smallest percentage is in the class of 
cases in which the basal ganglia are the seat of the tu- 
mor. When there is direct pressure on the optic tract, the 


438 











The existence of mental symptoms in a large propor- 
tion of these cases (49 per cent. of them) is the circum- 
stance that might, perhaps, most surely guide in the 
diagnosis, otherwise so difficult. 

The proximate consequences of increased intracranial 
pressure, which are the immediate cause of the diffused 
symptoms, have been differently interpreted. It was 
long maintained that the brain substance was nearly 
as incompressible as water. Room, therefore, could be 
made within the cranium for a neoplasm only by propor- 
tionate expulsion of blood and lymph, and by atrophy 
of the brain tissues in the immediate vicinity of the 
tumor. Adamkiewicz’s experiments have shown, how- 
ever, that the nerve tissue surrounding the tumor is 
compressed, 7.e., its solid molecules are approximated, 
and the fluid normally interposed between them is, to a 
greater or less extent, expelled. For, when a piece of 
laminaria was inserted under the skull of an animal pre- 
viously trepanned for the purpose, and was allowed to 
swell, thus rapidly encroaching upon the intracranial 
space, microscopic examination of the tissue in which 
the foreign body was embedded revealed the fact that all 
the nerve elements of this tissue were closely crowded 
together, thus apparently multiplied in a given space. 
The zone adjacent to this was intensely vascularized from 
dilatation and new development of capillaries, and, in ad- 
dition, it was hypertrophied from proliferation of con- 
nective tissue. 

In the experiment, the swelling of the laminaria was 
much more‘rapid than is the growth of any tumor, and 
the condensation and nutritive irritation of tissue were 
therefore exaggerated. To a greater or less extent, 
however, both these lesions must always be produced by 
the presence of a foreign body within the cavity of the 
cranium... Only when the tumor grows very slowly are 
they absent, or reduced to sucha minimum as to occasion 
no symptoms, either diffused or focal. 

The elements of gliomatous tumors are the most liable 
to so insinuate themselves between the elements of the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





brain tissue as to avoid compression, and no well-defined 
line of demarcation separates the tumor from the brain 
mass. In this respect the sarcomata contrast markedly, 
and may be distinguished by the naked eye by the zone of 
softening which circumscribes them. Carcinomata and 
tubercle directly destroy brain tissue and take its place. 

The occurrence, in twenty-three per cent. of the cases, 
of diffused without focal symptoms indicates that the 
centres of origin of nerve tracts have remained un- 
affected, though the vomiting and convulsive centres 
and the nervous filaments of the dura mater have been 
irritated ;-that lymph has been forced into the sheath of 
the optic nerve, or that a descending neuritis has been 
excited by propagation from the zone of cerebritis sur- 
rounding the tumor; and that the delicate psychic 
mechanisms of the cerebral cortex have been irreparably 
jarred and are out of working order. 

This immunity of motor, sensory, or special-sense 

nerve functions is usually due to the localization of the 
tumor in a “latent” portion of the brain; but it is also 
sometimes observed in cases in which the tumor occupies 
a (presumable) focus of nerve origin. Thus, although 
there can be no doubt that the ultimate origin of the 
motor nerves contained in the pyramidal tracts is in the 
central gyri and paracentral lobule, tumors seated in 
these localities have sometimes been observed entirely 
unaccompanied by motor symptoms, either irritative or 
paralytic. Two such cases are contained among the 
eleven of the table. In one of these there were forty 
hydatid cysts in the brain, a form of neoplasm very fre- 
quently latent. In the second case, however, there was 
amost extensive sarcoma occupying the lower half of 
the anterior central gyrus, posterior half of third frontal 
gyrus, and under half of insula. 
_ Two explanations are offered for these cases. First, 
that the elements of the neoplasm have insinuated them. 
selves so gradually between those of the nerve tissue, or 
have displaced them with so little injury, that the func- 
tions of this tissue have not suffered. ‘This explanation 
applies to cases in which, instead of the cells of a nu 
cleus of origin, the fibres of a nerve tract have been dis- 
placed, as in some extraordinary cases on record in which 
a tumor has occupied nearly the entire pons, yet has oc- 
casioned no motor symptoms. The second explanation 
applies only to cortical centres. According to Exner, 
the different mechanisms of the cortex, though specially 
concentrated at certain localities, exert their influence 
somewhat beyond these limits, though with constantly 
diminishing intensity and effectiveness. Hence it is oc- 
casionally possible, though the main centre be destroyed, 
that its action may be supplemented by that of others 
habitually subordinate. 

In more than three-fourths of the cases of brain tumor, 
in addition to the diffused symptoms hitherto described, 
the patient suffers from perversions or abolition of one or 
more cerebral functions other than psychic ones. These 
are known as the focal symptoms. 

The simplest focal symptoms are those elicitable by per- 
cussion and auscultation of the cranium. In a certain 
number of cases, careful percussion awakens pain over a 
definitely limited area; and elicits also a peculiar tympa- 
pitic sound (Macewen), indicative of a marked thinning of 
the cranial bone, and due to the more extensive vibrations 
of air in the nose and mouth which occur when the skull is 
thinner than normal. In a few rare cases auscultation 
discovers another sound, an arterial murmur synchronous 
with the arterial pulse. This is conspicuously heard 
with aneurisms, but is by no means confined to them. 
It is analogous to the murmur which may be heard in ra- 
-chitic children or in those with open fontanels, or even in 
certain cases of intense anemia. Other focal symptoms, 
and far more frequently encountered than the foregoing, 
depend on the perversion or abolition of mobility or 
sensibility in one or more cranial nerves or spinal nerve 
tracts; or on similar alterations of one or more of the 
special senses. Among the latter, however, is to be ex- 
cepted the impairment of vision directly traceable to 
choked disc or optic neuritis. An intense interest has 








recently attached to these symptoms as a means of 
unravelling the physiological problems of the localization 
of brain functions. For this purpose, however, the study 
of tumors is much less valuable than that of other brain 
lesions, such as, for example, localized softening; for 
their limits are irregular, and their effects, through 
transmission of pressure, often diffuse themselves in 
structural or functional changes far beyond these visible 
limits. For clinical purposes, therefore, it is necessary 
to ascertain first what symptoms are generated by lesions 
really limited to certain localities; second, to what extent 
the complication of these by others, diffused or symp- 
tomatic of different localities, may aid us in diagnosing a 
tumor instead of any other focal disease. 

Focal symptoms are always unilateral at the beginning 
—a most useful criterion in distinguishing tumor from 
diffused disease of the brain. The appearance of symp- 
toms on the side of the body opposite to that where they 
first began indicates an extension of the tumor across 
the median line, except when parts are affected which 
are endowed with bilateral cortical innervation. Exten- 
sion of the growth across the median line, for obvious 
reasons, most frequently occurs at the narrowest regions 
of the encephalon, the pons and (though less frequently) 
the medulla. It is, however, also seen in tumors of the 
corpus callosum, but the second hemiparalysis is much 
slighter than the first. 

Case (Bristowe, Brain, October, 1884): Illness twelve 
weeks. Left hemiplegia, gradually extending to right 
side; then general paralysis, principally on the left side, 
ten days before death. Progressive drowsiness or stupid- 
ity, aphasia. Sarcoma occupied anterior two-thirds of 
fornix and corpus callosum, extending into the centrum 
ovale in both hemispheres, but principally in the right. 

In addition to these symptoms involving purely cere- 
bral functions, the functions of respiration and circula- 
tion are sometimes modified from the direct or indirect 
morbid influence exercised upon the medullary centres. 

Lesions of Motitity.—These are by far the most numer- 
ous, the most varied in character and in combination of 
all the focal symptoms of brain tumor. They belong to 
three different classes: First, irritative, including tremors, 
choreiform movements, local spasms,* and Jacksonian 
epilepsy; second, paralytic, consisting in the partial or 
complete abolition of motive power; third, ataxic, imply- 
ing inco-ordination among functionally combined move- 
ments. 

Irritative Lesions of Mobility.—A fine tremor or a clonic 
spasm, incessant or periodically repeated, is often seen, 
either in muscles which have already become paralyzed, 
or in those which become paralyzed at a later date. 

Case (Berger, Arch. der Hetlkunde, XIX. Jahr.): 
Woman, aged forty-eight. During a year, about every 
eight days, an attack of clonic spasms in the right arm, 
then paralysis of the same arm, followed by paresis of 
the buccal branches of the right facial; clonic spasms 
persist after paralysis sets in: death a week later. 
Tumor in left anterior central gyrus, compressing the 
posterior and second frontal gyri. 

Case (Berkley, Med. News, 1882): Patient with spasm 
of the left angle of the mouth for two and a half years, 
Sudden death from cardiac disease. Calcareous nodule 
three-sixteenths of an inch in diameter on the right as- 
cending frontal convolution, an inch and a half above 


_the fissure of Sylvius; the locality corresponds to Fer- 


rier’s centre for the zygomatic muscles. 

Tremors and localized spasms are valuable diagnostic 
symptoms; for, first, they are more frequent with tumors 
than with other localized brain lesions; second, they are 
more frequent in the cortex; and, third, they are espe- 
cially frequent in the motor zones. All these circum- 
stances are demonstrated by the following tables. The 
first is compiled from Exner’s collection of one hundred 
and sixty-four cases, exclusively of cortical lesions. 

Tumors of cortex (44 cases): Spasm, 3 = 6.5 per cent. ; 
spasm and paralysis, 14 = 31 per cent.; paralysis, 14 = 31 





* The general epileptiform convulsions being a diffuse symptom. 


439 


Brain, 
Brain, 


per cent. ; no motor symptoms, 18 = 29 per cent. Total 
spasm, 17 = 38 per cent. 

Other lesions of cortex (100 cases): Spasm, 1 = .09 per 
cent. ; spasm and paralysis, 18 = 11.5 percent. ; paralysis, 
62 = 56 per cent. ; no motor symptoms, 36 = 82 per cent. 
Total spasm, 14 = 12 per cent. 

Thus, in more than one-third of all cases of brain 
tumor, localized spasms or contractures exist at some 
period of the disease. When present, they indicate a 
greater probability of localization in the cortex than in 
any other part of the brain; and after that, in the region 
of the corpus striatum and thalamus opticus. In the 
table, the highest percentage falls to tumors of the 
peduncle; but this fact is offset by the great rarity of 
tumors in this region. 


TABLE V.—PROPORTION OF CASES OF SPASM WITH TUMORS. 









































3 el gies ease 
Seat. eA ees eo ere ee ea Hag % 
BS/ 8/2515) 3] 2 ass 
B°| a /ds)s|3|5| shes 
Zz Lie 2 & a 
Cortex— 
Central gyri.......... 39 AA Pla 10M 28 ay eal 
Parietal lobe (motor).| 11 he ff 1 veh stl BE} 
Total motor zone ..| 50 4 31 | 11 35 7 5 
Frontal QyTl oie 14 2 1 4 Dili claliont 
Other latent parts....| 18 1 2 3] 23] 8 
Per cent, 
Total Cortex ..5.. 0 77 G | 34) 1% |-41) 68) 20=25 
Centrum ovale......... 124) 12) 22) 45) 34] 2% | 45=36 
‘Basal canvas. .— ose: 41 9} 10] 14] 19 | 46 S=19 
Pedunele Parsee ocsee 10 il 5| 3 6 | 60 2= 20 
Corpora quadrigemina.| 138 1 3] 2 30 C= be: 
ONS: his ceecieimicecusne 56 3 Ve [|code aki aes S14 
Cerebellum .........++. 165 | 20| 12) 26| 32] 19 | 107=64.5 
Medulla Heike dee sies stccee'e 30 8 2) 154) 10) 83 biG 
Ota) cretcinssveniianns 516 156 | 30 | 202 = 37.5 














It is evident that spasmodic contractions of muscles 
may be caused by irritation either of the nerve elements 
of a motor centre, or of the fibres of a motor tract de- 
scending from it, but that the first condition is more 
favorable. A continuous fibrillary twitching is frequent 
in cortical tumors. But tumors of the pons and medulla 
are rarely accompanied by spasm; it seems that the 
liability to irritation increases higher up in the tract, and 
also when the latter is more incompletely invaded. Irri- 
tation of the skin over the affected muscles will often 
throw them into spasm. 

Paralyses of Motility.—These are especially character- 
ized, as a rule, by their gradual development, a circum- 
stance which is most useful in distinguishing brain tumors 
from hemorrhage. It does not, however, serve to differ- 
entiate tumors from softening, for in the latter the paraly- 
sis is also gradually developed. 

To a certain extent the paralyses of tumors share the 
peculiarities of those caused by other lesions of the same 
locality. As already stated, however, in the case of 
tumors, the paralyses are rarely purely typical through. 
out the whole course of the disease, because they con- 
stantly tend to encroach upon other regions than that in 
which they originated; and because their influence, by 
transmitted pressure and nutritive irritation, is apt at all 
times to diffuse itself considerably beyond the region 
which they visibly occupy. A paralysis which may 
seem at a given stage to be entirely atypical may, how- 
ever, exhibit in the history of its development peculiari- 
ties which point out the true nature of the disease. The 
local diagnosis is best assured when a localized spasm 
has passed gradually into a localized paralysis. The 
paralysis has been preceded by a slowly progressing 
paresis, or by tremor or spasm in the affected muscles, or 
has existed in one set of muscles, or in one limb, or in one 
or more cranial nerves; or there has been a combination 
of paralyses of such nerves with others of the extremities, 


440 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











before the disease reached its complete evolution. Or, 
further, the very first appearance of paralysis may have 
been preceded by one or more diffused symptoms; or it 
may have been ushered in by an epileptiform convulsion 
or an apoplectic attack, remarkable for its brevity and 
incompleteness. Or a paralysis may declare itself at 
once, in a fully developed form, but isolated, as in one 
facial nerve, and after prolonged headache, attacks of 
vomiting, and change of mind or character of the pa- 
tient. The typical characteristics of the paralyses, ac- 
cording to locality, are as follows: 

Corter.—The paralysis, at the outset at least, is “dis- 
sociated,” monoplegic. One arm or one side of the face 
is affected, or the two together are affected on the same 
side. It is extremely rare that paralysis begins in the 
leg; but this extremity often becomes involved later, and 
then the patient suffers from a complete hemiplegia, 
difficult to distinguish at first from the common hemi- 
plegia due to hemorrhage into the internal capsule. It 
is very rare, however, that the paralyzed limbs become 
rigid. It is with tumors in this region that clonic spasms 
are most frequent, either before or during the paralysis. 
Symptoms of tumors of different regions of the cortex 
follow, approximately, the rules which have been laid 
down for other lesions, according as they occupy the 
“latent” or the motor zones. The latent regions are 
those parts of the brain in which, with rare exceptions, 
lesions produce no motor symptoms. ‘The motor zones 
are those whose lesions are always followed by spasm or 
paralysis, except ina very few cases, in which the absence 
of symptoms is explained by the extremely slow growth 
of the tumor, which allows nerve tissue to accommodate 
itself to increased pressure. When an “absolute field ” 
exists it will be found that, in all cases in which motor 
symptoms are absent, this field is entirely free from 
lesion. In the regions adjacent to these, lesions some- 
times do and sometimes do not producesymptoms. This 
fact, as already stated, has been explained in two ways 
—by the theory of transmitted pressure, and by the 
theory of a “relative field,” which contains motor mechan- 
isms of less degree of intensity and concentration than 
those belonging to the “absolute field.” The absolute 
motor zones are: 

First, for the upper extremity, the anterior central 
convolutions, especially the lower two-thirds, the upper 
half of the posterior central convolution, the paracentral 
lobule, and, in the left hemisphere, the greatest part of 
the superior parietal lobe, and possibly a few points on 
the occipital. 

Second, for the lower extremity, it is the upper third 
of both central convolutions and the paracentral lobule, 
and in the left hemisphere again the greater part of the 
superior parietal lobe. This “absolute field” is, accord- 
ing to Exner, surrounded by a relative field which oc- 
cupies the posterior half of the superior frontal gyrus, 
almost the entire convex surface of the other two frontal 
gyri, both parietal lobes, and the upper part of the oc- 
cipital lobe. This field belongs to both extremities. 

The centres for the muscles of the trunk have been 
placed by Horsley and Schiifer in the gyrus marginalis. 

Third, there is no absolute field for cither facial mus- 
cles or tongue, the mechanisms for both seeming to be 
diffused over the greatest part of the hemispheres. But. 
the seat of greatest concentration, for the facial nerve, 
exists at the lower half of the anterior central gyrus and 
the lower third of the posterior central; while a relative: 
field extends over the posterior half of both lower frontal 
gyri and the anterior part of the supramarginal gyrus. 
The principal centre for the hypoglossal nerve is the 
lower part of the anterior central gyrus and adjacent: 
part of the middle and inferior frontal gyri. 

Fourth, no definite cortical field has been outlined for 
either the motor-oculi nerve or the trigeminus. In regard 
to the first, however, it seems certain that all the branches. 
of both nerves are influenced by the centres of a single 
hemisphere. 

The zone for common sensibility coincides with the 
motor zone as above defined. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain. 





Fifth, the zones latent in regard to motor or sensory 
symptoms include all the frontal lobes, the temporo- 
sphenoidal lobes, the parietal lobe of the right hemi- 
sphere, and the occipital lobes. Lesions of these lobes 
may remain absolutely latent, and did so in 13 of Exner’s 
44 cases of tumors, that is, in 29 per cent. But, even 
when unattended by paralysis or spasm, lesions of these 
latent zones are liable to be followed by such disorders 
of speech, of vision, or of hearing as lead to the localiza- 
tion, within their boundaries, of the centres for these im- 
portant functions.* In Table V. it will be seen that 
there were 9 cases of paralysis, with or without spasm, 
occasioned by tumors in the non-motor regions; the per- 
centage of paralysis to whole number of such tumors be- 
ing 387 per cent. Out of the whole number of cases of 
paralysis from 77 tumors of the cortex (51 cases), the 
vercentage belonging to tumors of non-motor regions 
was 17.5 per cent.; that of those belonging to motor 
regions (42 cases) was 54 per cent. of the whole, and 84 
per cent. of the tumors of that region; while, finally, the 
probability that a tumor situated in the cortex would 
occasion some form or degree of paralysis is indicated by 
the relation of 51 to 77, or 66 per cent. 

Centrum Ovale.—A much larger percentage of tumors 
remain latent in this region than in the cortex, as, for 
example, 36 per cent., instead of 25 per cent. (see Table 
V.). The absence of symptoms is to be expected when 
the tumor neither occupies nor affects bundles of fibres 
coming from the motor regions of the cortex. In the 
following table Ladame’s and Bernhardt’s cases are com- 
bined, and show to what extent tumors situated in non- 
motor regions may yet inhibit the mechanisms of the 
motor regions. : 


TABLE VI.—PARALYSIS WITH TUMORS OF CENTRUM OVALE. 





























MOTOR REGIONS. NON-MOTOR REGIONS. 

n n nD n 

a Bi a A 

= oF hae, Ps 

Seat. S a Fe Seat. FS Zz FA 

Es} =] 3S iso] 

a ray a a 
Pars centralis ante- Pars frontalis ..... 37 37 
rior and _ posterior Pars occipitalis....| 10 23 
(EEN RS) id eee 61 16 Temporal lobe .... 2 3 
Other parts........ ar h 

PIGUA a eteteiniecers/s0i0's.0 61 16 ARO oaanneia 49 70 

















The paralyses which are associated with tumors of this 
region present nearly the same characteristics as do those 
associated with tumors of the cortex if they are near the 
surface; that is, they are liable to be monoplegic; but 
they resemble those of tumors of the internal capsule, 
if they approach the basal ganglion, in which case they 
may become completely hemiplegic, and may be followed 
by rigidity. Tumors in the anterior part of the centrum 
are chiefly indicated by motor symptoms, spasm. or 
paralysis; those situated posteriorly cause sensory symp- 
toms—hemianzsthesia, or pains on one side of the body. 
Usually a long period of paresis precedes that of com- 
plete paralysis. 

The percentage of cases of paralysis in tumors of the 


centrum ovale, whether calculated from the smaller ~ 


number of cases in Table VI. or from the larger num- 
ber in Table V., is about: the same, viz., 54 per cent. in 
the first case, 56 per cent. in the second. 

Basal Ganglia.—Tumors of the corpora striata, optic 
thalami, and lenticular nuclei occasion: hemiplegias, 
which often differ from those of hemorrhage in the same 
region, exclusively by their gradual rate of development. 
The paralysis is, however, sometimes monoplegic; thus, 





* The wide diffusion of the mechanisms for the motor-oculi nerve 
and the facial, which render their paralyses of little value in regional 
diagnosis, is probably correlated to the complex relations of these two 
nerves to the mechanisms of psychic existence, and their functions in 
the innumerable shades of facial expression. 


out of 41 cases, it was:confined to the facial nerve four 
times, to the arm once, to the arm and facial once, and 
to the leg once. It is extremely remarkable that large 
tumors may exist in this region without causing any 
symptoms whatever. This is the rule for tumors limited 
to the thalamus or to the lenticular nucleus. Acute 
lesions, such as hemorrhage in the latter ganglion, cause 
temporary hemiplegic symptoms, but these subside, 
probably because the function of the destroyed tissue is 
supplemented by that of other motor centres. But such 
temporary paraiyses are not seen with chronic lesions, as. 
for example, tumors, unless these are complicated by an 
accidental hemorrhage. 

But tumors limited to the corpus striatum will certainly 
cause paralysis if they involve the anterior two-thirds 
traversed by the motor tract of the internal capsule. It 
is injury to this tract which determines the phenomenon 
of “late rigidity ”; a phenomenon depending on the de- 
scending degeneration which reaches the spinal cord, and 
which, though so commonly seen after cerebral hemor- 
rhage, is not peculiar to that lesion, but only to the local- 
ity which it most frequently occupies. 

If a tumor involve the posterior third of the internal 
capsule, whose fibres pass between the corpus striatum 
and the thalamus, it tends to destroy the sensory fibres 
which pass in this locality (Charcot, Veysiére), and causes 
a hemianesthesia in addition to the motor paralysis. 
This complication is therefore of great use in establishing 
the diagnosis of tumors of this region, which from their 
encroaching tendencies are so liable to involve all parts 
of the internal capsule. It is possible that a transmitted 
irritation to sensory fibres has something to do with the 
high percentage of spasms observed in tumors of the 
basal ganglia (46 per cent., see Table V.). There were 24 
cases of paralysis, with and without spasm, which is 58 
per cent. of the whole number. 

Hemianopsia, or paralysis of some ocular muscles, oc- 
curs with such tumors of the thalamus as touch upon the 
corpus geniculatum externum. Athetoid movements 
and intention tremor are very characteristic of thalamic 
tumors. Still more so is Bechterew’s symptom, namely, 
preservation of the innervation of facial muscles for 
voluntary movements, with loss of the automatic move- 
ments involved in emotional expression,—as in laughing 
or crying. This isolated mimetic paralysis seems to be 
quite peculiar to lesions of the thalamus. 

Peduncle.—Asmight be expected, tumors of this region 
cause hemiplegic paralysis in almost all cases (eighty per 
cent.). Together with the extremities, the facial nerve 
and also the hypoglossus are usually involved. The 
most characteristic circumstance, however, is the paraly- 
sis of the motor-oculi nerve by direct pressure upon its 
trunk as it emerges in the interpeduncular space. The 
paralysis is on the same side as the tumor, that is, on the 
side opposite to the hemiplegia. The paralysis is usu- 
ally total, in which case there will be unilateral dilatation 
of the pupil, ptosis from paralysis of the levator palpebre 
muscle, and divergent strabismus from paralysis of the 
internal rectus. In other cases, one or more of these 
symptoms may exist alone. As the tumor grows larger 
it sometimes crosses the interpeduncular space, and com- 
presses the nerve on the opposite side. This important 
symptom existed in seven out of the ten cases of Ladame 
and Bernhardt. It isnot, however, absolutely pathogno- 
monic of lesions of the peduncle; for it results, with 
exactly the same forms, from every tumor of the inter- 
peduncular space; thus, from those springing from the 
base of the cranium. 

Corpora Quadrigemina.—Tumors of these bodies lie 
outside of the direct cerebro-spinal motor tracts, and 
thus produce much less definite motor symptoms. Some 
degree of paralysis existed in 5 out of 18 cases; in 1, 
paresis of the arm and facial nerve; in 2, a unilateral 
facial paresis; in 1, paresis of one leg; and in 1, paresis 
of one-half of the body. 

On the other hand, the motor-oculi nerve seems to be 
paralyzed as often as in the case of tumors of the pedun- 
| cles; a fact which might be expected from the proximity 





44] 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of the corpora quadrigemina to the nuclei of the nerves, 
which lie immediately below them. In 14 cases, diver- 
gent strabismus existed in 8 (5 cases of Bernhardt, 3 
related by Nothnagei). In 1 other case, the abducens was 
paralyzed, so that internal strabismus existed (Gowers, 
Lancet, 1879). 

Cerebellum.—Absence of true motor paralysis, taken 
together with impairment of the power of equilibration, 
is highly characteristic of tumors of the cerebellum. 
Out of a total of 165 cases, only 38 showed any kind of 
paralysis (23 per cent.). This is almost the proportion 
in which the symptom is absent in tumors of the cerebral 
cortex. Excluding the cerebellum and corpora quadri- 
gemina, the probabilities of paralysis with brain tumor 
are expressed by the percentage 89, while for the cere- 
bellum and corpora quadrigemina alone the percentage 
is only 24. 

Tumors of either lateral lobe of the cerebellum cause 
of themselves no motor symptoms, even ataxic, and may 
be completely latent. Out of the 38 cases of paralysis 
the tumor occupied the middle lobe of the cerebellum in 
4; in 5, one of the peduncles; in 15, though mainly situ- 
ated in a lateral lobe, it extended into the middle lobe, 
or else compressed the pons or medulla. 

The facial nerve may be affected either by an isolated, 
or by an alternating, or by a hemiplegic paralysis, in the 
rare cases in which hemiplegia occurs. The lesion is 
never really of cerebellar origin, but always secondary 
to encroachment upon the pons or medulla. 

Pons Varolit.—In this locality tumors produce the 
most extensive and also the most complex combinations 
of paralyses. They are occasionally paraplegic, and not 
infrequently they become, little by little, generalized 
throughout the four limbs. This creeping generalization 
is highly characteristic of tumors of the pons. On the 
other hand, only cranial nerves may be affected. 

Case (Wernicke, Archiv f. Psychiat., Bd. vii.): Pa- 
tient aged fifty-eight years. In July, headache, diplopia; 
difficulty in opening and shutting mouth. By end of 
August, paralysis of left facial nerve, including upper 
branches; rigidity of left masseter; eyes persistently 
deviated toward the right; diminished sensibility of face 
and head on the right side, that is, on the side opposite 
to the facial paralysis. Death occurred in October with- 
out further motor affection. Section discovered a tumor 
on the floor of the fourth ventricle, on the left side of the 
middle line. Associate nucleus of facial and abducens 
completely destroyed; left facial nerve nucleus, as also 
part of the fibres of the right trigeminus, destroyed. 

After the frequent generalization of the paralysis, the 
remarkable paralytic symptoms of pontine tumors are: 
1. The coexistence of hemiplegic paralysis of the ex- 
tremities with paralysis of one or more cranial nerves on 
the opposite side of the body; alternate paralyses. 2. 
The occurrence of a persistent conjugate deviation of the 
eyes, thus distinguished from the same symptom in 
lesions of the hemispheres, where it is always transitory. 
To these positive symptoms may be added an important 
negative characteristic, namely, the nearly complete 
absence of local irritative symptoms, and, to an even 
more marked degree, of general convulsions. The alter- 
nate paralyses are produced by tumors in the lower part 
of the pons, which injure the nerve nucleus or compress 
the nerve trunk on the side on which they are situated, 
and injure the general motor tracts of the limbs previous 
to their decussation, so that the resultant hemiplegia fol- 
lows the usual law for cerebral paralysis, and appears on 
the side of the body opposite to the lesion. When the 
tumor occupies the upper segment of the pons, anterior 
to the cerebral peduncles, the facial paralysis will be on 
the same side as the limbs, since it depends not on a 
lesion of the nucleus or nerve trunk, but on one involv- 
ing the central fibres after their decussation. When the 
tumor occupies the region of the abducens nucleus, the 
movements of both eyeballs to that side are paralyzed. 
The double nature of the paralysis proves that the nu- 
cleus common to the abducens and internal rectus has 
been affected. 


449 


In the most typical cases, all the branches of the faciai 
are paralyzed, including those innervating the orbicularis 
palpebre. The eye cannot be closed, and the patient 
presents the appearance of Bell’s paralysis. The electric 
excitability of the nerve may then be diminished. How- 
ever, neither of these last conditions is invariable, even 
when the paralysis is alternate. 

Double facial paralysis is extremely rare. It is lesions 
of the pons which have furnished the explanation of the 
remarkable phenomenon—conjugate deviation of the eyes 
—which for a long time puzzled pathologists. This de- 
viation implies paralysis of the abducens nerve of one 
side, supplying the external rectus, and coincident paraly- 
sis of a branch of the motor-oculi nerve supplying the 
internal rectus on the opposite side. The apparent re- 
moteness from each other of the nuclei of origin of these 
two nerves rendered this phenomenon extremely difficult 
to understand, until the discovery was made, in the 
pons, of a common nucleus, which unites fibres of the 
abducens with fibres from the lower nucleus of the motor- 
oculi on the opposite side. Destructive lesions of this 
associate nucleus are followed by a permanent conjugate 
deviation, as in the case (Wernicke) above quoted. It 
becomes evident that the transitory deviations of the eye, 
frequently seen immediately after an attack of hemor- 
rhage into any part of the brain, are due to a remote 
shock propagated to this same nucleus. 

The abducens nerve is not infrequently paralyzed alone, 
causing a converging strabismus of the affected eye. 

Isolated paralysis of the motor-oculi nerve is much 
more rare, and is seen only when the tumor or its influ- 
ence extends above the pons into the cerebral peduncles, 
or above them to the nerve nuclei. Ptosis, from isolated 
paralysis of the levator palpebre branch, has sometimes 
been observed alone, and, so far, in cases of tumors, but 
not in those of any other lesion. This symptom would, 
therefore, be useful in differential diagnosis. 

Paralysis of the hypoglossus isnot rare. Itis indicated 
by an impairment of the voluntary movements of the 
tongue and by disturbance of speech, dysarthria. This 
paralysis alternates with that of the extremities. It is 
distinguished from progressive bulbar paralysis by ab- 
sence of atrophy of the tongue. 

The motor branch of the trigeminus is sometimes 
paralyzed, more often irritated, causing, in the latter 
case, spasmodic trismus or clonic convulsions of the 
muscles of mastication. 

Difficult deglutition is also sometimes present, but does 
not seem to be attributable to paralysis of the pharynx 
muscles, but rather to be a secondary consequence of 
paralysis of the tongue and of certain muscles innervated 
by the facial nerve, the styloglossus, digastricus, and 
stylohyoideus (Nothnagel). 

The following table exhibits the various combinations 
of paralyses, which have been observed with tumors of 
the pons. 


TABLE VII.—MOTOR PARALYSES WITH TUMORS OF PONS (56 CASES). 














Cranial nerves Combination No motor 
alone. Limbs alone. of limbs and cranial symp- 
nerves. toms. 
3d nerve ...... 2;Hemiplegia... 7 On same side, 
7th nerve..... 3}Paraplegia.... 3]/Hemiplegiaand 
38d and 6th Four extrem- 7th nerve........ 4 
nerves ...... Hee in YB Aye aides 2| Alternate paralysis. 
6th and 7th |Armalone.... 1/Hemiplegia and— 
nerves ...... 3 30 DELVE sass 2 
7th and 12th 6th nerve ....... 3 4 
nerves...... 1 7th nerve........ 4 


3d, 7th, and 3dand 6th nerves 1 
12th nerves.. 1 3dand7th nerves 3 
3d, 5th, 7th,and 6th and ‘ith 


12th nerves.. 1 DCIyes Prescee 5 
3d, 6th, and 7th 

NELVES es ncnnee 1 
3d, 5th, 7th, and 

12th nerves... 1 

3d, 6th, 7th, and | 

12th nerves... 1 

Total...... 13 TOTAL ese! Total rsccecetrn 25 4 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





The number of cases in which the cranial nerves or 
those of the limbs were paralyzed independently of each 
other is, in this collection of cases, exactly equal. The 
number of cases of combined paralyses is just double 
that of either of the classes of isolated paralyses. Among 
the cranial nerves, the liability of the facial is evidently 
the greatest; it was affected, alone or in combination, 
twenty-four times; the abducens sixteen times. 

Medulla.—In this region the liability to paralysis again 
diminishes. Tumors of the medullaare not infrequently 
confined to the floor of the fourth ventricle, so that the 
motor tracts and nuclei are both left uninjured. In this 
case, the patient escapes all paralysis; indeed, he often 
remains with singularly few symptoms for the subject 
of an organic disease seated so near to vital nerve centres. 
Out of 30 cases, 12, or nearly half, remained free from 
motor symptoms. In one case, so far unique (Erichsen, 
Petersb. med. Zeitschr., 1870), a bilateral paralysis of the 
vocal cords was noted, due to lesion of the accessory 
nerve. 








TABLE VIII.— MOTOR PARALYSES WITH TUMORS OF MEDULLA 
(30 CASES). 
Nene ig hea Extremities. Combination. Negative. 
3d nerve...... 2|Hemiplegia ...  1|/Hemiplegia and— 
7th nerve ..... 2|Three extremi- 6th nerve ....... 
3d and “7th nts": Wane art Same side. 
nerves...... 1/Paraplegia.... 2|/Hemiplegia and— 
“th and ilth =(|General....... 2| 6th nerve (alter- 
nerves ...... NAtiNg) wees 1 
5th, 6th, and 3d, 6th, and 7th 
7th nerves... 1 MIGLV eS teneees 1 
od, 7th, and 12th 
NIONV.OS orsievelejerere 1 12 
7th and associ- 
ated 3d and 6th 
NOVV CS vreau. 1 
Motalls ss... 7 Totale.aer. 6 "Otel saesaae as 5 12 








The third form of motor lesion is atazia. 

This form of lesion is principally seen with tumors of 
the cerebellum and corpora quadrigemina; the latter, pos- 
sibly from the connection of these bodies with the cere- 


essential that the middle lobe be involved or indirectly 
affected ; tumors limited to a lateral lobe are characteris- 
tically latent. 

Forced movements, or inclinations of the body or head 
to one side or the other, are sometimes associated with 
tumor in a lateral peduncle on the corresponding side. 
A tendency to fall forward or backward has been asso- 
ciated with the situation of the tumor in the anterior or 
posterior extremity of the upper or lower processus 
vermiformis (middle lobe). 

A combination of ataxia with ocular paralyses was 
pointed out by Nothnagel to be highly characteristic of 
tumors of the corpora quadrigemina. 

Recently there has been described an ataxia in tumors of 
the frontal lobes closely resembling that supposed to be 
special to the cerebellum. It is due to paralysis of the 
muscles of the trunk, whose centre of cortical innerva- 
tion is placed by Horsley and Schiifer in the gyrus mar- 
ginalis, thus in the middle line. Hence with a unilateral 
tumor there will be bilateral ataxia. 

LESIONS OF SENSIBILITY.— With the exception of head- 
ache, already described as a diffuse symptom, alterations 
of sensibility are very much less prominent in the symp- 
tomatology of tumors than alterations of motility. 

It is evident from this table that, in the cortex, the 
seat of sensibility coincides with the seat of motility. 
Pain or anesthesia rarely exists without paralysis, or ex- 
cept in connection with tumors situated in the motor 
zones. The liability to pain, other than headache, with 
tumors of the centrum ovale, is very slight (5 cases out 
of 124).* 

It has already been pointed out that tumors of the 
basal ganglia will cause hemianzesthesia in paralyzed 
limbs, provided they involve the bundle of fibres which 
pass in the posterior third of the internal capsule; other- 
wise they will not be attended by lesions of sensibility. 
The table, therefore, expresses the probabilities of this 
precise situation, in giving the proportion of cases of 
pain or anesthesia as eight out of thirty-nine, or twenty 
per cent. 

The highest percentage is with tumors of the pons, 
and the next highest, if the few cases of tumors of the 
peduncles of the cerebrum be excluded, is with those of 
the medulla. In these places occur pain and anesthesia 


TABLE IX.—LESIONS OF SENSIBILITY WITH BRAIN TUMORS. 




































































WITH MoTOR PARALYSIS. WITHOUT MOTOR PARALYSIS. 4 gS eS 

6 |% 28s 

Seat. Unilateral. Double. Trigeminal. Unilateral. Double. Trigeminal. 5 § aac 
————— | | | 2 

&p Bg a 

Angs- .. | Anges- n Anges- : Angs- .. | Ances- -, | Anges-| © : 2 ood 

Pain. thesia, | Pain. thesia. Pain thesia Pain thesia Pain. thesia. Pain. thesia.| 4 z = a” 
‘Cortex (57 cases): ; 

CAMA VTP... s anccte es 6 v4 1 Saas 11 [14 =% 

Parietal gyri...c..+..-- 1 3 il 12 | 5=2% 
“ay Say eee ee are 1 Oe 9|1=10 
ERINDOLAllstece asec cvccs|)) oereeece 2 1 L138=%5 
WCCMNEAL ce ccclicesccecsee||  cecenece sees ete 1 O="0 
Entire cortex ........ 8 15 eee her 34 |28 = 40 
‘Centrum ovale (124 cases) 5 14 mtd Anite 105 |19 = 15 
Basal ganglia (39 cases) . 1 5 ony btefats 2 SIs 2p 
Peduncle (10 cases) ...... a a ; a a0ae ; anne 1 5 | 5=50 

Pons (51 cases) .....++- Db iden a oH bed [27 = 62.5 

Medulla (30 cases) ....... 4 5 2 1 1 baler 1 16 [14 = 46 | 

‘Cerebellum (167 cases) ... 2 7 1 1 4 5 5 ae isi eae, Seen £42 25 = 14.5 
Corpora quad. (18 cases) . 1 aoe Ae 1 ROE = |enoceul Wisconoel latce pepe edie [eth 

Total (491 cases) ..... Sie 6F of ail 59 = 12% 5 = 1% 4 = 0.8%| 10 = 2¢||8 = 1.2/8 =1.6%| ....] ....| 1 368 











Percentage of lesions of sensibility in all cases equals 25. 


bellum through the superior cerebellar peduncles. In the 
pons and medulla, the advent of paralysis is often pre- 
ceded for some time by a staggering or reeling gait “like 
a drunkard’s.” This same symptom is very conspicuous 
in tumors of the cerebellum, and, when associated with 
the negative symptoms of absence of motor or sensory 
paralysis, points very strongly to tumors of this region. 
For the development of the symptom, however, it is 


in the facial range of the trigeminus. When similar 
symptoms are excited by tumors of the cerebellum, it is 
only because the pons or medulla has been compressed. 


*The percentage of headache, however, was sixty-six, the highest 
after the cerebellum and rare cases of corpora quadrigemina. The 
liability to headache, from distention of the dura mater, is constantly 
seen to bear no proportion to perversions of sensibility due to lesion 
of sensory tracts or centres. 


443 


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Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Trigeminal neuralgia or anesthesia is, like cramp or 
paralysis of the masticatory muscles, a most important 
symptom for helping to localize a tumor in the posterior 
cranial fossa. It is noticeable (see table) that trigeminal 
anesthesia has hitherto been observed on the side op- 
posite to the paralysis, while anesthesia of the extremi- 
ties has nearly always existed on the same side. 

The cerebellum and corpora quadrigemina show the 
same minimum liability to lesions of sensibility as they 
do to motor paralysis. Their precentage, almost alike 
for the two cases, is, however, not lower than that of the 
centrum ovale. 

LESIONS OF THE SPECIAL SENSES.— Vis¢on.—Disturb- 
ances of vision are extremely frequent as symptoms of 
brain tumor, and are of three kinds: First, atrophy of 
the optic papilla as a consequence of choked disc, and 
therefore as a remote consequence of increased intra- 
cranial pressure; second, deviations of the eyeball or 
eyelids from isolated or combined paralyses of the nerves 
supplying the ocular muscles, the third, sixth, and 
seventh; and finally, third, amblyopia or amaurosis, re- 
sulting from direct affection of the optic nerve in its 
course through the cranium, or at its cerebral centres, the 
mode of development being therefore almost precisely an- 
alogous to that of paralysis of any other nervous tract by 
direct compression. The first two kinds of ocular defect 
have been sufficiently described; the third comprises two 
different kinds of lesions, those affecting (by compression) 
the optic tract or chiasma, and those which affect the 
optic stations at the posterior extremity of the thalami or 
at the corpora quadrigemina, or else at the final visual 
centres of the cortex. 

The optic nerve or chiasma is liable to compression 
from tumors arising from the base of the cranium or 
from the hypophysis, and also from tumors of the 
peduncle; an acute descending optic neuritis, with 
atrophy of the papilla, is usually excited. When one 
tract or one side of the chiasma is compressed, hemiopia 
results, a phenomenon dependent on the semi-decussation 
of nerve fibres which takes place in the human chiasma. 
Thus pressure on the right side beyond the chiasma, of 
such a nature as to injure the fibres of one tract, will 
abolish vision in the right half of both eyes. A tumor 
in front of the chiasma may cause temporal hemiopia of 
both eyes, since it injures fibres coming from the nasal 
half of both eyes. There is no way in which a double 
nasal hemiopia can be produced by tumors at the base of 
the brain. 

Tumors of the thalamus might be expected to affect 
the sight from lesion of the corpus geniculatum, with 
its branch to the optic tract. Asa matter of fact, how- 
ever, blindness is not very common from tumors of this 
locality—only 5 cases out of 26 (19 percent.) As already 
mentioned, hemianopsia is seen with tumors of the thal- 
amus, when they involve the corpus geniculatum exter- 
num. ‘Tumors of the corpora quadrigemina, however, 
have an immensely large portion of cases. Out of 11, 9 
showed either amblyopia or amaurosis, 5 with and 4 with- 
out choked disc (81 per cent.). 

Visual defects from lesions of the cortex are extremely 
interesting in connection with two physiological prob- 
lems, viz., the question of a second decussation of optic- 
nerve-fibres in the cerebrum (Charcot), and that of the 
localization of the mental centre of vision. This centre 
was placed by Ferrier at the angular gyrus, as an infer- 
ence from direct experiment upon the brain of monkeys. 
But Exner, on the authority of four cases of lesion reach- 
ing to the cortex, of which two were tumors, places the 
visual centre in the first and second occipital gyri—the 
cuneus and adjacent part of the lobulus quadratus. 

Case (Gowers, Lancet, 1879): Visual hallucinations of 
a peculiar nature, associated with some degree of am- 
blyopia, affecting both eyes, but more markedly the left. 
Tumor occupying first and second occipital gyri, posterior 
half of superior and inferior parietal lobes, the cuneus, 
and a part of the lobulus quadratus. 

Case (Jastrowitz, Centralbl. fiir prakt. Augenheilkunde, 
vol. i, 1877): Paralysis of both right extremities and 


444 


-and visual hallucinations of various kinds. 


facialis; aphasia, with agraphia; hemianopsia dextra. 
Tumor of the left occipital lobe, principally in the occip- 
ital gyri and the precuneus. 

Case (Pooley, Arch. f. Augen- und Ohrenheitk., Bd. 
vi.): Together with various characteristic symptoms of 
brain tumor in a syphilitic man, extensive binocular 
hemianopsia. Tumor in posterior lobe of left hemisphere, 
surrounded by extensive zone of softening. Left thala- 
mus completely softened. 

A tumor of one hemisphere may thus cause’ double 
hemiopia, a single or double amblyopia or amaurosis, 
The double ~ 
hemiopia from unilateral lesion, has been interpreted asa 
proof that, arrived at the cerebral hemispheres, optic fibres 
which had decussated in the chiasma, recrossed to the op- 
posite hemisphere, thus finally arriving at the same side 
of the retina as that from which they started. Hemiopia 
is habitually unaccompanied by choked disc. Crossed 
homonymous hemianopsia is the characteristic local 
symptom of disease of the occipital lobes. The symp- 
tom occurs also with lesion of any portion of the optic 
tract, from the chiasma to the occipital cortex. When 
the lesion is in the medulla of the left occipital lobe, to 
the hemianopsia is added another important symptom 
complex, namely, alexia and optic aphasia. It is deter- 
mined by injury to the association tracts running through 
the left occipital lobe from the occipital convolutions on 
both sides to the speech centre in the left superior tem- 
poral convolution. The patient recognizes objects by 
sight, but is tnable to name them, unless he either feels, 
hears, smells, or tastes them. He cannot read words, 
but can write spontaneously and under dictation. Mind 
blindness indicates with certainty lesion of the occipital 
lobes (Bruns). 

Six cases of amblyopia and amaurosis have been ob- 
served with cortical tumors, unaccompanied by choked 
disc. These are all to be attributed to a lesion of the 
visual centre; and, when located in the frontal lobe, the 
lesion must be regarded as indirect. The amaurosis or 
hemiopia, with tumors of the centrum ovale (thirty-nine 
cases, or thirty-one per cent.), probably always implies 
a transmitted lesion of the cortical visual centre. Of the 
two cases of hemiopia, referred to in table X., one is used 
by Exner and Nothnagel as documentary evidence in 
support of the theory of a visual centre in the cortex of 
the occipital lobe, but it is placed by Bernhardt among 
the tumors of the lobes. The total percentage of blind- 
ness is higher with tumors of the cerebellum than with 
those of any other locality, except the corpora quadri- 
gemina. Out of 91 cases there are 41 with some degree 
of blindness (45 per cent.). Of these, 23, or nearly half, 
are without choked disc; the blindness being therefore 
due to the direct action of the tumor upon some visual 
centre. It seems most probable that the centre affected 
is that of the corpora quadrigemina; the influence being 
transmitted through the superior cerebellar peduncles. 
The high percentage of blindness in the two localities 
so especially liable would be shown, therefore, to have 
the same significance. Tumors of the pons and medulla 
also determine amaurosis otherwise than by choked disc, 
through direct upward pressure upon the corpora quad- 
rigemina. The direction of the transmission is the 
same as for the upper (unassociated) nucleus of the 
motor-oculi nerve, which lies just below the corpora 
quadrigemina. Out of a total of 51 cases for medulla 
and pons together, there are 14 cases of amblyopia or 
amaurosis, or 27 per cent. 

To judge from this table we should infer that the 
chances of amaurosis in brain tumor were exactly equal, 
whether choked disc existed or not; but that the chances 
of amblyopia were three times as great without the 
choked disc as with it. This probably means that if 
choked disc occur, the impairment of vision which may 
have been initiated independently of it, by the direct in- 
fluence of the tumor, will rapidly increase to. complete 
blindness: whereas, without this local complication, the 
visual defect may for a much longer time, or even alto- 
gether, remain partial and incomplete. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 








TABLE X.—LESIONS OF VISION (IN 369 CASES). 






























































ool a wel ra > 
5 WITH CHOKED DIsc. WITHOUT CHOKED DIsc. aye peers ae 
2 ; : ; Z 
“oe =F ai ie ke i (mie gee z 
sss) 2 1-8) | 8 ol ea aa eee mee 25 
ae dha Hh ce 3 8 Hemiopia. | 4 . $ |S5F || Sg a2 
S o S| | q q 5 ae = S 
a = < a 4 < oe od 8° Z 
SURREAL wa ccicie ia e's ein neo sie 1 acme | wiaseerttd ears < 3 20 
BUSES er ccslate's|e1e 6. s:e.0:0 6 0,0.0700. iL aes F 3 2 n 12 
MOIloesciess cokes ensees ses eitetereste i! nor j 8 
SCR TECIREI ET  Yoreclarcisieie sieves | oie cies imate me eiteent d-cee. Ml eleeier Il). esses ove ete eee OF 3 
SIAMIPOEA Satainaieisciececics elses 8» afters end Abe Rea reece Watsees cote wate doele AGL 1 Maer 
Entire cortexX...........0+.. . BG |] eee | wees 3 Da ON esieceiots cae 4 2 10.5 16 4 43 
Centrum ovale ......:..600. COE essomrin MOR ie eer |e fete te Sis aan ie Le BLA 12 70 
ASO CANOE. sisa svieea sa. 26 nee eyarcel alll W | teisteletace ave 4 1 19 19 2 18 
Cerebral peduncle.......... 10 i nage verccuar| meo rere cree 2 : : Ser Sites 7 
PAE eMe Peters iste cis tieves: sieve cs 30 1 3 TSR oil wiccreecs 6 20 33 2 18 
MEG Aits sce scec assesses ce 21 Ano RV iD etnies 1 3 19 2 15 
PIETODENAN Tots) orsio (0 oisisis, 0.010.010 91 4 “14 EOE || Wm ereereyecete 9 14 25 45 11 39 
Corpora quadrigemina ..... ST erate 2 3 pe I adeetndnd 3 a 36 81 1 1 
MME eetetateiclctels sais. clsie' siete BBO) Gece 12 BU AM Rete el “nates dels 42 36 38 254 











Total lesions of vision = 127 in 369 cases = 34 per cent. 


Hearing, Taste, and Smell.—All these special senses 
together are less frequently affected than is vision alone. 
Out of a total of 869 cases of brain tumor, lesions of 
vision existed in 127, or 84 per cent. But ina total of 
561 cases (which include Ladame’s), hearing, taste, and 
smell were altogether affected only in 67, or 12 per cent. 
In 46 out of these 67 cases the patient suffered from either 
tinnitus or deafness, the latter rarely complete. In 29 
per cent., the tumor was situated in the cerebellum. 
This fact tends to confirm, if need be, the recent ana- 
tomical demonstration, which traces the central fibres of 
the acoustic nerve to the cerebellum. By far the highest 
percentage of disturbance of hearing is exhibited by 
tumors of the corpora quadrigemina. It is singular that 
reports of tumors of the frontal lobes so rarely mention 
symptoms indicating lesion of the olfactory tracts. It 
would seem that an indirect influence or diffused pressure 
is insufficient to pervert the sense of smell; this is af- 
fected only by actual disorganization of the tracts. Ina 
few cases, anosmia, associated with frontal headache, 
psychic disturbance, and absence of motor or sensory 
paralysis, has been a valuable symptom which correctly 
pointed to tumor in the frontal lobes. But anosmia has 
also been observed with a tumor of the supramarginal 
convolution. The sense of taste, though controlled by 
two medullary nerves, usually escapes injury, even with 
tumors of the medulla. Unilateral paralysis of the 
acoustic nerve, with correlative deafness, is strikingly 
frequent in tumors of the cerebellum. 


TABLE XI.—LESIONS OF SPECIAL SENSES (561 CASES—369 FOR 


























VISION). 
oe | 2 lee] # oad dt 
Seat of tumor. = g a & a & 
S/S Woeles tess 
ise Ay s Ay > Ay 
Cortex (59 cases) ..........- 1 1.5 4 7 9° | 16.0 
Centrum ovale (192 cases) .. 8 4 3 89 | 31.5 
Basal ganglia (41 cases) .... 2 4 oe 5 | 19 
Peduncle (3 cases).......... Bia Pies ia 3 Wace 
Corpora quad. (13 cases).... 4 30 at 9 | 81 
Cerebellum (167 cases)...... 26 | 15 2 1 41 | 45 
ONS ODI CASES) \scaics bese sees 3 5 9 16 10 | 33 
Medulla (80 cases) .......... 2 6 3 10 4 | 19 
ME DESI Nerr ttatctets's\s.<) o\0ie/sla'«.s)si¢ 46 8.0 21 8.5 || 120 | 21 























Disturbances of Language.—These symptoms were 
formerly confounded either with symptoms of mental 
alienation or else with difficult articulation due to tongue 
paralysis. But their interest and importance have been 
greatly widened by the modern discoveries that a patient 
may retain other mental conceptions yet lose that of 











spoken or written speech; and that the generic aphasic 
defect may be resolved into several modes: motor aphasia, 
sensory aphasia, agraphia, alexia. The cerebral region 
belonging to the faculty of speech occupies an extensive 
area in the left hemisphere, including the third frontal 
convolution, the insula, the posterior end of the first 
temporal convolution, the adjacent parts of the gyrus 
angularis and occipitalis sinister, together with sub- 
cortical association tracts. Tumors in the right hemi- 
sphere may also occcasion speech disturbance, when from 
their considerable size they compress the left hemisphere; 
or when they cause a distention of the opposite lateral 
ventricle; or because, as Oppenheim asserts, the right 
hemisphere participates to a real though subordinate ex- 
tent in the function of speech. 

When a disorder of speech has been a very early symp- 
tom of the tumor, it constitutes a valuable means of local 
diagnosis. Nevertheless speech symptoms not infre- 
quently fail though the tumor be situated in a speech 
centre; while, on the other hand, any form of aphasia 
may be caused by tumors at a distance acting on the 
speech regions by transmitted pressure, or encroaching 
on them in the course of their growth. With tumors of 
the central or frontal convolutions the aphasia is some- 
times preceded by a bradyphasia; or the patient finds a 
difficulty in beginning words, or in speaking above a 
whisper. 

When aphasia occurs with tumors of the left occipital 
lobe, or complicates an alexia or hemianopsia, it is always 
a sensory aphasia. Tumors of the third frontal convolu- 
tion are liable to produce spasms of Jacksonian epilepsy 
in the face, tongue, jaws, and larynx. 

From the foregoing analysis of the causation and 
especial probabilities of diffuse and focal symptoms, it is 
possible in a given case to answer the two questions: 
first, Is there a brain tumor present? second, In what 
part of the brain is it situated? 

I. ExisTENCE OF Brartn Tumor.—Although a tumor 
of the brain may develop during either childhood or ado- 
lescence, let us suppose it to have begun its growth in 
an individual of middle age, who perhaps has shown a 
tendency to tuberculosis. In such a case we can assume 
that the clinical picture will be somewhat like the fol- 
lowing: For weeks or months the patient will suffer from 
persistent or periodic headache, usually localized at one 
spot; the pain is peculiarly severe, and is increased by 
percussion. After a time there will be attacks of vomit- 
ing, which sometimes coincide with the most intense 
paroxysms of pain, and sometimes do not. These at- 
tacks, furthermore, seem to bear no relation to the char- 
acter of the food taken, or to the condition of the diges- 
tive organs; they do seem, however, to be dependent 
upon changes in the position of the body, as, for example, 
from the recumbent to the upright position. As in the 


445 


Brain, 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





case of sea-sickness, the attacks are sometimes incoerci- 
ble. They are associated with vertigo; and in turn the 
‘vertigo may occur independently of either the headache 
or the vomiting. It is apt to occur at intervals, and is 
often chronic in character. After the symptoms which 
have just been enumerated have lasted for a variable 
length of time, the patient’s gait becomes uncertain; he 
reels or staggers, or shows a tendency to fall forward 
or backward. This tendency sometimes increases until 
complete loss of equilibration renders the patient unable 
to stand, though he may be entirely free from paralysis. 
The muscles of one side of the face or of one arm begin 
to twitch, or even to be agitated by clonic spasms, which 
either may persist all the time, except during sleep, or 
else may recur in periodic paroxysms, followed by 
paresis, gradually increasing to paralysis in the same 
muscles or in others, e.g., in the arm or leg, after twitch- 
ing of the muscles of the face. The progress of the 
paralysis is apt to be interrupted by one or more convul- 
sions, or by attacks of apoplexy or of loss of conscious- 
ness; or one of these may usher in the first signs of 
paralysis, which at the outset may be complete, facial, 
monoplegic, or hemiplegic. Paresthesia or ansesthesia 
is next likely to manifest itself in the paralyzed limbs, or 
on the side of the face opposite to these. Afterward the 
symptoms succeed one another in about the following 
order: alternate paralysis of cranial nerves and extremi- 
ties; deviations of the eyeballs, isolated or conjugate; 
dilatation of the pupils, ptosis, much more rarely ap- 
pearance of Bell’s paralysis; occurrence at this time of 
diplopia, hemiopia, or amblyopia, gradually increasing 
to complete amaurosis; much more rarely deafness or 
anosmia, and the discovery of choked disc before or af- 
ter the development of ocular symptoms; progressively 
increasing modification of psychic character—at first 
marked irritability, then impairment of mental powers, 
loss of memory, apathy or hallucinations, maniacal ex- 
citement, and melancholic insanity ; before or at the same 
time with the appearance of this mental change there 
will be lesions of speech, dysarthria, aphasia, or word- 
blindness, the two latter often suddenly developed, as 
after an embolus, the first proportioned to the degree of 
tongue paralysis and gradual. A patient presenting the 
foregoing assemblage of symptoms, all progressively in- 
creasing, has, with very great probability, a brain tumor. 
In addition, is to be noted the freedom from pyrexia, 
and usually from changes in the rhythm of either pulse 
or respiration. The gradual, sometimes rapid, emacia- 
tion, the fact that acute accidents, though often followed 
by an exacerbation of existing symptoms, or even by the 
first appearance of new ones, have nearly always been 
preceded by others which have established themselves 
insidiously, are circumstances important to the diag- 
nosis. 

This being the general picture of the disease, individual 
cases are framed by the special emphasis of one or more 
symptoms, or the obliteration of others. The individual 
peculiarities depend upon (1) the locality of the tumor, 
(2) upon its rate of growth, (3) upon its complications, 
and (4), only to a very slight extent, upon its nature. 

Peculiarities due to Locality.—These may be divined 
approximately from such an analysis as has already been 
given of the symptoms proper to lesions of each given 
locality. The a priort judgment must, however, be 
modified in view of the tendency of tumors to encroach, 
in growing, upon territories adjoining their original seat, 
and also in view of the frequent diffusion of their influ- 
ence beyond any situation which they may occupy. 

The following summary of symptom groups is arranged 
in the order of characteristicness. It does not correspond 
to the order of frequency of locality, which, as indicated 
by the combined tables of Ladame and Bernhardt, would 
be as follows: 


CONTIN OV ALG i eisiclelestere sinceinictoisielotste/aloleistetey 192 = 29 per cent. 
Cerebellaninl sss vein. cic evoivatets wceiste cleraraereloteciets 167 = 27 4 
ICOTTO KS: kecoiclelaeiejpipseiargereleicterd ates se acelin eivteniotor 74=11 A 





Cente ween 


Basal Panga. ye sevens eve miutefelaiainisinielsiaraleis/ alot 


446 


Meduila rates crc ioleiaa weesisicemprteinneeiemiere ette 30 = 4 per cent. 
COrpora, QUAGTIPEMINA tenes colette s cies 18. = 2 ies 
Cerebral peduncle. c.s.; seem. amerie eee eer 10") ee 
Extra-cerebral (including pituitary gland). 71=11 es 

649 


But if we consider localities in the order of distinctness 
with which a tumor in them may usually be recognized. 
the order would be as follows: cerebellum, pons, cerebral 
peduncles, cerebral cortex, basal ganglia, corpora quad- 
rigemina, medulla. 

Locau Draenosts oF Tumors.— Tumors of Cerebellum. 
—The most characteristic symptoms occur when the 
tumor involves the middle lobe. Headache is early, 
severe, and prolonged, often occipital; vertigo and vomit- 
ing are prominent; they may be for a while the only 
symptoms; epileptiform convulsions of great violence, 
but not often repeated; choked disc occurs early, preced- 
ing amaurosis, but also followed by this; peculiar ataxia, 
resembling the gait of a drunkard; loss of equilibrium in 
standing, with tendency to fall forward or backward; 
often paralysis of one abducens combined with that of op- 
posite rectus internus; absence of other motor paralysis or 
of general sensory symptoms; loss of patellar reflexes; the 
intelligence clear till toward the end, when apathy deepens 
gradually into coma. From pressure upon the pyramids 
and the cerebral nerves, alternate paralysis is frequent, 
as are cardiac and respiratory symptoms from pressure 
on the medulla. From the same cause, singultus, irre- 
sistible yawning, salivation. All the nerves at the base of 
the brain are liable to be irritated and subsequently para- 
lyzed. Varied symptoms in the area of the trigeminal 
area; pains in the tongue, simulating a gouty neurosis; 
neuroparalytic keratitis; paralysis of the masticatory 
muscles; clonic spasms in the territory of the facial and 
vago-accessorius, in the larynx, soft palate, and pharynx. 
Unilateral paralysis of the tongue from pressure on the 
hypoglossal may be added to unilateral paralysis of the 
acoustic nerve. 

When a lateral lobe of the cerebellum is the seat of the 
tumor, the symptoms are apt to be complicated late in 
the disease by hemiplegia or hemianzsthesia or both, or 
by alternate paralysis. Cerebellar tumor is distinguished 
from pontine tumors by the marked ataxia which precedes 
the paralysis. 

Tumor of Pons, Lower Half.—Uncertainty of gait, 
rather than ataxia, succeeded by isolated paralysis of 
third, or sixth, or seventh, or twelfth nerve, not preceded 
by symptoms of irritation in the muscle which it supplies; 
or else alternate paralysis, passing into incomplete para- 
plegia or general paralysis; permanent conjugate devia- 
tion of the eyes; amaurosis in a third, choked dise ina 
fifth, of the cases; entire absence of convulsions; head- 
ache, vomiting, and vertigo milder than in cerebellar 
tumor, or absent, but intelligence affected in half the 
cases. 

Tumor of Upper Part of Pons.—Combination of symp- 
toms proper to cerebellum and pons, as lobe of cerebellum 
is frequently compressed. Isolated rather than conjugate 
paralysis of the third nerve; paralysis of the facial on 
same side as hemiplegia: irritation of the trigeminus, 
sometimes of motor root, occasioning trismus; or of 
sensitive root, causing neuralgia on the side opposite to 
the hemiplegia. Sudden death is especially frequent in 
tumors of the pons. 

In contrast with tumors of the cerebellum, sensory 
symptoms are manifold in tumors of the pons. The 
most common isa simple anesthesia of the extremities. 
on the side opposite the tumor; but sometimes without 
alteration of the cutaneous sensibility, the muscular and 
stereognostic senses are impaired. The tracts for the 
cutaneous sensibility and muscular sense are separated. 
Besides the Gubler form of alternate paralysis, when the 
facial is paralyzed on the side of the tumor, the hypoglos- 
sal, and extremities on the opposite side, there is occasion- 
ally seen a lesion of the trigeminus on the side of ‘the 
tumor with hemiplegia on the opposite side. “Lesion of 
the motor root causes paralysis of the masticatory muscles 
with atrophy and electrical degeneration; lesion of the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





sensory root causes first neuralgia, later anesthesia. 
Keratitis neuroparalytica also occurs. 

Variations in the form of paralyses are frequent and 
liable to be misleading. There may be no paralysis of 
the extremities, but only of cranial nerves, especially the 
peculiar lesion determining permanent conjugate devia- 
tion of the eyes. Oran entirely cerebral form of hemi- 
plegia may exist,or the lesion may limit itself to the nerve 
nuclei of the pons, paralyzing them without causing mo- 
tor hemiplegia, but crossed anesthesia or ataxia, or, 
through irritation of the pyramidal tracts, crossed inten- 
tion tremor. Only for a short time does a pontine tumor 
remain unilateral, but soon it crosses the median line and 
occasions much complication of the symptoms. The 
cranial-nerve paralyses become bilateral. The conjugate 
deviation of the eyes to one side is neutralized by a second 
on the opposite side, so that the ocular bulbs remain rigid - 
ly fixed in the middle line. All four extremities and both 
hypoglossal nerves become paralyzed. Since the coronal 
fibres which pass through the pons from both cerebral 
hemispheres are injured, the medullary nerves dependent 
upon them—the glossopharyngeal, vagus, and accessori- 
us—are paralyzed, a pseudo-bulbar paralysis results, with 
difficult deglutition, dysarthria, paralyses of the palate 
and pharynx, and disturbances of phonation. 

As rarer symptoms may be mentioned albuminuria, 
polyuria, mellituria, and fever. 

Tumors of the Cerebral Peduncle and Interpeduncular 
Space.—The characteristic symptom of this locality is an 
alternate paralysis in almost all cases (eighty per cent.), 
The limbs, the facial, and the hypoglossal nerve are 
paralyzed on the same side, the side opposite the tumor, 
The motor-oculi nerve is paralyzed by direct pressure on 
its trunk as it emerges into the interpeduncular space, 
and therefore on the same side as the tumor. The paraly- 
sis is usually total, so that there is unilateral dilatation 
of the pupil, ptosis from paralysis of the levator pal- 
pebree, and divergent strabismus from paralysis of the 
internal rectus. Such alternate motor paralyses may 
exist alone, when the tumor is limited to the pes pedun- 
culi; but if the lemniscus is involved, crossed sensory dis- 
turbance, crossed ataxia, or intention tremor from irrita- 
tion of the fibres of the pyramid will be added to the 
symptomatology. These symptoms may exist alone 
without motor paralysis when the tumor begins in the 
lemniscus. As the tumor grows larger, it crosses the in- 
terpeduncular space, causing bilateral oculo-motor pa- 
ralysis and paraplegia, often symptoms of the pseudo- 
bulbar paralysis. As in tumors springing from the base 
of the cranium, all the basal cranial nerves may ulti- 
mately be involved—trochlearis, abducens, trigeminus, 
and even facial. Vaso-motor symptoms occur when the 
substantia nigra is involved. 

Tumors of the Cerebral Cortexr.—The symptoms vary so 
greatly, according to the precise part of the cortex which 
is affected, that each part must be considered separately. 

Frontal Lobes.—Notwithstanding the important func- 
tions which doubtless pertain to the frontal lobes, a 
tumor in them not unfrequently remains latent. Bruns 
denies that psychic symptoms are particularly frequent 
in frontal tumors; but, according to our tables, they are 
present in forty-nine per cent. of the cases. One peculiar 
psychic symptom has been observed, namely, a tendency 
to crack jokes, the so-called “ Witzelsucht” of Jastro- 
witz. 
which has been already mentioned as depending on 
paresis of the trunk muscles, and which simulates the 
better known cerebellar ataxia. Tonic cramps of the 
muscles of the trunk and neck are sometimes noticed,— 
sometimes a persistent rigidity of the neck. Many 
symptoms are due to pressure upon neighboring parts. 
Pressure on the central convolutions will lead to mono- 
or hemiplegia. Growth downward toward the base of 
the brain may bring a frontal tumor into direct or in- 
direct contact with an optic nerve, or with the chiasma, 
resulting in a unilateral choked disc or unilateral nerve 
atrophy and blindness. Or there may be one-sided 
paralysis of the ocular muscles, especially the abducens; 


‘ison the right side. 


Another characteristic symptom is the ataxia, - 


or a unilateral anosmia; or an exophthalmus if the tumor 
penetrates the orbit. To these symptoms may be added 
attacks of Jacksonian epilepsy; motor aphasia; cireum- 
scribed tenderness on percussion; lesser degree of head- 
ache, but greater tendency to stupor. These concomi- 
tant symptoms may serve to differentiate between a 
frontal ataxia and an ataxia due to cerebellar tumor. 

Central Convolutions.—These contain the centres for 
all the voluntary movements of the body—centres, how- 
ever, extending into several other areas. Thus the gyrus 
paracentralis; the posterior part of the first frontal con- 
volution; the anterior part of the superior temporal, the 
gyrus marginalis (trunk muscles); the foot of third 
frontal convolution (motor-speech centre); second frontal 
convolution (centre for movements of head and eyes); 
neighborhood of facial and hypoglossal centres (move- 
ments of vocal chords and jaw muscles). Tumors in this 
extensive motor zone, therefore, are indicated by most 
characteristic symptoms of localized spasms and paraly- 
ses which occur early in their history. Horsley and Schii- 
fer’s experiments on the cortex have permitted further 
refinements of localization: for the thumb, in the posterior 
part of the anterior central convolution; for the foot and 
toe movements, in the posterior central convolution; and 
on the limits between the leg and arm centres, special 
centres for the movements of hip and knee. The larynx 
and the muscles of the trunk receive a double cortical 
innervation, and thus a unilateral tumor will cause 
muscular twitchings or Jacksonian convulsions on both 
sides of the body. As a second consequence of the 
double innervation, such regions as the eyes and larynx 
usually escape paralysis in hemiplegia. 

According to the most modern view, the motor cen- 
tres in the central convolutions are also centres for sensi- 
bility, and nevertheless sensory symptoms are usually 
lacking in tumors of the motor zone. Local muscular 
spasms are, however, frequently preceded by parzesthe- 
Sias in the affected limbs, constituting a sensory aura. 
Sometimes the whole attack remains limited to the aura, 
constituting a sensory epilepsy. Orthisagain is replaced 
by a psychic equivalent, a feeling of fear or excessive 
anguish. When the sensory symptoms are primary, it 
may be inferred that the tumor occupies the posterior 
central convolution. The frequent absence of sensory 
paralyses is explained by a wider distribution of sensory 
mechanisms, of which a part escape injury in all but the 
most extensive lesions. 

Parietal Lobes. —The symptoms differ on the right and 
left sides. <A left-sided parietal tumor, touching upon 
the gyrus angularis, is liable to involve the association 
tracts which pass from the occipital to the left temporal 
lobe—hence to cause the peculiar disturbance of speech 
known as alexia. This symptom fails when the tumor 
From contact with the posterior 
part of the internal capsule tumors of the parietal region 
may cause hemianesthesias; or the motor bundles of 
the internal capsule may be sufficiently irritated to occa- 
sion a hemiataxia. 

When, directly or mediately through pressure from a 
distance, the angular gyrus and optic radiations are in- 
volved, there may be ptosis, limitation of the visual 
field, and homonymous hemianopsia. Loss of the stereo- 
gnostic sense has been noted as a special symptom in 
tumors of the parietal lobes. 

Temporal Lobes.—Sensory aphasia is the characteristic 
symptom of tumor of the left temporal lobe. Tumors 
in this region, on the right side, areapt to be latent. Each 
auditory centre is connected with both ears, so that deaf- 
ness is rare; but auditory aure preceding convulsive at- 
tacks, and occurring on the same side, are not uncom- 
mon. In tumors of the gyrus hippocampi, and especially 
of the uncus, epileptiform attacks or their equivalents 
may be ushered in by the aure of a bad taste or fright- 
ful smell. 

Occipital Lobes.—The characteristic local symptom is a 
crossed homonymous hemianopsia. This symptom be- 
longs to the entire optic tracts from the chiasma to the 
occipital lobes. In the left occipital, as already men- 


447 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES: 














tioned, alexia and optic aphasia are associated with the 
hemianopsia. Occipital hemianopsia is distinguished 
from that due to a lesion of a lower part of the optic 
tract by the absence of various symptoms. There are no 
hemianopsic pupillary rigidity, no lesion of the basal 
cerebral nerves, as the motor-oculi or trigeminus; no 
thalamic symptoms, as hemianzesthesia, hemiathetosis, 
chorea, or mimetic facial paralysis. Jacksonian epilepsy 
is usually absent. Cerebellar ataxia may be determined 
by pressure on the cerebellum, though this is usually 
protected by the tentorium. 

Basal Ganglia or Lower Part of Centrum Ovale.—There 
is complete hemiplegia often followed by rigidity, thus 
closely resembling, except in its gradual development, 
the vulgar hemiplegia of hemorrhage. It is sometimes 
associated with complete permanent hemianeesthesia, 
when the tumor is in the posterior part of the hemi- 
sphere. It is often complicated late in the disease with 
symptoms of intraventricular effusion; then there are 
convulsions, retraction of the head, loss ‘of consciousness, 
slow pulse, contracted pupils, as in acute hydrocephalus. 
Localized spasms and monoplegias sometimes occur and 
are difficult to explain. 

When the tumor specially affects the corpus caudatum, 
the symptoms depend on the affection of the internal 
capsule at its anterior part; there is thus a pure hemi- 
plegia with corresponding convulsions and without sen- 
sory symptoms. With tumors of the thalamus, hemiplegia 
is also usual, but is accompanied by hemianeesthesia, 
pains, ataxic, choreic, and athetosic movements of the 
extremity opposite the tumor; and finally hemianopsia. 
Frequently there is a crossed mydriasis, as the nuclei for 
the internal ocular muscles lie on the latera: wall of the 
posterior part of the thalamus. The mimetic paralysis 
of Bechterew—already mentioned as characteristic of 
thalamic lesions—is also present. 

Corpora Quadrigemina.—The chief characteristic of 
tumors of the corpora quadrigemina is a combination of 
ocular paralyses with ataxia. This is particularly in- 
dicative of this special region when the ophthalmoplegia 
precedes the ataxia. If the ataxia appear first, there is an 
equal probability that the tumor is situated in the cere- 
bellum, where tumors are much more frequent—twenty- 
seven per cent. of the whole number, as compared with 
two percent. of tumors of the corpora. With the latter, 
convulsions are extremely rare; but the percentage of 
choked disc, amaurosis, psychical defect, is extremely 
high, and headache and vomiting are both frequent. 
Pressure on the external geniculate body may cause 
hemianopsia. Vaso-motor symptoms are uncommon. 
Scarcely to be separated from the foregoing are tumors 
of the pineal gland. Such tumors may be first manifested 
by a unilateral or bilateral paralysis of the trochlearis 
nerve. 

Medulla Oblongata.—The symptoms depend on a paral- 
ysis of the cranial nerves from the eighth to the twelfth. 
There are therefore deafness, paralysis, and atrophy of 
the palate and pharynx, with dysphagia; paralysis of the 
vocal cords; paralysis and atrophy of the tongue with 
dysarthria; disturbance in the cardiac and respiratory 
rhythms. To these characteristic symptoms, due to 
lesions of nerve nuclei, will be added motor and sensory 
paralyses as the long cerebro-spinal tracts become in- 
volved. 

Paralysis of the cranial nerves is almost always bi- 
lateral, as the tumor soon crosses the median line along 
which the nerve nuclei are situated. Acceleration of 
respiration is followed by dyspnoea, which passes over 
into Cheyne-Stokes respiration, and death often occurs 
suddenly through asphyxia. Toward the end of life 
singultus is frequent, and also a notable rise of tempera- 
ture. Extensive vaso-motor disturbances occur — dia- 
betes, polyuria. Through lesion of the cerebellar and 
olivary tracts a cerebellar type of ataxia often develops; 
and vertigo when the vestibular nerve is involved. 
Choked dise is not unfrequently absent. An emotional 
psychosis is not uncommon, and this, with the vagueness 
of other symptoms, has not seldom led to an erroneous 


448 





‘the direct compression of cranial nerves. 





diagnosis of hysteria. This seems still more plausible 
when the tumor penetrates the fourth ventricle, and 
causes intermittent symptoms of giddiness, fainting, 
headache, vomiting, and hysteriform convulsions. 

Besides localities in the cerebrum which may be the 
seat of an intracranial growth, the clinician must always 
inquire whether the tumor whose existence is suspected 
does not spring from the cranial bones or the dura mater 
lining them. Tumors of the anterior, middle, and pos- 
terior cranial fossee excite symptoms which approximately 
resemble those of the cerebral organs reposing in the 
same spaces, preceded by symptoms which result from 
From disten- 
tion of the very sensitive dura mater, the headache is 
peculiarly acute and violent. 

Antertor Fossa.—Tumors in this region may break 
through the roof of the orbit and cause the same symp- 
toms as a primary orbital tumor, namely, unilateral amau- 
rosis, ocular paralyses, trigeminal neuralgias. While the 
tumor remains limited to the anterior fossa, the olfactory 
nerve alone is exposed to pressure; and when the tumor 
compresses the basal part of the frontal lobes, the Symp- 
toms are usually vague. Tumors on the left. side may 
press upon the speech centre sufficiently to cause motor 
aphasia. Frontal ataxia is absent, for the gyrus margi- 
nalis is too far removed. The psychic symptom of child- 
ishness has sometimes been particularly noted. 

Middle Fossa.—The central part of this fossa contains 
the sella turcica with the pituitary gland. Lesions of 
the latter are. often associated with the peculiar symptom 
complex known asacromegaly. Apart from this strange 
disease, the characteristic symptoms of tumor in the mid- 
dle fossa are due to pressure upon the chiasma and the 
optic tracts. If the tumor be on the middle line, the 
optic fibres going to the inner half of each retina will be 
compressed, causing a bitemporal hemianopsia. This 
symptom sometimes occurs suddenly, lasts a short time, 
and vanishes. If the tumor involves one optic nerve in 
front of the chiasma, there is first unilateral amblyopia, 
then blindness of the same eye, then, as the tumor extends 
backward to the chiasma, temporal hemianopsia of the 
opposite eye, and finally complete blindness. 

Yet with these marked visual symptoms choked disc 
is not unfrequently absent. The fact has been explained 
by supposing that the tumor obstructs the passage of 
lymph to the sheath of the optic nerve. Convulsions 
and vomiting are less severe or altogether absent. 
Motor and sensory paralyses occur only when the 
peduncles have become involved; thus after the chiasma 
symptoms already described, an order of evolution which 
is highly characteristic. Before the tumor reaches the 
cerebral peduncles, it wilf have invaded the lateral 
region of the sella turcica, and determined the rich as- 
semblage of symptoms dependent on lesions of the motor- 
oculi and trigeminal nerves: ptosis, neuralgia, anzesthe- 
sia or ansesthesia dolorosa; trophic lesions of the skin and 
eyes; atrophic paralysis of the temporal, masseter, and 
pterygoid muscles; paralysis of the chorda tympani 
nerve and sense of taste. If the history of the case be 
exact the local diagnosis of tumors of the middle fossa 
can be made with much precision. 

Posterior Fossc:.—Tumors of this region cannot with 
any certainty be distinguished from those of the medulla, 
pons, or lower segment of the cerebellum. Amaurosis 
or amblyopia exists in one-third of the cases, thus even 
more frequently than in tumors of the cerebellum. | 
Through a bilateral compression of the cranial nerves 
or of the pons, tumors of the posterior fossa can deter- 
mine the typical symptoms of bulbar paralysis, usually 
preceded by unilateral symptoms in the territory of the 
trigeminus or acusticus. When the tumor is situated 
directly over the foramen magnum, all the cranial nerves 
may escape pressure, but those supplying the four ex- 
tremities be paralyzed. 

Headache is as violent, choked dise as cory a symp- 
tom as in tumors of the cerebellum. 

Parts OF BRAIN IN WHICH TUMORS ARE MOST FRE- 
QUENTLY LATENT.—Complete latency implies absence of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





all symptoms; incomplete latency implies absence of 
focal symptoms only. The localities in which the latter 
condition is characteristically observed are also those in 
which tumors may most often be completely latent. 
These localities are: the temporal, occipital, or even, but 
less easily, the frontal lobes of the cerebral hemispheres, 
provided the central gyri are not indirectly affected; the 
parts of the centrum ovale corresponding to these regions, 
and hence untraversed by fibres from the pyramidal 
tract; the lateral lobes of the cerebellum, the thalamus 
opticus, and the lenticular nucleus. Finally, it is possi- 
ble that in any portion of the brain a tumor may remain 
latent, providing it grow slowly enough. 

DIFFERENTIAL DrAGnosts.—The epileptiform convul- 
sions dependent upon cerebral tumor differ little or not 
at all from those of functional epilepsy. They are, how- 
ever, often slighter, or at least the loss of consciousness 
is much less profound. The headache, on the contrary, 
is chiefly noticeable for its extreme intensity and persist- 
ence, in which respect it exceeds even nervous headaches. 

The vomiting is also noticeable -for its violence, and 
for the absence of any other symptoms of disordered 
digestion, such as furred tongue, epigastric uneasiness, 
etc. The diagnosis in regard to these symptoms ulti- 
mately depends on their combination, and gn their asso- 
ciation with paralysis or with psychical symptoms. 
Conversely, the psychical symptoms of tumor are dis- 
tinguished from pure mental alienation chiefly by the 
existence of these physical signs; also by their greater 
vagueness, which renders precise psychiatric classifica- 
tion difficult or impossible. : 

It is by no means always easy to decide whether a pa- 
tient with cerebral symptoms is suffering from a diffused 
or a focal disease; and in the diagnosis of tumor it is 
necessary to exclude meningo-encephalitis, progressive 
general paralysis, chronic basal meningitis, hydroceph- 
alus, cerebro-spinal form of multiple sclerosis, brain 
abscess, locomotor ataxia. 

Tuberculous meningo-encephalitis, which not unfre- 
quently lasts as much as three months, has then a dura- 
tion not inferior to that of many tumors, and many of the 
symptoms are identical: violent headache, convulsions, 
vomiting, neuritis optica, changes of character, mono 
plegic paralysis, and spasms. In the diffused inflamma- 
tion, however, these paralyses are transient and variable, 
a condition sometimes, but rarely, seen in tumor. The 
disease, moreover, is always attended by more or less 
fever, by more marked variations in the pupils, by a 
slow, hard pulse, by obstinate constipation, by retraction 
of the abdomen, and by vaso-motor symptoms. When 
atuberculous tumor is associated with diffused inflamma- 
tion, it is masked by the symptoms characteristic of the 
latter. 

The appearance of spinal symptoms may decide the 
diagnosis, which could be still further confirmed by 
means of a lumbar puncture, and the discovery of pus 
or tubercle bacilli in the fluid. 

A tumor of the medulla may especially simulate pro 
gressive general paralysis by producing a diffused paresis 
without distinct paralysis, embarrassment of speech, de- 
pression of mental power, headache, and unequal dilata- 
tion of the pupils. A tumor, however, is indicated by 
the occurrence of amaurosis, convulsions, vomiting, 
localized paralyses; while the diffused disease is char- 
acterized by the outbreak of ambitious delirium, and by 
the peculiar trembling of the lips. There is no choked 
disc, but rigidity of the pupils and peculiar disturbance 
of speech. 

Tumors of the sella turcica may be closely simulated 
by chronic basal meningitis, which is most frequently 
situated in exactly the same locality and involves the 
same nerves. It is distinguished by the occurrence of 
descending optic neuritis, unattended by symptoms of 
intracranial pressure. In young children premature 
«closure of the fontanels with blindness would point to 
meningitis: enlargement of the head to tumor. 

Hydrocephalus may also have choked disc, and is usu- 
ally associated with depressed mental capacity. Slow 


Vor. IT.—29 


enlargement of the head in young children belongs 
either to this disease or to tumor. The rolling down of 
the eyes and subsequent retraction of the head point to 
an effusion. Ventricular effusions are not infrequent 
complications of tumor, especially of tuberculous tumor. 
General symptoms then predominate over focal symp- 
toms. Bruns and Oppenheim agree that it is impossible 
to make a positive diagnosis between tumor and acquired 
hydrocephalus in childhood. 

Multiple cerebro-spinal sclerosis may for a time simulate 
tumor, the disease being characterized by headache, 
vertigo, disturbances of speech and of vision (diplopia 
and amblyopia), and by the occurrence of apoplectiform 
attacks, followed by incomplete hemiplegia. The latter, 
however, are rare in tumor, but are apt to be frequently 
repeated in sclerosis. In sclerosis, on the other hand, 
there isan absence of convulsions and of motor paralyses, 
except after apoplectiform attacks. Instead, there is a 
diffused loss of power, with muscular rigidity, absence 
of vomiting and of choked disc. There are the positive 
symptoms of nystagmus, scanning or explosive speech, 
staggering gait and giddiness, spasmodic paralysis of the 
arms and especially of the legs, finally the characteristic 
intention tremor of the limbs. Yet tumors of the cere- 
bellum, pons, corpora quadrigemina, and the peduncles 
may all cause intention tremor through irritation of the 
pyramidal tracts. In tumors of these localities (except 
the cerebellum), choked disc is for a long time absent. 
The difficulties of diagnosis are greatest with children. 
Extension of the symptoms to the territory of the spinal 
cord speaks in favor of multiple sclerosis, while a dis- 
tinctly alternate hemiplegia speaks in favor of tumor. 
The course of multiple sclerosis is slowly progressive, ex- 
tending over several years, or is marked by acute attacks 
separated by intermissions. A modified choked disc may 
occur for a time, but subsides, and normal vision is pre- 
served, even when optic atrophy is considerable. 

Locomotor Ataxia.—It may occasionally be difficult to 
distinguish the ataxia of cerebellar tumor from that of 
tabes spinalis. But in the tumor the patient has a stag- 
gering or reeling gait, like that of a drunken man, and 
there is no sign of ataxia in either upper or lower ex- 
tremities when the patient is in a horizontal position 
(Althaus). The alterations of sensibility, characteristic 
of tabes, are absent in tumor, and most of the positive 
symptoms of tumors are absent in tabes. 

Abscess of the Brain.—The symptoms can be quite 
identical with those of tumor. General pressure symp- 
toms, including choked disc, are less intense with abscess, 
because this directly destroys brain tissue. Headache, 
however, is about equally violent in the two cases. 
Local symptoms are less marked with abscess; one reason 
is that abscesses are most frequently situated in the 
latent regions of the brain. If specific regions are 
affected, characteristic specific symptoms will develop; 
thus sensory asphasia and hemianopsia in abscesses of 
the temporal lobe from purulent otitis, or motor paraly- 
ses from lesions of the central convolutions after trauma- 
tisms. = 

Fever and chills, when present, are important indica- 
tions of abscess; but these signs are often absent, and sub- 
normal temperature is rather frequently observed. 

The course of brain abscess is usually rapid. But the 
most important element of differential diagnosis lies in 


the etiology, for a focus of pus in the brain is never 


primary, but always secondary to pus elsewhere. 

The evolution of abscess is habitually much more 
rapid, and its progression much more regular than that 
of tumor. An abscess is always to be suspected when 
localized cerebral symptoms develop in the course of an 
otitis media. Extremely chronic cases of this aural affec- 
tion sometimes pass into an acute exacerbation, during 
which the cerebral membranes become infected through 
the roof of the tympanum, through the fenestre, or 
through the auditory canal. 

Cerebral Hemorrhage.—The onset of the paralysis is 
sudden, instead of being slow and insidious, and the pa- 
ralysis is usually at once complete. But the cranial nerves 


449 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








are rarely affected, with the exception of the facial; 
vomiting, headache, vertigo, and choked disc are absent, 
as are also mental symptoms after recovery from the 
apoplectiform shock. Hemorrhage into the meninges, 
which scarcely ever occurs except in children and old 
people, does not resemble tumor in any of its symptoms 
with the exception of convulsions. 

Softening.—The diagnosis from tumor is often ex- 
tremely difficult when the softening is from the begin- 
ning chronic in character. Lesions of special senses are 
much less frequent in softening, and choked disc is rare; 
so also are lesions of cranial nerves, vomiting, and con- 
vulsions; while the headache is less circumscribed and 
intense. Contractures of paralyzed limbs are more fre- 
quent. Psychic alterations are marked, but are of a dif- 
ferent character from those of tumor. There is emotional 
instability instead of irritability, dementia rather than 
the depression and apathy of tumor. 

A diagnosis of the nature of the tumor can rarely be 
made. 

Curcinoma is often indicated by the rapid progress of 
the symptoms, and by signs of multiple foci successively 
developing. Perforating tumors are almost invariably 
malignant—carcinoma, sarcoma, or osteo-sarcoma. The 
tumor is nearly always primary, and destroys life before 
it has occasioned cachexia. 

Tuberculous tumor often complicates tuberculous men- 
ingitis, or is complicated by it. In either case the focal 
symptoms are much obscured by those of the diffuse 
disease. When isolated, a tuberculous tumor may be 
suspected from the youth or scrofulous constitution of 
the patient. 

Gummata.—Their diagnosis principally depends upon 
the presence of other signs of syphilis. The evolution is 
relatively rapid, and the invasion of drowsiness and coma 
may be hastened by the coexistence of diffused endar- 
teritis. 

Glioma.—This remains the most probable when the 
diathetic tumors have been excluded. Itnot infrequently 
develops after a blow on the head, and then seems to re- 
sult from chronic inflammation of the neuroglia. 

Intracranial aneurisms occasion symptoms which are 
indistinguishable from those of neoplasms proper. It is 
the basilar artery which is most often affected, and the 
symptoms then resemble those of tumors of the pons. 

But all the arteries are liable to be the seat of this 
lesion. It is said that headache is more diffuse and more 
intense than with other tumors, while vomiting is less 
frequent. Sudden attacks of loss of consciousness often 
occur, due undoubtedly to inequalities in the distention 
of the tumor and consequent variations in the brain 
pressure. 

Aneurisms of the posterior communicating artery oc 
casion symptoms of motor-oculi paralysis (ptosis, external 
strabismus, fixed dilatation of the pupil), and finally— 
the effect spreading to the corpora quadrigemina—am- 
blyopia. When the aneurism is seated on the internal 
carotid, the sensitive root of the trigeminus may be 
affected; hence neuralgias or anesthesia. Aneurisms of 
the carotid which communicate with the cavernous sinus 
are characterized by exophthalmia, and a susurrus which 
is heard when the stethoscope is applied over the eyeball 
(case Gruening). 

The termination of aneurismal tumors is peculiar, be- 
ing always by rupture and sudden death, with the symp- 
toms of intracranial hemorrhage. 

In addition to these various forms of definite brain 
lesion, a preliminary diagnosis is required between any 
brain lesion and certain general diseases: arteriosclerosis; 
neurasthenia, hysteria, idiopathic epilepsy, uremia, 
migraine. Choked disc is the most valuable single symp- 
tom for the positive decision in favor of tumor, amidst 
the mass of symptoms which confuse the diagnosis by 
being common to tumor and to these functional diseases. 
Bruns claims to have made twenty-two correct diagnoses 
of the existence and precise locality of a brain tumor; 
but they were all inone of two groups. First, the central 
convolutions, posterior and middle fosse, or the pons. 


450 


Second, the speech region, the cerebellum, medulla ob- 
longata, corpora quadrigemina, left occipital lobe, 
occasionally the frontal lobe. Bruns advises to rest. 
satisfied with the diagnosis of the posterior fossa, and 
only under very favorable circumstances to try to dis- 
tinguish between the pons, cerebellum, corpora quad- 
rigemina, or base of the cranium. 

Rarely is it possible to distinguish between a cortical 
and subcortical tumor, unless in the cases of alexia due to 
lesion of the association tracts between the occipital and 
first temporal convolutions. Collins claims that in a 


_ cortical tumor of the motor-speech region, the mental 


conception of words is destroyed, which is not the case 
when the tumor is subcortical and destroys only the cen- 
trifugal speech mechanisms. 

Proenosts.—The prognosis of cerebral tumor is not. 
modified by the diagnosis of either the seat or the nature 
of the tumor, unless the latter can be shown to be syphi- 
litic. Gummatous tumors sometimes yield with remark- 
able rapidity to the mixed treatment for syphilis. All 
others are invariably fatal, but after a longer or shorter 
lapse of time, and with somewhat different modes of 
termination. Thus, as has been said, aneurisms terminate 
by rupture, and death occurs with all the symptoms of 
cerebral hemorrhage. In the majority of cases the pa- 
tients die in coma, gradually developed from a condition. 
of apathy and drowsiness. These states are associated 
with continually increasing brain pressure, which often 
results in edema. Sudden death is not uncommon, and 
is dependent upon inhibition of the cardiac centre. This. 
sudden death may occur as an accident after the most 
variable duration of the disease; but even the mode of 
death, which seems to indicate the natural evolution of 
the morbid process, leaves a most variable time for this. 
to be accomplished. The patient sometimes dies as early 
as ten or even eight weeks from the appearance of the 
first symptoms; in other cases these have been prolonged 
for ten years. 

PATHOLOGICAL ANATOMY.—The histological structure 
of many cerebral neoplasms, including aneurisms, does. 
not differ from that of the same growths in any part of 
the body. ‘Tuberculous tumors, like miliary tubercles, 
always start from the lymphatic sheaths of the blood- 
vessels, beginning in a local accumulation of adenoid 
elements. Gliomataare a species of sarcomatous tumors. 
which are peculiar to the brain. They were described 
as neuromata, until Virchow demonstrated that they 
contained no nerve elements, but developed from the 
neuroglia. The glioma may consist almost exclusively 
of cells, and is then called a medullary glioma; or it may 
contain a large amount of connective tissue, which either- 
remains soft and of the myxoma type (myxoglioma), or 
becomes hard, fibrous, or even cartilaginous (fibrous. 
glioma). Finally, some among these tumors are so rich 
in vessels as to have acquired the name telangiectatic 
gliomata. All develop from the neuroglia. The tumor 
appears aS a grayish mass, becoming pink or red as. 
vessels develop in it. If these are numerous, apoplexies-. 
may take place into the substance of the tumor. The: 
three forms of malignant tumor of the brain are sarcomata, 
carcinomata, and melanoid tumors. The first are closely 
related to the gliomata, arising like the medullary variety 
of the latter; the chief difference consisting in the greater 
size of the cells and the larger amount of intercellular- 
substance. Cancer of the brain is nearly always enceph- 
aloid, primary, and not infrequently congenital. The: 
growth is rapid, and the size ultimately attained by the 
tumor is in inverse proportion to the vital importance of 
the part of the brain in which it is seated. Enucleation 
of the tumor is impossible. Cancer of the upper part of 
the cerebral hemispheres not infrequently perforates the 
dura mater, and even the skull. Conversely, cancer of 
the eyeball, usually melanotic, constantly tends to pene- 
trate the brain. 

Melanoid tumors are forms of carcinoma in which the: 
tissue is infiltrated with pigment. Their most frequent. 
seat is the eyeball, the pigment being derived from that. 
of the choroid. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain. 
Brain, 





Hydatid cysts are found in the brain, but they usually 
remain latent, especially if small and multiple. Other 
varieties of cyst are not infrequently formed by hemor- 
rhagic effusion, by softening of brain tissue from ex- 
tensive necrobiosis, or by the softening of myxomatous 
tumors. 

CoMPLICATING Lesions. — With glioma, congestion 
and hemorrhage in the vicinity of the tumor are the 
most frequent complications, the latter often being the 
cause of death. The tissue around the tumor is often 
the seat of an inflammatory softening. Effusion into the 
ventricles is often caused by compression of vessels 
which return blood from the choroid plexus. Such effu- 
sion is common with tubercle, and then may depend on 
granular thickening of the ependyma. 

A zone of non-inflammatory softening surrounds most 
tumors. It depends upon necrobiosis of nerve tissue, 
from localized obstruction to the circulation: and cedema. 
When this softening is extensive, functional regions 
quite different from those actually occupied by the 
tumor become involved. This circumstance, as has 
often been shown, by complicating the symptoms often 
materially obscures the diagnosis. 

When the fibres of the pyramidal tract have been 
affected by the tumor, descending degeneration or 
secondary sclerosis may set in, and even reach the lateral 
columns of the cord. This is, bowever, much less 
common than after hemorrhage; and, correlatively, late 
rigidity is correspondingly rare. Conversely, the ap- 
pearance of rigidity in limbs paralyzed from the effects 
of a cerebral tumor often indicates that hemorrhage has 
been excited in its vicinity. 

TREATMENT.—There is no radical medical treatment 
except for gummata, and for these the mixed treatment 
sometimes yields brilliant results. 

In 1884 an epoch-making event occurred. Two Eng- 
lish surgeons, Bennett and Godlee, attempted to remove 
a cerebral tumor by a bold surgical operation. Between 
1884 and 1893 this operation was performed eighty-five 
times. These eighty-five cases are recorded and analyzed 
in a table published in the Supplement to the REFERENCE 
HANDBOOK in 1894, to which, for details, the reader is 
referred. Out of the eighty-five operations twenty-four 
resulted in recovery, about one-thirteenth. Between 
1893 and 1899 many new cases of operation are recorded in 
tables published by Starr (Trans. Med. Soc. New York, 
1896) and also by Knapp (Boston Med. and Surg. Journ. 
October 12th, 1899). These collections are included in 
the list tabulated below, but to them have been added a 
number derived from other sources. The total number 
of cases in which the operation has been performed since 
1893 is one hundred and thirty-eight. These new cases 
have not been analyzed, but the model for their analyses 
is offered on pp. 122 e¢ seg. of the Supplement (vol. ix.). 


Prefrontal. 


. Carle: Revue de chirurgie, February, 1899. 

. Devic and Courmount: Revue de méd., April, 1897. 
. Obici: Il Policlinico, ii., 6, 1895. 
Thomas and Keen: Am. J. Med. Sc., November, 1896. 


PwOnDe 


Central. 


5. Abbe: Presse médicale, November 19th, 1895. 
6. Abrams and Tait: Occidental Med. Times, June, 1896. 
7. Annandale: Edin. Med. Journ., i., 899, 1894. 
8. Armstrong: Montreal Medical Ji ournal, May, 1896, 
9. Ballance: Med. Chir. Trans., 1xxix., 167, 1896. 
10. Beevor and Ballance: Brit. Med. Journ., i., 5, 1895. 
11. Bonhoeffer: Monats. f. Psych., April, 1898. 
12. Braymer: Charlotte Med. Journ., November, 1896. 
13. Bremer and Carson: Amer. Journ. Med. Sci., February, 1895. 
14 Broca and Maubrac: Arch. gén. de méd., February, 1896. 
15. Bruns: Neurolog. Centralbl., xiv., 125. 
16. Cornil and Doyen: Bull. de la soc. anat. de Paris, November, 
December, 1897. 
17. Crowley: Tr. Med. Soc., California, xxviii., 197, 1898: 
18, Czerny: Miinch. med. Wochenschr., No. 11, 1896, 
19. Dallas and Mongeri: Gaz. méd. de orient, 1897, 
20. Dana and Conway: N. Y. Med. Journ., i., 779, 1895. 
21. Doyen: Arch. f. klin. Chirurg., lvii., 876, 1898. 
22. Dreyfus: Lyon médicale, Ixxxviii., 195, 1898. 
23. Duncan and Maylard: Glasgow Med. Journ., April, 1897. 
24, Elliott: Boston Med. and Surg. Journ., June 5th, 1897. 





25. Eskridge and Parkhill: Med. News, August, September, 1896. 
26. Friedlander : Wiener klin. Wochenschr., January 21st, 1898. 
27. Gibson : Edinburgh Med. Journ., February, 1896. 
28. Graser: Arch. f. klin. Chir., 1., 901, 1895. 
29. Grisson: Neurolog. Centralblatt, xvii., 1188, 1898. 
30. Hassler: Ibid.. xvi., 1068, 1897. 
31. Hirschl: Neurolog. Centralblatt, xv., 609, 1896. 
82. Hitzig: Therapeut. Wochensch., Nos. 19, 20, 1896. 
33. Horsley : Lancet, 1894. 
34. Kappeler: Deutsch Zeitsch. f. Chir., xl., 500, 1895. 
35. Krauss: N. Y. Med. Journ., 1898 
36. Kronlein : Beitrige z. klin. Chir., 1895. 
37. Lanphear: Journ. Amer. Med. Assn.., April and May, 1895. 
38. Maneau: Archiv. méd. d’Anges, 1212, 1897. 
39. Meyer: Annals of Surgery, 1898. 
40. Murray: Lancet, March 16th, 1895, 
41. Mya and Cadwillia: I] Policlinico, March, 1894. 

2. Nason: Lancet, May 25th, 1895. 

43. Nedwill: Lancet, i., 1466, 1898. 

44. O’Hara: Intercolonial Quarterly Journ., 1874. 
45. Oliver and Williamson: Brit. Med. Journ., November 26th, 1898, 
46. Pel: Berlin. klin. Wochenschr., January 29th, 1894. 

chee and Richardson : Boston Med, and Surg. Journ., Febru- 

ary, 1899. 

48. Riezner: Deutsche med. Wochenschr., 1894, p . 497, 

49. Roth: Deutsche med. Wochenschr., No. 25, 1895, 

50. Schlesinger: Wiener klin. Wochenschr., No. 25, 1895. 

51. Sick : Deutsche med. Wochenschr., No. 2, 1897. 
2. Schnitzler: Centralbl. f. d. ges. Therapie, xvi., 65, 1898, 
53. Schwartz: Bull. Soe. de Chirurgie, xxi , 221, 1894. 


54. Shaw and Bush: Bristol Med. and Chir. Journ., ii., 99, 1895, 
55. Sinkler: Trans. Amer. Neurolog. Assn., 1896. 
56. Stratton and Crowley: Pacific Med. Journ., xli., 282, 1898. 


57. Sweeney: Northwestern Lancet, xiv., 261, 1894. 
58. Syme: Australasian Med. Journ., 1895. 
59. Tauber: Archiv di Psich. Russ., xxvii., 1, 1896. 
60. Von Wayenburg: Psych. en Neur., Hadem, ii., 109, 1898, 
61. Vierordt and yon Beck: Fortschr. d. Med., p. 495, 1894. 
62. Washburnand Lane: Trans. Clin. Soc., London, xxx., 154, 1897, 
63. Webster: Canada Practitioner, xx., 813, 1895, 
64. White: Lancet, ii., 1280, 1894. 
65. Wiener: N. Y. Med. Journ., October 15th, 1898. 
66. Wood and White: University Med. Mag., January, 1895. 
67. Ziehm: Zeitschr. f. prakt. Aerzte, No. 5, 1898. 
68. Ziehl and Roth: Deutsch. med. Wochensch., No. 19, 1897. 
69. Mann: Monatsschrift fiir Psychiat., iv., 369, 1898. 
70. Bonhoeffer: Monatsschrift ftir Psychiat., iii., 497, 1898. 
71. Haasler: Arch. fiir Psychiat., xxx., 660, i898 (recovery). 
72. Chipault: Gaz. des hop., Ixxi., 416, 1898. 
73, Kosinski: Medycyna Warozowa, XXVi., 1-31, 1898 (recovery). 
. Armitage: Lancet, ii., 1395, 1898 ( death). 
. Mills and Keen: Journ. Nerv. and Mental Dis., xxvii., 244, 1900, 
. Steffen : Med. News, Ixxvi., 175, 1900. 
Serene): Northwestern Lancet, July 15th, 1894 (recovery). 
Pel: Gaz. des Hop., January, 1895. 
Vv. Bramann: Langenbeck’s Archiy, Bd. 51, Heft 1 (Haeckel, 
Monatssch. ye 
80. Colman and Ballance: Lancet, March 21st, 1896 (ibid.). 
81. Gibson, Lancet, December 14th, 1895 (ibid.). 
82 Kronlein: Bruns’ Beitrage, Bd. xv., H. 1 (ibid.). 
83. Krognis: Revue de Chirurgie, 1896 (ibid.). 
84. Thomas and Keen: Amer. Journ. Med. Sci., 1896. 
85. Pearson: Dublin Journ. Med. Sci., cii., 484, 1896. 
86. Bieganski: Medycyna Warozowa, xxiy., 1896. 
87. Albert: Wien. med. Wochensch., xlv., 1895. 
88. Keen: University Med. Mag., viii., 1895. 
89. Oliver: Journ. Amer. Med. Assn., xxvi., 1896. 
90. Pel: Gaz. des hop., January, 1895, or Bd. iv., January 29th, 
1834 (Starr). 
91. Steele: Journ. Amer. Med. Assn., January, 1894 (Starr). 
92. Dana: Journ. Mental and Nery. Dis., June, 1895 (Starr). 
93. Nixon: Trans. Acad. Med. of Ireland, vol. xii., 1895 (Starr). 
94. Grasser: Deutsche Med. Zeit., 1895. 
95. Gaykiewicz: Neurol. Centralbl., 1895. 
96 Bruns: Neurology Centralbl., p. 125, 1895. 
97. Horsley : Clinical Journal, February 13th, 1895. 
98. Starr and McBurney: N. Y. Med. Record, February Ist, 1896, 
99. Starr: Tr. Med. Soc., New York, 1896. 
100. Starr: Amer. Journ. Med. Sci., 1894. 
101. Starr: Amer Neurol Assn., 1897, 
102. Starr: Tr. Med. Soc., New York, 1896. 
103. Starr and Keen: Amer. Journ. Med. Sci., November, 1896. 
104. Starr and Weir: Tr. Med. Soc., New York, 1896 (op. 1896). 
105. Starr and McBurney: Tr. Med. Soc., New York, 1896. 
106 Starr: Brain Surgery, 1894. 
- 107 and 108. Starr and McCosh: Tr. Med. Soc., New York, 1896. 
109. Starr: Medical News, Ixxi., 170, 1897. 
110. Cabot: Boston Med. and Surg. Journ., cxxxvi., 1897. 
111. Gessler : Med. Cor.-Bl. d. Wiirtemb. Aerzt. Stuttg., Lxvii., 1897. 
112. Robertson: Nashville Journ Med. and Sci., [xxxii., 1897. 
113. Clark : Glasgow Med. Journ., xlviii., 1897. 
114. Bair: Brit. Med. Journ., ii., 1082, 1897. 
115. Washbourne: Tr. Clin. Soc., London, 1896. 
116. Delorme and Schwartz: Bull. Soc. de Chir., 1895. 
117. Ruheman: Deutsche med. Wochen., xxii., 355, 1896. 


me ee 


OWID OE C 


Parietal. 


118. Von Beck: Beitrage z. klin. Chir., xii., 1. 

119. Colman and Ballance: Tr. Lond. Clin. Soc., xxix., 1896, 
120. Eskridge and Parkhill: Med. News, July 11th, 1896. 

121. Fitzpatrick: Australasian Med. Gaz., p. 581, 1894. 

122. McCosh: Amer. Journ. Med. Sci., May, 1896. 


451 


REFERENCE HANDBOOK 





OF THE MEDICAL SCIENCES. 





Temporal. 


123. Baer and Nicoll: Brit. Med. Journ., October 16th, 1897s 
124. Nicoll: Lancet, October 29th, 1898. 
125 Stewand: Northwestern Lancet, 1897. 


Cerebellar. 


126. Collins and Brewer: Med. Record, 1897. 

127. Gibson: Edin. Med. Journ., February, 1896. 
128. Guthrie: Prectitioner, 1xi., 69, 1898. 

129. Moran and Kerr: V irginia Med. Semi- Monthly, July, 1897. 
4130. Munn: International Journ. of Surgery, 1895. 
181. Murri: Lancet, January 30th, 1897. 

132. Parkin: Brit. Med. Journ., 1896. 

133. Pershing : Medical News, Mareh 26th, 1898. 

134. Stewart and Annandale: Edin. Hosp. Rep., 1895. 
135, Steele: Chicago Clin., xiii , 1-7, 1900 (death). 
186. Hirmanidas : Neurolog. Centraibl., 1895. 

137. Stewart and Annandale: Edin. Hosp. Rep., 1895. 
138. Fisher: Tr. Med. Soc., New York, 1896. 


To these may be added the following list of cases, also collected by 
Knapp, in which an operation was attempted, but removal of the 
tumor found to be impossible : 


Aldibert : Revue de chir., p. 158, 1895. 

Beck : In Auvray, pp. 359, 360, 361. 

Bruns: Brain Tumors. 

Carson: Annals of Surgery, xxviii., 328. 

Chipault: Gaz. des hop., Ixxi., 557, 1898. 

Collins: Tr. Amer. Neurol. Assn., 1895. 

Dinkler: Neurolog. Centralbl., xvi., 611, 1897. 
Eskridge: Denver Med. Times, J une, 1896. 

Fisher: N. Y. Med. Journ., April 16th, 1898. 

Gardiner: Amer. Journ. Med. Sci., May, 1899. 
Hermanides : Operative behand. van husengezwellen, 1894. 
King: Chicago Clinical Review, April, 1897. 

Krauss: N. Y. Med. Journ., July 30th, 1898. 

Lanphear: Journ. Amer. Med. Assn., April 28th, 1895. 
Rose: Medical Press and Circular, i., 175, 1894. 
Rossolimo: Arch. f. Psych., xxix., 528, 1897. 

Schultze : Deutsch. Zeitsch. f. Nervenheilk., ix., 217, 1896. 
Sonnenburg: Berlin. klin. Wochenschr., p. 939, 18! 94, 
Starr: Med. Record, 1., 145, 1896. 

Starr: Brit. Med. Journ., October 16th, 1897. 

Stieglitz: Amer. Neurol. “Assn., 1895. 

Taylor and Elliott: Boston Med. and Surg. Journ., 1896. 
Winkler: Bijdrage tot de Husenchirurgie. 


The later operations have not been able to modify the 
percentage arrived at in 1893, for in 1897 Bruns, after a 
somewhat complicated calculation from statistics, con- 
cluded that the number of successful cases was not higher 
than six in a hundred. 

Bruns, however, does not hesitate to advise the opera- 
tion whenever the tumor can be exactly localized in an 
accessible part of the brain. Foreven when it shall have 
been found irremovable, the operation may serve to 
relieve the frightful pain, or even to arrest the progress 
of choked disc toward blindness, and it seems to be the 
undercurrent of Bruns’ thought that in a disease like 
brain tumor, which he calls the most frightful of all dis- 
eases for the suffering it entails, it were really better that 
the patient should die in the attempt to secure relief, than 
that he should be abandoned to his suffering. 

Quincke’s lumbal puncture has been practised for the 
purpose of lessening intracranial pressure, but has often 
failed, perhaps from obstruction in the communications 
between the brain and spinal cord. The puncture has 
several times been immediately followed by death. 

The intellectual, philosophic, and even romantic inter- 
est attaching to the operations for brain tumors much 
exceeds their actual practical importance. The attempt 
has been made to estimate this from analysis, not only 
of the operations which have been performed, but also 
of the fatal cases of brain tumors on record, not operated, 
but submitted to post-mortem examination. The latter 
has shown that a very large proportion would have been 
inoperable, either because a local diagnosis could not 
have been made, or because the locality, though diag- 
nosed, was inaccessible; or because the tumors were 
multiple or malignant; or, finally, because they were 
too large for extirpation. The last objection can often 
be met by the observation that an early operation might 
have proved succcessful, though by delay the tumor had 
grown beyond the bounds of surgical possibilities. This 
observation, however, holds good for tumors in any part 
of the body. 

Tuberculous tumors—the most common variety by far 
in childhood—are frequently multiple, either at the time 


452 


of operation or by recurrence shortly after; and are then, 
of course, unfavorable for operation. For extremely 
malignant tumors (carcinoma) the prognosis is naturally 
as hopeless when the growth is situated in the brain as 
when it exists in other organs. On the other hand, sar- 
comata, when primary, have not unfrequently been re- 
moved with success. * 

A table quoted by Keen, in the article on Brain, Sur- 
gery of, in this volume (p. 416), shows the relative propor- 
tion of different varieties of brain tumors in a total of 
580 cases collected by Hale White and Bernhardt. 


‘Nearly a quarter of all (28 per cent.) were tuberculous, 


only 4 per cent. were carcinomatous. In 22 per cent. 
of the cases cited the nature of the tumor is not stated. 

Hale White estimates that only 9 of his 100 cases could 
be considered as operable. No tumor, even the most be- 
nign, could be considered operable which is situated at 
the base of the brain, or in the cerebral axis (Starr), 
which is widely infiltrated, or which, as already noted, 
is multiple. Out of 300 brain tumors in children col- 
lected by Starr, one-third were in the cerebral axis. Tu- 
mors of the cerebellum are fairly accessible, but opera- 
tions upon them have proved very much more dangerous 
than operations upon the cerebrum. The space for ope- 
ration is much narrower; precise localizing symptoms 
are much less distinct and frequently fail altogether. 
On the other hand, the general symptoms are especially 
severe, owing to the excessive intracranial pressure; and 
this same condition endangers the operation by causing 
the brain to bulge through “the opening. Theclose prox- 
imity of the affected part to the most vital organs of 
the cerebro-spinal axis renders shock imminent. The tu- 
mor is very frequently tuberculous, and finally optic 
neuritis has nearly always reached an advanced stage 
before the operation is undertaken, so that when, by 
exception, the patient has survived the operation, he 
has remained blind.+ 

Out of the 300 cases of tumor in children, 96 were situ- 
ated in thecerebellum. 'Thissingle fact suffices to estab- 
lish a relatively unfavorable prognosis for brain tumors 
in childhood. 

In this same list were found 56 cases of tumor of the 
cortex and centrum ovale, localities favorable for opera- 
tion; 16 of these, however, were not correctly diagnosed, 
and therefore could not have been operated on, even if 
the operation had been suggested. 

Out of the 40 which remain, localizing diagnosis would 
have been impossible in 21, though the autopsy showed 
that in some of them an operation would have been pos- 
sible. In 19 cases the tumors were in the central convolu- 
tions, or inthe subjacent centrum ovale, and in 13 of these 
local spasm followed by paresis made the precise diagnosis 
sufficiently clear. In the remaining 6 the locality was 
established by the symptom hemianopsia. The author 
estimates, however, that in only 16 of these cases could 
an operation have been undertaken with much hope of 
success, and as 10 of these were tuberculous, the number 
of cases in which even this new and heroic remedy offered 
hope of complete recovery was reduced to 6 out of a 
total of 300. 

The statistics for adults, as regards localization, differ 
somewhat from the above. A table of 644 cases, com- 
piled from the cases of Ladame and Bernhardt, shows the 
different localities in which the tumor was found. It 
was situated in the— 


Centrum 'Ovale:In eicieecesicisn aie ciniersiste 192 cases = 29 per cent. 
Corebellumidn: Oasda neetasels sleicwalnertre 162 = 27 

QOTtOX IN Gawlcccntsiensce ueunmeemes sone 14 a 
PONS IN Sone certain nie ae 56 “= Oe 
Basal gang lian ce. estima ensmaeannte 36 = Spee 
Mediilin ins. cocoswecoeemeuee ences 30. SS =o eee 
Corpora quadrigemina in............. 18 7 me ca 
Cerebral peduncle in ................- 10.75 be a 
Extraicerebraliincsacc we sees thee Vl SS ee 





*In the case reported by Weir and Amidon the cerebral symptoms 
occurred after the patient had already been operated: upon for sar- 
coma of the neck (Annals of Surgery, June, 1887 

+The symptom of choked disc, when present, has long been con- 
sidered more nearly pathognomonic than any other of cerebral tumor. 
Seguin has, however, recently declared that many cases of enormous 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Brain, 
Brain, 





This table can be compared with Starr’s, as follows: 


Children. 


GSISERALIUITIE Coty aie ole'o,b'e'8 sie vei 96 cases = 32% 162 cases = 27% 
Cortex and centrum ovale .. 56 a= 18% 266 aS — Ale 


Tumors situated in All cases. 





Thus consideration of the prevailing situation of brain 
tumors alone would seem to justify Bergmann’s dictum, 
that the field for successful operation is very narrow, the 
reverse of what can be now affirmed of trephining for 
brain abscess. Examination of the 85 cases in which 
operations have been performed between 1884 and 1893 
givesamore favorable view. The record shows that there 
were 39 successful operations against 46 unsuccessful 
cases, and one trephining to relieve intracranial pressure. 
These were performed in all parts of the world, even 
British Guiana having contributed a successful case in 
1888 (Rannie, British Medical Journal, 1888). The fol- 
lowing table summarizes these results. “Successful” 
implies that the tumor was found and removed, that the 
serious symptoms subsided, and that the patient lived 
more than two months, or even recovered completely. 
“Unsuccessful ” refers, not only to the death of the patient 
from the immediate consequences of the operation, but 
also to the impossibility of completing this, either be- 
cause the tumor was not found at the locality supposed, 
or proved too large or too deeply seated to be completely 
removed; finally to the speedy recurrence of the tumor 
so as to cause the death of the patient in a short time, 
notwithstanding the immediate success of the operation. 


IU DECENT oo oe dio dg age COS OOODIOOUDOGOOCLDO SON OCGIITST Ere 39 
Unsuccessful : 
MOT NOW TOUNG Yai s.<cclst idles 0 cisicese oe Sedeleislavinee tie 20 
POLST E TOMO VEU: crcielale clets'e.ele. ereie 4 tye,a/e i's 0 6 ates eteis's 10 
Death from operation or speedy recurrence of 
TERY LSAANI Wich ote elare’e'nisie\ sl eie/o vieia(eleleie aicveibin. 9 sie'e’ie e sisiel¥ivie 16 46 
85 


In 1888 Dr. Keen wrote (REFERENCE HANDBOOK, 
Brain Surgery) that the percentage of mortality was 
85 per cent. This calculation was based upon the 17 
operations which had then been performed, with 6 re- 
coveries, and included among them one case (Heath, 
Lancet, 1888, Case 27 of table), which we have placed 
among the unsuccessful cases, because, although the pa- 
tient survived the operation and was relieved, the tumor 
was too large for removal. The percentage of suc- 
cesses (11 cases out of 17) was nearly 65. To-day, the 
larger number of cases yields as succcessful about 46 
per cent., as failures nearly 54 per cent. The less 
favorable result is not surprising, for the operation has 
been attempted under a much greater variety of cir- 
cumstances, so that a greater number of unfavorable 
conditions have been encountered. For this reason the 
estimate of the operation has varied in the same way as 
did that for tracheotomy. ‘This operation on its first 
suggestion excited unbounded enthusiasm, until expe- 
rience showed how numerous conditions of failure were 
inherent in the disease for which the operation was per- 
formed, and which could not be overcome by any degree 
of perfection in its surgical technique. 

The precision is surprising with which small tumors 
have sometimes been localized for removal. In Seguin 
and Weir’s case (No. 24) the neoplasm was only the size 
of an almond, and lay an inch below the surface. In 
another case, however, reported by Seguin, a glioma 
one-half inch in diameter escaped detection. It was 
found at the autopsy at the locality diagnosed, under the 
motor centre for the left leg, but its consistency so re- 
sembled that of the brain tissue that it could not be dif- 
ferentiated (Case 63). The writer remarks that an opera- 
tion may be undertaken too early on the brain—7.e., 


tumors do not present choked disc, and, on the other hand, this ocular 
lesion occurs in persons who have no intracranial disease. “ Indeed, 
in my experience as regards tumors of the hemispheres, the rule is 
that the optic nerves are normal’’ (Boston Medical and Surgical Jour- 
nal, February 5th, 1891). 


before the tumor has grown sufficiently large to be ap- 
preciable, even although it may have occasioned path- 
ognomonic symptoms. 

In 19 other cases in which the tumor was not found, the 
reason for the failure was quite different. In Keetley’s 
case (41) the pons was found enlarged to three times its 
natural size by an infiltrating glioma. The only localiz- 
ing symptom presented had been a slight internal stra- 
bismus of the left eye (paresis abducens). This fact 
should have suggested a pontine, and consequently in- 
operable tumor, as also the fact that the knee-jerks were 
exaggerated, while absence of paralysis, and existence of 
vomiting, giddiness, and staggering pointed to a tumor 
of the cerebellum.* With the latter, however, the knee- 
jerks are habitually diminished, and this special combina- 
tion of negative and positive signs should suggest a lesion 
of the pons, in spite of the absence of many of its char- 
acteristic paralyses. The patient, a child of seven, who 
had had a fall fourteen days before the onset of the 
symptoms, had an attack of collapse followed by a sub- 
normal temperature just before the operation, another 
circumstance pointing to the pons. An exploratory 
operation was made through the left squamous bone, 
but nothing was found, and the child died two days later. 

In Pilcher’s case (31) there was a scar (after an injury) 
situated over the left angular gyrus, and the skull was 
trephined at this point. The patient had marked mental 
impairment, epileptic attacks, beginning in a conjugate 
deviation of head and eyes to the left, and tonic hemi- 
spasm on the right side. Schiifer (Brain, April, 1888) 
claims that excitation of the brain near the angular 
gyrus produces conjugate deviations of the eyes to the 
opposite side. The centre for such deviation is placed 
by Horsley at the posterior extremity of the middle 
frontal gyrus; and the autopsy in this case would seem 
to confirm that localization. A glioma was found on the 
left side, in the occipital lobe, but extending forward as 
far as the frontal lobe. The island of Reil was softened. 
The mental impairment, taken together with the conju- 
gate deviation of the eyes, pointed to the frontal lobes, 
where also the headache was situated. Nothing in- 
dicated the occipital lobe, and at the angular gyrus 
nothing was found. In Sciammana’s case (8) also the 
patient was trephined, unsuccessfully, at the seat of an 
injury to the head in the right parietal region. The 
tumor was a glioma, lying in the right centrum ovale 
and extending from the right inferior cornu to the cor- 
pora quadrigemina. Crossed paralysis had existed, left 
hemiplegia, followed by right oculo-motor and facial 
paralysis. This is not explained by the autopsy. 

Kerr’s operation (58) is the third on the list misled by 
a scar. The indication was the more plausible because 
the scar was situated over the upper part of the left 
fissure of Rolando, in a patient suffering with hemispasm 
and hemiparesis. A glioma was found in the left corpus 
striatum and optic thalamus. This is the only case on 
the list in which a tumor in this situation had simulated 
a cortical tumor. 

In Knapp’s second case (65), the trephine was applied 
over a tender spot in the right temporal region, although 
there were well-marked symptoms of a cerebellar tumor. 
After death, ten weeks after the operation, the tumor 
was found in the left lateral lobe of the cerebellum. In 
this case the left knee-jerk was absent, and there was 


. slight paresis of the left hand, symptoms which, together 


with the characteristic symptoms of tumors, might have 
sufficed to indicate the cerebellum. 

In seven other cases an erroneous diagnosis was made 
of tumor of the cortical motor centres (Fraser, Ham- 
mond, Amidon, Stokes, Walker, Dobson, Twynam), and 
in one (Beach) of tumor of the frontal lobe pressing on 
the central convolutions (Cases 5, 7, 8, 51, 55, 73, 80). 

In Fraser’s case (5) the localizing symptoms were right 
hemiplegia and contracture, indistinct speech, amnesic 


* The knee-jerks are usually diminished in tumors of the cerebellum, 
whereas they are exaggerated in tumors of the pons. This may be a 
useful detail in distinguishing between these two lesions, whose 
symptoms often resemble each other. 


453 


Brain. 
Brain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





aphasia, agraphia. The error depended on the duplicity 
of the lesion. There was a tumor in the middle of the 
right ascending parietal convolution, and another in the 
left temporal lobe involving the ascending convolutions. 
The amnesic character of the aphasia really pointed to 
the left temporal lobe rather than to the neighborhood of 
Broca’s convolution. It is difficult to understand the 
failure in Hammond’s case (7), as the autopsy revealed 
three cysts in a line in the anterior central convolution 
precisely where the lesion had been diagnosed. In 
Amidon and Weir’s case (8) the tumor was found in the 
cerebellum at the autopsy, although the patient had had 
left hemispasm and paralysis of the left arm. Two cir- 
cumstances, however, pointed to the cerebellum—with 
the left-sided paralysis coexisted a paresis of the right 
arm, thus a bilateral motor defect, and there was also 
optic neuritis on the left side. Stokes’ case (51) shows, 
as the author remarks, that the motor centre for the leg 
extends farther back than is usually assumed, or else that 
pressure transmitted from a distance may cause the 
same symptoms as a lesion at the centre. A spindle- 
celled sarcoma was found in the parietal lobe, just be- 
hind the leg centre, and being of the same consistency as 
the brain, could not be distinguished. 

In Walker’s case (55) the symptoms were very confus- 
ing. Staggering seemed to indicate a cerebellar tumor, as 
did also the vertigo and vomiting. Buta marked mental 
defect pointed to the frontal lobes, and motor aphasia to 
a lesion on the left side. On the other hand, left hemi- 
spasm and hemiplegia were to be referred to the right 
side of the brain, and hemorrhage and an offensive dis- 
charge from the right ear seemed to localize the disease 
more precisely near the petrous bone. Paresis of both 
hands pointed to the cerebellum; exaggeration of the left 
tendon reflex, on the contrary, confirmed the indications 
offered by the left hemiplegia. An exploratory opera- 
tion was performed over the left ascending frontal with 
negative result. Atthe autopsy a cystic mass was found 
at the left of the sella turcica, springing from the apex 
of the petrous bone. The record leaves unexplained why 
this should have been associated with discharge from 
the right ear. 

Dobson’s case (73) exhibited an apparently exquisitely 
precise symptom, namely, twitching attacks in left arm, 
beginning in thumb and first finger, with sensory aura 
in same parts. Horsley has located the thumb centre 
just behind the middle of the ascending parietal convolu- 
tion, and a signal symptom in Jacksonian epilepsy, initi- 
ated at this point, has several times guided to an exact 
diagnosis. But in this case the centre was evidently 
irritated by pressure from a distance. There were mul- 
tiple cerebral tubercles in the right hemisphere. This is 
the second case of multiple tumor on the list. 

In Twynam’s case (80) the tumor seems to have escaped 
detection, partly because it lay too far below the surface 
in the medullary substance, partly because, as in Stokes’ 
case, the tumor, though pressing on the central convolu- 
tions, lay behind them, in the parietal lobe. Besides 
the hemiparesis there was some loss of sensations, and 
this symptom, as well as the loss of muscular sense, 
seems to point to the parietal lobe rather than the central 
convolutions. Another fact in the same sense was the 
incomplete nature of the paralysis. The tumor found 
on autopsy was very large, 68 by 57 millimetres, ex- 
tending from the Rolandic fissure to the parieto-occipital, 
and bulged into the roof of the lateral ventricle. 

In Beach’s case (52), finally, a tumor was diagnosed in 
the left frontal lobe, pressing on the lower part of the 
central convolutions. The first local symptom had been 
a motor aphasia, followed by tremor, then twitching of 
right hand and eyelid, then paresis of right hand. The 
tumor was found at the supposed level, but, as in Cases 
51 and 80 (Stokes and Twynam), it lay in the parietal 
lobe behind the motor convolutions and between the 
posterior ascending branch of the Sylvian fissure and a 
small sulcus anteriorly which separated it from the as- 
cending parietal convolution. There were no sensory 
symptoms to aid the diagnosis. 


454 


In Wille’s case (25) a tumor of the left parietal lobe 
was diagnosed, but the diagnosis was guided by the ex- 
istence of a swelling over the left parietal bone. Only 
after this had been incised did right hemiparesis appear, 
including the facial nerve. In a second operation sub- 
dural pus was evacuated, but no tumor was found. At 
the autopsy was discovered a tumor the size of a pigeon’s 
egg in the posterior part of the left paracentral lobule, 
extending into the upper part of the ascending parietal 
convolution. Also, and this makes the third case of 
multiplicity, a second tumor was found in the middle of 
the ascending parietal convolution. In two other cases 
on this list the tumor lay in the cerebellum. In Wyman’s 
case (53) it had been diagnosed in the sella turcica, be- 
cause, in addition to the general symptoms, the patient had 
a divergent squint (paralysis of the motor-oculi), anosmia, 
and slight movement of rotation at the beginning of the 
convulsive attacks. There was great muscular weak- 
ness, but neither hemiplegia nor staggering. A tumor 
three-quarters of an inch long was found in a cavity hol- 
lowed out in the left hemisphere of the cerebellum. All 
the ventricles were distended with fluid. The great fre- 
quency of cerebellar tumors might, it would seem, have 
decided the surgeon to operate, if at all, in their locality. 
But instead of this he trephined the frontal bone above 
the supra-orbital ridge and passed a probe over the 
orbital plate to the sella turcica with necessarily nega- 
tive result. 

In Springthorpe’s case (47) a cerebellar tumor was cor- 
rectly diagnosed, and several symptoms pointed to press- 
ure on the right lobe of the cerebellum. In the fits there 
was conjugate deviation of the head and eyes to the 
right side; the right ear was moderately deaf, and the 
patient fell backward and to the right side. An opening 
was made over the right lobe of the cerebellum, clear 
serous fluid escaped, but no tumor was found. At the 
autopsy a glioma with a central cavity was found to 
occupy the middle lobe of the cerebellum. All the ven- 
tricles were full of blood-stained fluid. The main press- 
ure was upon the right side. 

The last case was reported by Gray and operated by 
Wyeth (84). The exact locality of the tumor was cor- 
rectly diagnosed, but it lay one-quarter inch below the 
surface (as had been expected from the absence of con- 
vulsions), and the consistency so closely resembled that 
of the medullary brain tissue in which it was embedded 
that an exploring needle passed through it without de- 
tecting its presence, and it was discovered at the autopsy 
with difficulty, and only by careful slicing of the brain. 

Nearly all the cases in which the tumor was not found 
at the site of operation proved fatal, the operation seeming 
to accelerate the natural march of the disease. One pa- 
tient, however (Amidon and Weir), survived ten weeks, 
another (Dobson)a month. Four cases illustrate the now 
accepted rule, that a scar, and still less a tender point on 
percussion, must not be selected as a site of operation, 
unless focal symptoms point to the same locality. 

In the five cases of cerebellar tumor a retrospect of the 
symptoms, after the autopsy, makes them seem more 
significant than they had appeared before the operation. 
Cases 47 and 53, as do many other cases which have not 
been operated on, show the impossibility of distin guish- 
ing with certainty whether a tumor of the cerebellum be 
situated in its lateral or its middle lobe. Nothnagel’s 
law of the frequent latency of tumors of the lateral lobes 
should always incline the diagnosis in favor of a central 
lesion, unless lateral symptoms are very well marked. 
The danger of hemorrhage, however, from trephining 
over the centre of the cerebellum, 7.e., of the sinus, is 
very great, and, on the other hand, a tumor of the middle 
lobe is sometimes accessible from the side. 

Operations on tumors too large for removal, when the 
cranial opening was really made over the seat of the 
lesion, have not always proved so dangerous as in the 
class of cases just described. Thus, Horsley (Case 45) 
removed first one-half of the occipital bone, ‘then the 
other, where an inoperable tumor of the middle lobe of 
the cerebellum existed. The patient had suffered for a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





long time from epileptiform fits, with violent rotary 
movements, from severe headache and distressing attacks 
of dyspnea. All these symptoms disappeared after the 
operation, and the patient’s life was prolonged in com- 
fort for two years. 

In Heath’s case (27), also, there was found, over the right 
ascending frontal convolution, a large adherent growth 
which could not be removed. Localized tenderness had 
existed over the site of the tumor. The patient was re- 
lieved of his headache by the operation, and, at the time 
of reporting, had made a good recovery. In Case 35 
(Limont and Page) a portion of a large glioma was re- 
moved, with temporary recovery, but the growth. re- 
curred. 

In Case 39 (Kocher) tumor of the cerebellum was diag- 
nosed from the four classical general symptoms, in the 
absence of focal symptoms. A double trephine opening 
was made to relieve intracranial pressure, one posteriorly 
on the right side below the tentorium, one anteriorly on 
the left side. In four days congestion of the optic discs 
had disappeared, but there was no improvement of vision. 

In Maudsley’s case (42) a tumor had been diagnosed in 
the left lobe of the cerebellum, the trephine was applied 
at this locality and a tumor found, but it was a solid 
nodule, irremovably attached to the temporal bone. The 
patient recovered from the operation. Five other cases 
proved rapidly fatal. The entire list of ten cases is sum- 
marized in Tables III. and LV. 

Death occurred after removal of the tumor in sixteen 
other cases. The causes may be thus tabulated: 

Five out of these 16 cases are tumors of the cere- 
bellum; 5 cases on Table IJ., 1 on Table III., and 1 on 
Table V., were also cerebellar; thus 12 out of the total 
number of 46 unsuccessful cases, or 26 per cent. 

The death from diphtheria (Castro) and that due to ac- 
cidental opening of the cerebellar sinus (Bullard and 
Bradford) are theoretically avoidable. The case of glio- 
sarcoma removed by McBurney had been correctly diag- 
nosed eleven months before, and the operation then ad- 
vised. At that time it might have been successful, so 
that in this case the fatal issue may fairly have been at- 
tributed to the delay. It may perhaps be assumed that 
the five deaths caused by septic meningo-encephalitis 
could have been avoided by more perfect antiseptic pre- 
cautions. 

The fatal issue is not clearly explained in the cases 
reported by Gray, Thomas, and Keen. The last case is 
particularly interesting, because the tumor had been 
correctly localized in the cuneus on account of the symp- 
tom of hemianopsia. It is the only case in the entire 
collection (before 1894) in which this symptom was thus 
rendered available. 

In 39 cases the operation was successful. The situa- 
tion of the tumor in these cases is shown in the next 
table. 

These cases of recovery include one, and only one, case 
of tumor of the cerebellum, and that was a cyst. This 
‘is to be reckoned against 12 fatal cases of cerebellum 
tumor, already noted. As might be expected, in the im- 
mense majority of successful cases the tumor is situated 
in the motor convolutions (29 out of 39 cases). This 
region unites all the conditions of success—facility of 
diagnosis, facility of operation, relative freedom from 
danger of shock. Among the unsuccessful cases the 
tumor was situated in the central convolutions only seven 
times, and in one of these the death was purely accidental, 
due to an epidemic diphtheria. In all the others death 
was due to septic meningitis, in one case complicated by 
syphilis. In one a communication existed between the 
tumor and the ventricle; in another, there was an adhesion 

to the longitudinal sinus. 
- Thesymptoms of lesion of the central convolutions are 
so well marked that when the tumor exists in this local- 
ity it cannot easily be overlooked. It sometimes hap- 
pens, however, that tumors in other localities simulate 
the symptoms proper to disease in the cortical motor 
centres. Thus: 1. The tumor may be situated in the 
subcortical region of the centrum ovale, as in Gray’s case 


Brain, 
Brain. 





(84). The diagnosis in this case, notwithstanding the 
monoplegia, was correctly made as subcortical, on ac- 
count of the absence of spasm or convulsion. 2. The 
tumor may lie in the frontal, parietal, or temporal lobes, 
and by transmitted pressure excite the symptoms proper 
to the motor area. The diagnosis, when possible, is 
made out by observing that lesions of intelligence, or 
speech, or sensibility, or vision, especially hemianopsia, 
have preceded motor symptems, and that the latter re- 
main incomplete—paresis, not paralysis. 38. Tumor of 
the basal ganglia may simulate cortical tumor. This 
occurred in Case 58 (Kerr). It is rather surprising that 
the mistake has not been made more frequently. That 
it has not, is due to the enormously valuable studies in 
“ Jacksonian epilepsy,” that may be ranked as the second 
link in the chain of investigation which, beginning with 
the researches of Hitzig and Ferrier on brain localization, 
have so rapidly led to brain surgery. Only one tumor 
of the occipital lobe has been operated on at its site, the 
diagnosis having been guided by the remarkable symp- 
tom hemianopsia (Birdsall and Weir, 15). 

In Pilcher and Dana’s case (31) the tumor occupied the 
left occipital lobe, but the operation was made at the 
site of a scar corresponding to the angular gyrus, The 
tumor, therefore, was not found. It is not stated 
whether the patient was examined for hemianopsia. 

It is claimed, especially by Starr, that an onset of 
symptoms with psychical changes is very characteristic 
of tumors of the frontul lobe. Such mental depression, 
however, is apt to occur with intracranial tumors in any 
locality, and cannot be considered a distinct indication 
of frontal-lobe localization until, by extension backward, 
motor symptoms begin to complicate the mental; or 
until conjugate deviation of head and eyes has become 
a signalsymptom in convulsive attacks; or untilanosmia 
be discovered. Inseveral of the frontal-lobe tumors here 
recorded an external lesion coexisted and guided the 
operator to the exact locality. 

It seems to have become accepted that a fairly large 
opening through the skull is preferable to the small tre- 
phine openings originally chosen. With such large flaps 
much greater facility is offered for detecting a tumor, 
whose remote pressure symptoms had confused the pre- 
operative diagnosis (see Gray’s case). 

From the foregoing record of cases we may deduce 
several propositions. 

In the first place, it has been demonstrated that it is 
practicable to open the cavity of the cranium, to pene- 
trate the dura mater, to lay bare the brain, and even to 
excise portions of its tissue. The successful removal of 
brain tumors has restored to favor as a legitimate sur- 
gical procedure the old operation of trephining, which 
had fallen into desuetude.* So far this surgical restora- 
tion has proved more useful in other cases of brain dis- 
ease than in that whichis the subject of the present arti- 
cle (see article on Brain, Surgery of). But the fact will 
always remain interesting, that it was the greater exploit 
of excising a cerebral neoplasm, which has, in entirely 
modern times, encouraged surgeons to the lesser effort 
of trephining for cerebral abscess and traumatic hemor- 
rhage; and revived the old rules of unhesitating trephin- 
ing in traumatic cases with depressed fracture. 

Again, when Hughlings Jackson first began to study 
the precise order of development of the sensori-motor 
phenomena in the class of convulsive attacks which now 
bears his name, their habitual dependence upon organic 
brain lesion had not yet been established. This has now 
been shown, and the cases of brain tumor attended by 
attacks of Jacksonian epilepsy have assumed the most 
favorable prognosis, because the fact of the attacks usu- 
ally indicates that the tumor is situated in the cortex of 
the central convolutions, and from the details of the at- 
tack the exact motor centre may be inferred. Pursuing 
still further the line of thought, neurological surgeons 
have argued that if a tumor in the motor area determines 


* Horsley, in a learned lecture, claims to have found evidence of 
operative trephining on the skulls of prehistoric men. 


455 


Brain, 
Branchial Cysts. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





a definite series of explosive symptoms—sensori-motor 
irritation followed by sensori-motor paralysis—the oc. 
currence of such symptoms, apart from indications of 
intracranial tumor, implies that the same motor region is 
irritated, though in some other way than by a neoplasm. 
Many cases of epilepsy, hitherto considered a functional 
disease,* have therefore been trephined, and in many of 
these, organic lessons, as cicatrices, have been removed 
from the surface of the brain or meninges, with the re- 
sult of allaying or arresting the convulsive attacks. 
Finally, even in the absence of all visible lesion, portions 
of cortical tissue, containing the centres of motor rep- 
resentation corresponding to the limb segments whose 
spasm initiates the attack, have been excised. 

It is not within the province of this article to discuss 
this latest and most interesting development of surgical 
method, which began with removing the tangible organic 
causes of epilepsy. We may observe, however, that the 
signal symptom of the attack (the felicitous expression 
is Seguin’s), which is held to localize the lesion, because 
indicating the point of earliest and most intense irrita- 
tion, does not necessarily show that the irritation origi- 
nates at this point. It is quite as possible that the nerve 
tissue has received an irritation propagated from some 
distant region, but not manifest until it has spent itself 
upon a motor centre and thence determined a nervous 
discharge. Excision of the motor centre, therefore, would 
remove, not a cause of the spasm, but only the first effect 
of some possibly inaccessible cause. 

From the frequent failure of the operation as a cure for 
epilepsy, one may suspect that some such condition of 
things often exists. The difficulty in these non-organic 
cases is paralleled in cases of tumor, when, though the 
convulsions are immediately initiated by irritation of the 
cortical motor area, the causal lesion is situated in some 
other part of the brain and cannot be found. 

Another parallel has a more hopeful aspect. It has 
sometimes been found in cases of inoperable tumor that 
the symptoms due to pressure—vomiting, headache, and 
convulsions—could all be relieved when the pressure was 
lessened by trephining or removal of large pieces of 
cranial bones.+ It seems therefore possible that in cases 
of epilepsy without gross or focal lesion, and before irre- 
mediable degeneration had set in, similarly afforded relief 
of intracranial pressure might arrest the disease. 

Traumatism, even when not more severe than that of 
a fall on the head, has always been recognized as an im 
portant factor in the etiology of brain tumors. Out of 
the 85 cases of operation on record, there is a history of 
a fall ora blow in 20.{ Morbid symptoms rarely develop 
very soon after the accident: months, sometimes years, 
intervene. In the light of the experience now accumu- 
lated, it is indicated to operate very early after the ap- 
pearance of symptoms indicative of intracranial neoplasm ; 
and the indication is especially formal if there isa history 
of previous traumatism. It is possible, as Seguin’s case 
shows, to operate so early that the tumor has not yet 
grown large enough to be found at the operation. This 
is, however, the only case on the list in which the operation 
failed from this cause; only when the tumor is situated 
entirely on the surface of the cortex is it liable to excite 
convulsive twitchings while yet very small; but in such 
a situation the tumor should be easily found. The 
danger of delay in operating is well shown in the first 
case of Starr and McBurney (Case 81). Eleven months 
intervened between the establishment of the diagnosis 
(when the operation was first proposed) and the time 
when the patient’s consent to the operation was secured. 
In that time the tumor grew to such a size that its 


* According to the present view, non-localizable, i.e., generalized 
epilepsy depends upon a diffused microscopic sclerosis (Féré, ‘‘ Les 
epilepsies’’) or a degeneration and vacuolation of ganglion cells 
(Dana, “‘ Treatise on Nervous Diseases”’). 

+ Horsley (see Case 45) removed first one half, then the other half of 
the occipital bone, ‘‘and the patient lived in comfort two years.” 

+ Cases 1, 3, 5, 16, 18, 24, 31, 387, 88, 41, 49, 55, 58, 68, 74, 75, 76, 80, 82. 
Case 38 is particularly interesting. It is that of a little girl in a Swiss 
school who was struck on the head with a ruler by the teacher. 

§ In Case 50 (Church) the tumor was a spider-like, filiform growth, 
extended on the surface of the central and frontal gyri. 


456 


removal was followed by death from shock in a few 
hours. 

The development of optic neuritis is not always pro- 
portioned to the size of the tumor, but much more to its 
situation. Hence, as has long been known, optic neuritis 
appears early and advances rapidly with tumors of the 
cerebellum, where the intracranial pressure is at its maxi- 
mum. An early operation is often indicated to relieve 
this pressure before the optic nerves should have atro 
phied, in which case the patient would remain blind, 
even though he survived the operation and were relieved 


of other urgent symptoms. 


An important decision formulated by Horsley is that 
syphilitic tumors should be operated on, and not left to 
the uncertain influence of internal treatment. Bergmann, 
on the other hand, maintains the sufficiency of this treat- 
ment, and the superfluous risk of the operation. 

If it be assumed that all tumors of the cortex and cen- 
trum ovale are conceivably operable, the proportion of 
operations to cases would be 41 per cent., since 266 out 
of 644 cases of tumor are situated in these two locali- 
ties. If to these be added 162 cases of the cerebellum, 
the proportion would rise to 65 per cent. 

The special difficulties surrounding tumor of the cere- 
bellum have already been emphasized. The general 
diagnosis is relatively easy, that is, it is usually easy to 
diagnose a tumor of the posterior cranial fossa and sub- 
tentorial. It is often difficult to distinguish between the 
middle lobe of the cerebellum and a lateral lobe; and 
usually impossible to distinguish between tumor of the 
bone compressing the cerebellum and tumor of the organ 
itself. A precious aid in diagnosticating tumors of the 
occipital lobe from those of the cerebellum is the exist- 
ence of hemianopsia in the former, as against optic 
neuritis in the latter. Case 41 (Keetley) shows how a 
tumor of the pons may be mistaken for a cerebellar 
tumor, when by exception the paralyses of cranial nerves, 
so characteristic of pontine tumors, are lacking. The 
prognosis in cerebellar tumors, however, is rendered bad 
far less by the difficulties of diagnosis than by the special 
dangers of the operation which have already been men- 
tioned. In the centrum ovale and cortex, on the con- 
trary, the dangers of the operation are at the minimum, _ 
provided the tumor can be found. The difficulty of 
finding it depends upon: 1st, whether it lie in a latent 
zone or in one whose symptomatology has been deter 
mined ; 2d, uponits proximity to the surface ; 3d, upon the 
differentiation of its consistency from that of the brain. 

The accessible regions of the cerebrum whose lesions 
have so far been connected with sufficiently definite dif- 
ferential symptoms are: The frontal lobes, the central con- 
volutions, the parietal lobes, the occipital lobes, the left 
temporal lobe, and the left insula. The differentiating 
signs have been sufficiently emphasized in the text. 
Tumors of the centrum ovale are always latent as to their 
locality—being indicated by general symptoms alone, 
unless they come near enough to the surface to irritate 
the cortex. In Gray’s case (86), Table I., the position was 
made out with great precision, but the failure was due 
to the third operative difficulty which has been mentioned, 
namely, the extremely soft consistency of the tumor. 

This difficulty can never be foreseen in advance, and 
seems to be as much to be feared with large as with 
small tumors.* Possibly some future therapeutic re- 
source will enable the surgeon to prepare his patient for 
operation by the ingestion of some food or drug which 
should change the consistency of the tumor. 

Medical resources at present are extremely meagre— 
after we have mentioned the use of mercury and iodide 
of potassium in cases of syphilitic tumor. An energetic 
inunction treatment is required, 4to 5 gm. mercurial oint- 
ment daily for six weeks—followed, after a pause, 
by a course of iodide of potassium, 5 to 10 gm. to 200 gm. 
of water, of which a tablespoonful three times a day. 

For vomiting, pain, and convulsions, morphine, chloral, 
and bromide of potassium are the three remedies, and the 


* It is characteristic of gliomata. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


greatest of these is morphine. For details of cranio- 
topography, operative procedure and technique, and the 
special dangers incident to the operation for brain tumor, 
the reader is referred to the article on Brain, Surgery of, 
by Dr. Keen, in the present volume. 

Mary Putnam-Jacobi. 


BRANCHIAL CYSTS.—Branchial cysts are cystic 
tumors of the neck and some parts of the head, originat- 
ing from congenital defects of development, their matrix 
being composed of fcetal epiblastic or hypoblastic tissue 
which remains in its embryonal state for an indefinite 
time, and later, by proliferation of its epithelial elements, 
gives rise to a distinct and characteristic type of cystic 
tumors. They have been variously designated as bran- 
chial cysts (Roser), dermoid cysts of the sheath of the in- 
ternal jugular vein (Langenbeck), deep-seated atheroma- 
tous tumors (Schede), tumors of the branchial clefts 
(Virchow), hydrocele colli congenita (Maunoir), hygroma 
colli (Luschka), and atheromatous cysts of the lymphatic 
glands (Luecke), in accordance with the nature of the 
contents of the tumor or the peculiar etiological views 
entertained by the different authors. It appears to me, 
however, that “branchial cysts” is the most appropriate 
term, as it expresses at once both the location and the 
character of the tumor. 

Toward the end of the first month of foetal life we see, 
under the frontal process, open in front and bounded on 
the sides by four plates, the pharyngeal cavity. The 
upper pair of plates constitutes the first branchial arch. 
The next three pairs of plates make up the second, third, 
and fourth branchial arches, which decrease in size from 
above downward, so that their median interspaces in 
front are narrow above and wider lower down. Between 
any two individual branchial arches, on each side, re- 
mains a transverse cleft, and, during early fetal life, 
these branchial clefts, with the exception of the first one, 
from which the external auditory canal, the cavity of the 
tympanum, and the Eustachian tube are developed, 
unite. The neck is thus built up of continuous lateral 
walls. From the second branchial arch are developed 
the styloid process, the stylo-hyoid ligament, and the 
lesser cornua of the hyoid bone; the third arch forms the 
large horns and the body of this bone; the fourth arch 
assists in forming the soft tissues of the neck. The 
larynx, trachea, and adjacent glands are developed from 
other centres of foetal growth. The primary origin of 
these tumors necessarily must correspond to the location 
of one of these branchial clefts, and clinical experience 
has demonstrated that they are most frequently found 
in the region of the second and third branchial clefts, 
in the vicinity of the larynx and pharynx, and in inti- 
mate relation with the sheath of the large vessels of the 
neck, in contradistinction to dermoid cysts about the 
orbits and in the scalp, which are more superficially 
located. In the case of a young lady, Langenbeck ob- 
served a cyst situated on the left side of the epiglottis 
and pharynx, which occupied one-half of the floor of the 
mouth, and which projected from underneath the chin 
on that side in the shape of a smooth tumor of the size of 
a fist. Respiration, deglutition, and the motions of the 
tongue were greatly impeded. The cyst contained eight 
ounces of atheromatous matter. The same author states 
that he has frequently found these tumors attached to 
the greater horn of the hyoid bone or to the thyro-hyoid 
ligaments, localities which plainly indicate that they 
originated from remnants of former branchial clefts. 

As they are often in intimate connection with the 
sheath of the large vessels of the neck, it is very impor. 
tant to study their anatomical relations to these important 
structures. The jugular vein is surrounded, throughout 
its whole course in the neck, by a distinct and separate 
sheath of areolar tissue which, on the outer side of the 
artery, penetrates into the deep tissues of the neck, thus 
completely separating the two vessels. The jugular, 
enclosed in its sheath, may be easily drawn over the 
artery toward the median line without producing any 
change of location of the artery. The vein being in 


Brain, 
Branchial Cysts, 








front of the artery and covering half of the lumen of the 
latter, it can be readily understood that when the vein is 
drawn forward, with its sheath, it can be injured, while 
the artery is not exposed to the same danger. Branchial 


_ cysts of the second and third clefts are always observed 


in the sheath of the large cervical vessels, usually in the 
carotid triangle above the omo-hyoid muscle. hey ap- 
pear to occur more frequently on the left side of the 
neck. Their shape is invariably round or oval, witha 
smooth surface. The contents of these cysts being either 
fluid or semifluid, fluctuation can be felt, more particu- 
larly if the tumor is palpated between two fingers, one 
of which is placed in the pharynx or on the floor of the 
mouth, and the other on the external surface. Only 
lateral motion of the tumor is possible, on account of its 
peculiar attachments to the deep tissues of the neck. If 
the tumor is of only moderate size the pulsations of the 
carotid artery can be felt on its inner margin. If it is 
large it overlaps the artery, in which case the pulsations 
of the vessel are communicated to the tumor. Smaller 
tumors can be made to pulsate by bending the head 
backward and in a direction opposite to the tumor. 

Branchial cysts should be classified according to their 
contents. The cyst walls being lined with epithelium, 
the only histological elements in the contents are epithelia. 
In most instances the epithelia lining the cyst belong to 
the tessellated variety, but Rehn discovered, in a blind 
congenital fistula ending near the mucous membrane of 
the pharynx, ciliated epithelium; and Neumann found 
cylindrical and pavement epithelium in two cystic tumors 
of the neck, one of which was congenital while the other 
was developed in later years. The physical and chemical 
properties of the cyst contents will depend largely on the 
amount and degree of activity of the retrograde processes 
which may have taken place in the epithelium. 

Clinical experience and pathological examination have 
shown that these tumors, according to the physical prop- 
erties of their contents, may be divided into the follow- 
ing four principal varieties: 

1, Mucous cysts; 2, atheromatous cysts; 8, serous 
cysts; 4, hemato-cysts. 

Variable as the contents of these varieties may be, 
more uniformity is observed in the structure of the cyst 
wall. In the primary stage of the affection it consists of 
a connective-tissue capsule with an epithelial lining on 
its inner surface, and a delicate layer of a loosely con- 
nected reticulum of connective tissue (pericystium) which 
is very vascular, and covers the outer surface of the 
cyst. “A high degree of intracystic pressure may cause 
atrophy of the epithelial lining and thinning of the walls 
of the sac, and, on the other hand, inflammatory prolif- 
eration produces great thickening of the cyst walls. 
While dermoid cysts contain the characteristic secretions 
of the skin and its appendages, the branchial cysts con- 
tain only the products of the epithelial cells, because their 
walls do not contain any hair follicles, sebaceous or 
sweat glands, as the branchial clefts close before these 
appendages are formed. 

1. Mucous BrancuiaAL Cysts.—As a primary forma- 
tion, this form of branchial cyst is usually found in the 
upper branchial clefts. Their origin is attributable to 
an imperfect closure of the upper portion of the branchial 
tract; consequently the cyst wall may derive its lining 
from the mucous membrane of the pharynx, and the re- 
tention of the physiological secretion produces a mucous 
cyst. Many of the so-called ranular cysts, about the 
base of the tongue, belong to this variety of tumors. 

2. ATHEROMATOUS BRANCHIAL Cysts.—This form of 
branchial. cysts has been described by some authors as 
deep-seated atheromatous cysts of the neck (Schede), 
and dermoid cysts of the sheath of the large vessels of 
the neck (Langenbeck). They are usually located in the 
second and third branchial tracts in the region of the 
hyoid bone, and are intimately connected with the sheath 
of the large cervical vessels. These cysts contain an 
atheromatous material resembling the contents of an 
ordinary retention cyst of the skin, with this difference, 
however, that they never contain anything which would 


457 


BWranchial Cysts. 
Branchial Cysts. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





indicate the presence of hair follicles, as lanuginose hair 
or sebaceous material, or any of the more complicated 
products of adermoid cyst. For the purpose of furnish- 
ing a clear clinical picture of this form of branchial cysts, 
I will give a synopsis of two cases which have come 
under my observation. 

Case I.—Mrs. H——, aged thirty six. German. 
Family history reveals no tendency to congenital mal- 
formations. About one year ago the patient discovered 
a small tumor on the right side of the neck, between the 
angle of the jaw and the larynx, which slowly increased 
in size, and after a few months became the seat of an 
acute inflammation which terminated in suppuration, re- 
quiring an incision for the relief of urgent symptoms. 
The fluid which escaped consisted of pus mixed with a 
gruelly substance. Prompt relief followed the incision. 
The inflammatory symptoms subsided and the tumor 
diminished in size. In afew weeks the opening clesed, 
leaving a small and painless swelling. The same symp- 
toms were repeated about four months subsequently. 
When the patient came under my observation, during 
the summer of 1888, I found a tumor about the size of a 
hen’s egg, located between the angle of the jaw and the 
larynx, resting directly upon the large vessels of the 
neck, as was evident from the distinct pulsations which 
it received and which could be seen and felt. The pos- 
terior portion was under the sterno-cleido-mastoid. Over 
its centre was seen the scar which had resulted from the 
previous incisions. The swelling presented a regular, 
smooth surface and an oval outline, with the long diam- 
eter parallel to the cervical vessels. It was only slightly 
movable from side to side, and perfectly immovable from 
above downward, showing that it had a firm point of 
attachment to the deep tissues of the neck. Fluctuation 
could be detected on the outer surface and also through 
the mouth. The original location corresponded to the 
third branchial cleft. As it had on two different occasions 
undergone acute inflammatory changes without any 
benefit resulting from them, the extirpation of the cyst 
was deemed the only measure which promised a perma- 
nent result. The operation was done under antiseptic 
precautions. A straight incision was made over the 
tumor, parallel to the sterno-cleido-mastoid. The cyst 
was firmly adherent to the surrounding tissue, as the 
result of antecedent inflammatory infiltrations, and re- 
quired much time and patience to effect its separation. 
After it had been isolated from all attachments on its 
sides, it was seized with a tenaculum forceps and drawn 
forward and toward the median line of the neck, while 
the sterno-cleido-mastoid was held in an opposite direc- 
tion, so as to afford easy access to its base. The attach- 
ments here were very firm, and it appeared as though 
the base of the tumor and the large cervical vessels un- 
derneath were embedded in a mass of cicatricial tissue. 
Keeping as close to the cyst wall as possible, I carried 
out the dissection very carefully, proceeding mostly with 
blunt instruments. When nearly one-half of the pedicle 
had been separated in this manner, we were suddenly 
surprised by a tremendous gush of dark venous blood, 
which in a second flooded the whole field of operation. 
It was only too evident that the internal jugular vein 
had been torn, and, for the purpose of preventing 
further loss of blood, and to guard against instant death 
by admission of air into the vein, I made firm digital 
compression above and below the injured vein, while my 
assistant pushed a sponge into the wound. Hemorrhage 
was controlled in this manner, and, as soon as I could be 
relieved by an assistant, I carefully removed the sponge, 
and, after locating as nearly as possible the exaet seat of 
bleeding, I seized the vein, with some of its adjacent 
tissues, with a stout pair of hemostatic forceps. I was 
fortunate enough to grasp the bleeding point at the first 
attempt, and the hemorrhage was completely controlled. 
The tumor was now removed, and by making slight trac- 
tion on the forceps I drew the vein forward and applied 
a catgut ligature without isolating the vessel. I was 
unable to ascertain the exact size or direction of the 
wound in the vein, but the ligature arrested the hemor- 


458 


rhage promptly and permanently. The wound was 
thoroughly irrigated, and, as in Langenbeck’s case, the 
vein seemed to disappear underneath the deep tissues of 
the neck. Inthe wound could be seen the cesophagus, 
lateral wall of the larynx, carotid artery in its sheath, and 
the great horn of the hyoid bone. After suturing and 
draining the wound I applied a graduated compress. 
For the first twenty-four hours after the operation the 
patient suffered from intense headache on the correspond- 
ing side, which induced me to believe that the circulation 
in the vein had been completely interraipted, either by 
the ligature alone or by the formation of a thrombus at 
the point of ligation. After the first twenty-four hours 
the patient suffered no further inconvenience. The 
wound healed by primary union, and the recovery has 
been permanent and complete. There is no question that 
the adhesions of the cyst with the sheath of the cer- 
vical vessels were due to the attacks of acute inflamma- 
tion which had preceded the operation on two different 
occasions. A microscopical examination of the contents 
showed flat epithelial cells, cholesterin crystals, fat 
granules, and a mass of débris, the product of epithelial 
degeneration. The cyst wall was composed of connec- 
tive tissue, thickened and infiltrated with embryonal 
elements, and lined with epithelial cells. 

The next case very nicely illustrates the oral variety 
of branchial cysts. 

Case II.—Mary H——, aged twenty-five. German. 
Her family history is good, especially as regards con- 
genital malformations, such as tumors or fistulee in the 
cervical region. Patient has always appeared round and 
full underneath the chin, but during the last four years 
a tumor has been growing rapidly on the floor of the 
mouth, until at present it is considerably larger than a 
goose’s egg. The mouth is completely filled by it, the 
tongue is pressed against the palate, its movements are 
limited, only the tip of it being visible at the upper 
border of the tumor, and speech and deglutition are 
greatly impeded. Laterally the tumor extends very near 
the angles of the inferior maxillary bone, and downward 
it overlaps the larynx and upper part of the trachea, en- 
tirely obliterating the round contour of the upper cer- 
vical region. It is painless and distinctly fluctuating to 
the touch, presents a smooth surface, and gives rise to 
no inconvenience except that which results from its 
mechanical interference with speech and deglutition. 
When the patient opens her mouth, the apertures of 
Wharton’s ducts are plainly visible on each side of the 
median line, and, by exerting lateral pressure upon the 
submaxillary glands, the patient can expel a stream of 
saliva from them. Previous treatment, consisting of ex- 
ternal applications of iodine, etc., had had no effect on 
the growth. Desiring to avoid any deformity resulting 
from an external cicatrix, I decided to remove the tumor 
through the mouth. A linear incision was therefore 
made in the median line, extending from above down- 
ward from the tip of the tongue to the symphysis menti, 
the ducts of the salivary glands being carefully avoided. 
Adhesions existing between the tumor and its surround- 
ing tissues were easily severed, when it was seen that it 
would be impossible to remove the tumor in its entirety 
owing to its immense size. The sac was therefore 
opened and a large quantity of its gruelly contents re- 
moved by pressure. The operation was then continued 
without any difficulty until the entire cyst had been re- 
moved. It was now noticed that the cyst was constricted 
in its middle by the inferior maxillary bone, the upper 
and lower portions of it bulging out on both sides of the 
constriction. There was no hemorrhage worth mention- 
ing. The body and great wings of the hyoid bone could 
be plainly felt in the posterior recess of the wound. The 
cyst wall was thin, and its external surface was quite 
vascular. The microscopical examination of the contents 
of the cyst, as well as the primary location of the tumor, 
revealed its branchial origin. The wound healed very 
kindly, and shortly afterward nothing in the looks of the 
young lady showed any traces of the deformity which 
had previously disfigured her face and neck. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Branchial Cysts, 
Branchial Cysts, 





3. SeRous BRANcHIAL Cysts.—This variety of bran- 
chial cysts is composed of thin cyst walls and serous 
contents, and may develop from any one of the branchial 
clefts failing to undergo complete obliteration. This 
affection has been described under the name of hydrocele 
colli (Maunoir), congenital hygroma of the neck (Wern- 
her), congenital hydrocele of the neck, and congenital 
cystic tumor of the neck (Thomas Smith). Maunoir, 
under the name of hydrocele colli, described certain serous 
cysts occurring between the angle of the jaw and the 
mastoid process, and between the larynx and the anterior 
margin of the sterno-cleido-mastoid, a region which cor- 
responds to the second and third branchial clefts, which 
were supposed not to have been obliterated at the time 
of birth. We have seen, however, that branchial cysts 
are not necessarily developed during intra-uterine life or 
soon after birth. All that is necessary is that the matrix 
for the cysts be present at birth, from which at some 
future time the tumor may be developed. These tumors 
appear as single or multilocular cysts with thin mem- 
branous walls; their internal surface is lined with pave- 
ment epithelium. Like cavities lined with a serous 
membrane, they contain a limpid, watery, or tenacious 
fluid, holding in suspension epithelial cells and choles- 
terin crystals. These cysts are formed anywhere in the 
neck, within the area of the branchial clefts, between 
the lower jaw and the clavicle. They are usually deep- 
seated, though occasionally they are superficial. They 
are painless, and give annoyance only from their size. 
Clinically they may be recognized from their location, 
their globular cystic form, soft fluctuating feel, and 
painless growth. The existence of tessellated epithelium 
upon the inner surface of these cysts has been demon- 
strated by Neumann and Baumgarten. When these 
cysts spring from the second or third branchial clefts 
they are usually deeply located. Hueter, in extirpating 
a tumor of this kind in a child two years of age, ascer- 
tained that it extended between the two carotid arteries 
back to the walls of the pharynx. When they are deeply 
situated they are usually in contact and connected with 
the sheath of the large cervical vessels, and receive a dis- 
tinct impulse from the underlying artery. When thus 
located, they offer the same difficulties to extirpation as 
do those of the atheromatous variety. The following 
case may serve as an illustration of this type of branchial 
cysts: 

"The patient was a healthy, strong, male child, six 
months of age. No history of congenital malformation, 
especially branchial fistula, in the family. When the 
child was born, a small tumor the size of a pea was dis- 
covered on a level with, and somewhat to the inner side 
of, the sternal origin of the sterno-cleido-mastoid muscle. 
The tumor was painless and movable, but rapidly in- 
creased in size. When the child was brought to me, the 
tumor was as large as a walnut. The skin over it was 
natural in appearance and movable. The tumor itself 
presented a smooth surface. Fluctuation was distinct, 
but the cyst appeared to be somewhat firmly attached to 
the adjacent tissues. The cyst was readily enucleated, 
the adhesions not being very firm except over the most 
prominent point of the tumor, where inversion of the 
skin had undoubtedly occurred during the closure of the 
external opening of the fourth branchial tract. The ad- 
herent portion of the skin was excised with the tumor. 
The cyst was found to be oval in shape and smooth, and 
the outer layers were quite vascular. The walls being 
thin and the contents serous, the whole tumor presented 
a translucent appearance. The wound was closed with 
sutures, and healed by primary union under an anti- 
septic dressing. Similar cases have been reported by 
Smith, Vonwiller, Frederick Treves, and others. 

Thomas Smith reports a case which would show that 
these cysts may occasionally disappear by spontaneous 
absorption of their contents. The patient was a healthy 
babe three weeks old. Immediately after birth a swell- 
ing was noticed in the neck, which rapidly increased in 
size. When the patient was first seen, a cystic tumor 
occupied almost the entire region of the left side of the 





neck, extending from under the lower jaw to the clavicle. 
The mother objected to any kind of treatment. Three 
months later the child was seen again, when the growth 
had greatly diminished in size. There was nothing to 
be felt but a loose, flabby, cystic mass, not much larger 
than a hen’segg. The skin over it was shrivelled, loose, 
and baggy. Three months later the tumor was still 
smaller. 

4. Hamato-cysts OF BRANCHIAL CLEFTS.—In some 
instances of serous branchial cysts the fluid is discolored 
by an admixture of blood from minute hemorrhages into 
the sac, but when the contents are of such dark color as 
to resemble venous blood, they are properly called he- 
mato-cysts, and from a pathological, diagnostic, and 
clinical point of view they constitute a distinct and well- 
marked variety of branchial cysts. Albert remarks that 
two kinds of these cysts have been observed: 1. Such as 
may be emptied by pressure, and are in communication 
with blood-vessels. 2. Those which cannot thus be 
emptied by pressure, and which simulate the appearance 
of an ordinary serous cyst so closely that their nature is 
recognized only by puncture. The latter class, when 
they occur in the neck, usually belong to the branchial 
cysts, because they are observed during early life, and 
originate in places which correspond to the location of 
the branchial clefts. This variety of cysts has been called 
hematocele colli by Michaux and hematoma by J. P. 
Frank. Hmato-cysts resemble the serous cysts in every 
particular, with the exception of the presence of blood 
in their contents. It is not an easy matter, however, to 
make a diagnosis of this variety of branchial cysts, and 
it should always be made by exclusion, due attention 
being given to the location of the cyst, the time of de- 
velopment, and the character of its contents. 

Branchial cysts are of comparatively rare occurrence, 
and the statistics cannot be relied upon in estimating 
the frequency with which these tumors occur, as many 
of them have been classified and described under the ge- 
neric and indefinite term “cystic tumors of the neck” 
without regard to their etiology. Guret, in 1855, com- 
piled 44 cases of serous and 6 cases of atheromatous 
cysts. Since that time quite a number of new cases have 
been described by Volkmann, Billroth, Esmarch, Roser, 
Langenbeck, Luecke, and Bruns. The serous variety of 
cysts is more likely to develop early; they are often con- 
genital, or appear during infancy or childhood, while the 
atheromatous cysts are the products of early adult life. 
Of 53 cases mentioned by Schede, 9 occurred between 
the first and tenth years of life, 21 between the eleventh 
and twentieth, 10 between the twenty-first and thirtieth, 
6 between the thirty-first and fortieth, 5 between the 
forty-first and fiftieth, and 2 between the fifty-first and 
sixtieth. 

Like the dermoid cysts, the branchial tumors show a 
tendency to develop during the period of puberty, ata 
time when the epiblast enters upon a new phase of de- 
velopment and becomes the seat of renewed and active 
tissue proliferation. The remnants of the branchial cleft 
may remain dormant, as a matrix for the future growth 
of the tumor, for an indefinite time, and may become the 
seat of tissue growth during puberty or upon the advent 
of any determining cause or causes. There are many in- 
stances in which remnants of feetal tissue have remained 
latent in the branchial tracts throughout a lifetime, for 
want of an exciting cause of sufficient strength to call 
into morbid activity the slumbering forces inherent in 
the histological elements of the matrix. 

DraGnosis.—The diagnosis is oftentimes no easy task. 
The importance of the tissues and organs which are in 
close and intimate relation with these tumors renders it 
imperative upon the surgeon to make a correct diagnosis 
before an operation is undertaken for their removal. 
The following conditions may simulate a branchial cyst: 
1, Aneurism; 2, angioma; 3, dermoid cysts; 4, rete:tion 
cysts; 5, affections of lymphatic vessels and glands; 6, 
struma cystica; 7, simple serous cysts. 

1. Aneurism.—As most of the branchial cysts are in 
immediate contact with the large cervical vessels, and 


459 


Branchial Cysts. 
Breast, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








usually receive the impulse from the underlying artery, 
it is always important to exclude the possible presence 
of an aneurism. At the age when branchial cysts are 
most frequent, aneurisms, except of traumatic origin, are 
exceedingly rare. Pressure “does not affect the volume 
of a branchial cyst, and the pulsations are felt only in 
one direction, away from the artery. Auscultation fur- 
nishes another important negative symptom. An ex- 
ploratory puncture, which should always be made in 
doubtful cases, will also furnish valuable information, as 
it will afford an opportunity to examine the contents of 
the tumor. In hemato-cysts the contents may resemble 
venous blood, but.a microscopical examination will show, 
in addition, the presence of epithelium or the products 
of epithelial degeneration. 

2. Angioma.—Deep-seated angiomata are occasionally 
met with in children, and, as the skin may present a per- 
fectly natural appearance, they might be mistaken for 
branchial cysts. If the tumor disappears under pressure 
it may be an angioma, but never a branchial cyst. 

3. Dermoid Cyst.—As dermoid cysts may occur in the 
same localities and at the same age, they are frequently 
mistaken for branchial cysts, and vice versa. As both 
varieties of cysts require the same treatment, a positive 
diagnosis is not essential. A correct anatomical diag- 
nosis can be made by examining the contents and the 
cyst walis. A branchial cyst contains only one constant 
histological element—epithelium,—as obliteration of the 
branchial tracts takes place long before the appendages 
of the skin are formed. A dermoid cyst, on the other 
hand, contains the products of secretion of the skin and 
its appendages. The walls of a branchial cyst are com- 
posed of a connective-tissue capsule lined with epithe- 
lium, while the sac of a dermoid cyst is composed of 
true skin. 

4, Retention Cysts.—The only two forms of retention 
cysts which call for consideration in this connection are 
the true atheroma of the skin, the result of obstruction 
in the ducts of the sebaceous glands, and the retro- 
tracheal cyst, which originates in a similar manner in the 
retrotracheal glands. Cysts arising from the second 
and third branchial clefts are always deeply located, and 
when first observed are distant from the skin, while an 
atheroma primarily develops in the skin, and usually 
grows in a peripheral direction. Lanuginose hair is 
sometimes found in the contents of an atheroma, the prod- 
uct of retained hair follicles; it is never seen in bran- 
chial cysts. 

Virchow has called attention to a peculiar kind of re- 
tention cyst which is found between the cesophagus and 
the trachea, and which arises from an obstruction in the 
duct of one of the retrotracheal glands. These glands 
are situated between the trachea and cesophagus, but 
their ducts traverse the entire thickness of the tracheal 
wall and terminate upon the free surface of the mucous 
membrane. These cysts are so located that they give 
rise to distressing symptoms, referable to deglutition and 
respiration, before they attain any considerable size, dif- 
fering greatly in this respect from the clinical history of 
a branchial cyst. 4 

5. Affections of Lymphatic Glands and Vessels.—A 
deep-seated, isolated, caseous, lymphatic gland might be 
easily mistaken for a branchial cyst, more particularly 
after the cyst had become the seat of inflammatory infil- 
tration. It is seldom that we meet any such extensive 
pathological changes in a single lymphatic gland as to 
simulate a branchial cyst, without participation of one 
or more adjacent glands. Again, in cases of diseases of 
the lymphatics, the general condition of the patient usu- 
ally indicates the existence of a serious affection, while a 
branchial cyst is a purely local condition, never affecting 
the general health except when it interferes with impor- 
tant functions of the neighboring organs. Cancerous or 
sarcomatous affections of the lymphatic glands would 
reveal themselves by the clinical symptoms characteristic 
of these tumors. 

6. Struma Cystica.—Cystic degeneration of the thyroid 
gland proper can never_be mistaken for a branchial cyst, 


460 


as the connection of such cysts with the thyroid body 
can be traced without any difficulty; but recently it has 
been ascertained that not infrequently small accessory 
thyroid glands exist in the neck which may undergo 
cystic degeneration, and Madelung has made the asser- 
tion that the so-called hydrocele of the neck is only a 
struma cystica of a supernumerary thyroid gland. The 
possibility of a cystic degeneration of such an accessory 
thyroid body should always be borne in mind in examina- 
tions for branchial cysts. 

7. Simple Serous Cysts.—Virchow asserts that many of 


.the serous cysts develop without a particular matrix, as 


new formations, in the connective tissue. It is a well- 
known physiological fact that the connective-tissue cells 
are occasionally converted into endothelia, as during the 
formation of new synovial membranes; hence we should 
a prior’ expect that in simple serous cysts, developed 
from connective tissue, the inner surface of the sac would 
be lined with endothelia the existence of which would 
be sufficient to disprove their branchial origin. 

In repetition I will enumerate the following points, 
which should be considered in the differential diagnosis 
of cystic tumors of the neck with special reference to 
branchial cysts: 1. Primary seat of tumor; 2, effect of 
pressure; 8, general condition and age of patient; 4, 
character of contents. 

Proenosis.—Branchial cysts always remain purely 
local affections and manifest no tendency to destroy life, 
except when they are of sufficient size to interfere, by 
their pressure, with the performance of important fune- 
tions of neighboring organs. On the other hand, it may 
be said that they manifest no tendency to spontaneous 
cure, and prove exceedingly obstinate to all forms of 
treatment short of complete extirpation. 

TREATMENT.—The inner surface of branchial cysts be- 
ing lined with epithelium, it is evident that obliteration 
of the sac can be obtained only after the destruction or 
removal of this epidermal lining. The radical treatment 
for the removal of these tumors must have for its object 
either the production of an artificial inflammation, in the 
interior of the sac, of sufficient intensity to destroy the 
epidermal matrix, or complete extirpation of the cyst. 
The former procedure is exceedingly unreliable, and ex- 
tirpation in many instances must be looked upon as a 
very formidable and dangerous operation. The follow- 
ing means have been employed in the treatment of bran- 
chial cysts: 1, incision; 2, actual cautery; 3, seton; 4, 
puncture, with subsequent injection; 5, extirpation; 6, 
antiseptic drainage. 

1. Incision.—In all cases in which incision was prac- 
tised, the relief from existing symptoms was prompt; the 
cyst collapsed, a certain amount of inflammation was 
established, suppuration followed, and in some instances 
the patient and surgeon were led to believe that a radical 
cure was obtained. Usually, after healing of the wound, 
a small nodule remained, which in a few months again 
became the seat of active tissue growth, and a speedy 
relapse was an almost constant occurrence. In infants 
the laying open of cysts is a perilous plan of treatment. 
Volkers relates a case in which a cystic tumor was laid 
open in a new-born child, who died sixteen days after- 
ward in consequence of the operation. A branchial cyst 
cured by simple incision is reported by Billroth. In the. 
case of serous cysts, in which the seton and iodine injec- 
tions have occasionally been successful in producing ob- 
literation, it seems to me that the same object would be 
accomplished more speedily and safely by incision and 
drainage practised in a similar manner as in Volkmann’s 
operation for hydrocele. : 

2. Actual Cautery.—Dieffenbach employed the actual 
cautery in opening the cyst in one of his cases, after he 
had made an unsuccessful attempt at removing it by 
extirpation, and after incision had failed in producing 
obliteration of the sac. The use of the cautery met with 
no more encouraging result. It would seem to me that 
incision, combined with an energetic use of ‘the cautery, 
would be most applicable in the most dangerous and 
formidable class of cases, viz., cysts which have become 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





firmly adherent to the sheath of the cervical vessels by 
repeated attacks of inflammation. 

3. Seton.—This form of treatment proved successful 
in several of Thomas Smith’s cases of serous cysts of the 
neck, but in some of them their branchial origin does not 
appear to be established. Smith uses a single thread of 
silk, and removes it before suppuration sets in. If the 
tumor is polycystic, he attacks only one cyst at a time. 
Gurlt very justly has entered his protest against the use 
of the seton. As in the case of hydrocele, the seton is an 
exceedingly uncertain agent in calculating with precision 
the amount of inflammatory action which will follow its 
use. The degree of irritation produced by it is very 
liable to be inadequate to produce adhesion, or it exceeds 
the desirable boundary, and induces suppuration with 
all its evil consequences. Butlin reports the case of a 
young child in whom a seton was passed through a 
serous tumor, and which was followed by death on the 
third day from the violence of the inflammation. For 
this and other obvious reasons the seton should never be 
used in the treatment of branchial cysts. 

4. Puncture, with Subsequent Injection.—In the transac- 
tions of the Fourth Congress of German Surgeons, the 
treatment of branchial cysts by puncture and injection 
was fully discussed. Esmarch’s experience appeared to 
be the most extensive, and his results were more uni- 
formly favorable than the practice of any other surgeon. 
He claims to have cured about a dozen cases by puncture 
and subsequent injection of Lugol’s solution of iodine 
(lodi, pot. iod., 4% 1.25; aque, 30.0). Whenever com- 
plete obliteration does not follow the first puncture, he 
repeats the operation. This method of procedure is as 
follows: By means of a fine hydrocele trocar the sac is 
emptied of its contents, when repeated injections of a one- 
per-cent. solution of carbolic acid are made to remove 
the masses of epithelium adherent to the cyst wall. 
These injections are continued until the water returns 
perfectly clear, then Esmarch injects from 10 to 20 
gm. of Lugol’s solution of iodine, which, after gen- 
tle pressure, to bring it in contact with the inner sur- 
face of the sac, is allowed to escape. The patient is then 
directed to return in six or eight weeks. Like a hydro- 
cele, the cyst refills rapidly and becomes somewhat 
painful. If after the lapse of the time mentioned the 
tumor has not greatly decreased in size, the same opera- 
tion is repeated, and in about six months the cyst will 
be found atrophied to a small tubercle. According to 
Esmarch, the cure in most cases has been permanent. 
From the discussion which followed Esmarch’s remarks, 
it is evident that the majority of German surgeons have 
no confidence in the efficacy of iodine injections in ob- 
literating branchial cysts. If we consider the numerous 
failures of iodine injections in cases of hydrocele, in 
which the anatomical conditions for success are so much 
. more favorable, we shall be better prepared to appreciate 
the causes of its still more frequent failures when used 
in the treatment of branchial cysts. In infants, even 
simple tapping is not always devoid of danger, as one 
instance of death is recorded caused by puncture. The 
case occurred in the practice of Volkers, who tapped a 
cystic cervical tumor in an infant eight days old, the 
child dying of trismus on the third day. 

5. Hatirpation.—A. positive diagnosis made, the best 
plan to pursue is to make an incision over the most 
prominent portion of the tumor, and, in case the adhe- 
sions can be separated without endangering the deep cer- 
vical vessels. the entire cyst should be removed. [If in- 
flammatory infiltrations obscure the field of operation at 
the base of the tumor, and after careful examination it 
is not deemed advisable to perform complete extirpation, 
the sac should be opened and the lateral walls excised, 
then the epidermal matrix which remains adherent to 
the sheath of the cervical vessels can be destroyed com- 
pletely by a careful but vigorous use of the actual cau- 
tery. If an early diagnosis is made, and prompt treat- 
ment instituted, complete extirpation should always be 
attempted, and will, in the majority of cases, prove suc- 
cessful and comparatively free from danger. 


Branchial Cysts, 
Breast, 





6. Antiseptic Drainage.—In the case of infants and 
very young children suffering from large serous cysts, it 
would be imprudent to resort to any of the severer meas- 
ures with a view to a radical cure. In such instances, 
drainage under antiseptic precautions should be resorted 
to as a temporary measure, and in some instances it may 
be followed by permanent results. The same course of 
treatment should be adopted in adults suffering from 
cysts which are inaccessible to any other operation, and 
in which irritating injections are contraindicated. 

Nicholas Senn. 


LITERATURE. 


Langenbeck : Beitrige zur chir. Pathologie d. Venen 

Archiy fiir klin. Chirurgie, vol. i.. pp. 1 and 356. 

Luecke : Ueber Atheromcysten der Lymphdriisen. 

Koenig : Lehrbuch der spec. Chir., Berlin, 1878. 

Gurlt: Die Cystengeschwilste des Halses, Berlin, 1855. 

Virchow and Hirsch: Jahresbericht, 1866, Bd. ii., p. 418. 

Hueter: Grundriss d. Chir., 1880. 

Wernher: Die angebor. Kystenhygrome, Giessen, 18438. 

Smith, Thomas: St. Bartholomew’s Hosp. Reports, vol. ii., p. 16. 

Treves, F.: Dissection of a Congenital Hydrocele of the Neck. Trans- 
actions Path. Society, vol. xxxii., p. 194. 

Senn, N.: Branchial Cysts of the Neck, 1884. Trans. Amer. Med. Assn. 

Albert: Lehrbuch der Chir. u. Operationslehre. 

Schede : Die Cystengeschwiilste des Halses, Berlin, 1855. 

Verhandl. d. Deutschen Gesellschaft f. Chirurgie, 1876. 

Butlin: Int. Encyclop. of Surgery, New York, vol. iy., p. 663. 

Luecke: Die Lehre von den Geschwilsten. Pithau. Billroth’s Hand- 
buch d. allg. und op. Chirurg., vol. ii., pp. 2 and 127. 

Virchow : Die krankhaften Geschwilste, Berlin, 1863, vol. i., p. 246. 

Schede: Ueber die tiefen Atherome des Halses. Arch. f. kl. Chi- 
rurgie, B. xiv., p. Ll. 

Storch: Ueber das Angeborene Hygrom des Halses. 
Kinderkrankheiten, Bd. xxxvii., p. 68. 

poare : Ueber einige angeborene Tumoren. Inaug. Diss., Zurich, 


Journal f. 


BREAST, FEMALE.—The breast (L. pectus, Ger. Brust, 
It. petto, Fr. sein) is one of the two rounded eminences 
situated, in the human species, one on either side of the 
thorax, and in the female secreting the milk for the 
nourishment of the new-born. They constitute the 
mammary glands and associate structures, that is, the 
true gland tissue, the stroma, and integument including 
nipple and areola. 

The presence of mammary glands (L. mamma, Fr. 
mamelles, Ger. Brustdrisen, It. mamette), zoologically con 
sidered, constitutes one of the most important considera- 
tions for grouping into one class (mammalia) all those 
animals possessing them. They are found in both male 
and female, but the size and development differ; the 
male gland as a rule remains throughout life in the em- 
bryonic condition, while the female breast passes through 
marked and important changes at puberty, at conception, 
after lactation, and at the menopause. 

Embryology.—In very early embryos, there is observed 
on either side a slight streak, running from the root of 
the stump-like fore-limb to the-hind-limb, and situated a 
little behind and parallel to the membrana reuniens in- 
ferior. This is observed in rats of 2.5 to 5.25 mm. 
(Henneberg) and in human embryos of from 4 to 8 mm. 
(Hirschland and Strahl), and was named by Schwalbe- 
Schmidt mammary streak (Milchstreifen). It is due to 
the cells of the ectoderm becoming deeper and more 
cubical. 

From the mammary streak there is soon produced, by 
multiplication of the cells, a well-marked ridge, the mam- 
mary line (Milchlinie or Leiste) (M/, Fig. 1035, A). This 
well-marked microscopic ridge was first studied by O. 
Schultze in the pig, and more recently by Kallius, Stahl, 
and Hirschland in human embryos of about 15 mm. 

In this line the epithelium develops more rapidly at 
certain spots, corresponding in situation and number to 
the future mammary glands. The line becomes monili- 
form, and finally isolated, spindle-shaped enlargements 
are produced by atrophy of the portion of the milk line 
lying between the enlargements (Fig. 1035, B). Thus 
the mammary hillocks (“ Milchhiigel ”) of Bonnet are pro- 
duced (Fig. 1036). The projection of the line of hillocks, 
above the surface of the skin, is only very transient. In 
human embryos, toward the end of the second month of 
intra-uterine life, the small tubercular thickenings, grad- 


461 


Breast, 
Breast, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








ually increasing in size, become lens-shaped, and their con- 
vex surfaces project into the cutis, forming the mammary 
points (Milchpunkte). 


Large numbers of the meso- 


i] ay i 


(My 


AN NN 
1G CU 





Fic. 1035.—A, Pig Embryo 1.5cem. long. Ml, Mammary line. 
long, with mammary hillocks. (O. Schultze.) 





B, Pig embryo 1.9 em. 


plugs into the mesoderm beneath (Fig. 1039). This sec- 
ondary epithelial development is the rudiment of the true 
secreting portion of the gland. The number of epithelial 
sprouts now seen (fifteen to twenty) corre- 
sponds with the number of excretory ducts 
which the mature glands will possess. The 
upper ends of the plugs are in the nipple 
zone, but the greater part of their lower ends 
project into the loose connective tissue of 
the cutis. 

There is now developed a new zone be- 
neath the nipple zone, composed of young, 
round, closely packed connective - tissue 
cells. Surrounding and supporting the epi- 
thelial elements of the gland, these form 
the stroma of the gland (stroma zone). 

A retrograde metamorphosis next begins 
in the central cells of the primary epithelial 
ingrowth, and from the centre the degenera- 
tion proceeds peripherally and downward. 
It takes the form of a cornification (Fig. 
1039, hp) and proceeds at first very rapidly, 
though its final progress is so slow that 
sometimes it is not complete until after 
birth. Ultimately it leads to the complete 
disappearance of the primary epithelial in- 
growth or mammary point. 

At the same time as the primary in- 
growth is degenerating the secondary in- 
‘growth, nipple zone, and stroma zone are 
continuing to develop. As the secondary 
epithelial plugs push their way into the 
underlying mesodermic stroma, they be- 
come clubbed below. At the same time 
the originally solid plugs are hollowed out 


dermic cells of the cutis collecting around the epithelial | and converted into tubes, and during the seventh month 


ingrowth form a condensed zone (nipple zone; ef. Fig. 
1036), from which later the nipple is developed. 

The further growth results in flattening above with a 
projection of the deeper convexity of the lens, especially 
in the centre. In this way there is produced a cone- 
shaped mass of the cells which sink deeper into the cutis. 

Around the apex of the cone the greatest activity is 
manifest; the cells push deeper into the cutis, and 
spread out below to produce a large ball-like mass 
(body) connected with the surface by a narrow elongated 
part (neck; Fig. 1037). This is the so-called club-shaped 
stage. 

There now appears on the free surface of the skin a 
small cavity, the “gland area” (Driisenfeld of Huss), 





X oe ere Je 2 
O Bornes aria ete oh 
COR Zor Fo eRe LAT 


GAS THe On 
“OSS OI5 ONE Cre. Csr 





Fig. 1036.—Mammary Hillock of a Pig Embryo 1.5 em. long, with 
the Nipple Zone (az) becoming Differentiated. 


which soon deepens. In the formation of this not only 
the deep but also the superficial layer of the epithelium 
takes part. Around the border of the depression a ring- 
like ridge of cutis, the first rudiment of the areola, is 
raised up. 

Upon the deep surface of the club-shaped mass, at 
about the twelfth week of intra-uterine life, small bud-like 
masses of the epithelial cells appear (Fig. 1038). These 
rapidly increase in length, and force their way as solid 


462 





of intra-uterine life, or about that time, give off numer- 
ous buds (Fig. 1039). In connection with these latter, 
small irregular groups of epithelial cells may be seen, the 





Fic. 1037.—Primitive Nipple, Club-Shaped Stage, of a Pig Embryo 


6.5 em. long. ep, Epidermis; cz, layer of cylindrical cells; cw, 
cutis wall; mt, mammary point; yg, blood-vessel. ; 


matrix of the acini. The branching of the ducts, even 
up to the time of birth, is but slightly advanced. At 
birth the milk ducts do not extend beyond the areola, 
and the whole gland shows an expansion of but 1 cm. 
and weighs only 30 to 60 cgm. (Puech). 

A rudimentary corpus mamme is represented by a 
well-defined rounded mass, around the circumference of 
which the lobes project irregularly. The whole is em- 
bedded in a well-developed stroma, which is surrounded 
by fat lobules of the subcutaneous tissue. The coarse 
connective-tissue fibres of the stroma radiate from the 
corpus mammee and become continuous with the fibrous 
capsules of the fat lobules. These latter surround but do. 
not mix with the stroma. Beneath, the stroma is con- 
tinuous with the fascia covering the pectoral muscle. 

The fat layer of the skin becomes locally thickened in 
the region of the gland, but not until five or six years 
after. birth does fat develop in the stroma between the 
gland lobules. 

At birth the ducts possess a simple epithelium, cubical 
in the deeper parts, but cylindrical in the region of the 


nipple. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Breast, 
Breast, 





The time at which the various changes noted above 
occur varies considerably, being by no means constant. 
Even in the new-born the development is not always 
equally far advanced. 

The nipple is developed in the human species toward 
the end of intra-uterine life. Then the mesodermic tissue 
which constitutes the nipple zone rapidly increases, and 
between the elements smooth muscle cells soon appear. 


Sane 
C2 
®e rey 












Fic. 1038.—Primitive Nipple of a 12 em. Pig Embryo with an Epithelial Sprout (sp). 


Cutis wall; mt, mammary point. 


The centre of the originally depressed gland area becomes 
situated upon the tip of a cone-shaped projection. The 
exact time of the elevation of the nipple varies, though 
sometimes occurring in embryonic life; yet frequently in 
children of from ten to twelve the depressed gland area 
with its surrounding wall still persists. 

Although in some respects in development the mam- 
mary glands resemble the sweat glands, yet I think it is 
now generally conceded that in the higher mammals they 
represent modified sebaceous glands. 

Upon the areola, sebaceous and sweat glands are de- 
veloped. Rein has shown that the enlarged sebaceous 
glands of the areola (tubercles of Montgomery) are ac- 
cessory rudimentary milk glands. 

Condition at Birth.—It will be seen that the new-born 
of both sexes possess all the skin ingredients of the 
gland, and moreover the gland can secrete milk, which 
is called in German “ Hexen Milch” 
(witches’ milk). This occurs from 
the fourth to the tenth day after 
birth, and isaccompanied by a swell- 
ing of the gland. It has been shown 
by Rein and others to be true milk. 
According to De Sinéty consider- 
able changes take place in these 
first ten days, after which there is 
some acinous tissue resembling that 
which is seen in the adult. But 
only the main ducts are excavated. 

From birth till puberty the breasts 
remain rudimentary, simply keep- 
ing pace with the general body 
growth. The intralobular ducts 
and beginning of the acini remain 
solid, and though there are some 
slight changes, such as the develop- 
ment of a few acini buds, yet the 
condition found shortly after birth 
persists. 

In the male no further change, as 
a rule, occurs. 

Changes at Puberty.—In the fe- 
male at puberty an abrupt change 
like that affecting the entire organ- 
ism takes place. This consists in further branching and 
growth of tubes into the surrounding tissue, and the 
stroma is also further developed. The fat which appear- 
ed in the stroma at the fifth to the sixth year rapidly in- 
creases in amount. Now development proceeds rapidly, 
but there is no distinct subdivision into the lobules, the 







\ 
Ipey 


LD oir as gemma hp 


(For other letters, see Figs. 1036 and 1037.) 


(e)\) (on Ds 
©) A) 





true secreting acini being few in number. At each suc- 
ceeding menstrual period a slight engorgement occurs, 
and it is probable that it is accompanied by increased 
development. At these times slight pricking sensations 
and pain may be felt, and in some cases a yellow secre- 
tion is expelled. Soon after puberty the breasts become 
very well developed, but they consist mainly of stroma 
and excretory ducts, with a relatively small amount of 
glandular tissue. 

Situation.—The breasts are situated in 
the superficial fascia, above the pec- 
toral muscles; as usually described they 
are said to extend from the second or 
third to the fifth, sixth, or seventh rib, 
and from the edge of the sternum to 
the fold of the axilla. These estima- 
tions are undoubtedly based upon ex- 
ternal conformation, and of necessity, 
therefore, refer only to those portions 
of the gland which cause its projection 
above the surrounding surface. 

Stiles, who witnessed the removal of 
over one hundred breasts which he had 
previously examined, found that the 
usual description takes no account of 
the peripheral processes, which extend 
in the subcutaneous tissue, often far be- 
yond the prescribed limit. Moreover, 
he has shown that this holds true for nullipare, as well as 
formultipare, though of course the processes are much 
more marked in the latter. He gives the following de- 
scription of the situation and relations of the breast: 

It is divided by two intersecting lines, a vertical (1-2) 
and a horizontal (8-4), into four segments (Fig. 1040), 
named respectively cephalo-mesal, cephalo-lateral, 
caudo-lateral, and caudo-mesal. For purposes of more 
careful description, a second division is made by two 
oblique lines (5-6), and (7-8) into four other segments, 
cephalic, lateral, caudal, and mesal. 

The vertical diameter (1-2) extends from the lower 
border of the second rib to the sixth costo-cartilage, where 
it begins to sweep upward toward the sternum. The 
horizontal (8-4) begins opposite the fourth rib or fourth 
interspace, just within the lateral border of the sternum, 


cw, 


' and extends to the mid-axillary line at the level of the 


eles 
CES 









cent ands 
sei sletch tl P 
Resinnoa 





OPES Gay 

Coleleleless 

igen 
0/0: 


‘@ 
Y, 


Fic. 1039.—Nipple of a 20 cm. Female Pig Embryo. The epithelial sprouts, excretory ducts sp 1, 
have n»ar their terminal end a lumen; secondary sprouts (sp 2) are also seen; hp, cornifica- 
tion of the epithelium is beginning. 


fifth rib or fifth interspace. The oblique line (5-6) extends 
from the upper border of the third costo-cartilage, a little 
external to the border of the sternum, to the seventh rib 
a little in front of the mid-axillary line. The oblique 
line (7-8) begins on the third rib a little beyond the ante- ° 
rior axillary fold, and extends to the sixth costo-cartilage 


463 


Breast, 
Breast. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





midway between its angle and sternal end. The circum- 
ference is obtained by connecting the extremities of the 
lines. 

When the arm is raised, as for operation, the nipple, 
in nullipare, is opposite the fourth rib or fourth inter- 
space and 2.5cm. mesad to the axillary border of the 
pectoralis major. Thus the extent to which the breast 
overlaps the border of the pectoralis major is consider- 
able. The level varies with the stature; as a rule in tall 
women the breast is low, while with short and broad- 
chested women it is high. 

Relations.—The relations of the posterior surface of the 
breast can best be treated by describing each segment 
separately. 

The meso-cephalic segment (Fig. 1040, A) rests entirely 
upon the pectoralis major; so also does the meso-caudal 
segment (D), except at its lower edge where it overlaps 
the aponeurosis of the external oblique. 

The cephalic half of the cephalo-lateral segment (B) 
rests upon the pectoralis major, the edge of the pectoralis 
minor, and fora slight extent upon the serratus magnus 
muscles. Upon the latter and under cover of the pec- 
toralis major it extends up into.the axilla as far as the 
third rib. This is the axillary tail of Spence. The cir- 
cumference of this segment crosses the border of the 
pectoralis major muscle, where its fibres leave the third 
rib to form the ventro-axillary fold. 

The caudal half of the cephalo-lateral segment (B) 
and the cephalic half of the caudo-lateral (C), with 
the exception of a small portion near the nipple which is 
over the pectoralis major, lie upon the serratus magnus. 
The caudal half of the caudo-lateral segment (C) over- 
lies those portions of the external oblique and serratus 
magnus which arise from the fifth and sixth ribs, except 
a portion near the nipple which is over the pectoralis 
major. 

Thus it will be seen that, with the arm in the position 
assumed for operation, fully one-third of the whole breast 
lies caudo-lateral to the axillary border of the pectoralis 
major. One-half of this overlies the axilla, filled with 





Fic. 1040.—Diagram to Show Method of Dividing Breasts for the Pur- 
pose of Description. 1 to 8, Lines of division for the location of the 
different sections (see text). A, Mesocephalic; B, cephalo-lateral ; 
CO, caudo-lateral; D, meso-caudal; H, cephalic: F, lateral; G, 
caudal; H, mesal sections or divisions. 


its fatty fascia containing numerous lymph nodes. 
These lymph nodes appear to be in direct contact with 
the breast tissue. 

The dorsal surface of the breast is concave, composed 
mainly of stroma containing projecting processes of the 
parenchyma. The stroma is continuous with a loosely 
interlaced network of connective tissue which forms the 
pectoral fascia. This fascia sends numerous septa be- 
tween the fibres of the muscle. It is quite thin and it is 
difficult to separate it from the muscle, particularly in 


464 


spare subjects. In some it attaches the gland so closely 
to the subjacent muscles that movement of the arm 
causes considerable movement of the gland. In others 
it is very loose, but even with these some movement is 
observed when the arm is raised. In this latter loose are- 
olar tissue spaces have been described by Chassaignac as 
serous burs (sub- or retro-mammary bursee). 

Close examination has shown that the portions of the 
parenchyma which project into the stroma of the dorsal 
surface send numerous minute processes into the retro- 
mammary connective tissue. Some of these even ac- 


“company the septa of the pectoral fascia between the 


muscle fibres. 

The anterior surface is for the most part smooth and 
convex. It is covered with skin continuous with that of 
the surrounding surface. The skin is thin and delicate 
and differs from that of the ventral surface of the body 
only at its centre, where the raised and pigmented areola 
surmounted by the nipple is seen. 

The circumference, although in the main circular, is 
more or less irregular owing to the processes of the par- 
enchyma. There are usually three fairly well-marked 
cusps. The largest projects toward the upper part of 
the axilla and has been already referred to as the axillary 
tail; another, much smaller, extends toward the lower part 
of the axilla; the third reaches toward the sternum. 

At the caudal border (Fig. 1044), the circumference of 
the breast, the parenchyma presents a furrow but slightly 
marked in young thin nullipare, more marked in fat 
women, did papecially prominent in multipare. 

The cephalic border of the circumference is as a rule 
ill-defined, the breast arising in a gentle slope from the 
surrounding tissue. 

Shape.—Emaciated subjects present a flat, discoidal 
breast with irregular surface; well-nourished subjects a 
hemispherical or conical with smooth surface. In adult 
nulliparee (Figs. 1044 and 1045) it is somewhat conical, 
due to the relatively large amount of gland substance com- 
pared with the stroma. In stout subjects the relatively 
greater amount of circummammary fat produces a hemi- 
spherical breast. After lactation it frequently becomes 
pendulous, a very marked sulcus being produced where it 
overhangs its base. This is due to the atrophic fatty 
changes which at this time affect the secreting structure 
and produce a flabby condition. In these cases the 
breast sometimes becomes almost cylindrical in shape. 
Rarely the base of the breast is contracted, producing a 
stalk. This is the pedunculated breast. 

Consistence.—In the virgin and nullipara the breast is 
firm and elastic. It loses its consistency after having 
attained full activity, especially if there has been a period 
of nursing. In women who have had several children 
the breasts are soft and flabby, overhanging their base to 
a greater or less extent. 

Wetght.—In the adult nullipara the breast weighs from 
140 to 200 gm.; in nursing women from 400 to 500, and 
in exceptional cases as much as 900 gm. 

Number.—A single pair of breasts is the least number 
normally found in any mammal. This is the usual num- 
ber in man, as also in apes and a few other animals. The 
largest number is found in certain of the insectivora, in 
whom there are as many as eleven pairs. Between these 
limits all gradations exist. Reduction of this number is 
very exceptional, but there are numerous cases on record 
of supernumerary breasts. 

Arrest may occur in their development at any time; 
when it occurs very early in embryonic life the breast is 
entirely suppressed (amazia). This is extremely rare in 
the human subject, and is frequently associated with 
other defects in development. Williams has written two 
very excellent articles, one on polymazia, the other on 
amazia. He finds complete absence of both breasts one 
of the rarest anomalies; outside those occurring in 
acephalic monsters with deficient chest walls, only four 
cases are recorded in literature. Complete absence of one 
breast is slightly less rare. A more frequent condition is 
the arrest of development at a later stage leading to rudi- 
mentary but functionless organs (micromazia). This 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Breast, 
Breast, 





also may affect one or both sides, and as with amazia may 
or may not be associated with deficiencies in the sexual 
organs or chest wall. 

Absence of the nipple (athelia) is much commoner than 
the above. Williams has pointed out that in these cases 
there is really no absence of nipple structures, but simply 














Fig. 1041.—Diagram Showing the Mammary Arrangement of Man’s 
Early Progenitors. (Williams. ) 


a failure of the embryonic gland area to become elevated. 
This is usually unaccompanied by other anomalies, and 
generally affects both breasts. The areola is rarely absent 
when the nipple is well developed, but with athelia the 
areola may be absent or slightly formed. Intermediate 
conditions between complete absence and the perfect 
nipple, due to degrees of elevation of the embryonic 
gland area, produce the various recorded congenital im- 
perfections. 

Numerous records of supernumerary mamme or nipples 
are found in literature. The condition is much more 
common than previously supposed. Bruce found in 815 
individuals, of both sexes taken indiscriminately, poly- 
mastism in 7.6 per cent.; in 207 males 9.1 per cent., and 
in 104 females 4.8 per cent. 3 

It has been supposed by some that any sebaceous gland 
may develop into a supernumerary mammary gland. 
There is nothing to lead us to believe that complex 
structures like the mamme may be developed suddenly 
on auy part of the body. A study of comparative 
anatomy and embryology seems to point clearly to an 
atavistic origin for their explanation. In the lemurs the 
inguinal and abdominal mamme are rudimentary, only 
one pair of pectoral mamme becoming developed. From 
them through the different types of animals, conditions 
are found indicating that the number of breasts is being 
gradually reduced. 

In embryology the investigation of the development 
of the mammary hillocks from the mammary line, al- 
though not yet worked out in all of its stages, has been 
carried far enough so that we are quite sure that the con- 
ditions as found in the pig aud other animals are the 
same in man. 

By a careful study of all recorded cases Williams found 


Vou. II.—30 








that the position occupied by the mamme in lower ani- 
mals and by the mammary hillocks in embryos was the 
same as that occupied by aberrant mamme. He con- 
siders that man’s early progenitors were possessors of 
seven pairs of breasts (Fig. 104i), three cephalo-lateral to 
the normal, and three caudo-mesal to them. 

First pair—in the pit of the axilla. 

Second pair—in the middle of the ventro-axillary 
border. 

Third pair—just cephalad and slightly laterad of the 
normal pair. 

Fourth pair—the normal mammee. 

Fifth pair—just caudad and slightly mesad of the 
normal pair. 

Sixth pair—caudad and slightly mesad of the preced- 
ing, near the costal margin. 

Seventh pair—caudad and slightly mesad of the pre- 
ceding, on the upper part of the abdomen. 

Out of 166 cases collected by Leichtenstern 
and Bruce, there were only 4, 2.41 per cent., 
which could not be assigned to one or another 
of these positions. These mamme erratic 
are supposed to be due to reversion to the an- 
cestral characters much more remote than those 
given above. 

The following table of 105 cases recorded by 
Leichtenstern shows the relative positions of 
the accessory mamme. On the anterior side 
of the thorax, 96 cases (91 per cent.); in the 
axilla, 5 cases (4.7 per cent.); on the back, 2 
cases; over the acromion, 1 case; over the out- 
er side of the hip, 1 case. Of those on the an- 
terior side of the thorax 94 per cent. were de- 
veloped caudad of the normal pair and in a 
converging position. 

Supernumerary mammee often are represented only by 
a nipple, which may or may not be surrounded by an 
areola (true polythelia); or the duct of the gland may 
open upon the surface by one or more openings, no nipple 
or areola being present; or there may be no communica- 
tion with the surface whatever. Rarely the extra gland 
is perfectly developed and functional. 

Rudimentary breasts cephalad of the normal ones are 
rare—but 12 out of 166 cases, or 7.2 percent. Abdominal 
mamme are very rare. In polymazia the normal pectoral 
mamme are aways present in their proper position and 
welldeveloped. Of Leichtenstern and Bruce’s 166 cases, 
there was only a single extra structure in 112, or 67.4 
per cent. 

Out of 2,189 men recruited in the military district of 
Donaueschingen 62 were found with one supernumerary 
teat and 4 with two—that is, 1 case in every 33, or 3 per 
cent. Besides, 48 others were found who showed discrete 
pigmented patches symmetrically placed upon the line 
usually occupied by supernumerary mamme or nipples. 
These represented small areole. 

Supernumerary mamme are more often found on the 
left than on the right side. So also in amazia, the right 
mamma is more frequently absent than the left. 

Anomalies arising late in the developmental process 
lead to two nipples on one areola (intra-areolar poly- 
thelia); or two on one breast (intramammary polythelia). 

Supernumerary mamme or nipples are probably found 

in all races. They have been noted by Owen in the 
orang and by various observers in many animals. Wom- 
en with more than one breast are no more liable than 
other women to bear twins. Supernumerary mamme 
appear often to be hereditary. In 7 out of 92 of Leichten- 
stern’s cases, or 7.6 percent., there was a history of such 
condition in near relatives. It is not usually associated 
with other malformations. 
_ Size and~Volume.—The breast, which at birth measures 
but 10 mm. in diameter, increases but little until after 
puberty, when it rapidly attains a diameter of 100-180 
mm. and a thickness of 50-60 mm. The greatest length 
is parallel to the border of the pectoralis major. 

Soon after impregnation it again increases in volume, 
and although it decreases somewhat at the fourth or fifth 





465 


Breast, 
Breast, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











month, it becomes greatly enlarged again at the end of 
gestation. The second or third day after delivery the 
milk begins to be secreted, and now the true functional 
activity of the gland is first established. The milk ac- 
cumulates in the alveoli and in the excretory ducts. The 
gland becomes harder, heavier, and more voluminous. 
It soon acquires a volume two or three times that of the 
gland before pregnancy. 

After lactation it returns again to its ordinary size, 
which it retains until another pregnancy and another 
period of activity. It is now less smooth, firm, and 
elastic than the virgin mamma. 

After the menopause the useless gland with the rest 
of the genitals becomes atrophied. The glandular and 
secreting structures are frequently replaced by fat, when 
but little reduction in size occurs. In other cases this 
does not occur, and the entire gland is reduced to a small 
fibrous area around the nipple and immediately beneath 
the skin. Thus it returns at last to a condition ap- 
proaching the infantile. 

The two breasts are seldom equal in size, the left usu- 
ally being the larger, sometimes quite considerably. 
This is thought to be due to the fact that women nourish 
the child more on that side. 

The size of the breasts presents considerable ethnologi- 
cal variations. Huschke says that, asarule, they are more 
voluminous in warm than in cold countries, and in moist 
countries and in valleys than in dry countries and moun- 
tains. As regards races, variations are considerable, the 
people of southern Africa being remarkable for their 
large and pendent breasts. 

In individuals, the size of the breast offers considerable 
variations. It appears that the development is inde- 
pendent of the build and constitution; large, robust 
women are frequently seen with very poorly developed 
breasts, while, on the other hand, small women are seen 
with large, well-formed breasts. 

The mamme are formed of stroma containing fat and 
the essential gland structure. It is therefore clear that 
size alone will not determine the activity of the gland. 
A breast may be formed of a maximum amount of stroma 
and a minimum amount of parenchyma (fatty mamme), 
or of a maximum amount of gland tissue and a minimum 
amount of fat (glandular mammee). For this reason 
large breasts may furnish much less milk than much 
smaller ones. 

De Sinéty has pointed out that city-bred women are 
likely to have breasts much more poorly developed and 
functionally less active than their country sisters. This 
he attributes to the social conditions in the city leading 
so often to the wet-nurse and bottle, and he believes that 
this, carried through several generations, has led to an in- 
herited characteristic. Thus the breast is following the 





Fic. 1042.—A Part of the Ventral Surface of the Corpus Mamm2, Show- 
ing the Branchings of Two Milk Ducts. (Henle.) 


law of morphology, that those organs which have become 
functionless and useless gradually are less and less de- 
veloped and finally disappear. 

Structure.—The breasts are composed essentially of 
three parts: first, the mamma proper; second, the cover- 
ing skin; third, the surrounding fatty tissue. The 
mamme, like all glands, consist of two parts: the par- 


466 


enchyma, and the stroma. The latter includes the fat, 
which is embedded in it, also the blood-vessels, lym- 
phatics, and nerves, which ramify through it. The par- 
enchyma is divided into a central compact part, the body 
or corpus mammee, surrounded by peripheral processes. 
It is made up of lobes (lobi mammee) divided into lobules 
(lobuli mamme). All of the lobules of a lobe empty by 
small into larger ducts. These ultimately lead to one 
large duct (ductus lactifer), which opens upon the nipple 
(papilla mamme) (Figs. 1042 and 1048). 

When the covering parts are removed, the gland pre- 


sents a flattened mass with an irregular, circular outline, 


thicker in the centre than at the periphery. The ventral 
surface is convex but quite uneven, due to the processes 
which project toward the skin. The thick central por- 
tion mentioned above is the corpus mamme, and upon 
the size and extent of this the external conformation of 
the breast depends. The dorsal surface, as already noted, 
is flat or slightly concave and much less irregular than 
the ventral surface (Figs. 1044 and 1045). 

The circumference is quite thick and well defined, but 
it is thicker below than above (Fig. 1044). When a sec- 
tion is made through the nipple, the cut surface of the 
corpus mamme appears triangular. The apex of the 
triangle is at the nipple, and the base, which represents 
the dorsal surface, rests against the thorax, from which 
it is separated by the stratum of loose areolar tissue. 

Extending from this central compact area of glandular 
tissue, the peripheral processes reach in all directions. 
As already noted, there are three main cusps: one extends 
cephalad toward and into the axilla; another caudad of 
the axilla; while the third reaches toward the sternum. 
Besides these large processes there are numerous small 
ones, which radiate in all directions around the circum- 
ference. These form numerous branched, interlacing 
processes enclosing and surrounding masses of fat. 

From the ventral surface triangular processes project 
toward the skin (7, Figs. 1044 and 1045), and from the 
apex of the triangle the connective tissue covering the 
gland is prolonged to the dermis. In thin women the par- 
enchyma at these points reaches almost to the surface. 

From the dorsal surface, much more delicate processes 
project into the retromammary tissue, even reaching 
through this and extending into the pectoral fascia to get 
between the fibre bundles of the pectoralismajor. These 
processes are very minute and are often overlooked. 

Both body and processes are completely covered by 
a delicate connective tissue. Those parts of this which 
cover the scattered branched parts of the gland are con- 
tinuous with the surrounding subcutaneous tissue. * It is 
too delicate to be deserving of a separate name, but has 
nevertheless been called by some the fibrous capsule of 
the mamme. 

Stroma.—The stroma is tough and compact. but soft 
and yielding. It is white in color and is composed of 
coarse, wavy fibres. In the nullipara, there is only here 
and there an isolated fat lobule; consequently the fibres 
are Closely arranged. In the multipara, much more fat 
is found in the stroma. Toward the periphery more fat 
lobules are seen, and the stroma of the peripheral proc- 
esses becomes directly continuous with the connective- 
tissue framework of the fat lobules. 

As stated above, from the apex of the processes on the 
ventral surface, the stroma is continued to the corium. 
These prolongations have received the name of ligaments 
of Cooper (7, Figs. 1044 and 1045). 

Between the ventral processes of the gland, and there- 
fore surrounded by the ligaments of Cooper, are supra- 
mammary accumulations of fat (adipose fosse). On the 
dorsal surface of the gland are other fat spaces (retro- 
mammary fat) (9, Figs. 1044 and 1045). This is separated 
from the pectoral fascia by loose connective tissue, and 
in it one or more large lymph spaces are found, the retro- 
mammary or submammary burse. The subcutaneous 
fat and that between the lobules give the smoothness 
to the surface of the gland, and when it is absorbed, as 
during lactation or in emaciation, the lobules of the 
gland stand out much more distinctly. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Breast, 
Breast, 





Under the nipple and areola, the stroma contains no 
fat. Its fibres are here very loosely arranged, and allow 
free mobility of the nipple. It is this also which allows 
the distention of the ducts and sinuses during lactation. 

Parenchyma.—The relative amount of parenchyma to 
the stroma varies in different nullipar, also even in the 
same breast one lobe or section may have numerous well- 





Fie. 1043.—Dissection of the Lower Half of the Female Mamma during 
the Period of Lactation. (Luschka.) a, a, a, Undissected part of 
the mamma; 1, the mammilla: 2, areola; 3, subcutaneous masses 
of fat; 5, three lactiferous ducts passing toward the mammilla 
where they open; 6, one of the sinuses or ampullze; 7, some of the 
glandular lobules which have been unravelled; 7’, others massed 
together. (Quain.) 


developed lobules, while another has few or none, these 
remaining almost as at puberty merely branching ducts. 
The parenchyma, on close inspection of a cut surface of 
fresh gland, is seen to be made up of closely packed sago- 
like grains. 

Ducts.—The ducts are also seen in a cross section, run- 
ning through the nipple to its summit, where they open. 
Arising from the acini the minute ducts unite to form 
larger canals, so that each lobule gives rise to a single 
duct (lobular duct) (Fig. 1043). These join to form larger 
and larger ducts until but one duct leaves each lobe. 
This is known as the galactophorous or lactiferous duct. 
These, fifteen to twenty in number, corresponding to the 
lobes of the gland, gather at the nipple, through which 
they pass, in a vertical direction, to open upon its summit. 
Beneath the areola, each duct presents an irregular, fusi- 
form swelling 12 to 15 mm. long and 6 to 8 mm. wide, 
known as the sinus or ampulla (Fig. 1043), also as the sac- 
culus or reservoir. Secondary ampulle occur here and 
there on the ducts. In the ampulla and the large ducts, 
milk accumulates in the intervals between nursing. Be- 
yond the sinus, the ducts are reduced in size and col- 
lected into a bundle, the largest ones occupying the 
centre. Side by side, surrounded by muscle, areolar tis- 
sue, and vessels, and without communicating, they pass 
to the summit of the nipple. Here separately by minute 
orifices, they open into the bottom of depressions. The 
orifices, which measure 6 mm., are distinctly smaller than 
the ducts. In the loose areolar tissue under the areola, 
the ducts and sinuses receive minute ducts from the ad- 
jacent lobules. 

The ducts are composed of two coats, an external and 
an internal. The external coat is formed of white fibrous 
tissue intermixed with longitudinal and circular elastic 
fibres. Smooth muscle fibres have also been described. 
They are said to be particularly abundant around the 
ampulle, where they form an imperfect sheath. The 
inner coat is formed of epithelium resting on a basement 
membrane. The epithelial cells, constituting a single 
layer, are flat in the lobular ducts, becoming cubical in 
the larger ducts, and columnar in the lactiferous ducts 
and ampulle. 

Lobes, Lobules, and Acint.—Each of the fifteen to 
twenty ducts is the outlet for a single lobe of the gland. 
Each lobe is of a reddish cream color and rather friable, 
and is a compound tubo-racemose gland. Although each 
lobe is in contact on either side with the neighboring lobes, 


there is no known communication between them. The 
lobes are separated, by a considerable amount of areolar 
tissue, into lobules, which in turn are made up of acini 
(Fig. 1048). 

The acini are small, spherical, or pyriform masses, 
measuring on an average 0.13 to 0.15 mm. in diameter, 
An acinus consists of a minute sac lined by a single layer 
of small granular epithelial cells (Fig. 1046 and 1047) rest- 
ing ona delicate hyaline membrana propria. This latter 
completely envelops the acinus, and is continued for a 
short distance on the minute excretory duct, with which 
the acinus connects. The above is the condition ina 
gland which has not yet become active. 

With the beginning of lactation an acinus enlarges, 
and becomes distended with a clear, slightly viscid yel- 
lowish secretion (Fig. 1047). Its cells are flattened against 
the membrana propria, and contain fat globules of vary- 
ing sizes. 

The fluid in the acini is the colostrum. It is produced 
for the first two to three days after delivery, when the 





Fic. 1044.—Vertical Ventro-dorsal Frozen Section of the Right Breast 
of a Woman, Twenty-two Years Old. C!-CVI, First to sixth ribs; A, 
clavicle ; B, pectoralis major; B’, pectoralis minor; C, external ob- 
lique ; D, intercostals; E, pleura; F, lungs; 1, skin of breast; 2, 
areola; 3, nipple: 4, mammary gland, central part; 4’, peripheral 
part; 5, milk ducts; 5’, sinus; 6, cusps of the mammary gland; 7, 
ligaments of Cooper, continued to the skin; 8, fat lobules; 9, fatty 
retromammary pad; 10, intramammary fat; 11, aponeurosis of pec- 
toralis major; 12, superficial fascia forming suspensory ligament of 
breast; 13, layer of loose areolar tissue between superficial fascia 
and subjacent serous aponeurosis of the breast; 14, submammary 
furrow. (Testut.) 


free secretion of milk is first established. Besides serous 
fluid, colostrum is composed of fat globules of varying 
size, similar to those found in normal milk but somewhat 
larger and having a tendency to agglutination; also of 
granular cells, spherical or oval in shape, having a diam- 
eter or from 3 to 25 u~ (colostrum corpuscles), The cor- 


467 


Breast, 
Breast, 





puscles consist of a mass of fat globules surrounded by 
protoplasm. 

By some these are considered to be fatty-degenerated 
leucocytes, by others the central cells of the originally 
solid acini, also fatty-degenerated. The subject has led 
to much controversy and is by no means settled. 

When fully active the acini secrete true milk. The 
protoplasm in the cells becomes broken up and displaced 
toward the outside by the accumulation of oil drops (Fig. 














Fig. 1045.—Horizontal Frozen Section 
of the Right Breast of a Woman 
Twenty-two Years Old. 1, Skin of 
axillary border: 1’, skin of sternal 
border; 8, 8’, subareolar fat lobules. 
For further description see Fig. 1044. 


1048 and 1050). The minute oil drops, at first separate, 
become confluent, forming larger globules which occupy 
the greater part of the entire cell. There are two main 
ways of explaining the liberation of these oil globules 
into the lumen of the acini. 

According to tbe first, the mammary gland is similar, 
functionally, toa sebaceous gland. The glandular cells 
are believed to multiply constantly during lactation. The 
cells in the deeper layer replace, toward the lumen of the 
acini, those in a superficial layer, and these becoming 
filled with fat globules degenerate and break down. 

According to the second, the fat globules as they ac- 
cumulate in the cell force the nucleus with its surround- 
ing protoplasm against the basement membrane. The 
fat globules continue to accumulate until the tension 
within the cell is so great that its membrane ruptures 
into the acinus, liberating the superficial fat and proto- 
plasm. But the cell itself isnot, as a rule, cast off. The 
protoplasm accumulates again around the nucleus, the 
cell wall is again formed, fat 
globules accumulate again and 
the process is repeated. It seems 
probable that after numerous 
repetitions the cell becomes 
worn out and is cast off, to be 
replaced by a new cell. 

Within an acinus the cells are 
cubical. or even columnar and 
of very unequal size.. Some are 
found large, distended with fat 
projecting into the lumen, others 
small, consisting merely of a 
nucleus and so little fat that it 
is obscured by the protoplasm. 
Between these are all grades. 

During lactation the acini have 
a comparatively wide lumen, the 
epithelial layer forming but a 
thin lining to the irregular tubu- 
lar or spherical spaces. 





1046. —Terminal 
Branches of a Milk Duct 
from the Breast of a 


FIG. 


Young Woman. (Bar- 


deleben, X 56.) 


468 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





At all times there are numbers of mast cells in the 
connective tissue surrounding the lobules. During lacta- 
tion these are immensely increased. They have been 
supposed to have some connec- 
tion with the secretion of the 
milk, but their exact function 
is not yet known. 

The milk which distends the 
acini during full functional 
activity consists of fat droplets 
which were present in the 
cells, and débris of disinte- 
grated protoplasin floating in a 
clear albuminous fluid (milk 
plasma). The milk globules 
from 2 to 5 in diameter do 
not coalesce owing to a deli- 
cate sheath of casein, Acher- 
son’s membrane. 

During pregnancy and lactation, the increase in 
the size of the gland is due to increase of the paren- 
chyma. This consists of an increase in the size and 
number of the lobules. Finally they inerease so 
much that they touch and cause a disappearance of 
fat between them. At this time or section the 
naked-eye appearance closely resembles that of a 
salivary gland. Moreover, at this time the super- 
ficial fat becomes absorbed, and the vessels become 
dilated and their walls thickened. The breast, due 
to the rapidly growing acini, presents to the hand 
an uneven feeling. The acini increase first on the 
peripheral procesess, thence along the larger ducts 





Fie. 1047.—Mammary Gland 
of the Dog. Transverse seec- 
tion of a terminal vesicle, 
showing an early stage of 
the formation of fat glo- 
bules. (Heidenhain.) 


..D toward the centre of the corpus mamme. 


After lactation the breast returns to a resting 
stage. The parenchyma undergoes involution, and 
fat is developed in the stroma. The acini are re- 
duced to narrow tubules, many becoming atrophied. 
The gland does not regain its virgin appearance ; 

therefore it is easy to tell an involuted multiparous from 
a nulliparous breast. The corpus mamme is loose, ir- 
regularly broken up, and less distinct. The peripheral 
processes are larger, with a more extensive distribution. 
It is therefore easy to separate the corpus mamme from 
them. The stroma is loose, and contains numerous fat 
lobules. The whole is less smooth, firm, and elastic; 
therefore it tends to be pendulous, and a sulcus is formed 
where it overhangs its base. With each succeeding 
pregnancy a 
new period of 
activity is fol- 
lowed by invo- 
lution. 

With the end 
of the sexual 
activity a grad- 
ual permanent 
atrophy of the 
secreting por- 
tion of the gland 
begins. This 
occurs, accord- 
ing to Stiles, by 
a fatty degeneration of the epithelium followed by its 
absorption. The atrophy is more or less complete and 
may leave only the ducts. In thin women, the corpus 
mamme is represented, after the menopause, by a flat- 
tened disc closely related to the skin, and also to the 
underlying pectoral muscle. The peripheral processes 
can scarcely be separated from the body, and are reduced 
to mere irregular threads. In fat women after the meno- 
pause the breast remains of a large size, but is composed 
aimost entirely of fat. A few ducts, here and there, 
form a wide meshwork except in the neighborhood of 
the nipple, where there is a flattened disc of gland tissue. 

The skin covering the ventral surface of the breast, 
except at its centre, does not differ from that of the ad- 
jacent thorax. It is thin, flexible, and very adherent to 
the subjacent fatty tissue and covered with minute hairs 





——— 


Fig. 1048.—The same Anatomical Relations as 


are shown in Fig. 1047. The gland, however, 
isin its highest stage of functional activity. 
(Heidenhain.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





and rudimentary sebaceous glands. Following pregnancy 
the skin is sometimes marked with bluish or whitish 
striz similar to those of the abdomen. 

In the centre of this skin is the areola surmounted by 
the nipple. The skin of the areola is thinner and more 
delicate than that surrounding it (Fig. 1051, A). It is pig- 
mented and marked by numerous well-developed sebace- 
ous glands. Its under surface is devoid of fat, but con- 
tains numerous unstriped muscle fibres. The areola 

















Fig. 1049.—From a Cross Section of the Corpus Mamme of a Woman 
who Died during Childbirth, showing the Cubical Epithelium of the 
(Bardeleben, X 116.) 


Tubules. 
measures 1535 mm. in diameter. Its color in nullipare 
is a rosy pink, whose shade differs with the complexion 
of the individual. 

In the second month of pregnancy the areola begins to 
enlarge and darken. This increases as pregnancy ad- 
vances and serves as one of the signsof gestation. After 
lactation the color fades, but seldom entirely disappears. 
In dark brunettes, during pregnancy, the pigmentation 
becomes very dark, almost black, and following lactation 
considerable pigment remains. In light blondes, on the 
other hand, the darkening of the areola is very slight and 
may subsequently almost entirely disappear. In the 
fifth or sixth month of pregnancy there is sometimes seen 
around the areola an irregular slightly pigmented ring, the 
secondary areola (Fig. 1051, B). 

The ventral surface of the areola is roughened by 
numerous slight elevations. These are caused by well- 
developed sebaceous glands, areolar glands. At the cen- 
tre of each a minute lanugo hair marks its opening. 
During pregnancy these glands enlarge markedly, form- 
ing hemispherical elevations from 2 to 5 mm. in diameter. 
They are now known as the tubercles of Montgomery 
(Fig. 1051). They are particularly numerous and well 
marked in the secondary areola (Fig. 1051, B). Toward 
the end of gestation they become very active, their pecul- 
iar fatty secretion keeping the areola moist and serving 
to protect it during suckling. 

The sudoriferous glands of the areola are remarkable 
for their large size and degree of convolution. 

Besides the above there are from five to fifteen acces- 
sory milk glands below the areola. They vary consider- 
ably in size, and open on the summit of the nipple. The 
areolar muscle proper is thickest beneath the nipple and 
fades toward the circumference of the areola (Fig. 1044). 
It is composed mostly of circular fibres among which 
are mixed certain radially disposed bundles. All are at- 
tached to the skin, making it therefore a skin muscle an- 
alogous to the dartos. 

The Nipple.—The nipple is situated a little meso-caudad 
of the centre of the breast on a level with the fourth rib or 
over the fourth intercostal space and about 12 cm. from 
the midline (Figs. 1044 and 1045). Developed from the 
gland area, in the third year it projects from the surface, 
and soon becomes conical or cylindrical. It attains its 


Breast, 
Breast, 


full size shortly after puberty. In some cases it is hemi- 
spherical, flattened, or discoidal, or with apex larger than 
base, pedunculated. It isabout 10 to 12 mm. long, witha 
diameter at the base of 9 to 15 mm., and points ventrad and 
slightly laterocephalad. Its tip isrounded and marked by 
fifteen to twenty minute depressions, milk pores, into 
which the lactiferous ducts open. These form the cribri- 
formarea. In some cases the nipple is retracted into a de- 
pression and projects only on response to stimuli. The 
skin of the nipple (Fig. 1051, 1), thin and pigmented like 
the areola, is remarkable for the number and size of its pap- 
illa. It possesses neither hair follicles nor sweat glands, 
but near the base are a number of sebaceous glands. 

The muscle fibres of the areola are continued up into 
the nipple, being separated from the skin below only by 
the sebaceous glands. They forma layer composed almost 
exclusively of circular fibres. From the inner side of 
this layer numerous muscle bundles are givenoff. These 
cross and recross and forma sort of trellis around the 
lactiferous ducts. Under the influence of cold, emotion, 
or touch these contract, causing circular folds in the 
skin of the areola, and causing the nipple to become 
firmer and more projecting. Besides causing this erec- 
tion of the nipple, the rhythmical contraction of the 
fibres tends to force the milk from the distended milk 
ducts and sinuses into the area cribrosa. If the fibres con- 
tract spasmodically, they act asa sphincter and retain the 
milk. Another set of fibres take their origin from the 
deep connective tissue below the nipple and end upon the 
under surface of its skin. They pass in variously-sized 
bundles through the connective tissue which surrounds 
the milk ducts. Contraction of these fibres causes the 
nipple to retract. 

During pregnancy the nipple becomes larger, more 
readily erectile, and more sensitive. Suppression and 
multiplication of the areola and nipple were considered 
with suppression and multiplication of the gland proper. 

Arteries.—The arteries which supply the breast are de- 
rived from three sources: from the internal mammary, 
from the lateral thoracic (long thoracic), and from the in- 
tercostal. The internal mammary, a branch of the sub- 
clavian, is the principal artery of the breast. It gives off 





Fig. 1050.—Transection of a Tubule of the Corpus Mamme. Ep, 
Glandular epithelium ; in the lumen are milk globules and colos- 
trum corpuscles. (Bardeleben, < 400.) 


two or three branches (rami perforantes), which pierce the 
chest wall and then pass to the cephalo-mesal edge of the 
gland, where they break into branches for both of its sur- 
faces. The lateral thoracic, a branch of the axillary, gives 
two or three branches (external mammary rami) to the 
external portion of the breast. Besides the above, twigs 
from the pectoral rami of the acromial thoracic artery 
pierce the major pectoral and supply the cephalic seg 

ment of the breast. Lastly, the intercostal furnishes sev- 


469 


Breast, 
Breast. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





eral small, short branches to the caudal segment and 
posterior surface. The above vessels, taking a sinuous 
course, break up into numerous branches which anasto- 
mose freely and ramify in the fascia surrounding the 
gland. From the wide-meshed, irregular network of the 
ventral surface two sets of branches are given off: one 
very small to the skin, the other much larger to the 
gland proper. These latter, situated in the stroma, di- 
vide and subdivide on the connective-tissue framework. 


5’ 
















f i 
ca 


4 \ \i 
M y 


; 


Vee 


; 
AAI We 


ti! HL 










Fig. 1051.—The Nipple and its Areola. 


ondary areola ; 6, venous circle of Haller. 


They finally form a close capillary network which sur- 
rounds the acini. The arterioles of the nipple do not 
form cavernous sinuses, and its erection is due entirely 
to the muscular tissue. 

Veins.—From the arterial capillary plexus around the 
acini a venous plexus arises. This proceeds toward the 
ventral surface of the gland and forms beneath the skin a 
large-meshed plexus. During the period of lactation these 
vessels are seen through the skin as blue lines. Around 
the nipple, these subcutaneous veins form a more or less 
complete ring, the venous circle of Haller (Fig. 1051, B). 

The superficial network communicates freely with the 
superficial veins of the neck above, with those of the 
abdomen below, and with the thoraco-epigastric vein 
laterally. These carry the blood into the subclavian, the 
intercostal, the internal mammary, and the axillary by 
branches which parallel the arteries. 

Lymphatics.—The following description of the lym- 
phatics is in the main that given by Stiles, and differs 
somewhat from that of otherauthors. There are five sets 
of lymphatic vessels: (1) superficial or cutaneous, includ- 
ing those of the nipple, areola, and surrounding skin; 
(2) subareolar plexus (Sappey); (8) intramammary; (4) 
those of the circummammary fat; (5) retromammary. 

The cutaneous lymphatics are similar to the cutaneous 
lymph vessels elsewhere. It is to be noted that those of 
one side of the body communicate with those of the 
other; thus explaining the occurrence of axillary infec- 
tion on one side from a tumor of the opposite. Upon the 
skin of the nipple and areola the network formed by these 
vessels is very close, being particularly rich upon the 
nipple. They open mainly into the subareolar group. 

The subareolar lymphatics consist of very large ves- 
sels, forming a wide-meshed network running horizon- 
tally in the loose areolar tissue around the lacteal sinuses, 
As noted above, the cutaneous vessels open into this 
plexus, as do also many of the intramammary vessels. It 
thus serves as a means of communication between the 
two. From the subareolar plexus of lymphatics Sappey 
states that there are two and sometimes three large 
trunks which open into the axillary lymph nodes. 


470 





A, In a non-pregnant; B, in a pregnant woman. 
2, areola; 3, tubercle of Montgomery ; 4, sulcus at the base of the nipple; 5, skin of breast; 5’, sec- 


The intermammary lymphatics begin as a plexus of 
small channels consisting of a single layer of endothelium 
supported by stroma. Each mesh of the network sur- 
rounds one or more of the ultimate lobules of the gland, 
and receives its lymph from the interacinous spaces. 
From this layer vessels parallel to the milk ducts proceed 
to the subareolar plexus into which they empty. 

These periductal as well as the perilobular lymphatics 
anastomose with others which are closely related to the 
blood-vessels. The larger 
blood-vessels are accompanied 
by two or more lymphatics 
which occupy their sheaths. 
The smaller vessels are usually 
accompanied by only one 
lymph channel, which is larger 
than the vessel and more or 
less completely surrounds it. 

The circummammary set re- 
ceives branches from the skin 
and the ventral surface and cir- 
cumference of the breast. It is 
merely a part of the general 
lymphatic system of the ven- 
tral chest wall. From this set 
larger lymph vessels proceed 
between the layers of the deep 
fascia. They soon pierce the 
deep layer of this fascia and 
proceed, as large muscular- 
walled lymph vessels, to the 
lymph glands. 

The retromammary lympha- 
tics include those of the pec- 
toral fascia. They receive 
branches from the posterior 
surface of the gland. Either 
directly or indirectly some of the lymph: from all other 
sets passes into these lymphatics of the deep fascia which 
accompany the mammary blood-vessels and thus reach 
the lymph nodes. 

The lymphatics of the inner part of the gland accom- 
pany the branches of the internal mammary artery 
through the chest wall and empty into the sternal lymph 
nodes situated along this artery. A great many accom- 
pany the branches of the axillary artery to empty into 
the axillary lymph nodes. The: retromammary lym- 
phatics of the two breasts communicate. 

During the activity of the breast the lymphatics are 
filled and the lymph nodes are red, solid, and composed 
almost entirely of lymphoid tissue. During inactivity 
the lymph vessels are but slightly filled and the nodes 
appear to take on a fatty change. This is particularly 
marked in senility. 

Nerves.—The nerves of the breast, excluding those de- 
rived from the sympathetic, which enter the gland with 
the arteries, are derived from three sources: first, from the 
second, third, fourth, fifth, and sixth intercostals; second, 
from the cervical plexus; third, from branches of the 
brachial plexus. The intercostals supply the breast by 
twigs from their anterior and lateral cutaneous branches. 
The third and fourth cervical nerves of the cervical plex- 
us give off the suprasternal, supraclavicular, and supra- 
acromial. Twigs from the middle of these groups, the 
supraclavicular, supply the upper part of the breast. 
From the inner and outer cords of the brachial plexus the 
internal and external anterior thoracic nerves take origin 
and pass forward to supply the pectoralis major and mi- 
nor muscles. Twigs from these nerves pierce these mus- 
cles to supply the breast on its under surface. These 
nerves receive their fibres from the anterior primary divi- 
sions of the sixth, seventh, and eighth cervical and first 
thoracic nerves. They proceed to the gland proper, to 
the skin, to the muscle fibres below the areola as well as 
to the blood-vessels. On and around the areola some of 
the nerves end in Pacinian corpuscles, and in the nipple 
they may end in tactile corpuscles in the papille. 

Stimulation of the mammary nerves causes an erection 


1, Nipple; 


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Breast, 





of the nipple, dilatation of the vessels, and secretion of 
milk. After section of the cerebro-spinal nerves erection 
of the nipple does not occur, but the secretion of milk is 
not interfered with. It seems probable that there are spe- 
cial nerves, aside from those of the blood-vessels, govern- 
ing secretion; but this has not been proved. Emotional 
disturbances (anger, fear, and so forth) arrest secretion. 

From 500 to 1,500 c.c. of milk is daily secreted. To 
remove this from the gland there is not only the me- 
chanical action of sucking, but also the activity of the 
gland itself. This latter consists in the contraction of 
the muscle fibres beneath the areola. By these the nipple 
is erected and by their rhythmical contraction the milk 
ducts and sinuses are emptied. The sucking not only 
stimulates the muscle to act, but also excites the sensory 
nerves of the nipple, thus causing a reflex stimulation of 
the gland acini and an increase of the secretion. During 
activity the vessels of the gland are dilated. The amount 
of the secretion appears to be influenced by blood press- 
ure. Frequent and rapid emptying of the gland causes 
a greater flow, possibly through secretion pressure within 
the cells. The oftener the breasts are emptied the richer 
the milk becomesin casein. The last milk obtained at any 
time is always richer in fat, as it comes from the acini. 

Human milk is always alkaline. Cow’s milk may be 
alkaline, acid, or neutral. The milk of carnivora is al- 
ways slightly acid. Various substances, when eaten by 
the mother, are secreted in the milk. Such are anise, 
vermouth, garlic, etc.; chloral, rhubarb, opium, iodine, 
mercury, lead, etc. Some substances, such as atropine, 
arrest the secretion of milk. 

Milk contains large amounts of casein, lactose, and fat, 
also certain inorganic constituents. Neither the casein 
nor the lactose occurs in the blood, and fat is found only 
in small amounts. The inorganic salts in the milk are in 
different proportions from those found in the blood. 
Food rich in proteids increases the amount of milk, but 
the relative amount of fat is increased more than the 
other constituents. With a pure flesh diet, the milk 
contains a very large amount of fat. Fat added to the 
food, if not accompanied by an addition of proteid ma- 
terial, rather diminishes than increases the amount of fat 
‘in the milk. It appears, therefore, that the fat in the 
milk is not obtained from the fat taken with the food, 
but is the result of the decomposition of the proteid. 
Increasing the carbohydrates of the food does not increase 
the amount of sugar in the milk. The greatest part of 
the sugar is therefore also derived from the proteids; so 
‘too is the casein. Both the milk sugar and the casein are 
probably formed by the action of ferments which remain 
‘In the cells and do not pass into the milk. It is clear that 
milk is a chemical product, and that it is due to the activ- 
ity of the cells in the mammary gland. Concerning the 
‘specific chemical source of the constituents, nothing is 
known with certainty. The relative proportion of the 
various constituents of the milk varies in the different 
‘months after delivery. The cause of this variation is not 
known, but by it those substances best suited to the child 
‘during its different periods of growth seem to be sup- 
plied. Abram T. Kerr. 


For good bibliographies, consult Quain, Testut, yon Bardeleben, | 


“Henle, Henneberg, and Profé. 


Altmann, R.: Ueber die Inactivitaéts-Atrophie der weiblichen Brust- 
driise. Arch. f. path. Anat., cxi., 318-340, Berlin, 1888. 

‘Bardeleben, Karl von: Handbuch der Anatomie des Menschen, 
Fiinfter Band, erste Abteilung. Von A. V. Brunn, Jena, 1897. 

Bonnet, R.: Die Mammarorgane im Lichte der Ontogenie und Phylo- 
genie. Anat. Hefte, vii., 337-876, 1897. 

“Bowlby, ae Aleve Development of the Mammary Glands. 
Journ., , 1143, London, 1882. 

Henle, J: P Hanabusn der systematischen Anatomie des Menschen, 
Bad. iii., 2 Aufl., Braunschweig, 1876. 

“Henneberg. B.: Die erste Entwicklung der Mammarorgane bei der 
Ratte. Anat. Hefte xiii. 

Kalius, E. ; Ein Fall von Milchleiste bei einem menschlichen Embryo. 
Anat. Hefte, viii., 153-163. 

oar Lehrbuch der Entwickelungsgeschichte des Menschens, 

ena, F 

Landois, L., and Stirling, William: A Text-book of Human Physiol- 
ogy, 4th ed., London, 1891. 

“Langer, C. von: Ueber den Bau und die Entwickelung der Milchdriise 
bei beiden Geschlechtern. Wiener Akad. Denkschr., 3 Band, 1852. 


Brit. Med. 








Michaelis, L.: Beitrige zur Kenntniss der Milchsecretion. 
mikrosk. Anat.. li., 1898. 

Middendorp, H. W.: Die on ie der Mamma. 
f. Anat. u. Phys., iv., 51-72, 1887. 

Profé, O.: Beitrige zur Ontogenie und Phylogenie der Mammaror- 
gane. Anat. Hefte, xi., 247, 1 

Quain : Elements of Anatomy, nite ed., edited by Schafer and Thane, 
vol. iii., part iv., 1896. 

Rein, G.: Ueber die Entwickelungegeschicte der Milchdriise. 
f. mikrosk. Anat., XX., 431, 1881; xxi., 678, 1882. 

Sappey: Traité d’anatomie déscriptive, ii. and iv., Paris, 1889. 

Stiles, H. J.: Contributions to the Surgical Anatomy of the Breast. 
Edinb. Med. Journ., XXxXvii., xxxviii., 1891-92. 

Schultze, O.: Beitrage zur Entw ickelungsgeschichte der Milchdriisen. 
Verhandl. d. phys, med. Geseilsch. zu Wurzb., xxvi., 1891-92. 

Schmidt, H.: Ueber normale Hyperthelie menschlicher Embryonen 
u. iiber die erste Anlage der menschlichen Milchdriisen tiberhaupt. 
Morphologische Arbeiten, vii., 1897. 

Testut, 1.: Traité danatomie humaine, iii., 
Paris, 1897 

Williams, W. R.: Polymastism with Special Reference to Mamme Er- 
raticze and the Development of Neoplasm from Mammary Struc- 
tures. Journ. Anat. and Physiology, xxvy., 1891. 

Williams, W. R.: Mammary Variations per Defectum. Journ. Anat. 
and Phys., xxv., 1891. 

Williams, W. R.: The Ontogeny and Phylogeny of the Breast. 
cet, ii., London, 1892. 


BREAST, FEMALE, DISEASES OF THE.—Amazzta. 
—Entire absence of mammary glands is extremely rare, 
and is accompanied by other deformities usually in- 
compatible with life. Absence of one breast is more 
often met with, and the corresponding ovary is found to 
be wanting as well (Scanzoni), or the great pectoral 
muscle of the same side. Probably absence of one breast 
and deformity of the other is the nearest approach to 
amazia found in the adult. A rudimentary breast may 
be so small as to justify the term micromazia. 

PoLyMASTIA.—Supernumerary mamme are not uncom- 
mon. Bruce,! in 4,000 examinations, found this deform- 
ity present in 1.54 per cent., a ratio greater than usual, I 
believe. He also finds men more often affected than 
women, in the proportion of 4 to 1, a result contrary to 
that obtained by Godfrain.? I have seen the deformity 
more often in females. Axillary prolongations are not 
infrequently met with, and may be mistaken for lym- 
phatics. They undergo the usual development during 
pregnancy, the secretion escaping by the nipple. Super- 
numerary mamme occur most frequently in pairs, and 
are situated below the normal glands, rather nearer to 
the middle line of the body; the situation next in fre- 
quency is above the normal glands and further from the 
middle line, z.e., toward the axilla. When the deformity 
is unilateral, the left side is most often chosen. Super- 
numerary glands below the normal mamme are larger 
and better supplied with nipple and areola than when 
situated on the side toward the axilla. They of course 
follow the evolution of the natural gland, becoming most 
apparent during lactation, and undergoing atrophy after 
the menopause. Klob has recorded an additional mamma, 
on the shoulder, the size of a nut; it was provided with 
a nipple. Two examples have been noticed on the back. 
Robert reports an instance upon the thigh; Percy, one 
upon the epigastrium. Multimamme are not over 
fecund, and may or may not be provided with nipples 
for the additional glands, or the secretion may escape by 
asmall opening. Functionally also there may be great 
variation. Ross* reportsa mulatto with a third breast 
beneath the normal left one. It was six inches in cir- 
cumference, was provided with nipple, follicles, and 
areola, yielded milk, and if not attended to was painful 
from overdistention. The nipple was too small for the 
child to nurse. Lynceus* reports a woman with four 
breasts in two vertical lines. All gave milk abundantly. 
Gardner ® mentions a similar case in a negress, the super- 
numerary glands being in the neighborhood of the axille. 
Percy ° reports the case of a vivandiére who had four mam- 
me in two vertical lines, anda fifth five inches above the 
umbilicus, in the middle line. This latter resembled the 
breast of an impubic girl; the other four secreted milk. 

Alexander’ records the case of a mulatto male with six 
nipples in two vertical lines, there being a distance of 
four inches between the nipples vertically. The subject 
of the report stated that his mother was malformed in 
like manner, four of her nipples giving issue to milk; 


Arch. f. 


Internat. Monatsschr. 


Arch. 


troisiéme ¢dition, 


Lan- 


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also, that, of several brothers and one sister, all save 
one brother were provided with four supernumerary 
breasts. Unfortunately, these statements could not be 
verified by an examination. Robert’s® case, already re- 
ferred to, is as follows: A woman, whose mother had 
three breasts, herself had a supernumerary mamma upon 
the outer surface of the left thigh, four inches below the 
great trochanter. Her own child sucked the additional 
mamma for twenty-three months. Four foster-children 
nursed from it during six years. Robert examined this 
mamma and found it atrophic like the (pectoral) others, 
the menopause being past. Handyside® reports three 
brothers each with four mammee. 
normal. Variations, both as regards nippies and areolex, 
are observed to occur, not only in connection with addi- 
tional breasts, but also with mammze in the usual situa- 
tion and otherwise normal. G. Honnaiis saw five nipples 
to one breast. Imperfectly developed nipples, or indeed 
entire absence of nipples, is more common, and this con- 
dition is the cause of much pain and inconvenience, 
owing to the infant being unable to nurse properly, and 
so inducing engorgement, with consecutive inflammation 
of the corresponding mamma. Congenital abnormalities 
of the mamma are hereditary. They have been seen, ac- 
cording to my experience, more often in the negro and 
mulatto than in the white race. 

HYPERTROPHY OF THE MAmMMaA.—Hypertrophy of the 
mamma is seen in both sexes, occurring in one or both 
glands. Lymphatic and scrofulous persons are more 
likely to be so affected. As a sequel of mumps, it may 
accompany atrophy of the corresponding testicle. Ol- 
phan?! quotes from the records of the Société de Bio- 
logie the case of a man who lost a testicle from can- 
cer, and subsequently died from a recurrence of the 
disease. One breast was enlarged, and showed, on 
microscopic examination, colostrum and milk globules. 
Gorham! records the following case: The patient, a 
soldier, received injuries in battle, and acquired Pott’s 
disease of the upper dorsal and lower cervical vertebre. 
Atrophy of the testes was observed, and coincidently 
progressive enlargement of both breasts took place. 
Sexual desire was in abeyance after the spinal injury. 
Four and a half years subsequent to the accident, Gor- 
ham says: “Each breast is at this period the size of an 
orange, glandular to the touch, and pendulous.” Prior 
to the spinal hurt, the patient had three children by his 
wife; subsequently, his figure and appearance changed, 
resembling that of an eunuch. This case appears to be 
the one previously reported by Thompson.!? Unilateral 
hypertrophy has not been noticed coincidently with non- 
descent of one testicle. Petrequin (Labarraque: Thése 
de Paris, 1875) saw a man with a pendulous mamma, 
48 cm. long; no cause discoverable. Enlargement of one 
breast in young boys has been noted as occurring without 
cause, but such increase may be simulated by retromam- 
mary lipoma, as in the instance recorded by Lobker.'? 

Hypertrophy of the mamma in the female has been 
noticed a number of times. Inasmuch as there are 
physiological variations in the size of the mamma, it is 
not easy to say just when enlargement becomes patho- 
logical. The breasts have been found to weigh many 
pounds, constituting enormous tumors pendent from the 
front of the thorax, sufficient, indeed, to prevent locomo- 
tion, to any extent, on the part of their unfortunate 
possessor. In Huston’s'™ case the right breast weighed 
twelve pounds, the left twenty pounds. Demarquay '° 
removed a left mamma, after second pregnancy, weigh- 
ing 8 kgm. (about 174 Ibs.). Skuhersky '® records mam- 
me of eighteen pounds and nineteen pounds. Esterle,!" 
in a case which came under his observation, judged the 
breasts, in the third month of pregnancy, to weigh from 
twenty-six to thirty pounds, confining the patient to bed. 
Chassaignac and Richelot report an instance of a breast 
which weighed thirty pounds, and hung down as low as 
the knee. Durston!® made an autopsy of a girl whose 
right breast was supposed to weigh forty pounds, and 
whose left actually did weigh sixty-four pounds. The 
skin covering such enormous masses as these will, of 


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The parents were . 





course, be greatly stretched and somewhat yellowish in 
color, usually roughened also. A certain woman was 
married in 1858. After two pregnancies the left breast 
was so large that it reached to the umbilicus, and was 
removed in 1858. After removal it was found to weigh 
sixteen and a half pounds. The following statement in 
regard to it is from Schmidt’s Jahrbiicher, t. evi., p. 51, 
1860: About 2 litres of milk, very white, flowed from the 
tumor, showing here and there a streak of blood, without 
odor, alkaline, thick, resembling good cream; specific 
gravity, 0.98 to 0.99. <A certain quantity, analyzed by 
Professor Schlossberger, showed: Water, 67.52; fat, 28.54; 
sugar and extractive matters, 0.75; casein, 2.75; salts, 0.41. 

The tumor was examined microscopically, and from 
this examination it appeared that “the stroma was made 
up of fibrous connective tissue split roughly, the cells 
communicating with each other by numerous projec- 
tions containing here and there fatty granulations. The 
small vesicles of the acini, pear-shaped, rounded, or 
elongated, . . . were slightly longer than normal, and 
enclosed, as did the commencing excretory canals, many 
small bodies having a well-defined outline, and contain- 
ing shining nucleoli anda large number of fatty globules. 
The larger excretory canals presented the usual structure. 
The lumen walls were made up of compact fibrous con- 
nective tissue, mixed with cells, but without trace of 
glandularelements. Epithelial lining was lacking. The 
origin of these cavities was due very probably to a 
partial dilatation of the tissue by accumulation of its 
contents, which had brought about, on the one hand, 
destruction of gland substance, and on the other, a new 
formation of connective tissue.” Demarquay’s case, 
already referred to, showed on microscopic examination 
fibrous degeneration. » There existed, in the extirpated 
breast, a central cavity containing a serous fluid in’ which 
were small oil globules, granular globules, and blood cells. 

Cause.—Nothing certain is known as to the cause of 
this increased growth; menstrual irregularity or actual 
suppression has seemed to be the exciting cause. In- 
crease with each succeeding pregnancy is noted. In 
Huston’s case the ovaries were found diseased. If we 
consider how close are the relations between the different 
parts of any system in the human economy, it is fair to 
infer some general disturbance of the generative apparatus 
prior to the onset of mammary hypertrophy; but of what 
character such disturbance is, we are, for the present, in 
doubt. 

Between the ages of fourteen and thirty the affection 
under consideration is most likely tooccur. While it has 
been established that both breasts may become hyper- 
trophied, the left seems to show a greater predisposition 
to such hypertrophy. An extremely interesting example 
of temporary '’ increase in bulk,— the erection of the 
mamma,—during a paroxysm of intermittent fever, is 
noted by Ferrus (Gaz. des Hép., 1846, No. 90, p. 858); it 
yielded to quinine. At the onset of the trouble the 
mammee are large and firm; subsequently, however, they 
are pendulous, and thus appear pedunculated; the lobes 
are easily distinguished, the areola is large, sensibility is 
lessened, and perhaps there may be some cedema at the 
depending portion. The beginning of the disease is 
insidious, and its progress is characterized by alternations 
of rapid increase and apparent quiet; entire retrocession 
is not observed. Durston’s ?° case followed a very rapid 
course, death closing the scene in three and a half months. 
After delivery, should hypertrophy commence during 
pregnancy, growth ceases. In Huston’s case, gangrene 
followed a blow, death ensuing. MacSwiney”! relates a 
case in which removal of one breast made the other grow 
faster. 

The prognosis is not grave, except when the mammary 
increase is accompanied by general emaciation, with fre- 
quent pulse. Esterle * met with such a state of affairs, 
and found opium to give relief up to the time of confine- 
ment, when improvement took place. It is possible that 
the induction of a miscarriage would be necessary, other 
means failing, but this should be done only when the life 
of the mother is gravely imperilled. 


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The indications for treatment are both local and gen- 
eral. If menstruation be absent, induce it; if it be too 
profuse, diminish it; if it occur during lactation, arrest 
it; should arrest of lactation be the exciting cause, then 
re-establish the secretion—in other words, keep the gen- 
erative apparatus normal. Jodine and iodide of potas- 
sium, to be administered internally and by friction, are 
indicated. Locally, support and compression by rubber 
bands will be found useful. Other means failing, removal 
of the ovaries, or the ovaries and tubes, might, by estab- 
lishing the menopause, bring about a cure of the trouble 
under consideration. Jam not aware that this last treat- 
ment has ever beenadopted; itis, however, physiological 
and worthy of trial. 

Other means failing to arrest growth, amputation is 
called for. Prior to removal of the breasts vascularity 
may be diminished by suspending the organs, as in ele- 
phantiasis of the scrotum. The use of Wyeth’s pins is 
to be thought of also. 

DISEASES OF THE NrppLe.—The nipple, save in lacta- 
tion, rarely attracts notice; during the active life of the 
mamma, however, it is far otherwise. Its physiological 
perfection is a matter of extreme moment, not for the 
mother only, but for the health of the infant. <A well- 
formed nipple of sufficient size, not buried deeply in the 
areola, but standing out from the skin surface, is to be 
secured before the end of pregnancy. Should this de- 
velopment not occur during the last months of gestation, 
gentle traction upon the nipple, with pressure backward 
on the areola, will be of use in aiding protrusion. Suc- 
tion by means of an air pump has also been tried. 

After, the termination of labor, two causes are para- 
mount in causing nipple disease: (1) Lack of develop- 
ment; (2) lack of cleanliness. The first offersan obstacle 
to the emptying of the breast, while the effort of the 
child to suckle excites the mamma to active secretion; 
as a result there will be retention and engorgement. The 
second, lack of cleanliness, conduces to an unhealthy con- 
dition, with a long catalogue of skin diseases, erosions, 
fissures, etc. Not only then is the protrusion of the nip- 
ple to be assisted in the manner described above, but 
the tender skin covering it and the areola should be 
hardened by frequent cool bathing during the eighth 
and ninth months of gestation, or perhaps by the em- 
ployment of a slightly astringent lotion. 

After the child nurses, the nipple and areola are to be 
gently and thoroughly cleansed, in order that the baby’s 
saliva or a little milk, etc., may not rest in the natural 
rugse of the part, and so induce irritation or a worse con- 
dition. Erythema and eczema present no symptoms not 
seen elsewhere; ecchymoses, from the child’s suction and 
chewing while suckling, are recognized by the ordinary 
signs. Paget has described a chronic eczema which has 
its starting-point in the nipple; after destroying the 
latter, the disease gradually extends both over the sur- 
face and into the substance of the mamma, and finally 
terminates in carcinoma. Investigation seems to nega- 
tive the simple character of this eczema, and it is known 
as malignant papillary dermatitis. The prominent char- 
acteristics are: a bright red raw surface, slightly raised, 
with a well-defined border; to the touch, a certain firm- 
ness or parchment induration; secretion scanty; existence 
very chronic. The areolaand nipple are affected; the 
latter disappears. The disease is recognized as epithe- 
lioma histologically and requires similar treatment. Re- 
moval of the nipple only is useless; complete removal of 
the breast, as for other carcinomata, is called for. 

Fissures, erosions, etc., when first established, are best 
treated by slightly astringent applications, afterward by 
emollient washes. Later, after the child has nursed, the 
breast may be washed, dried, and powdered with bis- 
muth subnitrate, lycopodium, etc. I have seen excellent 
results follow the application of pure rubber dissolved 
in chloroform to the fissures, before the child is allowed 
to nurse. The application of a four-per-cent. solution of 
cocaine is reported as giving excellent results. Shields 
and artificiai nipples of one kind or another may give 
good results, or the secretion of milk may require sup- 


pression in order to bring about healing. Abscess of 
the nipple is infrequent, and, according to Velpeau, 
occurs in a milk channel most often; under such condi- 
tions milk will escape after the discharge of matter. 
Rarely more than a drop or two of pus is formed. 

Chancre of the nipple and areola is usually acquired 
by inoculation froma mucous patch, and resembles chan- 
cre of the lip. Theamount of induration is very marked, 
not, however, appearing suddenly; parchment-like at 
first, the induration spreads to subjacent tissues, and 
may involve an area equal to that of a silver dollar. If 
the breast is being nursed, a scab is not allowed to form; 
otherwise a coveling crust is not unusual. The primary 
lesion of syphilis may appear as an erosion, fissure, or 
ulceration. An axillary bubo will develop in connection 
with it, more often just under the edge of the great pecto- 
ral muscle than deep down in the axilla. The progress of 
the chancre is slow and painless, changing, with the advent 
of secondary accidents, into a mucous patch. During the 
early stage only of the disease will there be room for doubt; 
absence of pain, however, and the presence of a raw sur- 
face are to be looked upon with grave suspicion. In the 
event of a nursing woman being affected, the mouth of the 
infant she nurses is to be scrutinized closely. 

Hypersthesia of the nipple, accompanying a rigid 
condition of the organ, has been noted, and will probably 
depend upon disturbed function of the uterus and ap- 
pendages. 

A similar hy pereesthesic condition of one or both breasts 
may be met with, and is likewise dependent upon an 
artificial mode of life, inducing defective menstruation. 

NEURALGIA OF THE BreEast.—Neuralgia of the 
breast, the so-called irritable mamma, is to be classed 
with the two preceding affections, and is the outgrowth 
of incomplete or deranged sexual life. The subjects 
are usually unmarried, but not always; young, under 
twenty-five years, slender, with pale complexion, of lax 
muscular fibre, and not dependent on their own exertions 
for a livelihood. They will show strong predilection for 
trashy literature and laziness, rather than for the standard 
authors and exercise; the ism of the day will prove a 
subject of absorbing interest to them. Other hyperes- 
thesic spots or lines generally exist upon the skin of such 
individuals,—along the spine, for instance, or over the 
intercostal nerves,—and certain attitudes or motions will 
be complained of as liable to induce great suffering. 
Some sorrow may have been experienced, and the subject 
of it, from overmuch thought, gradually develops sym- 
pathy for herself, changes her mode of life, and generates 
a mammary pain. Physical examination of the breast 
shows no cause for suffering. 

Treatment consists in regulating menstrual life and 
causing the patient to purste an active and useful exist- 
ence. In my hands, far more success has been thus at- 
tained than by resorting to, and relying largely upon, 
drugs. Menstruation, wheiher excessive or deficient, is 
to be rendered normal by appropriate means. An action 
of the bowels once daily is to be secured; the diet should 
be simple, nutritious, and not in excessive quantity; the 
clothing should be warm and loose, not confining natural 
movements; the function of the skin should be assisted 
by cold sponging; regular exercise should be insisted on; 
the patient should retire to bed early and rise early ; dime 
novels should be put aside and the classics read, so that 
both mind and body may gradually be led to a normal 
healthy condition;—under which régime the mammary 
pain is likely soon to depart. Briefly, the treatment may 
be stated in the old saying, “Live on sixpence a day and 
earn it.” 

ConTustons AND WounbDs.—Contusions of the mamma 
are of interest as having given rise to malignant disease 
in a certain number of cases. In order properly to esti- 
mate violence as a factor in the etiology of carcinoma or 
sarcoma, the number of bruised breasts not the seat of 
malignant growths should be known. This is manifestly 
impossible, and with our present knowledge we must ic- 
main in doubt concerning violence as a factor jn the etiol- 
ogy of malignancy. . Ecchymoses without thacmatism 


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have been observed in women menstruating with difficul- 
ty, blood also oozing from the nipple, perhaps. 

Wounds of the mammary gland bleed freely; paren- 
chymatous hemorrhage and much oozing follow. Press- 
ure with sponges or cloths wrung out in hot water is the 
most efficient hemostatic; healing is not rapid and pus 
formation is usual. 

Mastitis.—Irflammation of the breast may occur at 
any age, but is found far more often during the early 
days of a first lactation than at any other time. It is no 
uncommon circumstance for the mamme at birth to be 
somewhat swollen and to give exit to a small amount of 
discharge more or less milky in character; if let alone, 
no harm follows. Injudicious handling on the nurse’s 
part, to “work out the milk,” is almost always indulged 
in with the result of causing an abscess somewhat often. 
Up to and including early puberty mastitis is rare, and 
when present is apt to be chronic rather thanacute. The 
subjects are girls of feeble muscles, pasty complexion, 
torpid bowels, etc., and they present those symptoms 
which are generally grouped under the term strumous. 
Early opening of the abscess, general tonics, and out-of- 
door life, with regular hours, suffice fora cure. During 
pregnancy and the normal mammary development conse- 
quent thereon, abscess—save from traumatism—is very 
rare; but with labor the scene changes. The mammary 
inflammation and abscess which occur most frequently 
during the first month of lactation depend, in the great 
majority of cases, upon a defective development of, or 
morbid condition of, the nipple. The nipple is so small 
that the child grasps it with difficulty, suckling is imper- 
fect, and the mamma is not emptied; ora cracked and 
fissured nipple is so painful, when grasped by the baby’s 
mouth, that suckling is again imperfect; or, from the in- 
flamed nipple as a starting-point, trouble extends to a 
distance, through the lymphatics. The inflammation and 
abscess met with in early lactation are recognized as oc- 
curring, first, in the subcutaneous connective tissue out- 
side the gland proper—subareolar; second, beneath the 
gland in relation with the thorax—submammary ; third, 
in the connective tissue of the mamma—interlobular. To 
these three classical situations there should be added a 
fourth: in a lacteal sinus. The latter form of abscess, 
although not met with so soon after birth as the others, 
is worthy of recognition. 

The cause of mammary abscess is not difficult to find. 
Pregnancy calls into life a hitherto comparatively rudi- 
mentary organ for the performance of an active func- 
tion, and failure of any part of the organ determines an 
accident. The nipple, a healthy condition of which is 
essential to proper escape of the mammary secretion, is 
subject to violence, etc., from the infant, and an infec- 
tion follows. Lack of cleanliness is the cause most fre- 
quently met with. 

A subareolar abscess, not larger than a filbert, is found 
in the connective tissue of the locality indicated by the 
name, and is recognized by the usual signs. An early 
incision is indicated, in a direction radiating from the 
nipple to the periphery. I have never been able to ap- 
preciate the humanity of waiting until a mammary ab- 
scess “points”; great pain is thereby entailed upon the 
unfortunate woman, and the function of the breast is 
kept in abeyance, or perhaps permanently impaired. 
The many means for obtunding suffering now at the 
surgeon’s command render procrastination most injudi- 
cious from a pain-saving point of view, if from no other. 

Submammary abscess israre; a collection of pus forms 
in the connective tissue which attaches the breast to the 
great pectoral muscle. Inflammatory fever is apt to run 
high, movement of the arm and chest muscles increases 
pain, and the whole breast is pushed forward, is tense, 
retains its contour and imparts to the examining hand a 
sensation as though the mamma rested upon an elastic 
cushion; fluctuation at the periphery of the breast may 
sometimes be felt late in the affection. Large veins will be 
seen wandering through the skin which covers the breast. 
This variety of abscess may be caused by an interlobular 
mastitis, by an axillary abscess, by a cariousrib, or by the 


A474 


| A carious rib will generally be tuberculous. 





bursting of an empyema through the chest wall. An 
opening is best made, in the absence of some special indica- 
tion, below and to the outer side. The incision should be 
of moderate length, and a director should be introduced 
into the wound as a guide for the dressing forceps, which 
should be withdrawn openin the usual manner. The use 
of a drainage tube is expedient, and, should free exit for 
inflammatory discharge not be afforded by one opening, 
then another should be provided. The breast should be 
well supported and pressed against the chest by a bandage 
or by strips of adhesive plaster. Should an empyema or 
carious rib exist, treatment proper for it is to be instituted. 
Inflamma- 
tion of the gland proper or of the interlobular tissue fol- 
lows engorgement consequent upon a cracked or excori- 
ated nipple, or, indeed, upon any cause preventing free 
discharge of milk. A sense of discomfort is soon fol- 
lowed by pain, etc., and fever is very marked. Occa- 
sionally a chill ushers in the disease. The interlobular 
tissue is first attacked, and the inflammation may extend 
between several lobes, or to the sublobular tissue. The 
strong capsule of the mamma opposes extension toward 
the skin, and pointing occurs late, pending which the 
glandular tissue may become involved and suppuration 
in it occur, permanently impairing the affected lobe or 
lobes. Fluctuation is not found early, and should not be 
awaited; acute pain somewhat localized, hardness, and 
elastic tension, will suffice for a diagnosis, and will justify 
a puncture, followed by incision if matter escape. In 
this form of abscess, as well as in others, a sensitive and 
enlarged gland may be met with in the axilla. Should 
artificial opening be deferred, the matter slowly ap 
proaches the surface and then points rather suddenly. 
Successive abscesses may form in the mamma, as the in- 
flammation slowly extends from one place to another. 

Successive formations of pus dépéts, following acute 
mastitis, are indications of a too limited opening, with 
incomplete discharge of matter. During acute inflam- 
mation a mamma should not be nursed by the infant, but 
lacteal engorgement must be carefully prevented by the 
diligent use of a breast pump; it is usually not necessary 
entirely to arrest milk formation by drugs, etc., unless: 
a discharge of pus by the nipple is chronic or the abscess 
shows no disposition to heal. Acute inflammation of a 
lacteal sinus is infrequent, occurs usually long after the 
puerperal condition, is met with in anemic patients, and 
follows interlobular mastitis, or more often, perhaps, 
obstruction of the outlet through the nipple. Probably 
a catarrhal inflammation of the mucous membrane is 
present. The prominent symptoms are: pain over the 
sinus, which increases’ with distention; discomfort on 
pressure usually; and, during quiescence of the gland, 
pressure will cause pus to exude from the nipple. The 
two instances in which I have recognized this condition 
were treated in various ways; the mammary secretion 
disagreed with the nurslings and it became necessary to 
arrest lactation in order to effect a cure. 

It has been already said that the incision to evacuate 
pus from a mammary abscess should be made in the di- ~ 
rection of a line drawn from the nipple toward the per- 
iphery of the gland. 

Chronic abscess is sometimes, though rarely, met with, 
and is more apt to be confounded with scirrhous carci- 
noma than with any other morbid condition. It begins 
deeply in the gland, and incorporates surrounding parts 
by firm exudation; later, the nipple may be somewhat 
retracted, the skin dimpled, reddened, and adherent; also 
the axillary lymphatics may be enlarged and tender. 
Women whose health is poor and nutrition defective are 
usually affected. A local tuberculosis is to be suspected 
and the bacillus sought for. A diagnosis, differential, 
between chronic abscess and scirrhus is sometimes so 
difficult as to require an incision. The treatment is free 
incision, generous diet, and general tonicregimen. Port, 
beer, or porter will assist recovery by strengthening the 
patient. Tuberculosis of the mamma, with‘our present 
knowledge, would probably escape early recognition. 
A tumor slowly suppurating, leading to the formation of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Breast, 
Breast, 





sinuses with undermined edges, in a subject of tubercu- 
lous tendencies, would excite suspicion which the micro- 
scope would be called upon to confirm, by disclosing the 
bacillus. Extirpation will be, of course, the proper treat- 
ment; sinuses should be “ spooned ” and iodoform applied. 
In a certain number of women a breast which has been 
the seat of abscess becomes the seat of malignant disease 
subsequently. Ihave not been able to see that the two 
conditions bore to each other the relation of cause and 
effect. For, while carcinoma is found in a breast which 
has been the seat of mastitis, yet many mammie, which 
have been similarly affected, do not develop carcinoma. 
Ihave noted a carcinoma in one mamma which had al- 
ways been healthy, the other breast having suffered from 
inflammation afterconfinement. It is natural to suppose 
that, if much induration remains permanently after mas- 
titis, malignant disease would be more apt to develop 
in it than if no such induration were present. 

Mammary Tumors.—Classtfication.—With our pres- 
ent knowledge of mammary tumors, it may be safely 
said that any classification is but provisional, and will 
need modification from time to time, as additional facts 
are added to those already known. Tumors may be 
considered as indicating new formations and cysts, 
alone or in combination, and are best grouped according 
to their anatomical elements. It is unfortunately a 
fact that the clinical history of a growth cannot be 
stated so soon as the histology is known, but it can be 
done far more accurately now than was possible some 
time since, and more accuracy is daily being attained. 
I submit the following classification : 

I. Cysts. 

II. (a) Tumors resembling fully developed connec- 
tive tissue: fibrous tissue, fibroma ; adipose-tissue, lipo- 
ma ; mucous tissue, myxoma ; bone, osteoma. 

(6) Tumors resembling embryonic connective tissue: 
sarcoma. 

III. Tumors resembling epithelial (secreting) tissue: 
carcinoma. 

IV. Tumors resembling the more complex higher tis- 
sues: gland tissue, adenoma, nerve tissue, neuroma ; 
vascular tissue, angioma ; the two latter so rare as to be 
disregarded. 

Of the foregoing tumors, sarcoma and carcinoma are 
classed as malignant, the others as non-malignant or be- 
nign. Carefully kept clinical records, supplemented by 
accurate anatomical research, are greatly needed in the 
study of mammary growths, and the absence of such rec- 
ords renders much experience in the past quite useless at 
the present time. Probably no one word has brought 
about this result so much as the term “cancer,” which is 
used either clinically, or anatomically, or as a means of 
concealing ignorance, by different observers. Clinically 
it means malignant, anatomically it means carcinoma; to 
avoid misunderstanding, the term will not be employed. 

Oysts are sacs enclosing fluid more or less thick. <A 
lacteal cyst—galactocele—is a tumor containing milk, 
normal perhaps, but more often having undergone 
changes during retention. A sinus or duct becomes 
closed, and is gradually dilated by milk as fast as it is 
secreted. The tumor begins, as a rule, beneath the are- 
ola, without inflammation and with little pain, and ex- 
tends toward the periphery, usually in a nursing woman. 
Should the occluded duct be in a lobule, the tumor will 
commence deeply, and at a distance from the nipple. 
Increase at first is rapid; later, however, if lactation 
cease, diminution in bulk occurs, the cyst parting with 
its fluid and becoming more solid; its contents will then 
be curd-like, consisting of epithelium and fatty matters. 
Lacteal cysts of enormous size have been recorded; they 
are usually single, and do not involve the overlying skin 
unless inflammation supervene. When subcutaneous they 
are darker under direct illumination than is the adjacent 
skin. Inacase observed by me, tension of the cyst varied 
with the active or passive state of the gland. Pain is very 
rare, and the patient complains only of the size of the 
breast. The general outline of the cyst is oval and 
smooth, more rarely lobulated. This latter shape is due 


to rupture of the wall at some point, and escape of con- 
tents which become encapsulated in connective tissue. 
The diagnosis offers difficulty only when, from long re- 
tention, the cyst-contents have become more or less solid, 
but even then the previous history enables the surgeon 
usually to avoid mistakes. 

In a nursing woman, puncture or aspiration relieves 
temporarily, but does not cure, for the cyst refills quick- 
ly; injection with iodine tincture is equally inefficient. 
A free incision, followed by suppuration of the sac, or 
extirpation of the cyst, are the most reliable methods of 
cure; of the two, probably extirpation is the less pain- 
ful. In a non-nursing woman aspiration, followed by 
injection of iodine tincture, offers more chance of cure, 
and should be tried, but the more radical measures men- 
tioned above will probably have to be resorted to. 

Non-lacteal cysts occur before and after the meno- 
pause, and result from the obstruction and subsequent 
dilatation of one or more ducts. Such cysts are usually 
multiple, not large, scattered through the gland, and 
contain a fluid more or less thick, secreted by the lining 
membrane of the dilated duct. This fluid may be clear or 
colored; and these colored cysts, in which the colors red 
and yellow predominate, are found more often in advanc- 
ing years than at an earlier period (about puberty). In 
the nursing woman the cysts under consideration are rare: 
they are met with in sterile women, or in those who have 
long ceased to bear children and approach the menopause. 
Pain is exceptional, but weight and discomfort are com- 
plained of. Increase is slow and gradual; lymphatic im- 
plication is never seen. The diagnosis is made with 
difficulty; and, after all, that is a matter of small impor- 
tance, since extirpation alone promises relief, if multiple 
cysts exist. Discharge from the nipple is a not infre- 
quent accompaniment of cystic growths. Large single 
cysts are usually found near the centre of the mamma; 
multiple cysts, generally small, occur more often near 
the periphery. Both breasts are sometimes affected, but 
never to the same degree. Obstruction of a duct, caus- 
ing the cyst, occurs in the old, probably from contraction 
of the fibrous stroma, while in youth defective evolution 
—excessive—of an acinus is invoked as a cause; hence 
the terms “involution cysts” and “evolution cysts,” as 
they are called. The diagnosis rests on the slow growth, 
shape, consistence, and multiplicity, on the absence of 
glandular enlargement in the axilla, and, in case of punc- 
ture, on the escape of contents. When many cysts exist 
removal of the breast is the only procedure that will afford 
relief. In the case ofa single cyst the sac may be opened, 
suppuration induced, and a cure by granulation obtained. 
Hydatid cysts of the breast are extremely rare, and, the 
growth being slow, this variety will usually be con- 
founded with a retention cyst. On incision, daughter 
cysts may be seen, or hooklets may be found with the 
microscope. Healing by granulation, after discharge of 
the hydatid, is to be expected. 

Cysts in relation with tumors will be found under the 
heading of the appropriate new growths. 

Extravasation of blood, which may become encysted, 
has already been referred to. The ordinary wen—seba- 
ceous cyst—occurs rarely in the breast, and attains but 
small size. 

Tumors Resembling fully formed Connective Tissue— 
Fibroma, Lipoma, Myxoma, Enchondroma.—Of these the 
first named is much the most frequently met with; in- 
deed, it is much the least rare of benign mammary 
growths. It is composed of hyperplastic connective 
tissue, together with glandular elements, more or less 
imperfect. It is this latter circumstance which has 
given rise to confusion, the terms adenoid, fibro-ade- 
noma, adenocele, being used by various observers. 
The fibroma may enclose one or more cysts, from dilata- 
tion of contained ducts, or it may project, into a duct 
which becomes dilated, thus appearing as an intracystic 
or intracanalicular tumor. More precise information will 
be found under the headings Adenoma, and Tumors. 

Fibrous tumors are observed during the period of active 
menstrual life, preferably between the ages of sixteen and 





475 


Breast, 
Breast, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








thirty, yet instances have been recorded as early as twelve 
and as late as fifty-six years. An overgrowth existing 
in an active organ would be expected to induce pain and 
impair function; and the first expectation is verified in 
many cases, for pain in the breast during menstruation 
and pregnancy is common; during menstruation and 
pregnancy, also, increase in size of the tumor may occur, 
to subside as the gland regains physiological rest. Hered- 
itary predisposition is not apparent, and it is a singular 
fact that the negro, in whom fibroma uteri is very often 
found, is very rarely the subject of circumscribed fibro- 
mamamme. The variety of growth under consideration 
presents itself as a circumscribed, rounded mass, firm and 
elastic to the touch, with here and there, perhaps, a pro- 
truding boss, in which fluctuation may be apparent, in- 
dicating cystic association. The most usual site is that 
of the periphery of the breast, above the nipple, where the 
tumor will be found projecting under the skin; when 
deeply situated within the gland a fibroma is more apt to 
be intracanalicular. Variation in tension of a cyst, from 
absorption of its contents, will cause an apparent change 
of consistence in the tumor. <A capsule is usually present, 
but where much glandular tissue is joined with the fibrous 
—é.g., in intracanalicular growths,—the capsule is not 
complete. Neighboring tissues move freely over the 
growth. Section shows interlacing bundles of white 
fibrous tissue, with moist surface, and also, perhaps, acini 
or ducts dilated into cysts. While these fibroids usually 
occur singly, several may exist in one breast, or in both 
breasts simultaneously; they only exceptionally attain 
great size. The rate of growth is slow in solid tumors, 
but more rapid in the cystic variety; a sudden and very 
rapid increase is almost certainly an evidence of the cystic 
character of the tumor, and will cause change in its 
shape; cysts are more apt to occur (cysto-fibroma) toward 
the end rather than the beginning of menstrual life. A 
discharge of serous fluid from the nipple may occur with 
an intracanalicular growth; when the fluid is bloody, tel- 
angiectatic formation, or rapid growth (with increased 
vascularity), is probable. Adhesion of the growth to the 
skin, or surface ulceration, occurs as: an accident only. 
The neighboring lymphatics are not involved, and 
though a recurrence may be, and is, observed in rare 
cases, yet such recurrence is as a local growth without 
tendency to infiltrate adjacent parts. Fibroma rarely 
undergoes degenerative change—fatty, myxomatous, 
and cystic changes being the most frequent. So far as 
regards danger to life, a favorable prognosis is indicated. 
The treatment proper for fibroma is removal by incision, 
so directed as to interfere as little as possible with mam- 
mary function. 

Lipoma and enchondroma are not met with in the 
mamma, or so rarely as to be museum curiosities. Sub- 
mammary lipoma has been seen, however, a certain num- 
ber of times, and in no respect does it differ from fatty 
tumor elsewhere in the body, save perhaps that it has 
been more frequently observed in early life. The diag- 
nosis and treatment are the same as in other parts of the 
body. Myxoma is rare, and presents itself in the breast 
as a Single, rounded, perhaps bossed tumor, usually in the 
upper half of the breast. On section it appearsas a light- 
colored, jelly-like mass, yielding apparently mucin— 
hence the namemyxoma. Not infrequently fibrous, vas- 
cular, or fatty areas exist in the growth. The tumor origi- 
nates in the connective tissue between the lobules and is 
usually encapsulated. The latter half of menstrual life is 
the chosen age. Inflammation occurs exceptionally, but 
may induce ulceration of skin already infiltrated or 
stretched, with, perhaps, protrusion of the growth, 
which is movable usually in the mammary tissue and 
also upon the thorax. Increase is more rapid than that of 
fibroma, and the consistence is less firm; a cyst, if present, 
will not be recognized very easily. Involvement of both 
breasts (simultaneously) is not seen. Retraction of the 
nipple is not observed, pain is wanting, and adjacent 
lymphatics are uninvolved. An incision will usually be 
required in order that the diagnosis may be made. Re 
moval of the tumor by careful dissection will sometimes 


476 


be followea by a recurrence in situ ; removal of the en- 
tire gland, together with any involved skin, is therefore 
indicated. 

The term malignant, applied to a morbid growth, is 
used to indicate a tumor differing histologically from the 
tissue in which it is situated, having a tendency after re- 
moval to recur 77 situ, and having also a tendency to 
reproduce itself in distant parts of the organism. 

Sarcoma is a tumor composed of cellular elements of 
the connective-tissue type, which do not develop to ma- 
turity but remain embryonic; an intercellular substance 
is present, though but in scant quantity, and there is a 


new growth of vessels. 


Sarcomata are named according to the character of 
the cells of which they are mainly composed: spindle- 
celled, round-celled, myeloid, lymphoid, ete. Not infre- 
quently different parts of the same tumor show varia- 
tions of cell growth, and with some this is the rule, 
e.g., With myeloid tumors, in which the giant cells 
(myeloplaxes) rest in a spindle- and round-celled stroma 
(for histology see article on Tumors). Rarely seen before 
the establishment of menstruation, sarcoma invades the 
breast by preference between the ages of thirty and forty 
years, appearing infrequently after the cessation of men- 
strual life. In this respect it differs from carcinoma. 
Spindle-celled sarcoma is most often met with atan earlier 
age than other varieties. I am unable to connect the 
sterile or multiparous state with the etiology of sarcoma, 
although the relation with menstruation has been referred 
to. Traumatism is the unmistakable starting-point in 
certain cases; antecedent inflammation, save in very ex- 
ceptional instances, is lacking. 

Carcinoma, as I have noted, may deveiop from an in- 
duration left by puerperal mastitis; but I cannot recall 
ever having had such an experience with sarcoma. The 
upper half of the breast is more often affected. 

Inits general outlines sarcoma of the breast is rounded, 
oval, etc., in shape, and there exists a capsule which does 
not shut off the tumor from surrounding parts, so as to 
prevent extension; the capsule is formed of connective 
tissue pushed aside by the increasing tumor, and is infil- 
trated by its proliferating cells; outside of the capsule 
there are to be seen (microscopically), principally along 
the vesscls, uumerous cells, which I believe are already 
impressed with the character of the original tumor, or are 
direct offshoots from it, and develop into a similar neo- 
plasm. The insufficiency of any operation which at- 
temps to effect a cure without destroying such an area 
of infection is patent. The shape of the sarcoma varies 
with the rapidity of its growth, there being always a 
tendency to increase in the direction of least resistance. 
Sudden change in outline indicates a giving way of an 
opposing structure, cyst formation, or else extravasation 
of blood from a ruptured vessel; a general rounded out- 
line will be preserved, however. 'Trauma may give rise 
to extravasation of blood and consequent change of 
shape, but here the history aids the diagnosis. The 
growth of sarcoma varies much, and bears a certain rela- 
tion to its anatomy, the spindle-celled variety being of 
slowest growth and firmest consistence, and having a 
more perfectly defined capsule; while, on the other hand, 
a round-celled sarcoma is softer, grows rapidly, presents 
often rounded outcroppings, and the new-formed vascu- 
lar channels are apt to rupture and permit extravasation, 
not in one only but in several places. Cystic formation 
may cause sudden change of shape. Variation in rate of 
increase characterizes sarcoma; a nodule may remain for 
years without exciting suspicion, and then, from no known 
cause, grow with extreme rapidity. It is not usual for 
rapid growth to be succeeded by slow increase, but never- 
theless this has been observed. When cystic or other de- 
generation occurs, slow growth is not to be expected, 
but rather continuous progress; and the same is to be 
said when extravasation occurs, save from trauma. An 
intercurrent inflammation is apt to induce quick growth. 

Increased temperature is noted in rapidly growing sar- 
comata. The volume sometimes attained is enormous, 
tumors of many pounds in weight being recorded. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Breast, 
Breast, 





Sarcoma is usualiy single, and very rarely affects both 
breasts simultaneously. 

Adhesion to the chest wall is not usual, even if the 
tumor be of extreme size; on the other hand, implication 
of the great pectoral muscle is seen, but not so frequent- 
ly as in the case of carcinoma. Protrusion through an 
intercostal space into the thorax has been observed. 

Implication of the chest muscles will be recognized by 
investigating the mobility of the tumor when the great 
pectoral is alternately rendered tense and relaxed. The 
skin, although greatly stretched, generally remains mov- 
able over the neoplasm for a long time, and may be dis- 
colored red or purplish. Ulceration of the skin from 
pressure of, and incorporation with, a subjacent growth is 
much less often seen than in the case of a carcinoma. 
When, however, the skin has given way, fungous protru- 
sion is usual; the nipple is not affected, and a serous or 
somewhat blood-stained oozing, which has been observed 
in many cases, indicates involvement of ducts in or by 
the morbid growth; hence it occurs with cysts. 

Pain is often complained of; not, however, in my ex- 
perience, until the tumor had attained a certain size. 
When ulceration is present, a certain discomfort is to be 
expected. Iam inclined to attribute the occurrence of 
pain to pressure and traction upon nerves, rather than to 
the fact of their being involved in a rapidly growing 
tumor. Pain is referred to the arm in certain cases. 

Lymphatic enlargement is rare in sarcoma, and, when 
present, is due to irritative rather than to specific im- 
plication of the glands. Axillary bubo is therefore not 
often seen, and, if present, would raise a suspicion of 
carcinoma. The presence of ulceration, either from im- 
plication of skin in the morbid growth or from irritating 
applications, is often followed by hyperplasia of the ad- 
jacent lymphatic glands. 

It is believed that sarcoma becomes generalized by 
way of the blood-vessels rather than by that of the lym- 
phatics; hence the apparent immunity of the axilla in ad- 
vanced disease. 

General infection (sarcomatosis) is recognized by the 
formation of metastatic tumors, The lungs, presenting 
the first set of capillaries which sarcoma elements would 
meet after entering the circulation, would be expected 
frequently to be the seat of secondary growths, and such 
is indeed the fact. It is not possible to say at what time 
secondary tumors are most likely to appear, but it is al- 
ways wise to question the lungs before operating upon a 
sarcomatous breast, lest a pulmonary metastasis be pres- 
ent, and the operation do harm by reducing the patient’s 
strength. Local recurrence after operation is frequent, 
and while it is not possible to state the percentage in which 
a return 77 situ is to be looked for, yet it can be accepted 
as the result of clinical observation that the softer and 
more rapidly growing a sarcoma is, the more likelihood 
exists of recurrence; conversely, the firmer and more 
slow-growing the tumor is, the less chance is there of a 
return. Youth is more disposed to recurrence than age. 

From the foregoing, one would expect a round-celled 
sarcoma to justify a more unfavorable prognosis than a 
spindle-celled one. 

Cystic formations are present in many sarcomata; they 
result either from dilatation of ducts or from fatty or mu- 
coid degeneration, Calcareous, bony, or cartilaginous 
formations have been noted, and are to be regarded as 
curiosities. 

The only treatment that offers any prospect of acure is 
extirpation, free and complete, so as to remove not only 
the tumor, but the area of infection, already referred to, as 
well. Failure to succeed in this latter condemns a patient 
to early recurrence én situ. Local recurrent tumors also 
are to be excised, and immunity from return is thus 
gained. The removal of one tumor, when the disease is 
generalized, is useless. The well-known case of 8. D. 
Gross may be recalled with advantage :—A single woman 
was subjected to twenty-two operations in four years; 
the number of recurrent tumors removed was fifty-one, 
and varied in size froman almond to a hen’segg. Large 
portions of the pectoral, and also of the external and in- 





ternal intercostal muscles, were cut away. Ten years 
and nine months after the last operation she was in per- 
fect health. 

Melanotic sarcoma is very malignant. 

Carcinoma is an atypical new formation of epithelioid 
elements; for the anatomy, the reader will consult the 
articles on Carcinoma, and Tumors. 

Carcinoma is the most common and at the same time 
the most fatal of breast tumors; it affects all classes and 
all social conditions. Scirrhus and encephaloid, usually 
known as hard and soft cancer, are the varieties most 
often met with, the former in far greater proportion than 
the latter, however. Forty-eight to forty-nine years is 
generally accepted as the average age of patients com- 
ing under treatment; but it is to be remembered that the 
tumor will have existed for a certain time already before 
being seen by a physician, or, what is occasionally met 
with, but I am glad to say rarely, a patient will have 
been advised by a physician to pay no attention to the 
lump, and so a long time may be passed in fancied secur- 
ity. My personal experience leads me to consider forty- 
eight years too late an average age when carcinoma is 
first observed, forty-five or forty-six being more exact. 
The menopause is the period just before or just after which 
carcinoma may be expected to appear; indeed, the period 
of two years preceding the cessation of menstruation is 
especially favorable for its development. The earliest 
age at which I have seen a scirrhous carcinoma of the 
breast is twenty-seven years. Before thirty-five the oc- 
currence of carcinoma is very rare. Traumatism and 
preceding inflammation are occasionally exciting causes, 
but not sufficiently often to be considered as exercising a 
potent influence for evil. 

Heredity has long been held up as having causative 
power, but such predisposition can at most be traced 
to nine or ten per cent. Occasionally the opposite is 
seen, as in the case of Mme. Z—— and family,®* in whom 
sixteen deaths from cancer occurred in seventy years. 

While, then, blows, the remains of a previous abscess, 
and hereditary peculiarity may and do exist in a causative 
relation with carcinoma, yet the degenerative changes in 
the mamma consequent upon cessation of function is, 
without doubt, the most powerful influence in the de- 
velopment of carcinoma. Carcinoma begins in one 
breast; its presence in both should be accepted as indica- 
tive of general infection; it is never encapsulated, but is 
infiltrated into the adjacent structures. Thus, the out- 
line is not so well defined as in sarcoma, and while out- 
croppings are rounded, the body of the tumor may be in 
shape irregular; this is especially the case with scirrhus. 
Soft carcinoma is of rapid growth as compared with the 
hard variety; it is more vascular, more rounded in form, 
and gives to the hand a sense of fluctuation; the mam- 
mary gland is incorporated with, and not distinguishable 
from, the neoplasm. Scirrhous carcinoma, on the other 
hand, is of slower growth, of extremely hard consistence 
without much elasticity, presents to the examining hand 
firm but not large irregularities, and is apt to be flattenced,,. 
as indeed the mamma is flattened; in a late stage only is 
it to be seen as a projecting tuber elevating the skin. 
Scirrhus conveys to the hand a sense of weight rather 
than of bulk. Soft carcinoma may attain great size. 
As a point of differential diagnosis it is to be noted that 
scirrhus commences generally within the mamma, which 
is felt, in an early stage, to surround it on all sides, ex- 
cept toward the thorax, of course. Adhesion to chest- 
wall contraindicates an operation, the rule in this respect 
differing from that for sarcoma, which may sometimes 
be removed with advantage under such circumstances, 
if of slow growth. Fixation to skin, as well as to chest, 
is marked in the scirrhus variety, showing itself by 
lessened mobility and later by the formation of dimples. 

Adhesion to chest is recognized by lessened mobility, 
and is always preceded by the tumor becoming incor- 
porated with the great pectoral muscle; axillary swelling 
will also be found at this time if sought for. Retraction 
of the nipple is an almost constant symptom in scirrhus, 
and results from incorporation of the large ducts with 


477 


Breast, 
Breath, 








the tumor. Soft carcinoma and sarcoma do not present 
this peculiarity ; hence its importance from a diagnostic 
view. A discharge from the nipple would indicate im- 
plication of the ducts; it is a rare symptom and has no 
clinical significance. In adeno-carcinoma a serous dis- 
charge from the nipple is common. From the preceding 
it would be expected that a certain fixation of the nip- 
ple, the impossibility of drawing it forward, would be 
present before retraction took place; this is so, and con- 
stitutes a valuable diagnostic sign early in the life of car- 
cinoma (scirrhus). Besides adhesion and dimpling, in- 
fection of the skin may be recognized by the appearance 
of small, firm infiltrations, without elevation of surface 
or discoloration, in the neighborhood of the original 
growth. These indurations, which are first recognized 
by the touch, become harder, elevated, discolored, livid, 
and then ulcerate; in atrophic carcinoma they may even 
cicatrize. Their presence is indicative of an extremely 
large infected territory around the primary growth. 

I have never seen good results follow operations upon 
such growths; the resulting wound does not cicatrize, 
and the skin edges rapidly become infiltrated with new 
growth. Much importance has been attributed to the 
presence of large veins in the skin of a breast as indicat- 
ing a certain kind of tumor; I cannot admit that this is 
quite the fact, except in the general way that it is usual 
to find large vascular channels in the vicinity of a rapidly 
growing neoplasm. In atrophic carcinoma enlarged 
veins are very rarely seen, for here the circulation near 
the surface is not greatly increased. Ulceration in the 
skin is seen, commencing as a crack or fissure, which 
widens out and deepens, presenting the appearance of a 
shallow excavation with indurated edges and base usu- 
ally ragged, of pale color; the discharge is thin and ill- 
smelling; partial healing, with a thin, unhealthy scar, 
sometimes takes place. When softening of the tumor 
occurs, from one cause or another, and the skin gives 
way, there results a deep, crater-like pit, with everted 
edges, hard, irregular base, and profuse discharge. 
Hard carcinoma pursues the manner of ulcerating first 
described, soft carcinoma the latter. Fungous protru- 
sion I have not seen follow carcinoma ulceration. As 
has been said already it is seen in the ulceration of sarcoma. 

Pain is variable. I have repeatedly seen carcinoma of 
the breast, with implication of the skin and several 
glandular enlargements in the axilla, and yet the patient 
only accidentally discovered that the mamma was in- 
volved in any morbid process. Two such cases have 
come under my notice within the past month: both pa- 
tients were seen within four days after the discovery of 
the mammary swellings. The classical, lancinating, 
darting, shooting pains are exceptional in the incipient 
stage of the tumor; later, however, they are present; 
with inflammation and sloughing the pain is great; in 
atrophic scirrhus, with ulceration long continued, pain 
is extremely varied. Infection of adjacent lymphatic 
glands in carcinoma is a question of time; sooner or 
later it will occur, save in rare instances. The axillary 
glands, substernal, intercostal, and supraclavicular, 
sooner or later become involved. Just how soon glan- 
dular infection occurs is not known, as the primary 
growth exists some time before being discovered. 

The axillary enlargements result from the passage of 
elements from the original tumor through the lymphatics, 
and their arrest and growth in the lymph glands, thus 
reproducing the disease in the armpit, from which, con- 
tinuing their journey by lymph channels, tumor elements 
enter the general circulation, and carcinosis results. It 
will sometimes, though very rarely, be found that gen- 
eral infection occurs without glandular implication to 
any degree; this is to be explained by direct transmission 
through veins. Occasionally also slight glandular en- 
largement will disappear after removal of the original 
growth; in such a case it is clear that the glands were 
not carcinomatous, and were probably only irritated; 
but why this should occur in one case and not in another, 
we do not yet know. Carcinoma shows a predilection 
for the liver, lungs, and serous surfaces when it attacks 


478 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





internal organs. Colloid and cystic degenerations are 
those most often met with in carcinoma. Inflammation 
running into abscess is rarely seen except in connection 
with rapid growth, when also acute sloughing may occur. 

The prognosis of carcinoma is extremely grave, if left 
alone or if operated upon. S. W. Gross*’ gives the 
average duration of life for patients not operated upon as 
27.1 months, and for those who died after they had sub- 
mitted to an operation, as thirty-nine months; which 
shows that the operation added a year of life to each pa- 
tient. He furthermore computes the percentages of re- 
covery at 9.05. Owing to the fact that operation for re- 


moval of carcinoma is now extended so as to remove 


adjacent structures which may be involved in the growth 
the percentage of recovery has increased enormously; 
probably twenty-seven per cent. of patients operated 
upon for carcinoma mammée are now free from recur- 
rence for three years after operation. 

Carcinoma following long-continued ulceration of the 
nipple—Paget’s disease—has already been referred to. 

Within the past few years our knowledge of adenoma. 
has undergone a great change. Instead of being often 
met with it is now believed to be one of the growths 
most rarely encountered, and the so-called adenoid 
growths, adenocele, and adeno-cystic tumors are recog- 


_nized as composed of connective tissue. containing de- 


formed glandular elements—fibromata. 

It is doubtful whether it would be possible to differ- 
entiate clinically between fibroma and adenoma, nor in- 
deed does it-appear to be necessary, since both belong to 
the category of benign growths, and are to be subjected 
to like treatment. Perhaps the most notable fact observed 
in connection with adenoma is the extreme frequency 
with which cysts occur in its substance, a circumstance 
which is due of course to the presence of ducts which 
have undergone dilatation. 

Transformation or change in a tumor is met with and 
is always to be regarded with suspicion if characterized 
by rapid growth. 

TREATMENT.—A benign tumor of the breast is re- 
moved by freely uncovering it; the incision is to be 
directed from the nipple outward so as to do as little 
harm as possible to adjacent ducts, after which the 
growth is to be freed from attachment. It has been 
suggested that, to avoid a scar, the following manner of 
operating be adopted: “Carry an incision as long as 
necessary around the lower edge of the breast where it. 
joins the thorax, raise the breast, and through the incision 
indicated remove the growth from the posterior aspect 
of the gland, arrest hemorrhage, insert a glass drainage 
tube, replace the breast,” etc. Lateral stitches can be 
inserted before replacing the breast so as to give promi- 
ence to the breast. It is probable that few tumors re- 
quire such an operative measure; benign growths are 
usually situated in the upper half of the breast, not 
beneath it, so that an incision through the skin, and at 
once down upon the tumor, is more simple. As the 
mamma is generally covered save in exceptional in- 
stances, the presence of a scar may be disregarded. 

When malignant disease of the breast is presented for 
treatment it becomes necessary for the surgeon to decide 
whether an operation is expedient at all or whether the 
disease has spread so extensively as to preclude the pos- 
sibility of benefit by operative measures. While it is 
impossible to lay down hard-and-fast rules, it may be said 
generally that operation is not expedient if the growth 
cannot be removed; if life is to be shortened by the opera- 
tion; if pain and suffering are not to be diminished by 
the operation. The operation is to be undertaken if 
there is a good prospect of removing the growth; if life 
is to be prolonged; if pain and suffering are to be dimin- 
ished. These questions the surgeon must decide, after 
which the operation itself must be considered. 

It has been before said that outside and around a malig- 
nant tumor there is an area of tissue already sown with 
seed which, if not removed, will reproduce the original 
growth. Any operation which removes the tumor and 
leaves this infected area will certainly be followed by 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Breast. 
Breath, 





speedy recurrence; free and complete extirpation is there 
fore the first duty of the surgeon. In carcinoma, and 
perhaps sometimes in sarcoma, the lymph glands are in- 
volved; they are to be taken away. If they are enlarged 
and cannot be removed, no operation on the breast is to be 
undertaken. The glands above the clavicle, under the 
edge of the sternum, and along the ribs are to be searched 
for and removed. These two latter groups are more 
apt to be involved if the growth lies to the sternal side 
of thenipple. Notonly the lymph glands but the lymph 
channels should be taken away with the breast, and these 
channels are in close relation with the pectoral muscles 
and axillary fat; so that extirpation of a carcinomatous 
breast or a sarcomatous one calls for removal of the tu 
mor itself together with the entire mamma and skin over 
it which is or may be infected, both pectoral muscles, and 
axillary contents, consisting of fat, fascia, and lymphat 
ics. It will be best, save in rare cases, to.carry an incision 
into the neck, exposing the supraclavicular space, and to 
remove any lymphatics there found. It is difficult to state 
the lines of incision which shall enable the operator in all 
cases to carry out the above requirements. A tumor in 

volving the skin near the sternum, and one involving 
the skin near the axilla, will call for different incisions. 

Speaking generally, then: the breast is to be removed 
by an incision circumscribing widely the skin over the 
centre of the growth and passing through healthy tissue. 
This incision is to be extended into the axilla and down 
the arm, and will be more or less racquet-shaped, the 
handle passing through the axilla, and the other end, 
more or less round, corresponding to the mamma. From 
this incision a cut is to be carried upward over the 
clavicle into the neck. To facilitate closure of this ex- 
tensive wound I divide the skin downward several 
inches along the anterior axillary line. The flaps so 
marked out, consisting of skin and connective tissue, are 
very freely reflected, the incisions are then deepened, and 
the great pectoral muscle on which rests the mamma is 
reflected from the thorax and clavicle. The lesser pec- 
toral may be separated with the greater or be taken 
away during the dissection of the axilla. The axilla is 
now carefully cleaned by dissection of all fat and lym- 
phatics, during which the lesser pectoral if present is re- 
moved. The supraclavicular region, edge of sternum, 
and intercostal spaces are searched for lymphatics, which 
are removed. It may be expedient to take away a piece 
of rib if suspiciously near the neoplasm. Dissection is 
facilitated by removal of breast and axillary tissue in one 
piece. Bleeding during the operation is controlled by 
heemostats or ligature. Asa marked furrow in the mus- 
cle distinguishes the portion of the great pectoral which is 
attached to the sternum from that which is attached to the 
clavicle, separation of fibres is quickly and easily made, 
and the clavicular portion rarely if ever requires removal. 
When left it assists motion of the humerus. So far as 
my experience goes, splitting the great pectoral tendon 
and dividing the portion that corresponds to the removed 
muscle can be accomplished most easily with scissors. 

Closure of the large wound resulting from this opera. 
tion may be effected by skin grafting or by forming flaps 
as occasion seems to justify; or else healing by granula- 
tion may be permitted. Mixter fashions a large flap 
from the other side of the sternum, and causes the unaf- 
fected mamma to slide until it lies near the middle line. 

When dissecting an axilla I at once uncover the axillary 
vein at its lower (brachial) end,and with this as my land- 
mark the affair becomes simple. 

Occasionally ligation of the axillary veins is required; 
I have never seen trouble follow this procedure. 

I have observed that patients whose wounds do badly, 
from erysipelas or other cause, suffer speedy recurrence; 
an additional reason for securing early cicatrization. 
Recovery from amputation of the breast is usually rapid, 

-and the mortality is small. 

Recurrence after amputation demands extirpation as in 
the first instance, unless the secondary growth occur at 
a spot where complete removal is not possible. By re- 
peated operations I have prolonged life and given com. 








fort for years. Several years ago I operated upon a sin- 
gle woman, aged forty-eight, for the third time, remov- 
ing a small nodule as large as a pea, one-fourth inch in 
diameter, and also two indurated axillary glands. She 
was first operated upon in 1878, and for the two recur- 
rences in 1882 and 1885 respectively. Microscopical ex- 
amination enabled me to make a positive diagnosis in re- 
gard to its carcinomatous nature. An operation should not 
be undertaken if the primary growth cannot be removed 
together with involved axillary glands, or when it is ap- 
parent that general infection has already taken place. 
The surgeon, therefore, must not only examine the ap- 
parently affected region, but also investigate the integrity 
of internal organs as well. Extirpation of mammary 
growths by means other than the knife, e.g., by caustics, 
scarcely requires mention; so much the best instrument. 
is a knife, if properly guided. Until we can find a. 
caustic which will seek out and destroy the neoplasm, 
sparing healthy tissue, the knife will hold the first place. 
It may perhaps be expedient, when the tissue is very vas- 
cular, or when the ribs are suspiciously near the base of a. 
carcinoma, to apply a caustic after the knife has been used, 
but such instances are exceptions. When an operation is 
inexpedient, the surgeon must direct his efforts to the re- 
lief of the local discomfort by proper dressings, and to 
the amelioration of the general condition by appropriate 
medication. The condition of the patient is most un- 
happy, and I have always thought it expedient to allow 
opium or its alkaloid, morphine, in sufficient quantity to 
bring about a state of comparative relief. I have ob- 
served that in stout people recurrence of an extirpated 
growth is more rapid than in those of more slender build. 
L. McLane Tiffany. 


1 Journ. Anat. and Phys., July, 1879. 

3 Virginia Med. Month., vol. i., p. 87, 1874. 

4 Dict. des sc. méd., vol. iv., 1813. 5Tdem. 

7 Med. Times and Gaz., vol. ii., p. 70, 1855. 

8 Jour. gén. de méd., p. 57, 1827. 

® Jour. Anat. and Phys., November, 1872. 

10 Thése de Paris, 1880, p. 63. 

11 Lancet, 1840, vol. ii., p. 637. 12 Lancet, 1837, vol. i., p. 356. 

13 Wien. med. Presse, 1883. 

14 Am. Journ. Med. Sc., 1834, xiv., p. 374. 

15 Gaz. méd. de Paris, 1859, p. 818. 

16 Weit. neu. Beit. zur Chirur., 1841, pp. 42-64. 

17 Annali Univ. di Med., 1857, t. elxii., p. 53. 

18 Bibliot. de Manget, t. iii., liv. ii., p. 252 (from Labarraque, These 
de Paris, 1875). 19 Loc. cit. 20 Joc. cit. 

21 Dub. Quart. J. Med. Sc., 1870, p. 349. 22 Toc. cit. 

23 Brit. Med. Journ., 1874, 11, 106. 24 Joly: Thése de Paris, 1851. 

25 Trans. Edinb. Obst. Soc., 1875. 111, 122. 

26 Broca: Traité des tumeurs, vol. i., p. 152. . 

27 Tumors of the Mammary Gland, p. 164. 


BREATH,—air respired (E.) <A.S. bréd, breath, odor. 
Perhaps allied to Latin fragrare, to emit a scent: fragum, 
a strawberry; but this is uncertain.* Thus in the very 
origin of the word there is inherent the idea of odor. 
The breath consists of nitrogen and oxygen, the propor- 
tion of the latter being less than that present in the 
atmosphere; a little more than four per cent. of carbonic 
acid, aqueous vapor, ammonia, and organic impurities. 
Within the last quarter of a century, much work has 
been done in investigating the nature of the organic 
matter of expired air. Ben, in 1893, obtained 100 c.c. of 
water from 3,000 litres of expired air. The odor of this 
water was peculiar but not disagreeable - Its organic 
contents weighed 5 mgm. There were no alkaloids in 
it, but it gave a reaction for ammonia. It would seem 
that this organic matter is not capable of producing acute 
intoxication, but the untoward effects incident to breath- 
ing in limited spaces are due to lack of oxygen. There is no 
certain knowledge as to whether micro-organisms may be 
eliminated by the breath, although the laity believe in this 
possibility. Welch states that the consensus of authority 
is against the probability of such an occurrence. Experi- 
ments have shown the difficulty with which micro-organ- 
isms are detached from moist surfaces by air currents, so 
that itis likely that they are never conveyed to the outside 
air by ordinary quiet breathing. The proportion of car- 


2 Thése de Paris, 1877. 
§ Idem. 





* Skeats’ Etymological Dictionary of the English Language. 


479 


Breath, 
Breath, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





bonic acid is increased in the early stages of smallpox, 
measles, and scarlatina, and during the existence of any 
extensive skin disease. It is diminished in typhus fe 
ver. The temperature varies somewhat, being influenced 
slightly by that of the external air, but seldom falls be- 
low 90° F. When the temperature of the inspired air is 
very high, asin the hot room of a Turkish bath, the 
breath may appear, by comparison, to be cool. In fevers 
its heat is increased, but in the algid stage of cholera it 
is almost cold 

There is a deplorable lack of knowledge concerning 
the physiological odors of the breath In health the 
breath is nearly odorless, but there is a sweet odor from 
certain glands about the cutaneous limit around the 
nostrils. Nature has designed this as a sexual excitor, 
and together with other attractions between the sexes it 
helps to insure reproduction of the species. This is not 
characteristic alone of the female, but the male also, if 
living a comparatively normal life, possesses the same 
attraction. The pleasure of kissing is due chiefly to this 
source. Consequently, in blunted olfactories, osculation 
loses its greatest charm. Each person is characterized 
by his own peculiar nasal odor, and the more refined he 
is, and the higher in the scale of civilization, the more 
delicate the odor. On the contrary, the coarser the in- 
dividual, the more heavy the odor, e.g., negroes emit a 
musky odor. Individuals who are not in good condition 
for reproduction, or who are lacking in passion, possess 
slight nasal odors. It has been stated to be absent or 
disagreeable in pregnant women, 

Among the curiosities of literature, there are reported 
cases of luminous or bright red breath; and others of 
inflammable breath—in which there was a flash of flame 
from holding a lighted match near the mouth. This last 
phenomenon is probably due to the formation of com- 
bustible carburetted hydrogen from the chemical decom- 
position of breath. James Gray, in the Lancet, speaks 
of the “peculiar odor of the breath previous to death,” 
and cites two cases in which was exhaled the same phos- 
phoric odor just before death 

The term halitosis, diseased breath, is derived from the 
Latin halitus, breath, and the Greek, vdcoc, disease (How 
ard). Offensive breath does not express a morbid en 
tity. It is merely a symptom, however extreme it 
may be,—a functional disorder which may occur at any 
time of life. It is most common in the male; it may be 
due to various causes, never produces pain, is present 
under many different circumstances, is never dangerous, 
but it is sometimes the most striking and annoying fea- 
ture of a case, and is so disgusting and humiliating that 
it causes misery not only to the patient, but to all within 
his environment. Very slight causes often modify the 
delicate breath of health, and in certain morbid condi 
tions the odor is quite characteristic, and may be valu- 
able as a diagnostic sign 

The odor of the breath is modified temporarily by 
many causes. Mental emotion often exerts a power 
ful influence over the odor of the breath. If the many 
well-known pathological effects of excessive emotion be 
reviewed, this fact will not seem strange. For mental 
disturbance may so change the secretions of the aliment- 
ary tract and the glandular system that the normal elimi- 
nation of waste products is prevented, and an extra 
burden is thrown on the lungs, with resulting foul 
breath. Or the sudden excitement may cause a greater 
destruction of tissue than normal, so that before the in- 
testinal glands can-accommodate themselves to this in- 
crease the burden of vicarious elimination is thrown on 
to the lungs. The subjects are, as a rule, conscious of 
its presence. There is generally a pasty taste in the 
mouth, and this together with the disagreeable breath 
may be almost instantaneous with the occurrence of the 
emotion. Such patients are commonly neurotic and 
high-strung, and possess a mercurial temperament. 
Many volatile substances taken into the system through 
the ordinary channels are excreted in part through the 
lungs, and impart their odor to the breath. Thus tur- 
pentine, alcohol, onions, cheese, spices, and many other 


480 





alimentary and medicinal substances taken into the 
stomach are quickly detected by their peculiar smell in 
the expired air. In women the expired air frequently 
acquires a disagreeable character during the menstrual 
period, said to be due to the nasal and retro-nasal secre- 
tion of the mucous membrane, which at that time is con- 
gested. In feverish conditions the breath acquires a 
sweetish, or sometimes sickening, character. This is 
particularly noticeable in children, and in them is often 
suggestive of the odor of chloroform. In diabetes mel- 
litus there is often a peculiar sweetish odor, which is 
difficult to describe, and which has been likened to that 
of honey, sweet apples, or hay. In uremia the breath is 


‘said often to acquire a strongly ammoniacal odor due to 


the non-elimination of the urea, which persists in the 
blood and combines with the water to form carbonate of 
ammonia. The skin a!so exhales the same odor. In 
pyzemia also the breath is peculiar and characteristic. 
Dr. Tavignot, a French writer, described, some years 
ago, a peculiarity of the breath in glaucoma, to which 
he gave the name of haleine safranée ; and he maintained 
that this was constantly present in persons suffering 
from that affection. There are cases recorded of exten- 
sive burns in which the breath, formerly sweet, has 
assumed the disgusting odor of bisulphate of carbon. 
Migraine is often accompanied by a bad breath. Tuber- 
culosis can often be detected by a characteristic breath, 
Pernicious anzemia, pseudo-leukemia, and interstitial ne- 
phritis frequently have this symptom. 

Various mineral substances, which are themselves 
nearly or quite without smell, cause, when introduced 
into the system in sufficient quantities and during a cer- 
tain period of time, a very disagreeable odor of the 
breath. This occurs from stomatitis in some cases, and 
in others from the disturbance of digestion, induced by 
the chronic poisoning. The substances which most fre- 
quently are concerned in the production of toxic halitosis 
are: antimony, arsenic, lead, mercury, phosphorus, and 
sulphur. Sulphur imparts a distinct odor not only to 
the breath, but also to the perspiration after two hours. 

In chronic alcoholism the odor of the expired air is very 
foul, not necessarily alcoholic unless liquor has been re- 
cently taken, but possessing a peculiarity all its own, 
and unlike anything else. The excessive use of tobacco 
not infrequently imparts a foul odor to the breath. 

A permanent foulness of the breath is due either to in- 
terference with the elimination of the products of decom- 
position by the intestines and kidneys or to locai causes 
existing in some part of the respiratory tract. 

Perhaps the most frequent cause of a bad breath is 
dyspepsia, either gastric or intestinal. The hurry, ex- 
citement, and worry characteristic of our present cen- 
tury are greatly to blame for these ills. Overwork, ex- 
cessive application to business, sedentary habits, and the 
habit of “bolting” food, all briag in their train irre- 
mediable results. In this case the elimination of the 
products of decomposition and of the effete matters of 
the tissues by the normal channels is interfered with to a 
greater or less extent, and the task of their excretion from 
the economy is in part thrown upon the lungs. The ex- 
pired air contains a large amount of organic matter, 
which is often very ill-smelling and offensive. In cancer 
of the stomach or liver, disordered digestion is often 
heralded by a foul breath. In chronic constipation, es- 
pecially, the odor of decomposing organic matter is most 
marked. The most common causes of constipation are a 
decrease in the secretion of mucus from the glands in 
the intestinal walls, or deficient peristalsis of the mus- 
culature of the same. Hepatic disorders always entail 
certain disturbances of digestion. A very common symp- 
tom of intestinal worms, especially ascarides in children, 
is foul breath. 

Among local causes there are various affections of the 
mouth, nose, pharynx, larynx, and lungs. 

Dental caries is a well-known cause of foul breath. 
This arises not only in consequence of the decay of the 
teeth, but also, and chiefly, from decomposition of food 
lodged in the cavities and between the teeth; also from 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Breath. 
Breath, 





tartar and the micro-organism leptothrix buccalis.- These 
causes may give occasion to a fetid breath in persons who 
are careless in cleansing the mouth, even when the teeth 
are perfectly sound. Gingivitis, from arsenical or mer- 
curial poisoning, or from scurvy, may give rise to a bad 
breath, as may also syphilitic ulcerations of the buccal 
cavity or fauces. Pyorrhca alveolaris is also another 
cause. “Spontaneous stomatitis” occurs without any 
apparent cause. The entire interior of the mouth is 
affected, and the fetid saliva taints the breath. In many 
points this affection resembles mercurial stomatitis. Fol- 
licular stomatitis occurs at any age. This inflammation 
takes its origin in the follicles of the mucosa, on the in- 
side of the lips, and on the sides of the tongue. In certain 
cases a vesicular eruption (herpes) is the first manifesta- 
tion of the disease. There is a condition known as ca- 
tarrh of the tongue, which is usually associated with 
dyspepsia, but may occur independently of it. Here 
again décomposition of mucus, epithelial scales, and food 
particles as well as bacteria are the offending cause. In 
necrosis of the jaw which may result from mineral poi- 
sons, decayed teeth, or syphilis, the odor is frequently 
sickening. The breath of patients suffering with car- 
cinoma of the tongue and neighboring parts is very pen- 
etrating, but that from cancrum oris, stomacace, or noma, 
is almost unbearable, and once experienced can never be 
forgotten. 

In nasal polypi, after the secretion from the nose be- 
comes muco-purulent, the breath is apt to be disagreeable. 
Ozzena, from whatever cause produced, is frequently 
responsible for a most foul and repulsive odor. This is 
due, according to Browne, to the fact that “the crusts 
and discharges usually contain decomposing fatty glo- 
bules and micro-organisms.” Mouth-breathers with 
nasal stenosis are often afflicted with bad breath. ; 

Like the odor of necrosis of the jaw, that of follicular 
tonsillitis and pharyngitis is sickening. In the latter 
case the odor is due to decomposition of the secretion 
and food particles filling up the follicles, and is often 
suggestive of fecal matters. This inspissated secretion 
becomes cheesy in consistency. Chronic enlargement of 
the tonsils is apt to occur in young people with the so- 
called scrofulous diathesis. The breath in these cases is 
often foul. In diphtheria there may be a disagreeable 
foetor of the expired air suggestive of putrefaction. This 
is especially true of epidemic diphtheria. Putrid sore 
throat shares with diphtheria this symptom of halitosis. 
Syphilitic and tuberculous ulcerations in the larynx often 
impart an unpleasant odor to the breath, and the foetor of 
some forms of bronchitis, of bronchiectasis, and of abscess 
and gangrene of the lungs is too well known to require 
any description. 

Finally, some individuals suffer from a more or less 
fetid breath, the cause of which it is impossible to dis- 
cover. It is often congenital; it is constant, and not 
dependent upon any apparent deviation from health, 
but is often associated with a strong and unpleasant 
odor of the sweat and other-secretions. 

In the following table the various conditions leading 
to the production of a bad breath are arranged under 
their several classes for convenience of reference’ 


CAUSES OF HALITOSIS. 


Mental disturbance. 
‘Transient ... ~ Various ingesta, medicinal and alimentary. 
The menstrual period. 
Fevers. 
Diabetes mellitus. 
Ureemia. 
Pyzemia. 
| Glaucoma, (?). 
Burns. 
Migraine. 
Tuberculosis. 
Pernicious anemia. 
Pseudoleukzemia. 
Interstitial nephritis. 





‘Systemic..... 


Antimony. 
Arsenic. 
Lead. 
Mercury. 
Phosphorus. 


Vou. II.—81 


STORING seis e's 





Sulphur. 
Toxic «.....» 4 Alcohol. 
Tobacco. 
Gastritis. 
Dyspepsia. 
Cancer of stomach or liver. 
Constipation. 
Hepatic disorders. 
Enteritis. 
Intestinal worms, particularly ascarides in children. 
Dental caries. 
Toxic. 
Gingivitis. ~ Scorbutic. 
Syphilitic. 


Stomatitis. | “Spontaneous.” 


Digestive.... 


Follicular. 
Pyorrhoea alveolaris. 
Lingual catarrh. 
Necrosis of jaw. 
Carcinoma of tongue and other parts. 
Cancrum oris. 
Lack of cleanliness. 
Polypi. 
Herpetic. 
Syphilitic. 
From foreign bodies. 
Scrofulous, 
Idiopathic. 
Osteo-necrotic. 
Follicular tonsillitis. 
Follicular pharyngitis. 
Faucial...... 4 Syphilitic ulceration. 
Diphtheria. 
Putrid sore throat. 
i Carcinoma. ; 
Laryngeal... A Syphilitic. 
Ulceration. ( Tuberculous. 
Bronchiectasis. 
Putrid bronchitis. 
Tuberculous ulceration (cavities). 
Gangrene. 
Abscess. 
Carcinoma. 


Ozeena. 


Pulmonary .. 





Idiopathic. 


The treatment of a foul breath consists essentially in 
discovering, and, if possible, removing the cause. In by 
far the largest number of cases the origin of the trouble 
resides in digestive disturbances, usually associated with 
constipation, or in carious or dirty teeth. The first care 
of the physician should be, therefore, to regulate the di- 
gestive functions, and to see that the hygiene of the 
mouth is properly attended to. If the gums are spongy 
or receding, a tooth wash containing myrrh should be 
used. All cavities should be plugged with gold or some 
other suitable filling, as the dentist may advise, and the 
tartar, which accumulates between and behind the teeth, 
should be removed from time to time. The teeth should 
be picked, after each meal, to remove the particles of 
food, or, better still, they should be cleansed by means 
of dental floss, and should then be brushed with plain 
water, soap and water, or a reliable dentifrice. If the 
stomach is at fault, in addition to the remedies suitable 
to the condition, a piece of charcoal cake or charcoal 
powders may be taken shortly after meals. An odor 
which cannot be removed may be more or less effect- 
ually disguised by oil of nutmeg, cinnamon, cardamom 
seed, cloves, pimenta, lavender water, sweet-flag, leaves 
of the common partridge berry, or allspice, coffee, and 
other aromatics. A solution of carbolic acid (1 to 200) 
may be used as a mouth wash or gargle when the fcetor 
is due to organic destruction of tissue. The following is 
an agreeable mouth wash which will often disguise un- 
pleasant odors: Thymol, 0.50 gm. (74 grains); borax, 
1 gm. (15 grains); distilled water, 500 gm. (1 pint). The 
mouth is to to be rinsed frequently with this solution. 

For persistent foul breath, Howe advises the following 
combination. In the first place, the teeth should be thor- 
oughly cleansed and the gums sponged with a soJution 
of myrrh and water; then one of the following wafers 
may be allowed to dissolve in the mouth. 


R Pulv. cinnam., 
Pulv. pimente, 


EU Vee LO All nem retererenencis tee ciate eieieustele © ceUcU LD. By 
Sacchari alb......... Oe cleats « Sony 
Nikotol|, geaebine BVOC: 5 ete oi mde Sou q.s. 


Make fifty pills. 


481 


Brides-Les-Bains, 
Bromides, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





In conjunction with these wafers, the following may 
be employed: 


R Pulv. carui sem., 
Pulv. coriandri sem., 


Jelly, teaver 4 QS Seay oa. ....a& 388. 
pacchijalbys yeu seer apes 5 Metals rita ee Le 
Mucil. gum. acacie....... Vid ne eteetehe q.'s. 
Make fifty pills. Dissolve one in the mouth when 
necessary. 


All these deodorizers are, however, of necessity merely 
palliative in their effects, and the cause should always, 
if possible, be searched for and removed. 

In the preparation of the foregoing article the present 
writer has made free use of the material published under 
the same heading in the previous edition. 

Emma E. Watker. 


BIBLIOGRAPHY. 


Medical Press and Circular, London, 1880, xxix., 531. 
Journ. Anat. and Physiol., 1870, iv., 209. 

Bull. soc. de chir. de Par., 1872, 3, i., 286. 

Lancet, 1845, ii., 274; i., 11; ii., 701. 

Howe, J. W.: The Breath and the Diseases which Give it a Fetid Odor. 
Edinburgh Med. Journ., 1865, x., 961. 

London Med. Gaz., 1844, i., 224. 

Med. and surg. Reporter, 1876, xxxiv., 148. 

Brit. Med. Journ., London, 1886, i., 295. 

Maryland Med. Journ., 1895, xxxiii., 276. 

Eclect. Med. Journ., 1897, lvii., 1. 

Journ. Hyg., New York, 1895, xlv., 260. 

Edin. Med. Journ., 1884, xxx., 596. 

Browne on Diseases of the Throat, fourth edition, 1893. 
QGsler: Practice of Medicine, 1896. 

Holt: Diseases of Infancy and Childhood, 1898. 

skeat : Etymological Dictionary. 

Vaughn : Twentieth Cent. Prac. of Med., 1898, vol. xiii. 
Ernst: Ibid., vol. xiii. 

Gaston: Ibid., vol. xv. 

Duckworth: Ibid., vol. ii. 

Lyman : Ibid.) vol. ii. 


BRIDES-LES-BAINS is a spa in Savoy, France, often 
called, because of the composition of its waters, the 
French Carlsbad. Until recently the piace was practi- 
cally inaccessible, the nearest railway station being 








20 miles away. Now, however, the railroad has been 
extended and there is a station at Mofitiers, distant only 
3 miles. The village is most picturesquely situated, at. 
an altitude of 1,800 feet above sea level, in a valley run- 
ning from southeast to northwest, enclosed on either 
side by almost precipitous mountain slopes. 

Access.—The station of Mofitiers is on the Paris, Lyons, 
Mediterranean Railway, 672 miles, or 13 hours, from 
Paris; fare, 75 fr. 35 c. first class, and 50 fr. 90 c. second 
class. 

Analysis.—The following is the composition of the 


_water, according to an analysis made by Willm in 1890: 

















Grams, Grains, 

per litre. per pint. 
Carbonate Of calcium it. 1.6 ces sii se ao 0.3133 , 2.7752 
Carbonate of magnesium <).)....c.<005saeaee cee .0112 0992 
CATDONATE: OF IP OMS \erasein ical teeters elaieieroistote ce reletate 007: 0692 
GITECR corais ores a edo ialavecans bie eta volaze: vie ovetoveniatetannistere 0464 4108 
CHIOTIGS OF SOGTUIN oes. clev caibyale sister's ie cletaere 1.8318 16.2244 
Sulphate: of sodium Fran. hvac ..cceteawescnne 1.1604 10.2836 
Sulphate OF POCASSUUM oir «sve «isle/sisiesis'e viele cleiale 0946 8380 
Sulphate-or this oe aevik nicceviveceaeeemcent 0095 -0840. 
Silpnate’ of calcitims..ancesss cee ee ae Rote 1.7143 15.1940 
Sulphate of magnesium .............6+. efeccels 5288 4.6836 
Argeniate of Sodium. cava. sacncssises en nae -0008 0071 
Phosphates, bromides, iodides ....... ROSSA. Traces. Traces. 
Carbonic acid forming bicarbonates......... 2934 2.6012 
Free carponiecaGid: .x\.t-uvy.« esd ovate rela aene L017 -9008 








Indications.—The waters of Brides are in moderate 
doses laxative, in larger quantities (six to eight glasses. 
daily) purgative. It is claimed that they can be taken 
for many days in succession without increasing the dose, 
and they do not irritate to the same degree as do many 
of the stronger purgative waters. They are used in 
various disorders of the abdominal viscera, such as con- 
gestion of the liver following dietetic imprudences or al- 
coholic excesses or a prolonged residence in the tropics, 
gall-stones, constipation, functional disturbances of the: 
digestive tract, obesity, the so-called uric-acid diathesis, 
gravel, diabetes, anzemia and chlorosis, and chronic con- 





Fig. 1052.—Brides-les-Bains and the Glaciers of the Vanoise, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Brides-Les-Bains.. 
Bromides, 





gestion of the uterus and adnexa. In many cases treat- 
ment with Brides water internally iscombined with baths 
at Salins-Moitiers, distant two miles from Brides. 

Accommodations.—There are four hotels at Brides, in 
addition to numerous boarding houses, which afford 
good and ample accommodations at from six to eight 
francs and upward a day. A casino, music in the park, 
and the usual attractions of the continental spa are to be 
found here. There are two churches, a Catholic and a 
Protestant, the latter being served by an English clergy- 
man during the season. The climate is mild, but not 
enervating. The season extends from the middle of May 
to the middle of September. 

Satins-Mottrers.—This is a small thermal station in 
Savoy, France, distant 672 miles from Paris, on the Paris, 
Lyons, Mediterranean Railway. It is situated ina narrow 
valley in a grandly picturesque country, at an elevation 
of about 1,500 feet above the ievel of the sea. It is 2 
miles from Brides-les-Bains, with which it is connected 
by an electric railway. 

Analysis.—The following is the composition of the 
water, according to an analysis made by M. Willm, Pro- 
fessor of Chemistry at Lille, in 1890: 




















Grams, Grains, 

per litre. per pint. 

MAEM ALO OL CALCIUM «5 cre .a.c/0.5 0.000 ,0.n/0 diese vies 0.6488 5.8892 
Carbonate of magnesium -0089 0801 
Carbonate of iron ......... 0136 1224 
CA ee re cP: esses ales « 0332 2988 
Chloride of sodium ....... : 12.4886 112.3974 
Chloride of potassium ..... 1695 1.5255 
Sulphate of lithium .......... cA -0046 0414 
PUERTO EEO CONGHUIT): “aiueiaia «, ofaisie wares o1<s.a0 5 wea 2.0638 18.5742 
Sulphate of MagnesiuM ...........ceeeeeeee -8460 7.6140 
ATHOMIRVCIOL ROGIUI cs cwscccecsecccsccss ces 0007 0063 
Phosphates, bromides, iodides .............. Traces Traces. 
Organic matters and losses .............+6- .0192 1728 
Carbonic acid forming bicarbonates......... 5906 5.3154 
(PAPER CATOOIIC ACI ccs ccisiadieitsc.a=csuiee's cisvees 3854 3.3486 





Indications.—The waters of Salins-Mofitiers are em- 
ployed chiefly for bathing, usually in connection with 
the internal use of the water of Brides-les-Bains, but they 
are also taken internally in special cases. According to 
D. W. Samways, “for young people with enlarged 
glands, anemia, chlorosis, or general lack of vigor, these 
baths are excellent, especially in conjunction with the 
climatic advantages of the locality. For the overworked 
or neurasthenic, for those also in whom convalescence is 
tardy, they are similarly very reviving. For such cardiac 
affections as can be relieved or controlled by baths and 
exercises similar to those in vogue at Nauheim, and for 
certain congestions and disorders of the uterus and its 
appendages they are also very beneficial.” 

Accommodations.—There is a hotel at Salins-Moftiers, 
and there are also many boarding houses in the village 
where guests may find suitable accommodations. Most 
of those who take the baths, however, do so in conjunc- 
tion with the internal use of the waters of Brides-les- 
Bains, and live at the latter place. The climate is mild 
but invigorating. The season lasts from the middle of 
May to the middle of September. 

Edward O. Otis. 


BRIGHT’S DISEASE. See Kidneys, Diseases of the. 


BROMAL HYDRATE.—C.HBr,0,H20. Like chloral, 
bromal is an oily fluid which, uniting with water, forms 
a crystalline hydrate. Bromal hydrate occurs in white 
crystalline masses of a sharp, burning odor and taste, 
fusible at 53.5° C. (128.3° F.), and soluble in water. 
Physiologically the drug is severely irritant, and, ab- 
sorbed into the circulation, has been found by experiment 
(Steinauer) to cause restlessness followed by sleep, and, 
if the dosage be pushed, dyspneea, convulsions, and death. 
It may relieve pain, and has been thought to be of avail 
in averting threatened epileptic fits, but it is not official 
in the United States Pharmacopeeia and is little used in 





medicine. It has been given in three-grain doses (Stein- 
auer), but it is so disturbing to the digestive functions 
that the dose must be given in great dilution. 

Edward Curtis. 


BROMALIN.—Hexa-methylene-tetramine-brom - ethyl- 
ate; brom-ethyl-formin—(CH:.)s;NHC:H;:Br—made by 
acting upon hexamethylene tetramine with ethyl bromide. 
It is in colorless scales or a white crystalline powder, al- 
most tasteless and freely soluble in water. It is decom- 
posed by heat. Bromalin was introduced to take the 
place of the alkaline bromides in epilepsy, and may be 
used in other conditions in which bromides are indicated. 
The dose is gr. xv.-lx., and even large quantities are: 
said not to cause bromism. W. A. Bastedo. 


BROMAMIDE., — Tri - brom - aniline - hydrobromide — 
C.-H2Brs;. NH,HBr—nitro-tri-benzol is reduced by nascent 
hydrogen and then acted upon by hydrobromic acid to 
form bromamide. It occurs in colorless acicular crystals 
without odor or taste and is readily volatilized by heat. 
It is insoluble in cold alcohol, soluble in sixteen parts of 
boiling alcohol, and in chloroform, ether, and fixed oils. 
As an analgesic, sedative, and antipyretic it has been 
shown to act promptly and effectively in acute and chronic 
rheumatism and neuralgia. Dose: gr. v.-xv. in powder 
or capsule several times a day. W. A. Bastedo. 


BROMELIACEA..—A family of some forty genera and 
probably five hundred species, almost entirely tropical, 
in both hemispheres, a few sub-tropical. The family, by 
virtue of its structure, epiphytic habits and relations, is 
one of the most interesting known to botanists, and very 
many of its members are highly ornamental. Its economic 
importance is considerable. The pineapple is its most 
important product. The leaves of many species are im- 
portant fibre-yielders, and the well-known “Florida 
moss” or “black moss” (Tillandsia usneoides L.) has 
many uses. The dissolving power of pineapple juice 
upon albumen has been utilized in diphtheria to a slight 
extent. Its valueas an aid to stomach digestion is prob- 
ably of far greater importance, and the same property 
appears to exist in some of the leaf juices. 

Henry H. Rusby. 


BROMIDES.—1. GENERAL MEDICINAL PROPERTIES OF 
THE BRoMIDES.—Compounds of bromine, whose basylous 
radicle is innocuous enough to permit of their medicinal 
administration in decided quantity, all show a certain 
influence over the animal system, commonly, and un- 
doubtedly rightly, referred to the action of the bromine 
of their composition. Of the effects, the most striking 
feature is derangement of nerve function, which, in 
moderate dosage, takes the form of a deadening of reflex 
irritability, cerebral and spinal, and in poisonous admin- 
istration shows itself as failure of power, voluntary as 
well as reflex, in the cerebro-spinal centres. Clinically, 
the prominent effects are that the nervous, agitated, and 
wakeful subject becomes calm, tranquil, and predisposed 
to sleep; that convulsive seizures, the expressions of 
unnatural reflex irritability, such as the convulsions of 
epilepsy and of tetanus, tend to abate in frequency and 
violence; that a qualmish stomach becomes quieted, 
that tickling of the fauces fails to provoke gagging, and 
that sexual eagerness and even power wane. In pro- 
founder bromism what was at first intellectual laziness 
and indifference becomes positive stupidity, with failure 
of memory and with or without a certain grade of 
aphasia; what was a dulness of reflex activity passes to 
motor and sensory weakness—paresis of sight, hearing, 
and tactile sense and profound muscular debility, until 
at last, after apparently total abolition of all conscious 
existence, the poisoned subject dies, either from respira- 
tory or from cardiac failure. Minor effects, in cases of 
continuous bromide medication, are a peculiar fcetor to 
the breath, a tendency to an acneiform eruption, most. 
pronounced on the face, arms, back, and buttocks, and 
a tendency to congestion and even cedema of the fauces. 


483, 


Bromides. 
Bromides, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





and uvula, and, later, of the conjunctiva also. All of 
these various symptoms, formidable though many of 
them are, rapidly abate upon discontinuance of the medi- 
cine, and, as arule, leave no permanent morbid results. 
Other effects, notably derangement of the circulation and 
lowering of body temperature, are observed in the opera- 
tion of the most commonly used bromide, namely, the 
potassium salt, and also in that of the closely allied 
lithium bromide; but inasmuch as these are effects which 
are more or less common to all salts of potassium and 
lithium, it is an open question whether their occurrence 
in the present connection is not due rather to the basylous 
element of the bromide than to the bromine. Bromides 
are quick of absorption, and, generally speaking, fairly 
quick of elimination, and in such elimination are to be 
found in all the secretions—urine, feces, sweat, saliva, 
and even in the pus of the acne pustules. 

The most interesting effect of bromides, namely, the 
derangement of function of the cerebro-spinal nervous 
system, has been made the theme of much experimenta- 
tion for the purpose of finding just where the bromide 
influence strikes. As usual, the experiments are not 
wholly in accord, but their general drift clearly indicates, 
as H. C. Wood points out, that the deadening of func- 
tional activity occurs first and most severely in the per- 
ipheral ends of the afferent nerves and those portions of 
the axis that have to do with the reception of sensory 
impressions and their transmission as an impetus for 
motor reflex response. Later, and to a proportionately 
lesser degree, are affected the motor tract of the cord and 
the motor nerves. By this hypothesis is rendered in- 
telligible the oft-observed occurrence that a bromized 
frog, while profoundly indifferent to pricks or searings, 
from evident cutaneous anesthesia, may still retain 
enough command of motor power to hop, and vigorously, 
too, at will. 

The therapeutics of the bromides consist of the direct 
application, for clinical ends, of the bromine influence to 
blunt nervous impressibility. Such displays of nervous 
excitement as are the expression of a state of direct mor- 
bid irritation of the nervous system, in whole or in part, 
are conditions proper for the action of a bromide; but, 
on the other hand, the derangements of nerve function 
caused by exhaustion, general or local, are distinctly not 
to be treated by bromine medication For in such latter 
case, because of the generally depressing character of the 
bromine influence, the exhaustion will be deepened, and 
the nervous symptoms, therefore, intensified. Prominent 
illustrations of the conditions in which bromides may be 
of benefit are undue restlessness and wakefulness, or men- 
tal irritability or morbidness from any emotional cause, 
or from severe intellectual labor under pressure; undue 
excitability of a lusty sexual apparatus from too free in 
dulgence: and, more notable still, expressions of reflex 
action, such as the convulsions of epilepsy, of tetanus, 
or of strychnine poisoning; the convulsions of children, 
seasickness, or the vomiting of pregnancy or of neurotic 
poisoning. Conditions in which, on the other hand, bro- 
mides are useless or harmful are restlessness, wakeful- 
ness, or mental derangement from want of sleep, from 
starvation, from loss of blood, or devitalization from a 
prostrating disease, such as typhoid fever, or, locally, 
irritability of the sexual organs when associated with 
beginning of failure of power through exhaustion from 
excessive abuse. In cases for which bromides are fitting 
it is hardly necessary to say that the remedy will promise 
more if resorted to at the outset, and that large doses 
may conquer where small ones will utterly fail. In 
chronic and intractable disease, such as epilepsy, two 
points, besides sufficiency of dosage, must be observed, 
as follows: First, the blood must be kept evenly and 
continuously charged with the bromide salt. And, by 
reason of the rapid elimination of the salt, this result can 
be secured only by giving the daily allowance in at least 
three doses, whereof the evening one, having longer to 
last, should be larger than the others. Secondly, the 
medication must not be too speedily discontinued after 
apparent cure of the malady, but, on the contrary, must 


484 














be kept up for months, and even years, thereafter. In 
epilepsy, it is smgular that the form of the disease called 
petit mal should be, as it is, distinctly less amenable to 
bromide medication than the classical form in which the 
fits are outspoken. In epilepsy, when the disease is re- 
cent and of the latter variety, the curative power of the 
bromides surpasses that of any other drug; but, asa rule, 
the remedy will have to be pushed to the development 
of a certain grade of bromism before benefit appears. 

2. THE Bromipes Usep 1n Mepicine.—The bromides 
official in the United States Pharmacopeia are, among 
bases of the heavy metals, zine bromide, and among those 
of the alkali metals and metals of the earth, potassium, 
sodium, lithium, ammonium, strontium, and calcium bro- 
mides. Hydrobromic acid and brominated camphor also may 
be mentioned as being, logically, bromides, and further- 
more as showing in their action upon the animal system 
the peculiar bromine influence in addition to their other 
effects. Lastly, an ethereal bromide, namely, monobro- 
methane (“bromide of ethyl,” “hydrobromic ether”), al- 
though not official, has been used in medicine as an 
anesthetic. In the present article will be discussed only 
the bromides of the metals of the alkalies and earths, in 
which alone the bromine influence is the dominant me- 
dicinal virtue. For zinc bromide, see Zinc ; for hydro- 
bromic acid, see Hydrobromice Acid ; for brominated cam- 
phor, see Camphor; and for ethyl bromide, see Hthyl 
Bromide. 

Potassium Bromide : KBr.—Potassium bromide is offi- 
cial in the United States Pharmacopceia as Potass?i Bro- 
midum, Potassium Bromide. It occurs in “colorless or 
white, cubical crystals or granules, odorless, and having 
a pungent, saline taste. Permanentin the air. Soluble, 
at 15° C. (59° F.), in about 1.6 parts of water, and in 200 
parts of alcohol; in less than 1 part of boiling water, and 
in 16 parts of boiling alcohol; also soluble in 4 parts of 
glycerin. On heating the salt upon platinum foil, it de- 
crepitates; near 700° C. (1290° F.) it fuses without decom- 
posing, and at a bright-red heat it volatiiizes, communi- 
cating a violet color to the flame. The aqueous solution 
(1 to 20) is neutral, or has at most only a scarcely per- 
ceptible alkaline reaction upon litmus paper” (U.S. P.). 
In some commercial samples the alkalinity is said to be 
decided, sufficiently so to enable the salt to precipitate al- 
kaloids from solutions of their salts.!_ Potassium bromide 
should be kept in well-stoppered bottles. 

Potassium bromide is the most generally active, the 
best known, and the most commonly prescribed bromide. 
It is capable of producing to the highest degree the 
peculiar bromine effects already detailed, and also has a 
marked influence over the circulatory organs, and, if 
pushed to poisoning, a power distinctly to lower body 
temperature. The circulatory derangement consists first 
in a slowing and weakening of the heart’s contractions, 
passing even to stoppage of the organ in diastole; and, 
secondly, a probable—but probable only—narrowing of 
the lumen of the smaller blood-vessels, through vaso- 
motor spasm. Partly because of the effect upon the 
heart, and partly also because of the presumed effect 
upon the blood-vessels, potassium bromide is commonly 
held to induce partial capillary anzemia, especially of the 
nerve centres—spinal cord and brain. And because of 
this anzemia, in turn, it has been imagined by some, and 
become quite a text-book tradition with many, that the 
action upon the vascular organs is the only direct one 
that potassium bromide exerts, all the nervous phenomena 
being sweepingly accounted for as mere secondary con- 
sequences of a diminished blood supply to the cerebro- 
spinalaxis. Torefute this notion it seems only necessary 
to cite on the one hand the fact that other bromides than 
the potassic which have but little of the depressing effect 
of the latter salt upon circulation yet show the bromine 
influence over nerve function, and, on the other hand, to 
note that cerebro-spinal anzemia, occurring as it can easily 
be made to do experimentally by other methods and to 
any degree, is, when so determined, never followed by 
the peculiar phenomena of bromism. 

As the drug is medicinally given, the clinical effects of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bromides, 
Bromides, 





o 


potassium bromide are a salty taste in the mouth, with a 
little increase in the flow of the saliva, and perhaps also 
some diuresis, an abatement of all forms of nervousness, 
fidgets, or even spasms, with a tendency to mental calm 
and indifference, intellectual and physical sloth, and, if 
circumstances favor, drowsiness. Along with these sug- 
gestive symptoms the pulse falls somewhat in force and 
frequency. If the dose has been single and not over- 
large, little other than the foregoing effects will be de- 
clared; but, if the taking be continuous and the doses 
range high, the derangement may be profound, the sub- 
ject presenting the picture of one mentally dull even to 
idiocy, with perhaps some aphasia; dull of hearing, 
sight, and feeling; physically weak even to paresis, 
sexually impotent, and with the peculiar symptoms of a 
foetid breath, a whispering voice, a face broken out in 
acne, a congested or even cedematous faucial arch, a slow 
and failing pulse and respiration, and a depressed body 
temperature. In overwhelming dosage, paralysis of 
sense and motion becomes absolute, and death ensues 
quietly by failure of respiration or of cardiac action—the 
former if the poisoning has been progressive by accumu 
lating small doses, the latter if by a single overpowering 
charge. But, as usual with the bromides, so long as the 
condition is one short of death, the symptoms quite cer- 
tainly will ameliorate—and that, too, without lasting re 
sults—upon stopping the medication. In case of serious 
poisoning, the treatment must be in accordance with 
general principles, consisting in evacuation of the stom- 
ach, if a large single dose has been taken, and, for the 
rest, the employment of measures addressed to maintain 
ing the action of the heart and lungs. 

Potassium bromide is used, medicinally, exclusively 
for the peculiar purposes of the bromides generally, as 
set forth in the first section of this article. When the 
need is transient only, as to quiet a squeamish stomach, 
or to calm a restless subject and invite sleep, the dose 
will range from 1.3 to 8 gm., or thereabouts (gr. xx. to 
xlv.), according to the intensity of the disturbance 
and the susceptibility of the individual. When, on 
the other hand, a continuous and powerful impres- 
sion is necessary, aS in treating epilepsy or tetanus, 
the doses may have to be both large and frequent In 
dealing with epilepsy, the daily quantity will rarely be 
less than 6 gm. (gr. xc.) and may need to reach 15 
gm. (half an ounce), given broken up into three or four 
doses evenly distributed over the waking hours, except- 
ing as to the evening portion, which should be somewhat 
larger than the others. The actual dosage in a given 
case must be determined by the effects produced upon 
the fits. A clinical rule with some is to give the salt 
until the usual reflex gagging, occurring upon tickling 
the fauces, is found to be abolished. Even with the 
smallest daily quantity above named a certain degree of 
“promism ” will foliow the continuous giving, and such 
result must be expected. Rarely indeed will any im. 
pression be made upon the epilepsy until some bromism 
shows itself. In tetanus or strychnine poisoning the 
dosage of bromide reaches its maximum. Here the ex- 
traordinarily heightened reflex irritability which is the 
essence of the morbid condition in the two affections 
makes the subject comparatively insusceptible to the 
benumbing influence of bromine. Even so large a dose 
as 15 gm. (half an ounce) has been given at a single 
draught, and the daily total should certainly reach this 
figure. Yet in strychnine poisoning it must be remem. 
bered that the tetanus, if it does not kill within a couple 
of hours, then rapidly abates, and simultaneously, of 
course, disappears the insusceptibility to bromide influ 
ence. Care must be taken, therefore, to diminish the bro- 
mide dosing, as the morbid irritability fades, else, as has 
actually happened, the subject may be saved from death 
by strychnine convulsions only to be brought to the verge 
of the grave by bromide palsy. Potassium bromide is 
administered in solution either in simple iced water or, 
what is pleasanter and in case oi large doses makes the 
draught less obnoxious to the stomach, in water slightly 
alkalized by the addition of a little sodium bicarbonate , 








or, best of all, in water both alkaline and effervescent, 
such as Vichy? or Apollinaris. 

Sodium Bromide: NaBr.—The salt is official in the 
United States Pharmacopeeia as Sodii Bromidum, Sodium 
Bromide. It occurs in “ colorless or white,cubical crystals, 
ora white, granular powder, odorless, and having a saline, 
slightly bitter taste. From air the salt attracts moisture 
without deliquescing. Soluble, at 15° C. (59° F.), in 1.2 
parts of water and in 13 parts of alcohol; in 0.5 part of 
boiling water and in 11 parts of boiling alcohol. When 
heated to a bright red heat the salt melts, and, at a 
somewhat higher temperature, slowly volatilizes without 
decomposition. To a non luminous flame it imparts an 
intense, yellow color. The aqueous solution is neutral, 
or at most very feebly alkaline, to litmus paper” (U. 8. 
P.). Sodium bromide is hygroscopic, and should be kept 
in well-stoppered bottles. 

Sodium bromide is less unpleasant to taste than the 
potassic salt, and is in every way less deranging of func- 
tion. But yet, despite the fact that its innocuousness 
permits of its prescription in larger doses and for more 
continuous administration than may be possible with 
potassium bromide, the bulk of testimony goes to show 
that the sodic salt is of distinctly inferior curative power. 
Its use is, therefore, properly confined either to cases 
in which but a mild effect is called for, or to those in 
which, for any reason, the potassic salt cannot be given, 
or having been given must be abandoned. The fact that, 
weight for weight, the sodic bromide contains more 
bromine than the potassic (in the proportion of 77 62 
to 67.18) simply shows the more forcibly the intrinsic 
physiological feebleness of the compound. Sodium 
bromide should be given in the same manner as the 
potassic salt, and in the same dose, carefully to be aug- 
mented according to the effects produced. 

Lithium Bromide: LiBr.—The salt is official in the 
United States Pharmacopeia as Lithit Bromidum, Lith 
ium Bromide. It occurs as a “white, granular salt, 
odorless, and having a sharp, slightly bitter taste; very 
deliquescent. Soluble, at 15° C. (59° F.), in 0.6 part of 
water and in 0.3 part of boiling water; very soluble in 
alcohol, also soluble in ether. At a low red heat the salt 
fuses, and at a higher heat it is slowly volatilized. It 
imparts a crimson color to anon luminous flame. The 
aqueous solution is neutral to litmus paper” (U.S. P.). 
Being exceedingly deliquescent, this salt should be kept 
in well stoppered bottles. 

So far as observed, lithium bromide very closely re 
sembles the potassic salt in its effects, as the nature of its 
base would render likely. Dr. 8. Weir Mitchell, of Phila- 
delphia, who first advocated this bromide for use in the 
nerve affections for which potassium bromide is com 
monly prescribed, considers the lithic salt more, speedily 
and more powerfully hypnotic than the potassic. It has 
the demerit of comparative costliness. It contains pro 
portionally more bromine than does any other of the 
alkaline bromides, and has been recommended in one-half 
the dose of the potassic salt (Weir Mitchell). 

Ammonium Bromide: NH,Br.—The salt is official in 
the United States Pharmacopeeia as Ammonii Bromidum, 
Ammonium Bromide. It occurs as “colorless, transpar- 
ent, prismatic crystals, or a white, crystalline powder, 
odorless, of a pungent, saline taste, and permanent in the 
air. Soluble, at 15° C. (59° F.), in 1.5 parts of water and 
in 80 parts of alcohol; in 0.7 part of boiling water and in 
15 parts of boiling alcohol. When heated, the salt vola- 
tilizes completely without melting. The aqueous solu- 
tion of the salt has a slightly acid reaction upon litmus 
paper” (U.S. P.). 

From the point of view of the clinician, ammonium 
bromide may be regarded as substantially a duplicate of 
potassium bromide in medicinal virtues, while at the 
same time more acrid in taste and in local. action. It 
has been used for the same purposes as the potassic salt, 
and in the same dose, and has been strongly recommended 
by Brown-Séquard and others in epilepsy. It is less de- 
pressing than potassium bromide. 

Strontium Bromide: SrBr2.6H20.—The salt is official 


485 


Bromidia. 
Bromoform, 








in the United States Pharmacopoeia as Strontii Bromidum, 
Strontium Bromide. It is in “colorless, transparent, hex- 
agonal crystals, odorless, and having a bitter, saline taste. 
Very deliquescent. Soluble in 1.05 parts of water at 15° 
C. (59° F.) and in 0.5 part of boiling water. It is readily 
soluble in alcohol, and is precipitated from this solution 
upon the addition of an equal volume of ether, in which 
it is insoluble. When heated the crystals at first melt 
and then lose all their water (80.4 per cent.). The anhy- 
drous salt fuses at 630° C. (1166° F.). Toanon-luminous 
flame the salt communicates an intense, red color. The 
aqueous solution is neutral to litmus paper” (U. 8. P.). 
Owing to the extreme deliquescence of this salt it should 
be kept in well-stoppered bottles 

As in the case of the strontium salts generally, this one 
closely resembles in its effects on the animal system its 
potassic congener Compared with potassium bromide, 
however, strontium bromide is the better borne, having 
less tendency to derange digestion or to bring on the 
special symptoms of bromism. It may be prescribed in 
the same doses and for the same purposes as the bro- 
mides generally. 

Calcium Bromide : CaBr2.—The salt is official in the 
United States Pharmacopeia as Caleti Bromidum, Cal- 
cium Bromide. It is a “ white, granular sait, odorless, of 
a sharp, saline taste, and very deliquescent. Soluble, at 
15° C. (59° F.), in 0.7 part of water and in 1 part of al- 
cohol; much more soluble at a boiling temperature. At 
680° C. (1256° F.) the salt fuses, and at a higher temper- 
ature itis partly decomposed, with loss of bromine. The 
salt is neutral to litmus paper” (U. 8. P.). The salt 
must be kept in well-stoppered bottles. 

Calcium bromide does not seem to differ materially in 
properties from potassium bromide, and stands in medi- 
cine as an additional and not over-necessary substitute 
for the same, in the same range of application and in the 
same dosage. It was originally proposed by Dr. W. A 
Hammond, in 1871. Edward Curtis 


1U. S. Dispensatory, 18th edition, quoting Charles D. Chase. 
2 Seguin: Archives of Medicine. 


BROMIDIA isa proprietary remedy which is stated to 
contain ina fluiddrachm~ Chloral hydrate and potassium 
bromide, of each gr. xv., and gr. } each of the extracts of 
cannabis indica and hyoscyamus. Analyses indicate that 
it also contains oil of orange peel and extract of licorice 

W. A. Bastedo. 


BROMIDROSIS. — (Bromhidrosis, Osmidrosis; Ger. 
Stinkender Schweiss.) Bromidrosis, as a disease per se, isa 
pathological variation in the odor-producing constituents 
of the sweat as secreted, is associated as a rule with the 
functional disorder of the sweat apparatus, hyperidrosis, 
and, like it, may be either local or general. This condi- 
tion as such, if it occurs at all, is rare. 

The condition ordinarily denominated bromidrosis is 
due, as was taught by Hebra to be the case in the ma- 
jority of instances, to a rapid decomposition of the sweat 
after its secretion, with the resultant odor, warranting the 
term stinking applied to it. 

When local, as is more commonly the case, the regions 
affected are those in which sweating oftenest occurs in 
excess and in which its quick evaporation is more or less 
retarded or prevented by the nature of the parts or their 
covering . as the axille, groins, ano-genital region, and the 
feet—the last being by far the most frequent situation of 
the affection. Here the odor is marked and most charac- 
teristic, differing from the odor of other parts affected by 
its unmistakable, nauseating heaviness when once recog- 
nized—and one whiff is all sufficient,—the foul emanation 
rendering the near neighborhood of the unfortunate vic- 
tim anything but pleasant, and sometimes impossible. 

The change that takes place in the sweat is claimed to 
be due to the presence of a special micro-organism—the 
bacterium feetidum, a micrococcus which Thin, of Prague, 
recognized in sweat obtained from the feet. It has been 
shown by Parkes that soldiers with uncovered feet do 
not suffer from this affection, and he claims that the only 


486 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cause of the disease, if such it can be called, is the cover- 
ing of the feet, the absence of all coverings giving no 
opportunity for the development in the secretions of the 
special bacterium 

Treatment in general is linked with that of hyperidrosis. 
A level teaspoonful of the precipitated sulphur in milk 
twice daily has been highly recommended It is an em- 
pirical remedy, the action of it not being explained by 
Crocker, who claims to have succeeded more often by 
this than by any other procedure, local~ treatment not 
being necessary with it. However, dusting finely pow- 
dered boric acid well in between the toes and rubbing 
it into the stockings and shoes daily will be found as 


_ efficient, cleanly, and convenient a local method as any 


yet devised, and some local treatment will generally 
have to be resorted to Hot water applied as hot as can 
be borne for a few minutes before using the boric acid is 
a great aid 

If the sulphur treatment purges too freely, its action 
may be controiled by astringents. In five to ten grain 
doses salicylate of soda may be found useful. This may 
be tried when patients object to the sulphur. It has 
cured some cases. Among other local remedies may be 
mentioned chromic acid; painted on the feet in five to 
ten per-cent. solution, according to the obstinacy of the 
case, every three to six weeks, it has been used success- 
fully. Mutton suet with two per-cent. salicylic acid is 
in general use in the German army for rubbing on the 
feet, and further has the advantage of a lubricant when 
much walking is to be done. Formalin in one to ten per- 
cent. strengths in alcohol is of value It should be fol- 
lowed by the use of dusting powders. <A one-per-cent. 
solution of permanganate of potash has been well recom- 
mended. Various other remedies are extolled, but the 
boric acid will be found the best of all if preceded by the 
hot-water applications. Charles Townshend Dade. 


BROMINE.—Bromine is official in the United States 
Pharmacopeia as Bromwm, Bromine. It is described as 
“a heavy, dark, brownish red, mobile liquid, evolving, 
even at ordinary temperatures, a yellowish-red vapor, 
highly irritating to the eyes and lungs, and having a pe- 
culiar suffocating odor, resembling that of chlorine. Spe- 
cific gravity, 2.990 at 15° C. (59° F ), soluble in 30 parts of 
water at 15° C. (59° F.), and readily soluble in alcohol or 
ether (with gradual decomposition of these liquids): also 
in carbon disulphide, and in chloroform, with a deep red- 
dish-yellow color. On exposure to air or to heat it is 
completely volatilized” (U. 8. P.). Bromine has the 
same intense affinity for hydrogen that has chlorine, and 
so, in similar manner to chlorine, determines the oxidation 
of organic matter in the presence of moisture by appro- 
priating the hydrogen of the water and liberating the oxy- 
gen. The fumes of bromine are thus deodorant, like 
chlorine, and if present in an atmosphere in great volume 
would doubtless prove destructive to floating disease 
germs Mixed directly with foul-smelling or infectious 
matter, bromine is powerfully deodorant and disinfectant. 
Yet practically it is of little use in such capacity, by rea- 
son of its costliness, its bad smell, its caustic and bleach- 
ing tendency, and the exceedingly irritant action of its 
vapor upon the human air passages. Squibb estimates 
that an ounce of bromine, accidentally spilled in an ordi- 
nary chamber, would render the air thereof dangerous to 
life. 

Locally applied to living animal tissues, pure bromine 
is a very searching and painful caustic, and non-caustic 
dilutions act as detergent and stimulant lotions to foul or 
sloughing ulcers. Here again, however, the cost of the 
remedy and its offensiveness render it less practicable 
than its efficiency would suggest. For caustic purposes, 
bromine is applied clear, the patient being etherized, if 
the area to be cauterized is at all extensive, and the ope- 
rator taking care that his eyes and nose do not come too 
near the fumes of the very volatile and pungent liquid. 
For a strong lotion, a ten per-cent. solution in water may 
be employed, wherein the bromine is made to dissolve by 
the addition of one-third of its weight of potassium bro- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bromidia, 
Bromoform, 





mide. -For weaker lotions—any percentage less than 
three—bromine is directly soluble in water without any 
saline addition. Taken internally, bromine is doubtless 
absorbed as a bromide. It was formerly used as an inter- 
nal medicine in the class of diseases for which iodine or 
the alkaline iodides are now so extensively employed. 
For the specific purposes of the alkaline bromides (see 
Bromides), bromine is practically unavailable, because of 
its irritant action and offensive taste. Bromine has been 
given internally in the dose of from three to six drops of 
a two-and-a-half-per-cent. aqueous solution. 

ToxicoLocy.—Bromine is an intensely irritant, corro- 
sive poison. The fumes, inhaled, produce extreme irri- 
tation of the eyes, the air passages, and even the stomach. 
Severe bronchitis, pulmonary hemorrhage and inflam 
mation, and death may result. Swallowed in overdose, 
bromine produces the usual symptoms of the corrosive 
poisons, viz., intense gastric irritation, collapse, and 
death. <A half-ounce of bromine, swallowed, produced 
death in seven anda half hours. In case of poisoning 
by inhalation, the local irritation should be treated. by 
the breathing of the atomized spray of an alkaline solu- 
tion, such as Dobell’s solution. In poisoning by swal- 
lowing. the stomach must be washed out and ammonia 
given, largely diluted and mixed with olive oil. 

Edward Curtis. 


BROMINE-ARSENIC SPRINGS.—Ashe County, North 
Carolina 

Postr-OFFIcE.—Crumpler. Hotel. 

Accrss.—Via Norfolk and Western Railroad to Chil 
howie, Va., thence 39 miles by stage to the springs; 
also by private conveyance from Bristol, Tenn., 34 miles 
west. 

This spring was discovered in 1885. Since that time it 
has come into extensive use, and its waters are widely 
sold. The location of the spring is in a mountainous 
district, 2,725 feet above the sea level. There is a hotel 
with accommodations for about one hundred persons at 
the resort. The spring flows about sixty gallons hourly, 
ane following analysis was made by Prof Henry Froeh- 
ing: 





Solids. Grains. 
SES CITE CRPUIAIAL UES oct e Vavotoiel otal crsve sia su wbveve’e 0\scr ee, 0.0 < b0te o.sie'e 1.04 
AONE CAT WOTLALG se chassis cistereic de cis. osieieia sbi cie-e elsinjcle'g eres’ .93 
MASON: CATOOIALC 16 ie aivve cuore sbivivisicljvieine cess einer .62 
Lithium carbonate ......... SDE OUR HODTO HBS eOOe -03 
MAPS EIO AIRE CSOTAILGG Fete gicle'y.2. 5 Sips olgie-vic sete eo oes. oe Sieve lersiee sialé Trace. 
ZIDCECATDODALE S65 000 seiee ee britan aevowtoe ad acts ee LTACe: 
MATAR LELUOTACA Gi aiacatane sibie.Slecoie.s ayers. <facorers alevele/€s.e sa ett Trace. 
PreMaamSTUANIAYSIRLELSLUC cco cistc.s'a'e e's 0's occ.c:3 cle as'e's.b.u 6 8 wise os 6.8 62 
ReANUET I ATETSETTOLUCLONE occ (c/o ctvalee clece'e ohlsla e'ale  eib.c elels.e 6 ores . 21 
BOG CHIOTIAS 655406 05% sive v0 0 Ua Maisac sents crohis wiehros 65 
SOGIUM .arseniate: ... 6.0.0.8 ercjelatavote rafeiaiaeverspsiee di eia e's Trace. 
PM RSIMETAC NOG em ain rlslclec ascc cst ciel sein’ «tiaeinie-aiece sn ee Trace. 
MOTEUMAU DROVE: <5 cwresciec se cece cosces cvactiesitioe sess 04 
SCA DPRUTU DEI ONAILE  aicisie cinie)s. Sloteseyeie bi0.cie,aig:e elsreieiaiel plavaveliiets ayo, LLTACR: 
PATE DTROSD NAC ss ciosie oc aciaiels pape wereele coleleon's Poca’ 0 12 
EPEMITATMIA UG Asis aysip stece as ras ic ae.s © eeaces's tues ctie e vise. 08 
Reo ars cle araie: she lsvaraidie(e ati tee seh a elnigeiars o's aipera-e oi 1.08 
RAL VEICRULLULOLT Ait, cial osha ite aiere'e a, Parein B/apielatatele ale s:eayanniais 03 

CCE ge GB ACe OO eIEIeD Rahat hoe ee eke von Me aretersictals Se 5.45 


The water is unique in possessing recognizable quan- 
tities of copper and zinc. It also contains the somewhat 
rare ingredients of arseniate of sodium and the iodide and 
bromide of sodium. We also find an appreciable amount 
of carbonate of lithium and sulphate of iron. The water 
is not highly mineralized, but it possesses valuable quali- 
ties as a mild antacid, tonic, and alterative. It is useful 
in many of the affections benefited by this class of 
waters James I. Crook. 


BROMINE CHLORIDE.—By direct union of the two 
elements, bromine and chlorine, a compound is formed 
appearing as a reddish-yellow, volatile, mobile fiuid, sol- 
uble in water. This compound is powerfully caustic, 
but has never been used in regular medicine except as an 
ingredient of a caustic paste used by Landolfi, of Naples, 
for the treatment of cancer. Hdward Curtis. 














BROMIPIN is an addition product of oil of sesame, con 
taining ten percent. of bromine’ It is a yellow fluid 
having the appearance of a fixed oil, and it has a bland, 
oleaginous taste. In spite of the large amount of bro- 
mine which it contains, the oil is non irritating and may 
be given pure by mouth. It is readily absorbed and its 
action is of the same character as that of the alkaline bro- 
mides. Losio claims that it surpasses potassium bromide 
in chorea, epilepsy, and trigeminal neuralgia. Dornbliith 
found that one drachm given at the evening meal would 
ward off a night attack of cardiac palpitation or angina 
pectoris. The oily taste of bromipin is not pleasant, but 
very soon the taste is acquired, and the patients continue 
to take it for a long time without gastric or intestinal 
disturbance. The dose is one-half to two drachms daily 
for restlessness and nervous irritability, for chorea or 
epilepsy, up to four drachms a day It may be adminis. 
tered pure and unmixed, or with beer, or mixed with 
cacao, sugar, white of egg, and oil of cinnamon. A not 
unpleasant emulsion is made by taking two ounces of 
bromipin and emulsifying it with half an ounce of pow- 
dered acacia, half an ounce of syrup, and cinnamon or 
peppermint water to make four ounces, to be given in 
doses of from one to four drachms. W A Bastede 


BROMO-ALBUMIN is a ten per-cent. bromine com- 
pound of peptone, albumose, or protogen. It is given in 
doses of from one-half to two drachms in epilepsy and 
other nervous conditions Its indications are the same as 
those of the alkaline bromides. W A. Bastedo. 


BROMOFORM.—(Terbromide of formyl, CHBr; ) In 
chemical composition it is analogous to chloroform, 
CHCls, and iodoform, CHI;. It is formed by the action 
of brominated lime on alcohol in the same way that chlo- 
roform is made from chlorinated lime and alcohol. It is 
a bright clear liquid, specific gravity 2.9, taste sweet, 
and does not cause any irritation to the mucous mem- 
brane of the mouth; it has an ethereal odor is almost 
insoluble in water, but is soluble in alcohol and ether. 
It is very volatile and is rapidly decomposed by light, 
bromine fumes being evolved whicn impart a pink color 
to the liquid. 

Bromoform possesses anesthetic properties, but in a 
less degree than chloroform, the period of excitement 
being less pronounced and the anesthesia of shorter 
duration. It is also a powerful antiseptic 

A new application of this drug was brought to the 
notice of the profession in 1889 by Dr Stepp, of Niirem- 
berg, who advocated its use in whooping-cough. He 
claimed that the course of the disease was shortened in 
every instance, that the paroxysms were diminished in 
number and severity, that complications were less fre- 
quent, and that when present they were benefited by 
the treatment. The doses which he gave at different 
ages were as follows From six months to one year, M™ ij. 
three times a day; from one to two years, MT iij., from 
two to three, T iv.; from three to four, TL v , and from 
four to seven, TM vi. or vij. In prescribing the remedy 
its high specific gravity must be remembered, one minim 
being equal to five drops. 

The drug is given in a teaspoonful of water; it forms 
a “bead” in the water and is easily swallowed. It may 
be given in solution in water to which a small amount 
of alcohol is added, but should always be freshly pre- 
pared on account of its instability. It should be em- 
ployed with some caution, as ill effects have frequently 
followed its use. It has produced nausea, vomiting, and 
diarrhoea, and other symptoms of gastro-intestinal irri- 
tation. The more pronounced toxic symptoms are pallor, 
cold perspiration, staggering, dilatation of pupils, heart 
failure, collapse, and a tendency to narcosis. Fatal cases 
have been reported (Miinch. medic. Wochensch., xlv., 1211; 
Lunion méd., September, 1891). 

Stepp’s method of administration is not ‘to be recom- 
mended, and many of the cases of poisoning are ex- 
plained by the uncertainty of this dose. It is preferable 
to use it dissolved in alcohol. Compound tincture of 


487 


Bromol, 
Bronchitis, 





cardamon and syrup of orange may be added. Another 
mixture that is recommended is an emulsion of bromo- 
form with oil of sweet almonds, gum acacia, gum traga- 
canth, and syrup. All mixtures in which the drug is 
not dissolved are very uncertain, and require to be pre- 
pared with great care. ? 

How the drug acts is uncertain; whether as a specific 
or on account of its germicidal properties, has not been 
determined. Dr. Stepp thinks bromine is excreted by 
the lungs after the drug has been decomposed in the 
system. The reports of others who have used it for this 
purpose corroborate the views of Dr. Stepp as to its effi- 
cacy in whooping-cough. Beaumont Small. 


BROMOL.—(Tribromophenol.) This is formed by add- 
ing bromine water to a solution of phenol. It is deposited 
in white crystals; taste is sweet and astringent; odor re- 
sembles bromine; it is nearly insoluble in water. but is 
soluble in alcohol, ether, oils, and glycerin 

It has been introduced as an antiseptic in the treat- 
ment of wounds, ulcers, etc, Applied in its pure state 
it has a slight caustic action and favors the removal of 
sloughs. Asa dressing it is applied in solution in oil or 
as an ointment, one part in thirty. It has been used in 
diphtheria asa local application ‘to disinfect the throat 
and remove the membrane. 

When administered internally it is not acted on by 
the gastric secretions, and in the intestines is but slowly 
decomposed. Its action is therefore slow and prolonged. 
It is given in doses of gr. iij. to v. a day, and has proved 
of service as an intestinal antiseptic in cholera infantum 
and typhoid fever. For infants gr } to + may be given 
at each dose. Beaumont Small. 


BRONCHI, MINUTE ANATOMY OF.—As a preface 
to the histology of the bronchi, a short résumé of the 
gross anatomy seems here desirable. The bronchi—more 
properly bronchia, Bpoyyia, meaning swallow or throat— 
probably received the name through Plato, who taught 
that their function was to receive the liquids, the cesoph- 





Fic. 1053.—Represents a Transverse Section of the Bronchial Wall at 
the Fifth Bifurcation in the Human Adult. a, Epithelial layer of 
mucous membrane; b, hyaline basement membrane, formed from 
c, internal elastic layer, showing its varying thickness: d, d, mus- 
cular layer; €, muciparous crypts; f, cartilaginous lamina; g, ex- 
ternal layer; h, branch of bronchial artery. (About 30 diameters.) 
(Drawn with camera by Dr. F. Cary.) 


agus receiving the solids. Aristotle having supported 
this theory, the name remained so long in medical use as 
to become a fixture. 

The bronchia, beginning at the tracheal bifurcation 
opposite the third dorsal vertebra (fourth in female), 
terminate in the pulmonary lobules. The primary tra- 
cheal branches, from their distribution, are named the 


488 


. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





right and left bronchus. The former is shorter, larger, 
and more horizontal than the latter, and the septum bron- 
chiale separating them is placed to the left of the longi- 
tudinal (in the recumbent posture of the body) axis of 
the treachea. Hence bodies falling into the trachea lodge 
more frequently in the right bronchus. Hyrtl teaches 
that post-mortem examinations of the new-born, dying 
after a few respirations, show that the right lung re- 
spires before the left, and he explains the fact by the 
difference in size and location of the beginning of the 
right bronchus. The general rule of dichotomous sub- 
division obtains, but is not without exception; ¢.g., the 
right bronchus subdividing into three branches, one for 
each lobe. Occasional small branches are given off by 
the main trunk. Having reached the diameter of 0.21 
mm. (5p inch), they enter the apices of the pulmonary 
lobules. Here again branching at acute angles they 
dilate slightly,, becoming funnel-shaped, whence the 
name “infundibula vesice.” (See article Lungs.) 

SrructTurRE.—The bronchia are hollow, cylindrical 
tubes, which retain in structure, throughout a large por- 
tion of their extent, the characteristics of the trachea. 
Like the latter, they consist of four distinct layers: an 
external fibrous, a muscular, an internal elastic, and a 
mucous layer. 

The Heternal Fibrous Layer consists of a dense mesh- 
work of connective tissue, in which are to be found rings 
or lamin of hyaline cartilage. In the primary bronchia 
these are disposed as in the trachea, 7.e., in broken rings 
like the letter C, held together by fibrous bands. The 
ring is made’ complete by small transverse bundles of 
unstriped muscular fibres attached by microscopic ten- 
dons to the ends of the rings. By their contraction they 
increase the curvature of the cartilage and so diminish 
the calibre of the tube. The right bronchus contains six 
to eight of these cartilages; the left ten to twelve. Fur- 
ther removed from the trachea the cartilages gradually 
lose their ring-like shape, and are disposed in irregular 
polygonal laminz. Becoming smaller and less frequent, 
they finally disappear in tubes of less diameter than 0.238 
mm. ($5 inch), the fibrous layer still continuing to form 
the external coat. 

The Muscular Layer lies within the fibrous layer just 
described. It consists of separate bundles of unstriped 
muscular fibres, disposed for the most part transversely 
to the tube. It is better developed in the intervals be- 
tween the cartilages than just beneath them. As the 
cartilages disappear this muscular layer becomes better 
and better developed, until at last it completely surrounds 
the bronchioles, which, on section, but for the epithelial 
lining, might be mistaken for arterioles. The muscular 
layer can be traced to the final branching of the bron- 
chiole to form the alveolar passages, where, according to 
Rindfleisch, it becomes again better developed into a sort 
of “sphincter” at the point of entrance to the alveolar 
passages. The function of the muscular layer is to nar- 
row the calibre of the tubes. This is only manifested to 
any appreciable extent in the bronchioles. The carti- 
lages prevent any decided narrowing where they exist. 
In the experiments of Dr. C. J. B. Williams with elec- 
trical stimulation on bronchioles of less than a line in 
diameter, they were seen to contract until they nearly 
obliterated their lumen. Dr. Gairdner suggested that 
the contractility of the minute bronchioles may serve to 
expel collections of mucus which have accumulated in 
them, and which neither ciliary action nor the ordinary 
expiratory efforts would dislodge. 

The Internal Elastic Layer.—Within the muscular 
layer, and beneath the mucous membrane, lie longitudi- 
nal bundles of elastic tissue quite regularly disposed. 
They project, as it were, partly into the lumen of the 
tube, and so give, on transverse section, a wavy, corru- 
gated appearance to the lining membrane; on longitudi- 
nal section, a grooved or furrowed one. Piercing this as 
well as the muscular layer, chiefly in the bronchial tubes 
containing cartilages, are to be seen the muciparous 
ducts, lined with epithelium, leading inward to open on 
the free surface of the mucous membrane. The mucous 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bronchitis, 
Bromol, 





crypts lie in the external fibrous layer, chiefly in the in- 
tervals between the cartilages. 

The Mucous Membrane of the bronchia and bronchioles, 
forming the internal layer, possesses, throughout the 
greater portion of its extent, the characteristics of that of 
the tracheal mucous membrane. Like the latter, it con 
sists of epithelial cells of the ciliated columnar variety, 





- Fie. 1054.—a, A minute bronchiole splitting into the ultimate 
branches, which terminate in the alveolar passages; the epithelium 
has become of the simple pavement variety ; on the left branch can 
be seen one of the so-called “saccular dilatations”; b, artery; ¢, 
medium-sized bronchiole having no cartilaginous lamina. The re- 
mainder of the field is normal lung tissue. (About 30 diameters.) 
(Drawn by Dr. F. Cary, from a microscopical section, with camera.) 


superimposed upon a basement membrane, which latter 
is made by a condensation of the inner part of the inter- 
nal elastic layer. When the tube has reached the diam- 
eter of 0.2 mm. (5 inch), these cells lose their cilia, be- 
come shorter, smaller, and rounded, in the ultimate 
tubules becoming the simple pavement cells. Here the 
membrane loses its character as a mucous membrane, 
and resembles that which lines the alveoli (see article 
Iungs). Were and there in the larger tubes are to be 
found the cup-shaped cells (Becherzellen) of Schulze, the 
function of which is yet unknown. 

Vascular Supply.—From the thoracic aorta are given 
off the bronchial arteries, which, receiving occasionally 
branches from the first intercostal and internal mammary 
arteries, accompany closely the subdivisions of the bron- 
chia, supplying their walls, the walls of the large pul- 
monary vessels, the lymphatic glands, and the connective 
tissue of the lungs, to terminate finally in capillaries 
which inosculate freely with the respiratory plexus. In- 
jections thrown into these vessels will fill also the capil- 
lary plexus of the arteria pulmonalis. The correspond- 
ing bronchial veins empty in part into the vena azygos, 
in part into the vena pulmonalis; the venous radicles from 
the ultimate bronchioles emptying into the latter, those 
corresponding to the arterial branches to the bronchia 
and lymphatics, into the former. 

Lymphatie Supply.—The lymphatics arise in the alveo- 
lar septa. Stomata open on the alveolar walls between 
the epithelial cells, communicating thus directly with 
the alveolar cavity. They form a plexus in the sub- 
mucous tissues, accompany the branches of the bronchia, 
as well as the pulmonary veins and arteries. emptying 
finally into the bronchial glands at the roots of the lungs. 
Within the lungs they often possess a gray or black 
speckled appearance, from the absorption of pigment or 
foreign bodies. 

Nerve Supply.—The nerve supply to the lungs is de- 
rived from the pulmonary plexuses formed from branches 





of the vagus and sympatheticus. The filaments from 
these plexuses— situated at the lung hilum—follow the 
ramifications of the bronchia, becoming lost finally on 
them, and in the parenchyma of the lungs. When care- 
fully stained they are seen to possess, in parts of their 
course, the microscopic ganglia to which Remak and 
Schiff first called attention. 

The sensibility of the bronchia must be very slight; at 
least this seems to be true of their smaller branches, be- 
cause of the slight complaint made by consumptives in 
whom large portions of bronchial and lung structure are 
being destroyed. Lewis L. McArthur. 


BRONCHITIS.—In no affection is the practical impor- 
tance of the distinction between acute and chronic dis- 
ease better illustrated than in bronchitis. A bronchitis 
of recent origin or of sudden development is hardly the 
same disease as a bronchitis of long Standing, because, 
aside from the fact that they both involve the same local- 
ity, and that cough is a leading symptom in both, the 
essential features in the course of each are quite dissim- 
ilar. Moreover, in acute bronchitis itself the conditions 
vary to such an extent, according to the part of the 
bronchial tract affected, that it will be more advanta- 
geous to consider so-called capillary bronchitis separately. 
Hence we prefer, in beginning with acute bronchitis, to 
restrict the term to that common affection known as an 
acute catarrh of the larger and medium-sized bronchi. 

1. Acute Broncuitris. — Symptomatology. — Nearly 
every one in our climate has experienced the first stage, 
at least, of an attack of this complaint. When a catarrh 
of the upper respiratory tract has been severe enough to 
pass beyond the larynx and trachea and become a veri- 
table bronchitis, though yet only extending to the primary 
divisions, the symptoms are then readily distinguishable 
at sight from any other cough-producing affection. Pain 
is soon complained of and the patient’s gesture in de- 
scribing it is distinctive. Instead of applying his finger 
ends against one side, as he does to indicate the stitch or 
side stab of a pleurisy or a pneumonia, or holding his 
side as in pleurodynia, he lays his open hand on his breast 
as if taking an oath, and then passes it across the chest 
from side to side to indicate a suffocative sense of pain 
and tightness, which in severe cases feels as if the chest 
were transfixed with a dise of iron. Instead, also, of a 
carefully chosen and maintained decubitus, he changes 
frequently about, or else sits up and leans forward, a 
sure sign of a bilateral cause in dyspnoea, and one, 
therefore, which usually would exclude either a pneu- 
monia or a pleurisy or phthisis. Although the patient 
may complain of difficult breathing, and although in 
active attacks he may breathe with both nostrils dilated, 
yet it will be noticed that, quite differently from what 
takes place in other febrile pulmonary affections, the 
respiration is but slightly accelerated; and, furthermore, 
the thermometer tells the same story in this as in inflam- 
mation of other mucous membranes, namely, that it rarely 
causes a greater rise than 100.5° to 101.5° F., unless some 
other element is entering into the course of the com- 
plaint. The other indications of a febrile complaint are 
usually present in a moderate degree also. The face is 
flushed, the eyes are watery, the voice is husky, the 
pulse somewhat faster than usual, the tongue furred, and 
along with a dry skin (not always) and headache there is 
also some: chilliness, but not a distinct rigor, like that 
which ushers in a pneumonia. 

The pain of bronchitis is an early symptom and often 
a sign that an acute catarrh, in its journey downward, 
has just entered the bronchi; for it isone of the peculiar- 
ities of the nervous supply of the respiratory tract that 
its sensitiveness differs markedly in different portions. 
The much greater irritability of the larynx over the 
trachea is well known, but it has been found by experi- 
ment that nearly the same proneness to cough on irrita- 
tion is localized at the bifurcation of the bronchi. From 
this point onward, however, the irritability progressively 
diminishes until, as a result, serious accumulations of 
fluid may form in the smaller bronchi without occasion- 


489 


Bronchitis, 
Bronchitis, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








ing other symptoms than dyspnea. This early inflam- 
matory irritation will prove, on examination, to interfere 
with the breathing, mainly from spasmodic action of the 
bronchial muscles, conjoined with swelling of the mu- 
cous membrane itself, and consequent narrowing of the 
affected tubes, in much the same manner as the wide 
outlet of the nasal passage is closed in the beginning of 
acoryza. As soon, therefore, as a secretion bathes the 
irritated mucous surfaces, though the tubes be largely 
filled with it, the breathing becomes easier from relaxa- 
tion of the spasm and reduction of the tumefaction, 
while the pain likewise is mitigated, except just after a 
fit of coughing. 

Cough is a necessary element in bronchitis, and its 
sound indicates its character, so that a practised ear will 
distinguish it as bronchitic without difficulty. With 
reference to this subject of cough sound, it may be said 
that all coughs can be divided, according to their sound, 
into two classes, whose nature and import may be recog- 
nized by simply hearing, without necessarily seeing, the 
patient. The first, or the irritant cough, is the result of 
direct or reflex irritation alone, and it neither produces 
expectoration nor is caused by any need for expectora- 
tion. It isalways composed of separate coughs or hacks, 
which, however frequent and prolonged, or even though 
they be severe enough to prevent all sleep, are yet each 
independent of the other, like the blows of a hammer. 
The second, or the expectorant cough, on the contrary, 
is like the running of a chain over a pulley, and though 
it may be deliberate and slow, yet each cough is con- 
nected with the preceding and the following cough, and 
when once begun it will not stop until some expectora- 
tion has occurred. The patient, and all within hearing 
are aware that the cough cannot be arrested until some- 
thing is brought up, though, as in acase of viscid chronic 
bronchitis, the pellet which is dislodged at last seems an 
insignificant product for such a strangling time as the 
sufferer has had of it. To the irritant class belongs the 
characteristic hack of acute and of chronic pleurisy, and, 
therefore, also the ominous slight cough of early phthisis. 
It becomes, however, very loud and barking in hysterical 
or uterine cough. One of the most violent coughs which 
I have ever heard was in a lady who proved to have a 
polypus extruding from the os uteri, and as soon as it 
was removed this cough, of several years’ standing, 
ceased. Children often have such coughs at night, from 
intestinal irritation, and the cough of ‘thoracic aneurism 
is another instance of the kind, and lastly, it is the cough 
of direct laryngeal irritation, asin croup. This irritant 
cough, if present at all, is found only in the very first 
stage of acute bronchitis, and soon gives place to an ex- 
pectorant cough, which is comparatively slow if moist, 
and rapid if dry; its conclusion in expectoration being 
always announced by the last one or two coughs being 
more or less liquid, and following after a short or very 
prolonged antecedent series, according to the character 
of the secretion expectorated. 

In acute bronchitis, as just remarked, all cough is in 
the beginning painful. As each paroxysm ceases, the 
patient presses his hand against the chest with an ex- 
pression of distress, and in dread of the next return. 
After a while he experiences a good deal of soreness be- 
‘tween the ribs, with some tenderness on pressure, which, 
however, must not be confounded with the same symptom 
in either pleurisy or pleurodynia, for in bronchitis it is 
located at the attachment of the diaphragm and of the 
,other muscles engaged in the act of coughing, and is but 
the common result of unwonted muscular exertion. 

Cough, therefore, is the chief cause of the patient’s 
discomfort in acute bronchitis, and simply to allay it is 
the main indication in treatment. Hence the relief will 
correspond with the ease of expectoration, and this in 
turn depends upon the character of the secretion. Asa 
rule, the secretion first formed is the most difficult of ex- 
pectoration, owing to its viscidity. It is composed of a 
clear, tenacious mucus, much mixed with air from the 
protracted efforts of coughing, and contains also a few 
mucous corpuscles, and sometimes streaks of blood. Af- 


490 


ter a time the secretion becomes either more liquid from 
greater watery admixture, or else more turbid and yel- 
lowish, according to the formation of a greater or less 
quantity of pus. This latter change, in acute bronchitis, 
is a sign pointing toward recovery, for as the expectora- 
tion becomes more purulent it rolls into rounded masses 
of increasing consistency, but of less frequent formation, 
until but one or two such accumulations are expectorated 
in the morning, and then they cease altogether. When 
that desired termination will occur is uncertain, for the 
duration of acute bronchitis. like that of other catarrhs, 
varies indefinitely, as it has no critical periods and ends 
irregularly. 

Dracnosis.—Bronchitis is oftenest confounded with 


/ pneumonia, especially if the expectoration be bloody. 


From lobar (croupous) pneumonia we have already indi- 
cated some points of difference in the nature and bilateral 
extent of the pain, in the history usually of an antecedent 
naso-pharyngeal or laryngeal catarrh, in the absence of a 
distinct rigor at the beginning, in the moderate rise of 
temperature, and in the non-acceleration of the respira- 
tion. Physical exploration of the chest now completes 
the demonstration. In acute bronchitis there is no dul- 
ness on percussion anywhere; if anything, the stroke note 
is increased in intensity all over the chest, and the vocal 
fremitus is diminished. In the early “dry ” stage auscul- 
tation reveals sibilant asthmatic breathing in both lungs, 
varying constantly in intensity, and usually sufficiently 

marked to mask or extinguish the vesicularmurmur As 
soon as secretion commences, the whistling sounds give 
place to sonorous rhonchi produced in the larger tubes, 
mixed with the characteristic subcrepitant rale proceed- 
ing from the lesser bronchi. This rale is not as dry or 
sharp as the crepitant réle of pneumonia, and specifically 
differs from it in occurring during both inspiration and 
expiration, while the pneumonic rale is known by the 
wholly clear and high-pitched expiration which follows 
it. As the bronchial rale is itself often heard only at the 
end of inspiration, it should be watched for a number 
of respirations, and especially after coughing, when its 
true character will be revealed by its being heard also in 
expiration; or else it is greatly modified by the cough, 
while the pneumonic rale can neither be removed nor 
modified by any respiratory act This distinction also 
separates the bronchial rale from a pleuritie friction 
sound, which it often closely resembles, for whereas the 
friction sound, like the subcrepitant rale, is heard during 
both inspiration and expiration, it cannot be modified by 
a deep inspiration or ever coughed away 

ErroLogy.— Bronchitis is sometimes an accompaniment 
of other acute diseases, like smallpox, but especially of 
measles and pertussis, ahd then it is apt not only to pro- 
long convalescence, but also to cause permanent mischief 
by generating a proclivity to asthma. In typhoid fever, 
bronchitis is often an early symptom, and it then may be 
so pronounced as to mask the presence of that disease. 
The course of the temperature, however, will soon sug- 
gest the correct diagnosis, to be soon confirmed by the 
development of the proper signs of the infection. The 
bronchitis then usually subsides during the second week. 
The most significant fact, however, connected with its 
etiology is that bronchitis occurs only exceptionally as a 
direct result of excitation of the bronchial mucous mem- 
brane itself, by any irritant property or ingredient of the 
inspired air. The frequency of bronchitis among work- 
ers in dusty air, such as millers, rope-makers, etc., does 
not militate against this statement, for when every such 
instance is taken account of, it only shows that dusty air 
can cause bronchitis, as also measles does, but it does not 
explain why the great majority of cases of bronchitis 
have not been in dusty air at all Recent researches also 
prove that bronchitis isnot the result of any form of bac- 
terial invasion through the air which enters the lungs. 
Its occurrence in phthisis can always be attributed to ex- 
trabronchial processes and not to primary infection of the 
mucous membrane, for no demonstration has been more 
conclusive than that the air in the whole bronchial tract 
is normally sterile, all germs having been filtered out of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bronchitis, 
Bronchitis, 





it or destroyed during its transit through the nasal pas- 
sages. This explains, as Lister pointed out, why pneu- 
mothorax caused by traumatic injuries of the lungs is not 
followed by suffocative pleurisy. 

On the other hand the one great fact in the etiology of 
bronchitis, oftener illustrated by experience than any 
other, is its causation by some chilling of the skin. The 
peculiarity here is that this chill need be but very par- 
tial and often of cutaneous areas quite remote from the 
lungs. Sitting with wet feet in a cool room will induce 
a severe attack of the complaint much more commonly 
than the breathing of any kind of air, however cold or 
hot or dry or moist it be. So a cold draught upon the 
nape of the neck, especially if the skin be perspiring, 
always entails a risk, even in the healthiest persons, of an 
attack of bronchitis or of a catarrh of some other part of 
the respiratory tract. Such effects of surface chilling, 
however, are best illustrations of that most common dis- 
order which is denominated “catching cold.” Consider: 
ing how frequent this derangement is, and how often it 
leads to severe or fatal internal derangements, it is 
strange that so little progress has been made in the inves- 
tigation of the pathology of chill. It seems to me that 
we must look for its most probable explanation in the 
sudden iocal closing of the arterial circulation of an in- 
ternal part by reflex vaso-motor irritation from the sur- 
face. Experiments on the kidney have shown that clamp- 
ing the renal artery for only twenty minutes causes such 
damage to the renal secreting cells that albuminuria last- 
ing two weeks may be set up by this brief arrest of the 
arterial flow. Now it isa general law of vaso-motor as- 
sociation that the cutaneous nerves are always in relation 
with the vascular nerves of the internal organs under that 
part of the skin, so that the same kind of vascular im- 
pression, whether stimulant or sedative, to the surface 
nerves is reflected to the nerves controlling the circula- 
tion of the deeper parts. It is in accordance with this 
law that cold suddenly applied to the abdomen will con- 
tract.the internal arteries and check a post-partum hemor- 
rhage, or a warm poultice to the chest soothe the pain of 
a pleurisy, etc. But besides this general law, there are 
many examples of special vaso-motor associations between 
distant parts. Thus the nerves of the feet are closely as- 
sociated with the vaso-motor nerves controlling the circu- 
lation of the pelvic viscera, so that cold to the feet will 
check menstruation, and dry heat thus is one of the most 
reliable emmenogogues. Whoever has an irritable stric- 
ture of the urethra should not get his feet wet. The 
nerves of the nape of the neck also have wide relations of 
the same kind. Hence it seems reasonable to surmise 
that the process of “catching cold” is caused by the irri- 
tant surface impression of a chill reflected by some cus- 
tomary nervous association so as to shut off the arterial 
blood from some internal tract or viscus sufficient to in- 
flict an injury there comparable to the injury to the kid- 
ney cellsin the experiment above alluded to, and the sub- 
sequent inflammatory development is the expression of 
the local reaction to that injury. 

Pathology.—Acute catarrh of the primary and medium- 
sized bronchi is rarely a dangerous complaint, and, if we 
consider its frequent occurrence, it is the least serious of 
any of the pectoral affections, ‘particularly when com- 
pared either with laryngitis on the one side, or with 
catarrh of the smaller bronchi on the other. A post-mor- 
tem examination, if it could be had, of an adult who at 
the time of his death was suffering from a severe chest 
cold such as we are now considering, would reveal very 
little, if any, departure from health, owing to the removal 
of all traces of hyperemia by the emptying action of the 
elastic fibres which line the tubes. We can best judge 
of the morbid changes by observing the traces of an in- 
cipient bronchitis in those who have died from other dis- 
eases. The first step is a hypersemia of the vessels of the 
inner fibrous coat, which become swollen and softened and 
infiltrated with lymph cells, accompanied by cedema of 
the basement membrane. from which are detached nu- 
merous ciliated columnar epithelial cells, while new cells 
from the deeper layer of the epithelium are successively 








cast off mixed with leucocytes from the congested blood- 
vessels. 

Treatment.—There is no disease in this country which 
so often brings patients for a prescription as this form of 
bronchitis. This is due not only to its own exceptional 
frequency, and the discomfort which it occasions, but 
also to the just dread which a visitation of cough causes 
among most persons. Ordinarily, of course, they are 
mistaken in supposing that phthisis means a He glected 
cough, and therefore that “it will never do to let a cough 
run”; but there is cause enough always for shortening 
every bronchial catarrh in order to prevent the formation 
of a habit of the kind, which is common to all inflamma: 
tions of the mucous membranes. The aim, therefore, 
should always be to prevent an acute bronchitis from be- 
coming chronic, either actually or potentially, and hence, 
in this complaint, the less trust in nature, or in sponta- 
neous recovery, the better. When called to a patient 
who has not passed beyond the condition of hy pereemia 
and swelling (generally termed “the dry stage ” of bron- 
chitis), the physician’ s first duty should be to induce se- 
cretion as quickly as possible. If the patient be not too 
young, or too old, or too debilitated, much the most 
effectual proceeding to secure this end is to dissolve a 
grain of tartar emetic in a teacup of water, and tell him 
to take a teaspoonful of this every ten minutes. As soon 
as he begins to be slightly nauseated by it his pain rapid- 
ly subsides, owing to the anesthetic effect of antimony ; 
the spasm of the bronchial tubes relaxes, and soon a wa- 
tery secretion flows and expectoration begins. It is not 
necessary to carry the administration of the antimonial 
to the point of producing emesis, for it cannot abort the 
inflammation, and we have much better remedies for the 
succeeding stages of the complaint. 

As we have remarked before, cough is the one symp- 
tom to combat in acute bronchitis (not bronchiolitis), for 
it is apt to do a great deal more than produce expectora- 
tion. In acute (not chronic) inflammations the first indi- 

cation is to secure quietude of the inflamed part, and 
every act of cough is an infringement of this rule. The 
severe pain which each paroxysm causes proves the mis- 
chief which it occasions, and hence, as some coughing 
must occur in order to remove the secretion formed, the 
purpose should be to render the secretion capable of re- 
moval by as few acts of coughing as possible, and then 
to suppress the superfluous remainder. Hence the more 
watery and the less adhesive the mucus can be made, and 
the less reflex irritation there be from the inflamed part, 
the sooner will the bronchitis subside. To fulfil the first 
indication, namely, that of inducing a watery flux, the 
most efficacious remedies are oils. To prove this, one 
need introduce only a few drops of sweet oil into his nose 
and note the flow which will speedily follow. The ac- 
tion of castor oil on the intestinal mucous membrane is 
another illustration of the action of oils, and we may 
mention in passing that castor oil on this principle is a 
dangerous cathartic to give to infants with bronchitis, 
from its tendency to fill their small tubes with too much 
secretion. Now certain oils have a particular affinity for 
the bronchial mucous membrane, and hence have a right 
to be classed among expectorants, and one oil, the oleum 
lini, or linseed oil, has this property to such a remarkable 
degree that it is one of the very best means at our dispos- 
al for painful bronchial coughs of every kind, including 
phthisical bronchitis. I was first led to use it from the 
fact that domestic experience had long shown the sooth- 
ing effects of flaxseed tea in bronchitis, and I feel certain 
now that no other remedy is so effective as the oil itself 
in active inflammatory states of the bronchial mucous 
membrane. To insure a good emulsion it is better to 
make it in some quantity, thus: Irish moss, 3i., boil in 
water for an hour and strain, making O iij., then add ol. 
lini eK Vee Ol: gaultheriee, ol. cassie, 44 3 ij., glycerini 
RNS yas simpl. % x., ac. hydrocyanici dil. ™ clx. A six- 
ounce cough mixture of this emulsion may then be made 
by the addition of a grain of morphine and a drachm 
and a half of chloral, of.which the dose for an adult is a 
tablespoonful taken an hour after meals. A firm in Dan- 


491 


Bronchitis, 
Bronchitis, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





bury, Conn., has made a proprietary article out of this 
emulsion, and I am told sells it widely under the name of 
Linolin. 

When the bronchitis develops in the course of a de- 
scending catarrh from the pharynx and larynx, and espe- 
cially in those with laryngeal pain, the action of full doses 
of aconite is very beneficial. A combination of tincture of 
aconite and camphorated tincture of opium with spirit 
of nitrous ether and syrup of senega may be employed 
for the same purpose as the linseed-oil emulsion, espe- 
cially in patients who dislike all oily mixtures. Iodide 
of potassium, in doses of four grains, also comes under 
the head of liquefying expectorants, and to a less degree 
the carbonate of ammonia. 

After a few days, in many persons the secretion often 
increases, especially in those who have had repeated at- 
tacks, until it becomes a very inconvenient and obstinate 
bronchial flux. Here the indication is for a combination 
which will start secretion and at the same time not allow 
it to become too viscid. Dr. C. J. B. Williams’ favorite 
prescription for phthisical bronchitis, with abundant ex- 
pectoration, is useful under these circumstances; it con- 
tains nitric acid, iodide of potassium, syrup of senega, 
and balsam of tolu. The addition of belladonna renders 
it still more certain in diminishing the flux. 

The use of hot drinks on going to bed, especially those 
containing alcohol, for the purpose of getting up a per- 
spiration, should be reprobated. Alcohol is uniformly 
mischievous in all catarrhs, acute or chronic, and the 
benefit of perspiration can be much better obtained by a 
Dover’s powder and aconite taken while the patient 
wraps himself in an extra covering and sits with his feet 
to a fire without moving from it for some hours until he 
can go directly to bed, This, then, should not be too 
warm, for a nocturnal perspiration is always risky. 

Counter-irritation is justly reputed among the laity as 
of much service in bronchitis. At the very start, a 
sinapism to the chest, especially if made large and ap- 
plied for only a short time, may cut an attack short. 
After the second day it is rarely of any use, and further- 
more it should never be applied in measles, as the action 
of mustard on the skin when inflamed by measles is apt 
to be very severe, and I have known of two fatal cases, 
in children, of gangrene of the surface of the chest from 
the ignorant use of mustard in this exanthem. Stimu- 
lating embrocations, however, such as the soap liniment, 
with turpentine and aqua ammoniz, are useful both in 
the onset and decline of bronchitis, if only to lessen the 
cutaneous hyperesthesia or sensitiveness to draughts, 
which accompanies all severe catarrhs of the respiratory 
mucous membrane. 

2. AcuTE BRONCHIOLITIS, OR CAPILLARY BRONCHITIS. 
This formidable disease, with a mortality of from thirty- 
five to fifty per cent. of all attacked, is much more than 
a simple bronchitis, for the accompanying inflammation 
not only extends beyond the terminal bronchi into the 
alveoli, but also affects the peribronchial tissue, and may 
even involve the pleura. The affected tubes lie far with- 
in the substance of the lung, and, having lost all carti- 
lage, they ramify as small thin membranous channels 
between textures rich in blood-vessels and in meshes of 
connective tissue. An inflammation reaching to them, 
therefore, may thus give rise, by involving the surround- 
ing structures, to both acute and chronic changes of 
greater constitutional effect than in the case of any sim- 
ple mucouscatarrh. <A pretty sure indication of this fact 
is found in the sudden rise of temperature which is ob- 
served whenever an acute bronchitis is passing into a 
bronchiolitis, for this proves that a profounder reaction 
has occurred than pertains to the course of a mucous- 
membrane inflammation. It is difficult, indeed, to draw 
a sufficiently marked distinction between the lesions 
which are apt to arise from the extension of a bronchio- 
litis and the phenomena of so-called catarrhal pneumonia. 
The term catarrhal has been objected to as applicable to 
a pneumonia, because the air cells cannot be said to con- 
tain mucous membrane, but the significance is obvious 
enough as indicating a pulmonary consolidation arising 





492 


in a pneumonic process whose origin really comes from 
the bronchial tubes. While, therefore, capillary bronchi- 
tis as such is a frequent disease of early childhood, and 
often proceeds to a fatal termination without general im- 
plication of lung tissue, in adults pneumonia, consecu- 
tive to diffuse bronchitis, is a common affection, especial- 
ly in the aged or feeble, or when supervening upon 
a chronic bronchitis. In these patients greater areas of 
consolidation are found in both lungs than is common in 
children; but it is difficult to demonstrate any specific 
difference in the morbid processes themselves, as the gra- 
dations between the two are of every degree, the smaller 
bronchi being almost exclusively affected in some adults, 


-and pneumonic consolidation being the most pronounced 


lesion in many children. 

The main reason for the gravity of capillary bronchitis 
is to be found in the comparative weakness of the bron- 
chial muscles of patients affected with this disease. This 
cause pertains equally to the affection in children and in 
the aged. The muscular coat begins in the trachea and 
in the primary bronchi, where it joins together the free 
ends of the incomplete rings or C-shaped cartilages, and 
can thus on occasion contract the calibre of even these 
larger tubes. As the bronchi further divide, the muscu- 
lar layer relatively increases, becoming more or less a cir- 
cular coat, until it ends at the alveolar passages as a thick 
bundle of annular muscle fibre cells, forming a kind of 
sphincter (Rindfleisch). Upon the muscular layer lies the 
thick layer of longitudinal yellow elastic fibres which are 
continued on into the texture of the air vesicles them- 
selves. Now, as the one function of muscle is to pro- 
duce movement, it is plain that these muscles, acting 
upon the recoil of the elastic fibres at the moment when 
the external expiratory muscles are driving the air 
through the tubes in coughing, could, by a quick contrac- 
tion upon the current of air, greatly assist the propulsion 
of fluids toward the larynx. 

In children the bronchial muscles are not only relative- 
ly of much less development and power in proportion to 
their youth, but they are equally weak in the muscular 
apparatus of the throat and in the expiratory muscles of 
the chest, the latter having the further disadvantage of 
the yielding nature of the chest walls to which they are 


-attached. Young children, therefore, cannot clear even 


their throats of mucus, but rather swallow that which is 
brought up, and in proportion to their debility, whether 
due to age or to imperfect development, will the danger 
increase of suffocative accumulation in their air tubes. 
In the aged, on the other hand, bronchial palsy, consecu- 
tive to chronic bronchitis, is the commonest condition 
which leads to a fatal complication. 

Capillary bronchitis affects children more commonly 
in the first year of life; the frequency then diminishes 
progressively up to the third or fourth year; and, finally, 
the disease may develop from any of the common causes 
of acute catarrh of the respiratory tract. Itis, therefore, 
of exceptional severity in whooping-cough, and ranks as 
the commonest cause of death in measles. It occurs also 
during the winter months, as one of the complications of 
dentition. At other times it develops upon an ordinary 
cold, which has begun with sneezing, and, after setting 
up a coryza, goes on to develop laryngo-tracheal symp- 
toms for several days, until finally symptoms of a more 
pronounced constitutional kind begin to manifest them- 
selves. The child becomes heavy and drowsy, with 
longer and more severe paroxysms of coughing, followed 
by dyspnoea, which is evidently due to paroxysmal spas- 
modic action in the bronchial tubes. After a time the 
nostrils begin to be permanently in action, a constant 
restlessness sets in, the respirations become accelerated, 
the head grows hot, and the face is deeply reddened dur- 
ing the attacks of coughing, which, though very hard, 
vet do not bring up much secretion. The cough has a 
peculiar whistling character, quite different from the 
brassy sound of croup, and a distinct wheeze is audible 
in many cases without applying the ear to the chest. 
The thermometer now shows that a rising fever is on 
hand, for a temperature from 102° to 108° F. in a child 


~ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bronchitis, 
Bronchitis, 





witha cough should always cause solicitude. Percussion 
at this stage does not afford much information, but later 
on it may reveal localized areas of dulness, especially in 
the infrascapular and subaxillary spaces. Auscultation 
sometimes affords nothing but highly puerile respiration, 
but oftener a great number of high-pitched, fine, sibilant 
sounds are heard accompanying both inspiration and ex- 
piration. The presence of areas of consolidation is some- 
times made out by localized exaggeration of both breath- 
ing and voice sounds, especially after a fit of coughing. 
It should be remembered that a child’s chest, being so 
much smaller relatively than an adult’s, is proportionate- 
ly more resonant, and often transmits sounds of all kinds 
over to the side opposite to that on which they origi- 
nated. 

Meantime, with the progress of the case, both pulse 
and respiration grow moreand more frequent. The child 
can nurse or drink only with a short, hurried effort, and, 
as the respiratory obstacle increases, its chest begins to 
show signs of disordered breathing which are very sig- 
nificant. The lower ribs and the epigastrium sink in dur- 
ing inspiration, indicating widespread obstacles to the 
ingress of air. On the other hand, the residual air in the 
lungs both increases and becomes rarefied, so that the su- 
pra- and infra-clavicular spaces become distended and 
the upper part of the chest seems scarcely to move with 
the breathing. As the case progresses the body tempera- 
ture varies from 102° or 103° in the morning, to 104°, 
105° F., or even more, in the evening. The pulse rises 
from 150 to 180 or 200, and the respirations to 50, 80, or 
100 per minute, while the constant tossings of the patient 
and its expression of terror too plainly indicate the dread 
of approaching suffocation. As might be expected from 
the lack of air, its cry is low, plaintive, and short. If re- 
lief does not come, signs of exhaustion, from the excessive 
labor of the breathing, begin to appear; the lips first 
turn blue, the face and surface generally become cool, 
pale, and livid, the pulse grows thready, the cough ceases, 
and the stupor of carbonic-acid poisoning grows deeper 
until death closes the scene, with or without slight con- 
vulsions. 

The duration of the disease is not very definite. In fa- 
vorable cases it may last ten days and then occupy a 
week in recovery, with increased but more expectorant 
coughing at first, and with a plain increase of inspiratory 
power. In others who recover, the febrile stage may 
yet last for from three to four weeks. In a certain pro- 
portion of cases the disease passes into a fibroid alteration 
of extensive regions in one or in both lungs. As the in- 
flammation then becomes chronic the peribronchial con- 
nective tissue greatly hypertophies, causing more or less 
obliteration of the air cells, and, finally, adhesions of the 
thickened pleura to the chest walls. Great bronchial dil- 
atation is then apt to follow in the consolidated parts, 
surrounded by emphysematous lobules, and a constant 
secretion of muco-purulent sputa is thrown off. These 
symptoms, combined with the great emaciation of the 
patient, seem to leave nothing wanting for the diagnosis 
of tuberculous phthisis. Often, however, so much im- 
provement of a permanent kind occurs, if the patient 
survives for a few years, that the prognosis need not be 
as hopeless as the same degree of wasting would imply 
in an adult. 

The post-mortem appearances, after capillary bronchi- 
tis, vary according to the participation of the lungs in 
the inflammation. If the case has been chiefly bronchitic, 
the lungs do not collapse when the chest is opened, but 
may even bulge out as if they had been compressed by 
the ribs. This pseudo-emphysema is caused by the oc- 
clusion of the bronchi by mucus and other products of 
the inflammatory process. Commonly, however, the sur- 
face of the lungs is irregular from alternate collapsed and 
overdistended lobules, according as the valve-like action 
of the secretion in the tubules had allowed more air to 
pass during inspiration or more during expiration; the 
condition of overdistention being produced when less air 
could be forced past the obstacle during expiration than 
during inspiration, and a condition of collapse being pro- 


duced when the reverse was true. The areas of pneu- 
monic consolidation, on the other hand, present just the 
same appearances and changes that occur in cases in 
which a bronchus has been plugged by a foreign body. 
The inflammatory process then involves the whole paren- 
chyma of the lobule, both of the air vesicles and intersti- 
tial tissue, so that instead of complete resolution follow- 
ing as in croupous pneumonia, fibrous or caseous changes 
are apt to remain. The bronchi, which are universally 
stuffed with mucus, pus, epithelial cells, etc., show very 
generally a reddish and swollen mucous membrane, this 
condition extending even to the primary bronchi, if not 
to the trachea; in which respect the appearances pre- 
sented in this disease contrast strongly with those ob- 
served in simple bronchitis. 

Treatment.—We scarcely need say that the treatment 
of capillary bronchitis should be prompt and decisive, 
and hence according to clearly defined purposes. As 
soon as the thermometric rise and the other symptoms in- 
dicate the threatening approach, the aim should be to 
shorten the acute stage of the inflammation as quickly as 
possible. For this purpose aconite is the best medicine, 
and should be given with the set determination to make 
the patient feel it. Every two hours doses of one, two, 
or three drops of the tincture of the root, in a solution of 
citrate of potash, should be given until the pulse falls in 
frequency and “excitement.” Should the pulse grow 
weak or intermittent under this course, the use of stimu- 
lants will soon show that the acute inflammation is itself 
a guard against too great doses of aconite, for only a few 
teaspoonfuls of brandy will be enough soon to counter- 
act the depression of aconite, which in a normal state, or 
in a chronic disease, would continue for hours. There is 
no remedy which can do as much as aconite just at this 
juncture; later on, it is mischievous, but at the beginning 
it is much the best antipyretic and antiphlogistic that can 
be employed, because of its specific effect in lessening the 
initial engorgement of the respiratory mucous membrane 
when acutely inflamed. We see this exemplified in ton- 
sillitis, in which disease, when given in full dose, it often 
cuts short the otherwise tedious course of the affection 
toward suppuration; and a like power to prevent the 
congestion and the formation of muco-pus may be fairly 
attributable to it in bronchitis, while its anesthetic effect 
is beneficial both to relieve the pain and to control the 
consequent asthmatic spasm of the bronchioles. We do 
not have the same reason to fear cardiac weakness in capil- 
lary bronchitis of children as in the aged, for the heart of 
the child is relatively stronger than that of the adult, at 
least as regards the right side, which has about the same 
thickness in early life as the left. 

When sibilant rales begin, we should add, and continue 
systematically to give, the tincture of belladonna in full 
doses, combined with half a drachm to two drachms of 
the spirit of nitrous ether, in sweetened water or milk, 
every three or four hours. This combination is not to be 
omitted until convalescence begins; for while the aconite 
may be dropped as soon as signs of exhaustion appear, or 
if the temperature is relatively low, the belladonna and 
nitre should be faithfully persisted in as respiratory stim- 
ulants, to strengthen the function most imperilled, and 
also to lessen the complication of bronchial spasm. 

Then when moist rales, a recurrent dyspneea, and ex- 
citing hard cough come on, we have a plain indication 
to try to expel retained secretions. Here a single emetic, 
administered every twelve hours, is of true service. 
Some writers condemn emetics on the ground of failure, 
in their experience, to afford relief by their use. If 
wrongly administered, emetics are not remedial in bron- 
chitis, but dangerous instead; still, that is no reason for 
neglecting the most efficient method of expelling mucus 
in children. Vomiting is both natural and easy to chil- 
dren, while expectoration is much the reverse, and no 
one who has witnessed the great relief following upon 
the effective action of the abdominal muscles after an 
emetic, in dislodging a quantity of mucus where the 
hardest coughing of children had failed to produce any 
effect, will doubt that emetics can do great good in the 


493 


Bronchitis, 
Bronchitis. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 











hands of those who know how to use them. In the pres- 
ent instance, neither antimony, ipecacuanha, nor apomor- 
phine should be employed, because they excite too much 
bronchial secretion, and hence when they do act they give 
but the most evanescent relief. Often also they fail to 
act as emetics at all, whereupon their effect is bad, for 
nothing is so calculated to fill the tubules with liquid as 
a prolonged nausea. Instead of these emetics we would 
recommend, first, the turpeth mineral, or yellow sulphate 
of mercury, in doses of two to five grains; or, second, the 
sulphate of copper, half a grain; or, third, the sulphate 
of zinc, in a dose of five grains combined with the same 
amount of powdered alum, in a tablespoonful of water. 
None of these emetics operates except in the one way of 
irritating the nervous association with the gastric nerves 
to expela gastric irritant. The heart is not depressed 
by them, nor the bronchial mucous membrane rendered 
cedematous; and moreover, if emesis does not follow very 
speedily after their administration, they do not act at all, 
and may safely be left alone, as far as the bronchial mem- 
brane is concerned, if a second dose has not been followed 
in ten minutes by vomiting. The case, then, is not one in 
which emesis should receive further trial, at least for an- 
other twelve hours. A more frequent administration of 
emetics than once in twelve hours is useless. 

When the struggle for breath once begins in deadly 
earnest, the indications change to the two purposes of 
supplying oxygen and of sustaining the patient in the 
dread struggle. Why should the necessary restlessness 
of the patient be now smothered by opium? 

It is difficult to see any reason for the employment of 
this drug, from first to last, in this critical disease, other 
than that of securing the deceptive quiet which this most 
effective paralyzer of respiration may occasion in bron- 
chitis preparatory to a quiet forever permanent. A 
much better relief to the distress and cough is afforded by 
a mixture of chloral and camphor, to which a very small 
quantity of an opiate is added, as in the following: R 
Chloral, 3i.; Magend. sol. of morphia, M x.; syr. simpl., 
% ss.; aq. camphore, ad 3 iij. M. Sig.: Teaspoonful 
in sweetened milk. In the mean time, if pure oxygen gas 
can be procured for inhalation, we can speak very favor- 
ably of its aid in battling for life in these cases, both by 
assisting the breathing and by strengthening the heart. 
On this account, the air of the room in the immediate 
neighborhood of the patient should be constantly renewed, 
while at the same time any chilliness noticeable in it 
should be counteracted by artificial heat, tempered with 
steam. Inhalations of steam vapor are not called for, 
if laryngitis is absent, inasmuch as the necessary meas- 
ures for steaming may interfere with the free supply of 
oxygen. 

The indications to sustain the patient’s powers now call 
for the most fearless use of alcoholic stimulants. Of all 
such preparations brandy does best for children, and may 
be given to them with or without milk, generally best in 
some hot liquid; in the suffocative stage of bronchitis it 
may be given continuously in doses of one, two, three, 
or even four drachms every hour. It will be noted, now, 
that cardiac stimulants are of the most service, and hence 
external irritants will often greatly aid the other measures 
adopted. While an external covering is of great value in 
the first onset, and then the more soothing its effect the 
better, exciting ones are the effective means at the last. 
We would recommend, therefore. a jacket of wadding for 
the chest, covered with oiled silk, during the early stage 
of the complaint, to be followed later on by baths in hot 
mustard water. The latter should be taken once in six 
hours, and should be continued each time until the skin 
is reddened; and occasionally a cloth wrung out of a hot 
infusion of capsicum, 3i. to the pint, should be applied 
to the chest for from five to ten minutes, and then the 
wadding jacket should be put on again as before. An- 
other good point in practice is to give an infant who is 
struggling for breath something hot to swallow every 
few minutes. Half a teaspoonful of hot milk and lime 
water, or some such excitant of the act of deglutition, 
powerfully helps expectoration, as I have had frequent 


494 








occasion to note, as well as relaxes bronchial spasm. 
Kroenecker found that every act of deglutition acts as a 
cardiac stimulant, and raises the blood pressure. 

Many of the favorite remedies employed by different 
writers in the treatment of broncho-pneumonia can be 
mentioned only briefly, because, having tried them, we are 
too uncertain of their beneficial effects to prescribe them 
hereafter in cases of our own. First, ammonia, as a car- 
diac stimulant and expectorant, is largely employed, and 
in older children may be beneficial, as it certainly is in 
the pneumonia of adults. The difficulty with it in little 
patients is the irritation which its administration, however 
disguised, causes in them compared with adults, for it 
excites both coughing and crying. Quinine is given in 
pulmonary inflammations with the same regularity at 
present as blood-letting was resorted to half a century 
ago, and with no better reason. Aconite is a far more 
certain antipyretic than quinine in this complaint; while 
the depression produced by quinine upon the heart in 
children is decidedly more permanent than that of aco- 
nite, and at the same time there are no compensations to 
warrant its administration. 

3. CHRONIC Broncnitis.—This common disease, unlike 
the preceding, is usually a complaint of middle or of de- 
clining life, and fully illustrates in its course the invete- 
racy and proneness to relapse of all chronic disorders of 
mucous membranes. Although the structural changes 
which chronic bronchitis induces may become very exten- 
sive and may involve secondarily the most distant parts 
of the body, producing changes in the abdominal viscera 
and in the entire circulatory system, yet it always remains 
essentially a local and not a constitutional disease. This 
is a matter of practical importance to the physician, and 
is well shown by a comparison between chronic bronchitis 
and pulmonary phthisis, the disease with which it is 
most apt to be confounded, on account of the most prom- 
inent symptoms of each being cough and profuse expec- 
toration. Thus, a significant difference meets us at the 
outset in the personal appearance of patients, even in the 
advanced stages of these two complaints, and one which 
indicates a difference of both nature and origin. Phthisis 
from the beginning is a wasting constitutional disease, 
frequently manifesting a loss of bulk in every structure 
which is related in any way to the function of respiration, 
before any respiratory changes can be detected, except 
perhaps quickened breathing. The early contraction or 
want of action of the lung apices produces a characteris- 
tic elongation of the neck from sinking down of the clav- 
icles, which causes the patient to carry his chin forward 
beyond the line of the chest and abdomen. The muscles 
of the neck also appear thin and ribbon-like, although the 
imperfect respiration causes these auxiliary muscles to 
stand out more plainly under the skin in forced inspira- 
tion than they doin health. Following upon this change 
in the neck, there is a peculiar retraction of the cheek tow- 
ard the angle of the jaw, while the early emaciation 
appears in the pinched features, the sharply defined nos- 
trils and ears, and the too clear conjunctiva, which shows 
the sclerotic through it like a polished glass ball. The 
hands, which in all cases show emaciation better than the 
face, look bony, and have a bird-claw contour, from 
wasting of both dorsal and palmar muscles; while the 
bones generally, like the muscles, have a tendency to be 
narrow and thin. The skin of the consumptive is of silky 
smoothness, with long blue veins, and, except at the on- 
set of the daily fever, is moist as well as soft. In con- 
trast to all these characters, a case of severe bronchitis 
presents us with a round and much distended chest in the 
very region where it is flattened or sunk in phthisis. 
The clavicles, therefore, are elevated instead of depressed, 
and the neck is directly shortened. The chin, instead of 
being carried forward, is drawn back, and the neck mus- 
cles are large, broad, and massive, being much hypertro- 
phied by the labor which they are called upon to undergo 
in lifting the chest, because in chronic bronchitis the ver- 
tical movement of the chest walls is increased in propor- 
tion as the lateral and the antero-posterior movements are 
decreased. Chronic bronchitis, moreover, being a non- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


febrile disease, does not cause atrophy of the muscles, 
and hence the powerful array which may be seen under 
the skin of the neck whenever coughing begins. Owing 
to the same cause, the supraclavicular depression, which 
is nearly obliterated in phthisis, is much deepened in 
bronchitis, in some instances sufliciently so to admit of 
several fingers being laid in the cavity; and if emphy- 
sema also be present, quite notable tumors rise from the 
bottom of the depression during coughing, which are 
caused by the distended subclavian and innominate veins. 
The face is turgid, the complexion is often suffused, the 
nose and ears are thickened, the conjunctiva has an wde- 
matous appearance and is traversed by tortuous veins, 
while the skin, particularly if emphysema and consecutive 
chronic hepatic congestion be present, is dry and leathery, 
and can be drawn into wide, non-elastic folds. Every- 
where under this thickened skin the veins appear en- 
larged, tortuous, and dark-colored. 

Symptomatology.—The most common history of a 
chronic bronchitis is that the patient was at first subject 
to frequent attacks of acute bronchitis, especially in the 
last weeks of winter or in a belated spring. His cough, 
he tells us, hung on by his taking a fresh cold every time 
he went out or the weather changed: and he tells his 
story correctly, because he had reached that state of sus- 
ceptibility to relapse on slight provocations which is the 
penalty of leaving an inflammation of a mucous mem- 
brane only partially healed. Just as an old gleet will 
return after some trifling error of diet, so does a bron- 
chitis revisit its victims upon the slightest chill or expo- 
sure to a draught of air. So soon, however, as milder 
weather comes, when the skin is kept in a state of gentle 
perspiration, the bronchitis is displaced and the cough 
ceases until the chilly season comes round again, when 
the same experience is repeated, with an increase, each 
year, of the severity or the duration, or both, of the bron- 
chiticattacks. Afteran indefinite length of time, accord- 
ing to the individual case, the cough becomes permanent, 
and merely decreases in severity during the favorable sea- 
son. But meantime it is worthy of note that not until 
long after the bronchitis has become continuous, so to 
speak, does the patient’s general health seem to suffer 
materially; for, in great contrast with a true consump- 
tive after the same lapse of time, he loses but little in flesh 
or color, and in summer often seems quite well. Pro- 
longed cough, however, at last begins to tell, and the first 
sign of injury is usually breathlessness upon muscular 
exertion. Thisis mainly due at first to weakening of the 
air vesicles by overstrain, and may be entirely recovered 
from. Another complication is soon added, which in 
some individuals comes on much earlier, namely, asth- 
matic breathing. This isa most unwelcome addition to 
a bronchitis, for it rarely parts company with it thereaf- 
ter, and meantime greatly increases the textural mischief 
wrought by the primary disease. In time dyspnea be- 
comes habitual, whether the patient has been coughing 
or not, and ere long signs of embarrassment of the pul- 
monary circulation develop from weakness of the right 
ventricle, the far-reaching results of which are now to be 
detailed. 

The cough of chronic bronchitis is varied in character 
according to the quantity and quality of the secretions 
expectorated. One kind has been graphically termed 
“dry ” catarrh, from the small amount but great viscidity 
of the discharge. This secretion can scarcely be pro- 
pelled along the bronchial walls, and when it reaches the 
bifurcation of the trachea the most violent and rapid par- 
oxysms of coughing commence, in which reflex laryngeal 
spasm participates, causing the sound to become like a 
whistling squeak. The patient has to use every expira- 
tory muscle to the utmost, and doubles himself up with 
the effort, while his face grows purple and his eyes and 
nostrils water, until the tenacious streak of mucus is 
finally dislodged with much gagging or even vomiting. 
This severe coughing naturally produces injury of the 
small bronchi and of the air vesicles from mere mechani- 
cal violence, so that emphysema is more likely to occur 
in this than in any other form of bronchitis. 


Bronchitis, 
Bronchitis, 








The other and more common form is that in which the 
secretion is abundant and liquid. The amount and con- 
sistency of this, however, vary greatly. Some are able 
to get rid of the most of it at one fit of coughing, and then 
remain measurably free for hours; others have a steady 
flux, which rarely allows them any prolonged intermis- 
sion in their efforts at expectoration. This bronchorrhea 
is apt to be particularly harassing at night, and is the tor- 
ment of many old persons, who can rarely lie down after 
midnight. In the majority of cases this condition is de- 
pendent upon cardiac weakness, and hence, even in the 
best summer weather, when the cough is much mitigated 
although still moist, rales will be found to prevail at the 
bases of both lungs posteriorly. 

The character of the expectoration of these patients 
varies also in other respects. In some the watery flow 
is markedly predominant, and, when expectorated into a 
vessel containing water, the muco-pus floats in irregular 
masses on the surface, owing to the air which is entan- 
gled inits meshes. In others pus itself is raised in great 
quantities and in rounded masses. In still ether cases, 
however, which are usually of long standing, the expec- 
toration is very liquid in parts, and of a brownish tinge 
(“prune juice”), with masses of fetid, purulent, and 
rather adhesive secretion which sinks to the bottom of the 
cup. This feetor has been interpreted asa sign of pro- 
longed retention in some cavity on the way, and there- 
fore an evidence of sacculated enlargement of the bron- 
chi. While this is doubtless true of most cases, yet it is 
not so of all, and the fetid secretion may then be caused 
by some special putrefactive ferment in the bronchial 
wallitself. This is rendered possible by the curious fact 
that the feetor is so much greater in many instances than 
is found in the largest phthisical vomice, and, moreover, 
is so much less easy to disinfect. Itis sometimes difficult 
to distinguish it from the odor of gangrene of the lungs, 
and the diagnosis has to be based upon the different ante- 
cedent history and subsequent course. The breath also. 
often remains offensive after the expectoration has chietly 
lost its odor; at other times, the foetor comes and goes 
without any assignable reason, Neither is it necessarily 
a dangerous complication, for the worst case, as regards. 
odor, that I have ever seen was in a young man who had 
it for several years, while his general appearance contin- 
ued extremely good. 

Acute Broncho-Pneumonia Supervening upon Chronic 
Bronchitis.—Chronic bronchitis may terminate rather 
suddenly by the supervention of an acute diffuse bronchi- 
tis with consecutive pneumonia. There is reason to fear 
an access of this kind if a patient, who has suffered from 
this complaint for a long time, begins to feel chilly and 
feverish. A development of fever in a comparatively 
non-febrile complaint like this is always of serious sig- 
nificance, as it isin the bronchitis of children. The cough 
becomes much more severe and exhausting, and the im- 
plication of the smaller bronchi is rendered probable by 
the characteristic appearance in the sputa of long threads 
ot mucus hanging down from the larger masses as they 
float in the more liquid portion. These mucus-strings 
are derived from the smaller bronchi, which they nearly 
occlude until expelled by great effort, and, if the patient’s 
strength fails, the symptoms rapidly assume a grave con- 
stitutional character. The cough grows more and more 
ineffectual, the fever increases, and a low delirium sets 
in, with much subsultus tendinum, a dry tongue, and 
often free sweating. It is an unfavorable sign when the 
patient no longer attempts to sit up, or to turn on his 
side, or when the cough ceases. Physical exploration 
shows the ordinary signs of broncho-pneumonia, and 
while the prognosis is always serious, it is worst when 
among the antecedents there has been a weak, dilated 
heart, emphysema, bronchiectasis, or old age. 

PATHOLOGICAL ANATOMy.—There is no disease the 
general course of which is better explained by its morbid 
anatomy than chronic bronchitis. The changes that are 
found after death are so manifestly explanatory of the 
ante-mortem history that both the symptoms and the se- 
quel of chronic bronchitis are best understood by keep- 


495. 


Bronchitis, 
Bronchitis, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ing in mind the organic alterations which produce them. 
After chronic bronchitis, there is usually found consider- 
able discoloration of the lining mucous membrane of the 
bronchi, either brownish and generally diffused, especial- 
ly if the case has been complicated by cardiac disorder, 
or else in scattered red points, which increase to patches 
about the bifurcation of each bronchus. Of greater sig- 
nificance, however, than these vascular signs is the hy- 
pertrophy of the mucous membrane itself, which shows 
also a very irregular surface from still greater thickening 
of the subjacent longitudinal elastic fibres and hypertro- 
phy of the muscular coat. Like all hypertrophied un- 
striped muscular fibre. the muscles are frequently found 
ina state of fatty degeneration, and evidently possess but 
little of their normal contractile power. This is especial- 
ly the case in the sodden tissues found in bronchorrheea. 
The bronchi themselves appear to be passively dilated, 
and on section of the lung multitudes of the tubules are 
found to resemble the primary divisions in calibre, until 
further examination shows that they spring from smaller 
bronchi than themselves. The secretion found differs 
according to the form of the disease in life, being highly 
purulent and tenacious in the so-called dry catarrh, and 
filling all the smaller divisions with watery mucus in 
those characterized by more flux. It is, however, as we 
proceed further into the adjoining tissues that the most 
instructive lesions are found. Emphysema, as might be 
expected, is always present to a lesser or greater extent, 
sometimes occupying mainly the edges of the lung, at 
other times spreading out in every direction, interspersed 
with bands of fibrous tissue which strikingly assimilate 
the appearance of the viscus to that of a case of fibroid 
phthisis. The recent demonstration, however, of the 
specific nature of tuberculosis and its dependence upon a 
parasitic organism, renders it as incorrect to speak of a 
bronchitis turning into phthisis as of a urethritis chang- 
ing into syphilis; while, of course, it is not denied that a 
peribronchial inflammation, due originally to a chronic 
bronchitis, may afford a good nidus for the reception and 
development of the phthisical virus. The common ac- 
companiment of fibroid thickening from any cause, 
namely, the development of bronchiectatic cavities, leads 
to a still further resemblance to phthisis, and one which 
in some cases makes it difficult to settle the diagnosis 
without a full history of the beginning and course of the 
disease. 

Besides the production of emphysema, one of the com- 
mon results of chronic bronchitis is a slow implication of 
the surrounding connective tissue, which, as we have 
seen in capillary bronchitis, occurs with great rapidity. 
Peribronchitis is distinguished by a tendency to pass 
from lobule to lobule outward, until it involves the pleu- 
ra and produces thickening of that membrane. This 
effect has been ascribed by some to an extension of the 
inflammatory changes along the nutrient channels, which 
belong to the bronchial arterial system, rather than to 
those of the pulmonary vessels. One result is a great 
fettering of the expansion of the lungs in this complaint, 
so that on inspection of old cases we often find the lower 
ribs contracted, and either wholly immovable or else fall- 
ing in with each inspiration, the only well-marked tho- 
racic movement being vertical, and carried on mainly 
by the neck and shoulder muscles. 

The results of such changes upon the circulation now 
remain to be briefly considered. It is inevitable that the 
right ventricle should sooner or later become enlarged and 
dilated by the prolonged obstruction caused by the dis- 
ease in the pulmonary circulation. Universal venous 
congestion, therefore, is a common result of a bronchitis 
which has lasted long enough to embarrass the outflow 
into the lungs. Brown induration of the liver, with 
gastro-intestinal derangement, follows. The marasmus 
of chronic hepatic disease shows itself over the body in 
the dry, thickened, and wrinkled skin, in general arte- 
rial rigidity and muscular atrophy, and in a tendency to 
interstitial increase of connective tissue throughout all the 
organs. Hence old bronchitic cases, instead of resem- 
bling the soft, white, emaciated forms of the phthisical, 


496 





much oftener look like the withered and dusky sufferers 
from cirrhosis of the liver. The portal congestion in- 
duced by the hepatic obstruction produces gastric catarrh, 
constipation, and hemorrhoids, and later the kidneys par- 
take in the venous stasis, so that the urine becomes scanty, 
and high-colored. As the return current of blood be- 
comes more and more impeded, ascending cedema from 
the feet develops on to general anasarca, in the usual 
fashion characteristic of cardiac dropsies. 

Etiology.—The causation of chronic bronchitis is de- 
pendent, in the majority of cases, upon recurrent acute at- 
tacks, as just described. The original proclivity to such 
attacks, however, undoubtedly varies in nature in differ- 
ent cases. Some persons seem to have a hereditary dia- 
thetic tendency to bronchial catarrh, beginning generally 
with a chronic sensitiveness of the pharynx. These cases 
are characterized by imperfect circulation of the feet. 
There are a number of individuals, however, who are 
prone to chronic hyperemia of all mucous membranes, 
which shows itself in swollen and reddened eyelids, and 
in chronic nasal, pharyngeal, or aural inflammations; they 
also have disorders of the abdominal viscera, accompanied 
by sediments in the urine, etc., allof which ailments seem 
connected with some irritant in the blood from malassim- 
ilation; and when persons of this class contract a bron- 
chitis they seem never to get rid of it. That the gouty 
diathesis disposes to chronic bronchitis is well known, 
but so also do all sclerosing disorders, such as chronic 
alcoholism, with or without cirrhotic changes in liver or 
kidneys, and particularly when arterial degeneration is 
added. Lastly, mitral valvular disease leads to bronchial 
stasis and flux, the more so on account of the peculiarity 
of the bronchial arteries which .communicate freely not 
only with the general systemic veins, but also with the 
pulmonary veins—vessels, therefore, which lie in the di- 
rect track of a mitral obstruction. 

Diagnosis.—The diagnosis of chronic bronchitis is diffi- 
cult only when the discrimination has to be made be- 
tween it and fibroid phthisis or chronic pleurisy. The 
points in which it differs from phthisis have already been 
reviewed. Fibroid changes in the lung, however consec- 
utive to chronic pleuritic adhesions, are very analogous 
to those in many cases of chronic bronchitis; but the ini- 
tial history of the former is very different, as it begins 
with pleuritic pains and continues frequently to repeat 
this symptom to the last. Similar pains also characterize 
the course of fibroid phthisis to a much greater degree 
than they do bronchitis. Physical exploration of the 
chest is not very satisfactory in chronic bronchitis, from 
the too great number of signs. Aside from a few cases 
with pleuritic adhesions, the sounds obtained by percus- 
sion are usually not much altered from the normal except 
in the direction of increased resonance. Auscultation, 
however, meets with nearly every sound which can be 
generated in the chest. When we reflect that in a well- 
marked old case we may have a much greater than the 
usual number of large tubes, filled in varying degree with 
various kinds of secretions, in close proximity to asth- 
matically narrowed bronchi, and these again near cavities 
as large as ordinary vomice, surrounded by fibroid bands, 
emphysematous lobules, and lastly, pleuritic thickenings, 
we should not be surprised if we meet simultaneously 
noises belonging to each of these conditions, interspersed 
with certain areas in which we would find diminution or 
absence of all sound, whether normal or adventitious. 
This is the case to such an extent that a differential diag- 
nosis, based upon physical signs alone, is not to be 
trusted, 

Treatment.—One of the first indications in the treat- 
ment of any chronic discharge from a mucous membrane 
is to disinfect it, for experience proves that in so doing 
we remove a leading cause of the inveteracy of the com- 
plaint, viz., local irritation of the membrane by its own 
perverted secretion. It has been pithily said that it is no 
business of a mucous membrane to secrete mucus, but 
rather only an aqueous, slightly saline fluid, with but a 
trace of mucus to diffuse it equally over the surface. The 
presence of a layer of mucus, therefore, is a sure sign of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Bronchitis, 
Bronchitis, 





something wrong, and we may add that the longer that 
layer is allowed to remain, the more it acts as an irritant 
by its fermentative operation upon the subjacent mem- 
brane. In practice, there can be no doubt that the sooner 
mucus is removed, the sooner will an inflamed membrane 
recover, as we see illustrated by washing the bladder in 
cystitis. But washing isonly a mode of disinfection, and 
hence illustrates the same general principle. In the ali- 
mentary canal, the natural gastro-intestinal secretions are 
each strongly antiseptic, and therefore the presence of a 
gastric or of an intestinal catarrh is evidence of the ab- 
sence of those preservative, as well as digestive, juices. 
The best remedy for catarrhs of that mucous membrane, 
therefore, is the restoration of those secretions. On the 
other hand, where those secretions cannot reach, as in 
chronic dysentery, I have repeatedly succeeded in ar- 
resting, without any internal medication, the muco- 
purulent discharge from old rectal ulcers simply by 
ordering the rectum to be thoroughly washed out after 
each passage by an enema of hot water, made disinfect- 
ant by the addition of twenty drops of the oil of pepper- 
mint. 

I refer thus generally to the subject only to emphasize 
the more that prime indication in managing so intract- 
able a disorder as chronic bronchitis, for next to the lesser 
exposure of the skin to chill, it is plain that the mitiga- 
tion of a bronchitis during the summer season is owing 
to the fact that the patients are at that time able to inhale 
the open air so much more continuously than when they 
are jealously housed in winter. The open air is “ bland,” 
not because it contains some soothing ingredient charac- 
teristic of a given locality, but simply because the oxygen 
which it contains is the natural disinfectant for the respi- 
ratory passages. The best, indeed the only cwrative pre- 
scription for a settled case of chronic bronchitis, is a place 
where the patient may spend two or more years in con- 
tinuous outdoor life, preferably in a tent, and sleeping 
in a hammock, because all catarrh will cease when the air 
tubes have become thoroughly disinfected. The choice 
of climate, therefore, is not to be regulated by its heat or 
its moisture, or the reverse, but rather by the number of 
days in which it is comfortable to remain outdoors with 
out exposure to chill. 

Another prime indication subserved by open-air life is 
the toning-up of the weakened bronchial muscles and of 
the heart. Throughout the whole animal kingdom, the 
muscular power is directly proportioned to the activity 
of the respiration, that is, to the amount of oxygen taken 
into the system. It is the wonderful breathing capacity 
of insects which explains their wonderful muscular en- 
ergy, and so soon as muscular tissue begins to weaken, 
or is prone to fatty degeneration, the greater is the need 
to afford it the freest supply of oxygen. This principle, 
therefore, illustrates the clinical fact that one of the most 
efficacious remedies in chronic bronchitis, and especially 
in the bronchorrhea of the aged who have enfeebled 
hearts, is iron. As the only réle of iron in the system is 
to carry oxygen, so I have been accustomed to prescribe 
the tincture of the chloride of iron, with excess of hydro- 
chloric acid, in every case of heart disease and of chronic 
bronchitis, as a prophylactic against dilatation or muscle 
failure, with the result of greatly diminishing the expec- 
toration in the bronchial trouble and enabling the pa- 
tients to sleep much more continuously at night. In dis- 
tinction from its effects in phthisis, iron is always well 
borne in chronic bronchitis, partly, no doubt, from the 
more febrile character of the former disease. As adju- 
vants to iron, we may recommend the ethers, such as the 
compound spirit of ether, the spirit of nitrous ether, dulc., 
and, in cases in which there is cardiac complication, dig 
italis. 

A certain class of remedies may also be chosen for their 
antiseptic powers, such as the balsams and terebinthinates 
like copaiba, buchu, tolu, etc. The objection to them, 
however, is that they are apt to disorder the stomach, 
and hence can be employed advantageously only now 
and then, especially cn some exacerbation of the chronic 
disease with pain and increased coughing. Carbolic acid 


VoL. I1,—32 





itself, made up into pills and taken in doses of about 
twelve grains a day, is more effective and better borne. 
A drink composed of twelve grains of carbolic acid, half 
an ounce of glycerin, and half an ounce of paregoric in a 
pint of water, to be taken through the day, is a frequent 
prescription when the cough is severe and the expectora- 
tion at all offensive. One of the best remedies of this 
class is the carbonate of creosote or creosotal, on account 
of its agreeing so well with the stomach, as it often im- 
proves the appetite and digestion. An emulsion of it can 
be made readily with a small quantity of glycerin so that 
a tablespoonful will contain twenty grains of creosotal, 
the ordinary dose, to be taken three or four times a day, 
On the same principle we would recommend the daily 
use of inhalations of carbolized sieam, described in the 
article on Asthma. The use of quinine, also, as an anti- 
septic, in moderate daily dose, however, is to be recom- 
mended on general principles, particularly when there is 
free secretion of pus. The nitric acid, in combination 
with the iodide of potassium, is sometimes of great 
service in profuse expectoration, especially when there 
is reason to diagnose the presence of sacculated bron- 
chial cavities. In some of these cases the oxide of 
zinc, with belladonna, has seemed to diminish secretion, 
as it does in phthisical cavities with profuse expecto- 
ration. 

In those cases in which the expectoration is very vis- 
cid, and the cough correspondingly severe, I have found 
no remedy equal to the emulsion of linseed oil, already 
referred to. It soon renders the sputa less tenacious, and 
similarly lessens the violent coughing, while it seems to 
promote a restoration to a more healthy circulation by 
lessening the congestive tumefaction through the specific 
action of oils on such conditions in mucous membranes. 
The aid of chloral and morphine is also valuable here in 
checking the irritability of the bronchial nerves. In this 
class of cases a good deal of benefit may be derived from 
a prolonged course of mineral waters; those containing 
the largest proportion of common salt are to be preferred. 
Such a course is also to be recommended in those cases, 
above described, of litheemic or of gouty tendencies, and 
in the bronchitis of chronic alcoholism. If there be much 
asthmatic wheezing, the administration of iodide of po- 
tassium with belladonna, and occasionally a course of ar- 
senic, will prove of service. In all cases of difficult ex- 
pectoration, it is well to remember the help which may 
be obtained from sipping hot drinks. A cup of hot coffee 
taken thus, before rising in the morning, may enable a 
patient to rid himself of an accumulation of mucus which 
otherwise would be voided only by repeated and exhaust- 
ing efforts. 

The importance of protecting the skin of persons 
affected with bronchitis, in such a climate as ours, cannot 
be overrated. They should be dressed in buckskin un- 
derwear from head to foot throughout the whole autumn, 
winter, and spring months. The suit should be worn 
over a light flannel, which may be changed to thicker 
material in midwinter. Ail chest protectors should be 
discarded because they are altogether inadequate for a 
condition in which a chill to any part of the surface, and 
especially to the feet is quite enough to set up a fresh 
access of inflammation. Whensuch exacerbations occur, 
one of the best measures is to resort to free diaphoresis 
by the hot-water and blanket pack. The patient should 
go to bed and undergo this thoroughly, three or more 
times a day, and by so doing he may effectually cut short 
a severe visitation of hisenemy. During the summer, it 
is very desirable that the patient take daily cold salt- 
water sponge-baths, followed by active friction. This 
measure certainly lessens the tendency to catching cold, 
and the same may be said of the use of oil inunctions for 
the whole body, to be practised every morning in the 
winter, with the precaution of exposing the body only 


’ jn a warm room. 


The treatment of acute diffuse bronchitis, supervening 
upon the chronic form of the disease, belongs more prop- 
erly to the subject of broncho-pneumonia. 

William H. Thomson. 


497 


Broom, 
Bubo, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








BROOM. SCOPARIUS.—Broom-tops. “The tops of 
Cytisus Scoparius (L.) Link. (fam. Leguminose)” (U.S. 
P.). Thisis a densely growing, erect, yellow-flowered 
shrub of Europe and adjacent Asia, two to five feet high, 
its branches terminating in thick masses of long, exceed- 
ingly slender twigs, which are used like brooms, whence 
the popular name. These twigs constitute the drug of 
commerce. They are two to three feet long, one-eighth 
to one-fourth inch thick, sharply five-angled, of a very 
dark green, and exhaling a peculiar odor when bruised. 
This odor largely disappears with time, when the drug 
becomes inferior. The leaves, which are rarely present, 
are sub sessile, trifoliolate or reduced to one leaflet, the 
latter oblong or oval or obovate, somewhat hairy. Yel- 
low papilionaceous flowers are often present, and perhaps 
some flat pods, looking like undevelopedpea pods. 

Composition.—Broom contains tannin, fixed and vola- 
tile oil, wax, and the two peculiar bodies scoparin and 
sparteine. The volatile oil slightly assists the diuretic 
action of the scoparin. The latter is an amaroid 
(Co:H»22010), amorphous or in yellowish crystals, soluble 
in alcohol or hot water, and diuretic by directly stimulat- 
ing the renal secretion. It is occasionally given in doses 
of 0.5 to 1.0 gm. (gr. vii.-xv.); but is a very expensive 
remedy. Sparteine (C:;HasN2) is a yellow, syrup-like, 
aromatic, volatile alkaloid, soluble in alcohol and water, 
and yielding crystalline salts. It is a powerful poison. 
It has a primary circulatory stimulant action, contract- 
ing the arterioles and increasing blood pressure, thus as- 
sisting the diuretic action of the scoparin and volatile 
oil. The secondary action, which is very prompt, is to 
weaken the heart muscle and partly or wholly to over- 
come the vasomotor contraction. The drug is thus a 
cardiac sedative and in over-doses a paralyzing cardiac 
poison. It is also sedative to other muscles, and may act 
asa mild anodyne. It was originally used as a cardiac 
stimulant, but was found disappointing, and is now little 
used, mostly in the form of the official sulphate, in doses 
of 0.01 to 0.02 gm. (gr. 4% to 4). 

Broom is very considerably employed as a diuretic. 
The fluid extract is official and is given in doses of 1 to 
4 c.c. (4 to 1 fl. dr.). The five-per-cent. infusion is a 
better form of preparation, in doses of one-half to one 
ounce Henry H. Rusby. 


BROWNSVILLE, Texas, a town of 6,130 inhabitants, 
is situated on the north bank of the Rio Grande River, 
opposite Matamoras, in the extreme southeastern corner 
of the State. Itis a port of entry, and hasa warm, moist 
climate. It is not a health resort, and is mentioned here 
simply to indicate the climatic conditions which exist in 
this section of the country. 


CLIMATE OF BROWNSVILLE, TEXAS, LATITUDE, 25° 53’; LONGI- 
TUDE, 97° 26’. PERIOD OF OBSERVATION, SEVEN AND ONE-HALF 
YEARS. ELEVATION OF PLACE OF OBSERVATION ABOVE SEA 
LEVEL, TWENTY-EIGHT FEET. 


















Data. January.| July Year. 

Temperature (Fahrenheit scale) — 

ANMETAGE INCA: ion aicwitle Meche elalate elo alot ate 59.5° 84.4° 73.1° 

AV OLSQOTANIE cdecisnie ciiesieiaie ale sistereeciticts 17.2° 15.2° 

Mean of warmest 66.9° 92° 

Mean of coldest ..... 49,7° 76.8° 

Highest or maximum . siatatelereeir aetna 83° 98° 

TOW ESOL FH TALI cteicietstetetetovs eisieiererelons 18° 68° 
Humidity — 

Average relative (per cent.)..........65 79.6 71.9 76.3 
Precipitation— 

AVETAS IN ICHEN. crclsisieieicrs ee eieln eletelsielalars 2.10 2.63 82.03 
Wind— 

Prevailing Girectlon cases ssc ceva sleia= N. 8. E. 8. E. 

Average hourly velocity in miles ....... fe 6.9 6.9 
Weather— 

Average number clear days ..........+. 8.1 13.3 116.3 

Average number fair days............+- 8.1 14.2 148.9 

Average number fair and clear days.... 16.2 27.5 265.2 








NoTE.—If the above chart is not self-explanatory to the reader, he 
is referred to the article upon Baltimore. where in a similar table 
some of the terms are commented upon. : 

Edward O. Otis. 


498 





- is open for the reception of visitors all the year. 





BROWN’S WELLS.—Copiah County, Mississippi. 

Post-OFFIcE.—Brown’s Wells. Hotel and cottages. 

Access.—Via Illinois Central Railroad to Hazelhurst, 
thence five miles by stage line to springs. 

Brown’s Wells are situated near the central part of 
Mississippi, 40 miles south of Jackson and 150 miles north- 
east of New Orleans. The location is among the pine 
hills of Mississippi, though hickory, oak, and other 
growths abound. The climate here is very salubrious, 
and extremes of either heat or cold are seldom observed. 
The temperature rarely falls lower than 20° F. in the 
winter or rises above 98° F. in the summer. The eleva- 
tion above the sea level is quite considerable. The resort 
Four 
springs are found in the neighborhood, but only two have 
been analyzed. Examination of Spring No. 1 was made 
by Prof. John -R. Chilton, of New York, with the follow- 
ing result: 


Sprine No. 1. 


ONE UNITED STATES GALLON CONTAINS: 


Solids. Grains 
Sodiam sulphate 5. «s/c cc'es 0 ops'ven nelet nee nes elena 17.76 
Magnesium) sulphate. cic ccc ccc sce cles uretenigitaieeemne 
Calclum ‘Sulphate. -Jivs.aos dis. clea e's, cles’ eles siesta nee 97.60 
Aluminum Sulphate sci « siciegisicsne vvesicecietete aegis 8.11 
Tron protostllphate 72%... cise spices cs nuveleieniennieeiete 36.52 (?) 
Calcium Chloride Avi... cieacls aed’ etleseicerstsiateenntne - 16.44 
Organic matterA Ha.ce ciletcniloe sein ateneene dentate 92 
Free sulphuric: acidinic.cieces seivecmesricnies sielesacesiepie 40,88 (?) 

TO bal Sisete ereiecs vis ots pie; steietaeeees ss oie/elele alelcalawtteeaye 263.23 


This analysis shows a very potent mineral water. Itis 
probable, however, that the chemist’s report has been 
misread in some of the findings, and a new analysis is 
consequently desirable. According to a quantitative 
analysis by State Geologist George Little, Spring No. 2 
contains : 


Alumina. 

Organic matter. 

Carbonic acid gas. 
Sulphureted hydrogen gas. 


Calcium carbonate. 
Magnesium carbonate. 
Sodium carbonate. 
Iron sulphate. 


The proprietor of the springs, Mr. M. L. Morehead, 
presents many testimonials from well-known physicians 
certifying to the value of the waters. They are said to 
be very useful in rheumatic and gouty disorders, in ob- 
stinate disturbances of the alimentary tract, in functional 
liver complaints, in dropsical affections due to nephritis, 
and in anemia and allied disorders. Juwmes K. Crook. 


BRYONY. BRYONIA.—“ The root of Bryonia alba L. 
and Bryonia divica L. (fam. Cucurbitacee)” (U.S. P.). 
There are eight species of Bryonia, natives of the Medi- 
terranean region. The B. divica groWs as far north as 
England. They are tendril-bearing, cucumber-like vines, 
with very large, starchy roots, growing mostly in sandy 
soil. Their bitter and active constituents are doubtless 
for the protection of their nutritious roots against forag- 
ing animals. 

The roots are sliced, mostly transversely, to facilitate 
drying. These commercial slices are white discs (becom- 
ing gray with age), from one to four inches in diameter 
and one-fourth to nearly one-half inch in thickness. 
They are not appreciably thinner at the centre, though 
the bark is slightly broader than the fleshy portion. 
There are several concentric circles of short wood bun- 
dles. The surface is granular and slightly harsh to the 
touch. The fracture is short and sharp. There is a 
characteristic, though faint odor, and a powerful and 
disagreeable bitter taste. It is not adulterated, 

Composition.— With much starch and gum, and some 
sugar, the active constituents are the two bitter gluco- 
sides bryonin and bryonidin. 

Action and Uses.—Bryony is a hydragogue cathartic, 
practically identical with colocynth and elaterium. Like 
these, also, it is a stimulating or irritating diuretic, and 
thus emmenagogue, for which latter purpose it has 
been much employed. It is poisonous in over-doses. A 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


— 


Broom, 
Bubo, 





ten- per-cent. tincture is official, the dose being 8 to 15 ¢.c. 
(2 to 4 fi. drs.). The extract, dose 0.2 to 0.4 gm. (gr. 
iii.-vi.), is a preferable form of administration. 

HH. H. Rusby. 


BUBO (from fovfdr, the groin; Ger., Leistenbeule ; 
Fr., bubon), a term originally used by medical writers of 
antiquity to designate glandular tumors of the groin, 
was applied by authors of the period of the Reformation 
to glandular inflammations of every part of the body irre- 
spective of their nature. Modern writers have again 
reserved the term for inflammatory affections of the lym- 
phatice glands of the groin While buboes are alluded to 
in the earliest medical treatises of which we have any 
knowledge, and the pathogenetic importance of the geni- 
talia in their causation was apparently familiar even to 
Hippocrates, the distinctive types of the affection which 
are now generally recognized were, of course, unknown 
until long after the general outbreak of syphilis, which 
appeared at the close of the fifteenth century. Then, 
besides the adenitis, which suppurates and often leaves 
an ulcer, there presented itself a bubo which from its in- 
ception is indolent, unattended by pain, and rarely the 
seat of suppurative change. Gaspard Torella, Fallopius, 
Nicolaus Massa, Paracelsus, and other writers of that 
memorable epoch in the history of venereal diseases speed- 
ily recognized and described with sufficient accuracy this 
earliest systemic manifestation of syphilis. Nevertheless, 
the nature of buboes was so little comprehended that 
they were regarded as sympathetic in character, or as 
unsuccessful endeavors of nature to check through them 
the invasion of the system by the disease. That the ma- 
jority of buboes result from the deposit in the lymphatic 
glands of a poison conveyed to them from a distance 
could not have been known prior to the discovery in 1651, 
by Olius Rudbeck, of lymphatic vessels situated in differ- 
ent parts of the body and possessing a function of absorp- 
tion like that of the lacteals previously described by Asseli. 
Even then precise knowledge of the subject was slowly 
developed, and it remained for the observations of Hunter, 
Swediaur, Benjamin Bell, and Ricord to depict the clini- 
cal symptoms and finally establish the etiological relations 
of the different varieties of the disease under considera- 
tion. 

ANATOMICAL AND PATHOLOGICAL —The subcutaneous 
cellular tissue of the groin encloses, together with the 
superficial blood and lymphatic vessels, a varying num- 
ber (eight to twelve) of lymphatic glands, which receive 
their lymph from the subumbilical segment of the ante- 
rior abdominal wall, from the external genitalia, urethra, 
perineum, vagina, cervix uteri, anus, and inferior ex- 
tremity. The size of the inguinal, as of other lymphatic 
glands, in their normal state is so small that in persons 
with a panniculus adiposus of ordinary thickness they 
cannot be felt through the skin. Oval or elongated in 
form, the glands of the groin are arranged in two quite 
distinct groups, the larger of which follows the course of 
Poupart’s ligament, while the smaller forms part of the 
cribriform fascia covering the saphenous opening. The 
individual glands of these groups, when naturally large 
or enlarged from disease, present distinctive directions. 
Those which overlie the ligament have their axes parallel 
to the inguinal fold, while those of the lower group have 
their axes parallel to that of the lower extremity. This 
factor is of considerable importance, in that it often gives 
a clue to the source of the ganglionic complication, since 
the lymph from the external genitalia is conveyed to the 
upper, while that from the lower extremity passes to 
the lower chain. It must not be forgotten, however, 
that these groups communicate very freely with each 
other by numerous lymphatic vessels, in which the circu- 
lation is from the upper to the lower glands. Indeed, it 
is through the glands over the saphenous orifice and 
through one or two glands (Rosenmiiller’s) deeply seated 
underneath the fascia lata, that the lymph must pass 
from both lower extremity and genital area before it can 
enter the generallymph receptacle inthe abdomen. This 
anatomical factor will account for the not very infrequent 





occurrence of two suppurating glands on the same side 
of the body, of which one belongs to the upper and the 
other to the lower chain, the inguinal fold lying between 
them. 

Formed of a capsule embedded in the periglandular adi- 
pose tissue, containing within it lymph sinuses. networks 
of reticular connective-tissue and lymph cells. the lym- 
phatic gland, when the seat of inflammatory changes, 
presents appearances which vary greatly with the degree 
of the inflammatory process and the nature of the primary 
cause. The acute adenitis which may follow in the wake 
of any traumatic or specific infection of the skin or mu- 
cous membrane, and which manifests itself clinically by 
moderate swelling and tenderness of the affected gland, 
is associated with dilatation of its blood vessels and pro- 
liferation of the lymph corpuscles contained in the meshes 
of the reticular network or stroma.'' When this cellular 
infiltration becomes excessive the reticular network suffers 
from compression; it becomes rarefied, the capillaries are 
obstructed or completely torn. When deprived of their 
nutrition the infiltrating cell masses are speedily converted 
into pusfoci. Through the confluence of these the gland 
capsule, already distended from the inception of the proc- 
ess, becomes an irritant to the surrounding parts; the 
subcutaneous cellular layer and the skin more or less rap- 
idly participate in the morbid changes, and soon the sup- 
purating bubo, having attained twenty fold the size of 
the normal gland, is emptied spontaneously or by the 
knife of the surgeon. After the evacuation of the pus 
the abscess cavity speedily contracts, and cicatrization 
ensues with such rapidity at times that the wound is 
closed in a week from the opening of the bubo. Not 
always does this process of repair follow so quickly the 
elimination of the pus. The behavior of the periglandu- 
lar tissue is a most important factor in the events that are 
to follow. This is often the seat of more extensive in- 
flammation than the gland itself. Minute abscesses form 
around the inflamed gland from obstruction of its afferent 
vessels, so that after the elimination from the gland itself 
this remains embedded in a secondary abscess cavity 
formed about it. Covered by granulations. it may in 
time appear as a foreign body in the floor of an ulcer, or 
it may remain for months covered by integument yet sur- 
rounded by indolent sinuses Nor is the pathological 
process that ends in suppuration necessarily limited to 
one gland alone. The infection may be conveyed from 
the gland originally involved to one or more in the vicin- 
ity, until a number of them are bound together in one 
large inflammatory nidus, the suppuration of which usu- 
ally entails the destruction of a considerable extent of 
skin. Toa large extent, the termination of an adenitis 
depends upon the nature and gravity of the primary dis- 
ease. If theirritation in the lymph radicles of the affect- 
ed gland is mild or evanescent, as in herpes, balanitis, 
erysipelas, or gonorrhea, the consecutive adenitis rarely 
proceeds to suppuration. Absorption of the infiltrating 
cellular elements may supervene in a few days or even 
hours. On the other hand, long continuance of the local. 
irritation, whatever its character, will at times completely 
change the results of the glandular inflammation in that: 
the cellular infiltration, being insufficient in extent to in- 
duce suppuration, yet not disappearing by absorption, 
leads to organization. Here it is not the exuded lymph 
corpuscles that are converted into a durable tissue, but. 
the reticular substance which forms the framework of the 
gland. In the suppurating adenitis this disappears; in 
subacute adenitis it undergoes a reactive hypertrophy. 
In the course of time the septa of the gland increase so 
greatly in thickness that the lymph corpuscies between 
them are seriously encroached upon Hence the firm 
fibrous appearance of the section of a lymphatic gland 
that has been the seat of a chronic inflammation 

ETIOLOGY AND VARIETIES —The inguinal glands differ 
in no way from those of other parts of the body, and the 
morbid processes to which they are subjected can be du- 
plicated in those of the groin Hence a priori reasoning 
as to the venereal origin (using the term in its widest sig. 
nificance) of an adenitis here situated must be strenuously 


499 


Bubo. 
Bubo. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








deprecated. Violent exercise, strains while lifting or while 
mounting a horse, direct trauma, herpes, furuncles, ecze 
ma genitalium, and scabies may all be the source of an. 
inguinal adenitis. Some time ago there appeared at 
my Clinic a lad of seven years, with two suppurating 
glands, the one above, the other below the ligament. 
The most careful inspection of genitalia and lower ex- 
tremity failed to reveal anything abnormal. The cervi- 
cal glands were not enlarged, nor were there traces of 
tuberculosis or syphilis discernible. The only adducible 
cause of the bubo was a severe fall from a sand bank, 
which the boy had sustained one week before aggravated 
symptoms supervened. Buboes such as these, which in 
no way depend upon an inoculable, undiscoverable pri- 
mary disease, and which stand neither immediately nor 
remotely in connection with the sexual act, I have been 
in the habit of designating non-venereal buboes. 

Each of the three typical venereal affections, viz., gon- 
orrhea, the chancroid, and the initial lesion of syphilis, 
may be attended by complications of the inguinal glands, 
which are known as venereal buboes, and are subdivided 
into, 1, the simple or inflammatory; 2, the virulent, and 
38, the syphilitic varieties. They are produced respectively 
(1) by the irritation of a gonorrhea and chancroidal or 
syphilitic ulcer; (2) by the chancroid solely, and (3) by 
the presence of the initial lesion alone. 

1. Buboes are rarely produced by gonorrhea. While 
a slight tenderness of the neighboring glands not infre- 
quently attends a urethral discharge, it is very exception- 
al to witness in them an inflammation that ends in sup- 
puration. Ferry states that in the United States Marine 
Hospital Service two and one-half per cent. of gonorrhcas 
are followed by suppurating buboes (Jowr. Amer. Med. 
Se., 112, p. 571). In three hundred and twenty-seven 
cases of gonorrhoea seen by Sigmund, suppurating buboes 
developed in nineteen. Yet bubces of considerable size, 
with extensive destruction of tissue, are occasionally en- 
countered as complications of gonorrhea. They have 
been met mostly in very young subjects, in persons of 
tuberculous habit, or in subjects debilitated by a previous 
attack of syphilis. Again, it is not unusual to find a 
chronic hyperplasia of one or more of the inguinal glands 
after repeated and prolonged urethral discharges, a con- 
dition analogous to that of the cervical glands in persons 
prone to catarrhal affections of the throat. The term 
“sympathetic bubo,” formerly applied by preference to 
gland complications of gonorrhea, is gradually being 
discarded. _ Whether the bubo results from purulent pre- 
putial catarrh, gonorrhcea, or chancroid, instances are not 
rare in which there can be detected that cord-like swell- 
ing along the dorsum of the penis which is but the evi- 
dence of a lymphangitis developed by direct propagation 
of the disease from its first seat. Still, the morbid proc- 
ess in the lymphatic vessels does not usually manifest it- 
self by perceptible symptoms. Like the cas deferens in 
epididymitis, the lymphatic vessel conveys the irritant to 
the gland without being often seriously affected by it. 

2. The chancroid is by far the most common precursor 
of the bubo. From its very inception to the period of its 
repair, and even for months after its complete closure, 
the chancroid may be the cause of an inflammatory bubo. 
This the soft sore may accomplish in its dual capacity of 
harboring the ordinary pus-formers and the special bacil- 
lus of Ducrey and Unna. Ricord formulated the law 
that when the chancroidal virus is absorbed into a !7m- 
phatic gland there must inevitably be a suppurating 
bubo, the pus from which, in turn, will reproduce a 
chancroid. When the pus from a bubo of chancroidal 
origin is not inoculable, it is presumed that the fluid ab- 
sorbed from the chancroid did not possess the characteris- 
tic qualities of chancroidal virus. This is the distin- 
guishing feature between the simple and virulent buboes 
originating in chancroids. Still, it is difficult to com- 
prehend why a large, suppurating, yet non-virulent 
bubo should follow from the irritation of so small an area 
as is usually covered by a chancroid, when it so rarely 
follows the infinitely more extensive irritation of the 
urethra from gonorrhea. It has been estimated that the 


500 





proportion of simple to virulent buboes (following chan- 
croids) is nearly equal; it being 149 simple to 1388 viru- 
lent.?. These figures are far from conclusive, since every 
case should be made the subject of most careful inocula- 
tion before being utilized in statistics. The relative fre- 
quency of buboes in general as a complication of chan- 
croids has been more accurately determined. Fournier# 
has observed 207 chancroids of which 65 were compli- 
cated by suppurating buboes. 

In 146 cases of chancroid observed at my dispensary in 
the Medical College of Ohio, during a period of two 
years, suppurating buboes were recorded in 40. Thus it 
appears that in about 28 per cent. of the total number 
of chancroids buboes appear. In private practice the 
proportion is not so large, since with proper treatment 
of the primary ulcer ganglionic infection can generally 
be averted. It-is a remarkable fact that in women bu- 
boes are not so prone to develop as in men, owing prob- 
ably to the fact that the latter cannot abstain from work 
for a trivial soft chancre. The size of the original sore 
does not appear to influence, in any manner, the action 
of the inguinal glands, since it is not unusual to tind de- 
structive buboes following small and superficial ulcers, 
while destructive chancroids remain uncomplicated. 
The retention of the discharge from the chancroid is, no 
doubt, an important element in the production of bu- 
boes, since those of the freenum and those associated with 
phimosis are relatively most often followed by them. 
With few exceptions the chancroidal bubo develops in 
the groin of ‘the same side occupied by the first sore. 
When this is situated in the median line, and particularly 
when it involves the frenum, bilateral buboes are apt to 
supervene. Only in very exceptional cases is the irrita- 
tion or virus conveyed across the median line, to the 
glands of the opposite side, through the anastomosis of 
the lymphatic vessels. Occasionally a bubo will form in 
the median line at the root of the penis, or in the pubic 
region, where a small lymphatic gland is often found at 
the confluence of the lymphatic vessels of the two sides. 
Pubic buboes were encountered in 3 out of 298 cases.4 

The pus from chancroidal buboes is ordinarily sterile 
and free of micro-organisms. Inoculation with it asa rule 
fails. This has been shown by Strauss, Spitscka, and 
others. The most extensive investigations relative to 
this question have recently been made by Deutsch.® 
He examined the pus from 66 buboes. Thirty-seven oc- 
curred with the soft sore, 29 with the hard or mixed 
ulcers. Bacteriological experiments were made with 
a view to establish auto-inoculability, and to determine 
the length of time required for the bubo to heal. Of 
the 87 cases occurring with the chancroid, inoculation 
upon the abdomen with the production of a typical 
chancroid was successful in only 3 cases. In these 
3 cases the pus from the bubo showed the Ducrey 
bacillus. The pus from chancroidal buboes could be 
classified under three categories: (a) Sterile pus; (0) 
pus containing ordinary pus formers; (¢) pus containing 
the Ducrey bacillus with .or without the admixture of 
other microbes. In the 29 cases occurring with the 
hard or mixed sore, auto-inoculation was successful in 
only 8 cases, and in only 1 was a typical hard sore pro- 
duced. It may safely be stated, therefore, that in the 
great majority of cases suppuration in buboes is the re- 
sult of toxic absorption, and is not due to the entrance of 
micro-organisms themselves into the lymph channels and 
nodes. 

3. Syphilis. The initial lesion of syphilis is almost in- 
variably followed by a sclerosis of the upper chain of the 
inguinal lymphatic glands, of which the innermost is first 
involved during the first fortnight after the primary sore 
manifests itself. In the course of a few weeks the other 
glands of this region (Pleiades ganglionnaires), and subse- 
quently the glands in general, become affected. Fournier 
failed to find induration of the inguinal lymphatics 5 
times in 265 cases; Berkeley Hill® 3 times in 176 cases; 
whereas Bumstead 7 has never “ met with a chancre which 
was not attended by induration of the neighboring lym- 
phatic ganglia.” It is a characteristic of the syphilitic 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bubo, 
Bubo, 





bubo that it involves the entire chain of lymphatic glands, 
and that its progress is not attended by acute symptoms. 
Hence this form of bubo is often termed éndolent. In its 
morbid anatomy nothing of an inflammatory nature is 
apparent. The small-celled infiltration which takes place 
in the initial lesion of syphilis is reproduced in the ingui- 
nal glands. Every mesh of the reticulum is fully dis- 
tended by cells. The induration resulting therefrom con- 
tinues for months, and even for years, without termi- 
nating in inflammation or necrosis of the gland. As in 
the case of the primary induration, after continuing for a 
varying length of time, a fatty metamorphosis of the 
cells ensues; the detritus is absorbed, and the gland re- 
turns to its normal condition (Rindfleisch).£ In gallop- 
ing syphilis and in that of lymphatic subjects, the ingui- 
nal glands at times undergo extensive suppuration. 
Even then it will be found that the immediate cause of 
the inflammation is a secondary pus infection of the pri- 
mary ulcer, with the development in it of phagedsena. 
This suppuration of an indolent bubo, therefore, has 
neither a favorable nor a contrary influence on the subse- 
quent course of the syphilis. While the suppurating 
adenitis is, as a rule, a sequel of. the soft chancre, its pres- 
ence does not infallibly demonstrate the non-infecting 
(chancroidal) character of the primary sore. 

Bubon @ EHmblée.—The buboes which have been thus far 
considered are ascribable to plainly discernible lesions in 
the area of origin of the lymphatic radicles of the affected 
gland. Therefore they are secondary in character. The 
question has for a long time been discussed whether, 
without the development of a lesion at the point where 
the virus entered the body, this could be directly absorbed 
and conveyed to the glands and produce in them its pecul- 
iar pathological effects. Authorities of great weight 
(Vidal, Reynaud, Benjamin Bell) have cited numerous 
instances in which such absorption without local reaction 
is supposed to have taken place. To designate this par- 
ticular form of ganglionic disease the terms “ primary 
bubo,” “idiopathic bubo,” and “bubon d’emblée” have 
been used as synonyms. It has already been observed 
that primary buboes could arise from direct trauma, ex- 
cessive exercise, strumous habit, and other like causes. 
Aside from these etiological factors, it isat present deemed 
impossible for a venereal bubo to develop without pre- 
existing primary trouble. It is within the experience of 
every one that this primary affection may be very trivial 
in extent and of remarkably short duration, therefore es- 
caping the attention of the patient. Here, as in the case 
of the minute dissecting wound that may lead to suppu- 
rating lymphadenitis, and even to death, the original le- 
sion, or some trace of it, can always be found. Until it 
can be demonstrated that chancroidal pus or syphilitic 
virus can be made to permeate the unbroken skin, there 
is no good cause for believing in the bubon d’emblée. It 
is particularly through the efforts of Ricord, Langlebert, 
Fournier, and others that the “idiopathic bubo,” for so 
long a period the subject of most ardent polemics, is now 
generally believed to have no actual existence. 

SyMPTOMATOLOGY.—Simple Bubo.—The appearance of 
an inguinal bubo is ordinarily announced by a feeling of 
discomfort while walking. A passing sense of fulness 
causes the patient to examine the part, when he finds one 
or more tender glands in the groin. Palpation at this 
time reveals the presence of a resistant, movable swelling, 
tender to the touch, and varying in size from a bean to a 
cherry. Within a few days the symptoms rapidly in- 
crease in severity. The tumefaction, increasing in ex- 
tent, is oblong in form with the long axis parallel to the 
groin when a gland of the upper chain is affected, and 
parallel to the axis of the thigh when one of the lower 
group isinvolved. A decided elevation of the skin be- 
comes apparent before its implication in the process oc- 
curs. Pain is usually complained of, and it is either 
sharp and spasmodic in character or dull and constant. 
Hence follow disturbed sleep and impeded progression. 
With the extension of the inflammation to the periglandu- 
lar tissue, the mobility of the swelling disappears, the 
tumor loses its well-defined outline, the skin itself be- 


comes adherent and the seat of more or less redness. 
Even when symptoms so pronounced as these have con- 
tinued for a week or more, resolution may supervene in 
the course of two or three days. Such a fortunate ter- 
mination is more likely to ensue when the primary affec- 
tion was a gonorrhea, balano-posthitis, or herpes. But 
in undoubted cases of chancroid a gradual resolution of 
the acute inflammation, or its termination in a chronic 
induration, is not at all infrequently observed. These 
terminations are quite as likely to follow in the buboes 
which supervene during the early stages of the chancroid 
as in those that attend the reparative process of the sore 
or that follow its cicatrization. 

When the inflammation passes to the suppurative stage 
the indurated mass generally presents a softer spot, which 
is as often situated out of, as in, the centre of the swelling. 
With the increase of the area of softening the skin changes 
toa dusky hue. An examination, while the skin is still 
intact, reveals distinct fluctuation, and when the attenu- 
ated integument is indented by the finger the indurated 
wall of the abscess can ordinarily be distinguished. It is 
at this time, from ten days to two weeks after the begin- 
ning of the bubo, that the pus is usually evacuated by 
incision. In quantity this does not often exceed an ounce. 
If left to itself, weeks will often elapse before the skin 
yields to the ulcerative process, during which time the 
abscess increases in its dimensions until it contains at 
times from four to six ounces of thick, creamy pus. 
When permitted to open spontaneously, the abscess usu- 
ally opens at one point only, although two or three aper- 
tures are often formed. This feature of inguinal suppu- 
rating buboes requires especial mention. When the 
swelling has attained the size of a walnut or small peach, 
it will often appear to be subdivided by a deep furrow 
into two quite distinct growths, of which the smaller is 
usually situated below and nearer the median line. 
When suppuration is finally established, a separate open- 
ing will be formed or made necessary for each division 
of the swelling, irrespective of the question as to whether 
more than one gland is involved. Not always does the 
suppurating bubo run so acute a course. Instances are 
not at all infrequent in which the inflammatory symp- 
toms develop in successive stages with intervals of quies- 
cence. Such buboes often require several months before 
maturing, and for these cases the term “subacute” is 
occasionally reserved. The pus contained in them is usu- 
ally watery in character, and ordinarily not very abun- 
dant. 

The clinical course of a simple bubo, after it has dis- 
charged, does not differ materially from that of an abscess 
from other causes. In about thirty per cent. of all cases, 
and particularly in those in which an early incision was 
made, the walls of the abscess become agglutinated, and 
suppuration rapidly ceases. Generally, however, the 
discharge continues for from one week to many months 
before the abscess cavity is obliterated. Chronicity of dis- 
charge characterizes particularly those abscesses in which 
more openings than one have formed, and in which si- 
nuses lined with exuberant granulations undermine the 
skin. In many of these cases, the force of the inflamma 
tion having been spent on the periglandular tissue, these 
sinuses lead down to one or more glands. When the in- 
tegument covering the sinuses finally yields to the sup- 
purative process, or is divided by the knife, the gland 
covered by granulations will appear in the floor of the 
ulcer or in the wound thus produced. 

Virulent Bubo.—With the conveyance of the ptomains 
or of the specific microbes from the chancroid to the lym- 
phatic gland, suppuration in the latter is inevitable. 
The bubo of absorption, which results from this, in its 
inception presents symptoms precisely like those that 
belong to the simple bubo. The rapidity of development 
of the symptoms alone might arouse suspicions as to the 
virulent form of adenitis. It is only after the evacuation 
of the abscess that the differential diagnosis becomes 
practicable. Inoculation with the pus of the virulent 
bubo invariably produces a chancroid; inoculation with 
the pus from a simple bubo yields negative results save 


501 


Bubo, 
Bubo, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





in syphilitic subjects (vide supra). But the inoculation 
test is superfluous, since the progress of the virulent bubo 
after it is opened is usually sufficiently pronounced. . The 
margins of the wound which gave passage to the pus 
become inoculated with the chancroidal virus. As in the 
chancroid, during its period of progress the integument 
covering the virulent bubo is rapidly destroyed until a 
true chancroidal ulcer, varying much in area and depth, 
presents itself in the groin. When fully exposed to 
view, the floor of the bubo, from absorption, presents the 
yellowish-gray, irregular, and worm-eaten appearance of 
the chancroid. The margin of the ulcer, tumefied at 
one part, appears attenuated or undermined at another. 
From the entire surface there is exuded a watery pus 
which is often tinged with blood. Capillary hemorrhages 
from the bubonic ulcer are often encountered as in the 
chancroid. Indeed, the clinical history which belongs 
to the chancroid is on a larger basis duplicated in the case 
of the bubo. Healing in rare instances in a few weeks, 
in less fortunate cases it continues in its destructive 
course for months, and occasionally even for years. 
When thus protracted, the ulceration usually assumes the 
serpiginous type, healing in one portion and extending in 
another. Thus the ulcer gradually spreads over abdo- 
men, thigh, pubes, or gluteal region, leaving frequently 
ungainly cicatrices. In these cases the ulcerative action 
is often so sluggish that, as in lupus or rodent ulcer, it is 
almost imperceptible. Continuous auto-inoculation of 
the skin in the vicinity of the ulcer is the only plausible 
explanation of these protracted forms of bubo. Phage- 
dena, that most terrible complication of the venereal 
sore, occasionally attacks the virulent bubo. Under its 
influence the bubo may in a few weeks become convert- 
ed into an ulcer the size of the palm. Superficial in 
some cases, in others the ulcer under its influence dips 
down into the tissues, producing extensive sloughs. 
Progressing among the blood-vessels, it has been known 
to open them and induce fatal hemorrhage. Fatal results 
have likewise been induced by the excessiveness of dis- 
charge and from pyemia. 

Syphilitic Bubo.—The inguinal adenopathy of syphilis 
is but the reproduction on a larger scale of the indurating 
process manifested in the primary lesion. Appearing 
early and affecting an entire group of glands, the syphi- 
litic adenopathy yields a row of larger and smaller tu- 
mors, freely movable and easily felt, except in very obese 
subjects. These tumors are hard, resistant, not tender to 
the touch, and usually largest on the side of the primary 
sore. Oftener than in the other forms of bubo, the dor- 
sal lymphatics of the penis participate in the morbid proc- 
ess and appear in the form of indurated cords with ir- 
regular nodosities. Like the enlarged lymphatic glands, 
these lymphatic cords are freely movable. It has already 
been observed that indolence characterizes the syphilitic 
bubo. Only in persons of scrofulous taint, and in cases 
of great malignancy of the syphilitic virus (galloping 
syphilis), doessuppuration ensue. With or without treat- 
ment, the syphilitic bubo continues while the primary 
and many of the secondary manifestations remain. It is 
rare to find these buboes subside completely, even under 
treatment, in less than two or three months, and in many 
instances they survive all other syphilitic lesions, when 
they assume great diagnostic importance in determining 
the presence or absence of a syphilitic taint. After con- 
tinuing sometimes in an unaltered state for two or three 
years, they finally subside spontaneously. 

TREATMENT.—The treatment of buboes must necessa- 
rily vary with the nature of the primary trouble. Ina 
prophylactic way nothing can be done to prevent the 
syphilitic bubo, while much can be accomplished in the 
prevention of simple glandular inflammations as compli- 
cations of the chancroid and gonorrhea. In both these 
affections violent exercise and excessive walking and rid- 
ing should be strictly interdicted. Irritant applications 
to the primary disease should be strictly avoided, since 
too astringent urethral injections and irritating ointments 
applied to chancroids are often the immediate causes of 
gland complications. What influence has the cauteriza- 


502 


tion of the chancroid upon the development of buboes? 
If statistics be carefully examined, it will be found that 
in about thirty per cent. of all cases buboes supervene, 
and that their development is uninfluenced by the use of, 
or abstention from, cauterization. For this reason the 
application of violent caustics to chancroids is being more 
and more discarded. Of much greater importance as a 
prophylactic is cleanliness and the securing of a free es- 
cape for all discharges. It is for this reason that chan- 
croids treated in private practice are much less often 
complicated by buboes (according to my experience, one 
to eight) than those of hospitals, and particularly of dis- 
pensaries. 

When the evidences of an adenitis become unmistak- 


able, every effort must be made to bring about resolution 


of the inflammation, since this favorable termination is 
possible in every instance save those in which the chan- 
croidal virus has been observed. Asin other inflamma- 
tions, rest in bed is the chief antiphlogistic measure, and 
its importance must be fully explained to the patient. 
Applications of very cold cloths will at this time prove 
serviceable. A rubber bag is preferable, since it acts at 
the same time asacompressor. Localapplications of the 
liquor plumbi subacetatis, with cold compresses, have been 
highly recommended by Hamilton and Zeiss], and are 
doubtless often beneficial. It is at this period of the in- 
flammation that repeated applications of the tincture of 
todine are so frequently resorted to. Although this prac- 
tice has stood the test of time, and has the sanction of 
eminent authorities, it seems to me devoid of benefit and 
often pernicious in its results, since it not infrequently is 
followed by violent inflammation of the skin and hair 
follicles, even to the extent of vesication. Another im- 
portant objection to the tincture of iodine is the fact that 
the artificial condition of the skin produced by it fre- 
quently prevents the early detection of suppuration. 
When, for the purposes of absorption, iodine seems in- 
dicated, I have lately employed the iodide of lead quite 
extensively, using in connection with it veratrin, bella- 
donna, or opium to allay pain. Inunction with iodine- 
vasogen, six per cent., likewise serves a good purpose. 
Since compression, where it is practicable, plays an: im- 
portant rdle in the treatment of inflammations, it should 
be used here. It can be best applied by means of a bag 
half-filled with small shot. If the patient cannot be re- 
tained in bed, collodion applications and a compress, 
held in position with a spica bandage, should be resorted 
to. Happily for the patients, a number of methods of 
aborting the inflammation which were formerly practised 
have been entirely abandoned. Among them may be 
mentioned methodical compression by instruments, re- 
peated blistering with the subsequent application of 
mercurials, the forcible rupture of the gland capsule, and 
the use of the seton. To these may be added the subcu- 
taneous incision of the gland and the somewhat analo- 
gous procedure of Auspitz. The latter observer punc- 
tures the inflamed gland even before suppuration can be 
detected. A probe is introduced through the opening 
and the glandular septa are torn; the substance of the 
gland is thus broken up and discharges through the exer- 
ternal wound. This practice of Auspitz has not found 
and does not deserve many followers. Nevertheless, it 
has been most highly indorsed by Bumstead. Intra- 
glandular injections of iodoform emulsion, carbolic acid, 
and corrosive sublimate have been used to avert suppura: 
tion. Welander (Arch. f. Dermat. u. Syph., 1891, H. 3) 
advocated the injection of a one-per-cent. solution of ben- 
zoate of mercury. Of 78 cases reported, 56 were cured 
without suppuration. Perry (Joc. cit.) employs it in all 
non-suppurating buboes, injecting twenty to thirty min- 
ims of the solution. More than two injections are rarely 
necessary and the time required to effect a cure is four- 
teen days. 

When suppuration has been established, the treatment 
of the bubo must not vary from that of abscesses in other 
easily accessible portions of the body. Ubi pus, ubi inei- 
sio is a rule that should be adhered to in the disease 
under consideration. The ways in which the pus is to be 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bubo, 
Bubo, 





evacuated are numerous. Within the last fifteen years 
aspiration has often been resorted to, and has been highly 
recommended by annumber of French and German ob- 
servers. When it is evident that the purulent accumu- 
lation is small, and that a suppurative periadenitis has 
not yet developed, aspiration cannot be too often prac- 
tised. Attended by little pain, it can do no harm, and 
is sometimes followed by permanent agglutination of the 
abscess walls. Among recent writers R. Hahn speaks 
most favorably of it. Ina series of two hundred cases, 
seventy per cent. were cured by aspiration alone. In 
three-fourths of the cases one aspiration sufficed (Mittheil. 
aus der Hamburg. Krank. Anstalt, 1898). When the 
abscess is large and the skin attenuated, the only hope 
for a speedy recovery lies in the prompt and complete 
evacuation of the pus. The use of the Vienna paste, 
blisters, and multiple incisions to effect this have been 
properly abandoned. The last-named method, particu- 
larly recommended by Vidal, Zeissl, and Langston Park- 
er, and still practised by many older practitioners, is 
prone to result in the formation of a number of ulcers in 
the groin. In the great majority of cases, a single inci- 
sion, with a narrow blade, is all the operative interference 
called for. Until two decades ago the incision usually 
made was parallel to the inguinal fold and extended the 
entire length of the swelling. The result of such an in- 
cision is almost invariably a wound the edges of which 
are in apposition except when the patient is lying down. 
Again, when ulceration of the margins of the wound en- 
sues, the skin is very apt to become undermined or invert- 
ed. Hence very ungainly cicatrices result that might 
ordinarily be avoided by making the incision in a differ- 
ent manner. A good procedure is the following: The 
field of operation being prepared in the usual way, local 
anzesthesia is produced by the ether spray or preferably 
by the Schleich method (see Anesthesia, Local (Surgi- 
cal), in Vol. I.). The long and narrow knife, while held 
perpendicularly to the surface of the body, is then 
gently forced into the centre of the fluctuating area. 
‘The skin and capsule of the gland resist slightly the in- 
trusion of the blade. When this resistance has been 
overcome, the cutting edge of the knife is turned about 
ninety degrees and then withdrawn. With a little press- 
ure, or by inserting a grooved director into the cut, the 
accumulated pus rapidly escapes. To prevent a too 
speedy closure of the opening, it is advisable to insert a 
strip of iodoform gauze or carbolized gauze, which also 
insures the ready drainage of the abscess cavity. When 
this is removed, after remaining twenty-four hours, it 
will invariably be seen that the aperture, measuring 
from one-eighth to one-fourth of an inch in diameter, 
is circular in outline, and sufficiently large to permit the 
escape of the pus as rapidly as it is formed. The after- 
treatment consists of the application of bichloride gauze 
fomentations, or the use of the balsam of Peru 10, and 
castor oil 100, mixture. For cleansing the abscess cavi- 
ty, injections of of hydrogen dioxide may be called for 
from time to time. Thus treated the bubo usually heals 
in from ten days to two weeks. As already remarked, 
the bubo often has a tendency to point at a number of 
places, when it of course becomes imperative to use the 
knife repeatedly. The practice of Milton, who uses a 
very large needle for this purpose, might profitably be 
imitated in timid patients and by practitioners unaccus- 
tomed to the use of the knife. Not so, however, in case 
of extensive periadenitis and of virulent bubo. When 
the abscess is very large, a somewhat freer incision is 
necessary. Even here it seems to me better to make it 
parallel to the axis of the limb, irrespective of the direc- 
tion of the bubo. The wound thus made is more easily 
maintained patent, and in making it there is manifestly 
less danger of wounding the deep-seated vessels than 
from the incision as generally made. Almost immediately 
after opening a large bubo there will be a sinking in of 
the integument. In the course of a week, or even less, 
this skin becomes discolored, curled upon itself, or under- 
mined. Under these circumstances it is always best to 
remove the cutaneous flaps with a few strokes of the 





curved scissors, thus converting the abscess into an open 
ulcer. In other cases fistulee in the groin continue to 
discharge indefinitely. They should be freely laid open 
with the knife or elastic ligature, and the exuberant gran- 
ulations removed with the sharp spoon. When once the 
bubo has been converted into an open ulcer its treatment 
is ordinarily successful, no matter what applications be 
made, although at times stimulating medicaments are 
called for to overcome the sluggishness of the granula- 
tions. Among the large number of agents specially rec- 
ommended for this purpose there should be mentioned 
iodoform, tincture of iodine, tannin, permanganate and 
chlorate of potash, preparations of iron, and boric acid. 
Iodoform usually acts so satisfactorily as almost to merit 
being called a specific in the treatment of the open bubo. 
Applied in the form of ointment alone, or with tannic 
acid, or in ethereal solution (iodoform, 8; ether. fort., 
30), it soon causes the floor of the ulcer to be covered 
with small and healthy granulations which rapidly lead 
to its permanent closure. When the odor of iodoform is 
an insurmountable objection to its use, the permanganate 
of potash (0.5 to 380.0), in aqueous solution, is an excel- 
lent substitute. The balsam of Peru dressing already 
referred to also forms an excellent application. When 
the reparative process is exceptionally protracted, from 
the size of surface involved, skin-grafting has been used 
with as much success as in other portions of the body. 

Attention has already been directed to the fact that 
the lymphatic gland covered by granulations often pre- 
sents itself in the floor of the bubonic ulcer, or is hidden 
in the depths of asinus. The gland then acts as a for- 
eign body. It should therefore be removed as soon as it 
is discovered. Whether this is to be accomplished with 
scissors, ligature, or Volkmann’s spoon must be deter- 
mined by the circumstances of the case and the predilec- 
tions of the surgeon in charge. 

Kecision.—W ith the development of modern methods 
of wound treatment excision of buboes, which if left alone 
would probably suppurate, has become a favorite method 
of treatment. It is not to be recommended as a routine 
procedure, because of the extent of operation necessary 
to remove all glands and of the danger of wound infec- 
tion from the primary ulcer. Furthermore, the time re- 
quired for cure, averaging thirty days, exceeds that 
which is needed when conservative measures alone are 
adopted. 

Excision is indicated when infection has taken place in 
a number of glands and when it is evident that the proc- 
ess of suppuration will be long continued. By free ex- 
cision in these cases the healing process can be curtailed 
as to time. Primary union should not be sought for; in 
most cases it will fail. 

It is self-evident that the systemic treatment of pa- 
tients afflicted with buboes must not be neglected. Nu- 
tritious diet and tonics are always indicated after the 
process of suppuration has become somewhat protracted. 
This is particularly true if the ulcer shows any tendency 
to phagedena. It is then that cod-liver oil, quinine, and 
alcoholic stimulants are indicated, and that the most 
effective local measures must be resorted to. Blisters, 
fuming nitric acid, the carbo-sulphuric paste, bromine, 
and even the actual cautery must at times be employed 
before the tendency of the ulcer to spread is permanently 
overcome and the process of cicatrization is well estab- 
lished. Fortunately, this class of cases is becoming rarer 
from year to year. 

Syphilitic buboes, as a rule, require no local treatment. 
As the secondary manifestations of the disease disappear 
under treatment, the enlargement of the inguinal glands 
also subsides. When the induration in them persists 
after other symptoms have yielded to treatment, inunc- 
tions with the mercurial ointment or the oleate of mer- 
cury over the ganglia will often cause their reduction in 
size. Compression might also be resorted to in these cases 
with marked benefit. Joseph Ransohoff. 


1 Rindfleisch: Pathol. Gewebelehre, p. 139. 


2 Jullien: Traité pratique de mal. vénér., 1879, p. 429. 
3 Dict. nouveau des sc. médicales, yol. v., p. 764. 


503 


Bubo Plague. 
Bubo Plague. 


4 Griinfeld: Real-Encyclop., Bd. ii., p. 613. 
5 Centralblatt f. Harnk., 1897, p. 354. 

® Art. Bubo, Quain’s Dict. 

7 Ven. Dis., p. 479 (fourth edition). 

5 Rindfleisch: Loe. cit., p. 172. 


BUBO PLAGUE.—(Synonyms: The Pestilence, or Pest; 
the Black Death; the Plague of Egypt; the Oriental, Le- 
vantine, Indian, or Pali Plague [Mahamari] ; Adeno-Ner- 
vous Fever, Typhus Pestilentialis, Malignant Polyade- 
nitis, Pestis Bubonica, etc.) 

DEFINITION.—The bubo plague, or more briefly, the 
plague, is a disease which at times is widely dissemi- 
nated, and which consists of a single paroxysm of acute, 
infectious, and contagious, febrile disorder. It is charac- 
terized clinically by a sudden onset, short course, great 
mortality, and, specifically, by the occurrence of carbun- 
cles, ecchymoses, and petechiz upon the general surface, 
and occasionally by gangrenous inflammation of the 
lungs, more commonly by the development of glandular 
swellings, tending to suppurate, in the inguinal and axil- 
lary regions and exceptionally elsewhere in the body. 
The plague is endemic in certain localities, notably those 
bordering on the eastern shore of the Mediterranean Sea 
and in the Oriental countries adjacent thereto. Occasion- 
ally it extends widely as an epidemic, especially along 
the great paths of commerce to other parts of the world, 
even to the Arctic zone, thus becoming pandemic. It is 
apt to prevail particularly during certain seasons of the 

ear. 
z Discovery of the Specific Cause in the Bacillus Pestis.— 
The plague bacillus was discovered by Kitasato in an 
investigation of an outbreak at Hong-Kong made by 
direction of the Japanese Government and published in 
1894 under the auspices of the University of Tokio. 
Yersin and Roux, by independent research, which was 
made almost coincidently with that of Kitasato, also dis- 
covered the same micro-organism. The plague bacillus 
is a short bacterium or coccobacillus, almost as broad as 
long, measuring about 2 in its greatest diameter. As 
the bacteriological characters of the plague micro-organ- 
ism have been discussed in the article on Bacteria, in Vol. 
I., it will be necessary here merely to call attention to a 
few facts of especial interest from the clinical standpoint. 
This bacillus pestis enters the human body with great fa- 
cility, and rapidly multiplies after its introduction. It is 
found generally in the contents of the alimentary canal, in 
the blood, in the interior of organs, and especially in lym- 
phatic glands, and in the discharges from buboes. While 
possessing extreme virulence in its action upon the ani- 
mal organization, its own resisting power to chemical dis- 
infectants is feeble. Carbolic acid in weak solution (one 
per cent.), or even lime water, will render it innocuous. 
Experiments made recently in the laboratory of the United 
States Marine Hospital Service at Washington, D. C., 
have demonstrated the fact that it is easily destroyed by 
all of the ordinary disinfectants. It dies in four days, if 
kept at a dry heat of 60° C. (140° F.), or in half an hour 
if subjected to a temperature of 80° C. (176° F.), and ina 
few minutes if subjected toa heat of 100° C. (212° F.). 
On the other hand, it develops easily in many culture 
media at the ordinary temperature—18° to 22° C. (64.4° to 
71.6° F.). It loses its virulence by drying, and retains 
its virulence only when subject to the action of mode- 
rate heat and moisture. Dr. Walter Wyman, Surgeon- 
General of the Marine Hospital Service, in a recent offi- 
cial report on the bubonic plague, from which this state- 
ment is taken, gives a succinct account of the disease as 
it has come under the notice of his department. As re- 
gards its causation, he says: “The presence of organic 
matter, animal or vegetable, and in a state of decomposi- 
tion, would seem to furnish the most favorable nidus for 
its growth, which will account for its more prolonged 
existence in Oriental countries and the comparative rarity 
of its appearance in Europe since the existence of mod- 
ern and improved hygienic conditions. This does not 
mean, however, as was maintained by some at the Venice 
conference, that filth and crowding are alone responsible 
for the disease. The malady is pre-eminently of bacterial 


504 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





origin, and wherever the microbe is found, there the 
plague is likely to develop. The length of its life, when 
exposed to favorable conditions outside of the human 
body, has an important bearing upon the quarantine meas- 
ures necessary to be enforced, particularly with regard 
to merchandise from an infected port.” From a number 
of experiments made to determine the temperature and 
time required to kill the bacillus outside of the human 
body (according to the report of the German Plague 
Commission as quoted by Bowhill), “the longest time 
that infected material as lint, wadding, earth, etc., re- 
mained active was eight days. Sputum, from patients 
affected with the pneumonic form, kept in a vessel 
plugged with cotton wool, was no longer virulent in six- 
teen days. In ordinary drinking water the bacilli die in 
three days, in sterilized water in eight days, and in ster- 
ilized bilge water in five days. The bacilli are killed by 
drying at ordinary room temperatures in four days, ac- 
cording to Bowhill. The bacillus of plague is found in 
the dust of infected houses and in the soil, which has 
been contaminated by discharges from the body. It is 
also found in the bodies of domestic animals and vermin 
which dwell in infected houses and which die in great 
numbers during an epidemic. It is believed that mice, 
rats, dogs, beetles, flies are important factors in commu- 
nicating contagion. The results of the study of the fla- 
gellate parasite of the rat’s blood, the trypanosoma, by 
Rabinowitsch and Kempner,* establish the fact that fleas 
are the active agents of communication of this form of 
hematozoon infection. It is probable, in a similar man- 
ner, that fleas, especially in the Orient, convey the plague 
bacillus, especially as dogs and rats are so commonly 
infected at an early stage of the epidemic. Ina recent 
paper, Professor Galli-Valerio, of the University of Lu- 
sonne, combats the idea that the particular flea, which is 
parasitic in the rat, can be instrumental in conveying the 
infection of bubonic plague directly to man. In experi- 
ments made upon himself, he was unable to obtain any 
evidence that this flea (Typhlopsylla musculd) will remain 
upon the body of a man unless under compulsion, or that. 
it will puncture the skin of man. Surgeon-General 
Sternberg, U.S. Army, ina recent article in which this ref- 
erence is found, says that “he admits, however, the 
possibility that plague might be transmitted from man to 
man by the well-known domestic flea (Pulex irritans).” 
As plague bacilli have been found in the intestinal con- 
tents of the rat’s flea, it is possible that this parasite may 
after all play an active and important part in disseminat- 
ing the plague among the rats and other inferior animals, 
and also contribute its quota toward causing infection of 
house dust which mingles with food and drink of man. 

Nosology and Clinical Forms.—The terms plague, pest, 
pestilence, the Black Death, la Grande Mortalité, and 
similar popular names have in the past been applied 
without discrimination to every form of epidemic disease 
attended by great mortality. In early times, therefore, 
epidemics of erysipelas, hemorrhagic or black measles, 
cerebro-spinal fever, typhus, and other infectious diseases, 
even leprosy, have been confused in the public mind and 
in the medical records with the bubo plague, and it is 
difficult, if not impossible, to declare at this late day, in 
some instances, exactly what form of infectious disease 
was responsible for the epidemic in question. By degrees, 
however, as knowledge of pathology and diagnosis in- 
creased, the term plague has, by exclusion, come to be 
understood as applying solely and only to the disease now 
under discussion. Therefore, whenever the word plague: 
is used in this article it means the bubo plague, or malig- 
nant polyadenitis. 

It has been observed and should be borne in mind that. 
the clinical manifestations following infection with the 
plague bacillus may be modified to a certain extent by 
natural causes or attending circumstances, social as well 
as meteorological, so that the symptoms may not be: 
identical in form in different countries or in different. 


* Zeit. fiir Hygiene u. Infektionskrank., 1899, xxxi., p. 251, and Jour- 
nal Amer. Med. Assn., April 28th, 1900. 


te 


——— = 


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Bubo Plague, 
Bubo Plague. 





epidemics. Thus the black death, which ravaged Europe 
in the fourteenth century, presented features which, in 
the minds of some nosologists, create a doubt as to its 
really being an instance of the bubo plague. When we 
recall the sanitary, or rather horribly unsanitary condi- 
tion of most European countries at that time, and the 
mode of living which then prevailed, we may find suffi- 
cient reason for some modification of the symptoms of 
the plague as known at the present day. Dr. J. C. Wil- 
son,* from whose able summary of the literature of the 
plague this remark was extracted, also states that a like 
difference of opinion exists in regard to the relationship 
between the Indian or Pali plague, which has from time 
to time prevailed in Northwestern India during the pres- 
ent century, and the true plague. The black death of 
the fourteenth century and the Pali plague, though pre- 
senting many of the characteristics of bubo plague, differ 
from it, while they resemble each other in one important 
particular. Among the earlier and more common symp- 
toms of note are those dependent upon gangrenous in- 
flammation of the lungs, a lesion, according to Hirsch, 
extremely rare in bubo plague. This author informs us 
that recent observations have fully confirmed the early 
opinion that the Pali plague differs from that of the Le- 
vant chiefly in this modification, and cites Pearson and 
Francis as saying of the former disease that “the collec- 
tive symptoms are more like those of plague than of any 
other known disease. . . . We believe it to be in all es- 
sential particulars identical with the plague of Egypt.” 

Clinically, the cases of plague have been grouped ac- 
cording to their severity into three classes: (1) The typi- 
cal, ordinary, or grave cases. (2) The fulminating cases. 
(3) The abortive, or larval, cases. 

Adopting the usual basis of classification by systematic 
writers, which is more in accordance with the semeiol- 
ogy and pathology, we have: 1. The bubonic or gangli- 
onic form. 2. The pneumonic form. 3. The septiceemic 
form. 

“Of these forms,” says Wyman, “the bubonic is the 
most common, the pneumonic the most fatal. The meth- 
od of infection—that is to say, the point of entrance of 
the specific microbe—is a point still under active discus- 
sion, and is different not only for the various types and 
forms given, but also varies in different countries and in 
different sections of the same country. For example, in 
Hong-Kong, where the natives as a rule go barefooted, 
infection, in a large number of cases, has been traced to 
abrasions and wounds of the lower extremities. In India, 
some covering or protection for the foot is usually worn, 
but the natives suffer from the bites of insects and vermin; 
consequently the point of entrance of the infection has 
been largely upon the hands andarms. Infection through 
the intestinal tract, while admitted, is as yet largely un- 
explained; for in spite of the assertions of Wilm, some 
breach of continuity would seem to be necessary for the 
entrance of the micro-organism. Asa rule, a small red 
spot marks the point of infection; this becomes succes- 
sively a vesicle and a pustule, andin the ganglionic form, 
and ina large proportion of cases, a general redness, or 
a series of vesicles, marks the passage of the infection 
along a lymphatic tract or channel. These vesicles have 
been of very frequent occurrence in the Bombay epi- 
demic.” 

Essential Character of the Disease.—At the present day, 
plague is classed as a contagious miasmatic disease (Lie- 
bermeister) in a group with enteric fever, cholera, epi- 
demic dysentery, etc. Up to the seventeenth century, 
the plague was commonly ascribed to moral causes, as a 
visitation of the wrath of an offended higher power upon 
the people for their sins, or to some evil combination of 
the stars, which were supposed to preside over the health 
of man. It was Sydenham who first clearly pointed out 
the true nature of the disease and showed that it was like 
other disorders and therefore due to purely natural causes. 
In opposition to the ancient belief that the epidemic was 


*“The Plague.’ Pepper’s “‘System of Practical Medicine,’’ by 
American Authors, Philadelphia, 1885, p. 771. 





produced by some atmospheric or nieteorological condi- 
tion, or hypothetical “epidemic constitution of the at- 
mosphere,” Sydenham acutely observed that infection 
either from a sick person or some fomites or infected 
clothing is an essential prerequisite to the outbreak. 
While maintaining the teachings of experience that 
changes of the atmosphere and the season of the year do 
affect the prevalence of epidemic diseases, and that, in 
point of fact, the plague itself is more apt to prevail in 
summer and the early fall in the temperate zone, and to 
diminish to a minimum in the winter, he insists that still 
something more is necessary. In his medical observa- 
tions (chap. ii.) on the “ Pestilential Fever and the Plague 
of the Years 1665 and 1666 as it Appeared in London,” 
he remarks:* “[ am far from denying that a statement 
made by several authors, as to the plague having origi- 
nated during periods of the year other than that men- 
tioned above, may be possible. The fact, however, is a 
rare one, and when it takes place, the ravages of the dis- 
ease are less. . . . On the other hand, [ have grave suspi- 
cions that the mere atmospheric condition, however much 
Aotwadne (loimodes, Gr., from loimo, the plague), is by no 
means sufficient in and of itself to originate plague. 
Either the disease itself must continue to survive in some 
secret quarter, or else, either from some fomes, or from 
the introduction from pestilential localities of an infected 
person, it must have become extended. And, even in 
these cases, it cannot become epidemic, except with the 
conditions of a favorable atmospheric diathesis. Except 
upon this principle, J cannot comprehend how, of two 
towns near each other, and under the same conditions of 
climate, the one shall be grievously afflicted with the 
plague, the other be wholly free, and that by merely cut- 
ting off all communication between itself and the place 
infected. Yet this was done not many yearsago, through 
the care and foresight of the Grand Duke Ferdinand IL., 
who effectually stopped on the borders of Tuscany a 
plague that devastated nearly the whole of the remaining 
parts of Italy.” 

Former Epidemics.—It is probable that epidemics of 
plague raged prior to the dawn of history, since as far 
back as our records extend we meet with references to 
pestilences, which recall the features of this form of epi- 
demic disease. Manetho, an Egyptian historian, who 
lived at the beginning of the third century B.c., described 
pestilences, resembling the plague, which ravaged the 
valley of the Nile during the reign of the most ancient 
Egyptian kings. The early Jewish writers of the Bible 
refer repeatedly to the plague asa visitation upon the 
people for various acts of disobedience. Zechariah (xiv. 
12-18) refers, about 487 B.c., toa plague that shall “ smite 
all the people who have fought against Jerusalem,” 
and “the heathen that come not up to keep the Feast of 
Tabernacles”; but the description given does not agree 
with the clinical features of bubonic plague. “Their 
flesh shall consume away while they stand upon their 
feet, and their eyes shall consume away in their holes, 
and their tongue shall consume away in their mouths,” 
which rather applies to an affection like leprosy than to 
an epidemic disease such as the plague. In fact, in Le- 
viticus, the “ plague of leprosy ” receives a great deal of 
attention. Some confusion has arisen from the fact that 
the Hebrew word translated plague means “a smiting,” 
and was applied to various kinds of disease without much 
diserimination, with either moral or medical signification. 
It has been recently stated,+ with much appearance of 
probability, however, that the bubo plague is referred to 
in the Bible at a date more than eight hundred years pre- 
vious to the hitherto accepted record, which has gencrally 
been dated 300 3.c. Drs. F. Tidswell and J. A. Dick, ia 
a communication presented to the Royal Society of New 
South Wales, have furnished evidence to show that the 
plague of 1141 n.c., described in the First Book of Samuel 
(chaps. iv.-vi.), was true bubo plague. After the Philis- 
tines had captured the Ark of the Covenant, and taken 





*Sydenham Society’s edition of the works of Thomas Sydenham, 
M.D., London, 1848, p. 101. 
+ Nature, March 22d, 1900. 


505 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





it to Ashdod, severe illness broke out among the people. 
“The hand of the Lord was heavy upon them of Ashdod, 
and he destroyed them and smote them with emerods.” 
The Ark was afterward taken to Ekron, and here again 
we are told, “There was a deadly destruction throughout 
all the city, . . . and the men that died not were smitten 
with the emerods, and the cry of the city went up to 
heaven.” The word “emerod,” on account of similarity 
of spelling and sound, has usually been taken to mean 
hemorrhoids, but in the Revised Version of the Old Testa- 
ment it is stated to mean “tumor,” or “plague boil.” 
The epidemic in Philistia occurred at the time of the reg- 
ular plague season, and mice are mentioned in connection 
with it, which furnishes additional evidence that the epi- 
demic was plague, for a connection has been clearly es- 
tablished between the death of rats and the plague, at 
Bombay and elsewhere, as has been already mentioned. 
Thucydides described a plague which prevailed in 
Athens from 489 to 482 B.c., and reappeared again eigh- 
teen months later. Acron of Crotona is said to have dis- 
sipated the cause of this plague by means of fires kept 
burning in the streets. During this epidemic, Athens 
lost more than one-third of its population. Thucydides 
himself suffered with the disease, and Hippocrates noted 
it, in the aphorism, “ All fevers complicated with buboes 
are bad, except ephemerals.” Dr. Adams, the translator 
of the Sydenham Society’s English edition of Hippocrates, 
mentions the curious omission of all allusion to the conta- 
giousness of certain diseases by Hippocrates, although 
his contemporary, Thucydides, in describing the plague, 
expresses himself in such terms as put it beyond doubt 
that he regarded the disease as being of a contagious na- 
ture. Not the least reference to contagion, in any shape, 
is to be found in any of the Hippocratic treatises. 
Plague was epidemic in Libya, according to Rufus of 
Ephesus, in the third century B.c. The great plague re- 
ported by Livy, who died 221 B.c., is said to have de- 
stroyed a million persons in Africa; no records remain, 
however, of itsextension to Europe. The earliest account 
in the Christian era of a great epidemic of the plague is 
furnished by Procopius. This outbreak began in the 
year 542 in Egypt, from whence it extended to Palestine, 
Syria, and Persia; it then passed from Asia Minor into 
Europe, at Constantinople, where it carried off ten thou- 
sand victims in one day (548 A.D.). From this asa centre 
the plague, becoming pandemic, spread in all directions, 
carrying death and destruction in itstrain. It is estimat- 
ed that shortly before the close of the sixth century fifty 
per cent. of the inhabitants of the Eastern empire had 
perished, either directly from the plague or indirectly 
from the destitution and disturbance of society incident 
upon the plague. This epidemic, known as the Justinian 
plague, is of historical importance, as the disease at this 
time established itself in Europe, where it maintained a 
foothold for more than a thousand years. In the seventh 
century it appeared in England. The fourteenth cen- 
tury again witnessed the spread of the plague from the 
East, whence it extended throughout Armenia, Asia 
Minor, Egypt, Northern Africa, and nearly the whole of 
Europe. In all the epidemics of this century, Hecker 
calculates that one-fourth of the entire population of 
Europe, or 25,000,000 persons, perished. R. B. Anderson 
(“America Not Discovered by Columbus”) says that 
“the black plague reduced the population of Norway 
alone from 2,000,000 to 800,000.” It was during this 
period that Venice took measures to check the spread of 
the plague and appointed three guardians of the public 
health charged with this duty. In 1403 there was opened 
the first quarantine establishment on a small island adja- 
cent to Venice. In the fifteenth century the plague re- 
curred frequently in nearly every part of Europe, the mor- 
tality being not less than 40,000. During the sixteenth 
century the epidemic continued. In 1572 50,000 died at 
Lyons, in 1576 Venice lost 70,000. In the seventeenth 
century occurred the great plague of London (1664 and 
1665) of which Sydenham, Defoe, and Mr. Pepys wrote. 
It is said to have proved fatal to one-third of the popula- 
tion, or more than 68,000 inhabitants of this metropolis. 


506 


In 1656 it raged for five months in Naples, causing the 
death of 300,000 people. This, however, was the last ex- 
tensive outbreak of the plague in Italy, as the great epi- 
demic in London in 1665 was its final appearance in Eng- 
land previous to the occurrence of some isolated cases last 
year. In France, it still lmgered in the provinces until 
1668, although malignant epidemics had ceased several 
years before. Inthe early part of the eighteenth century 
two outbreaks occurred in Europe. The first spread from 
Turkey, through Hungary, to Russia, Norway, and Swe- 
den, and thence along the Baltic to the Netherlands, com- 
ing to anendin 1714. Six years later, the last great out- 
break on the European continent took place. It prevailed 
in Marseilles in virulent form, costing the lives of from 
40,000 to 60,000 people in this one city alone. In 1721 
it appeared in Toulon and spread over Provence, carrying 
off 87,000 out of a population of less than three times that 
number. In 1748 Sicily was attacked, the mortality at 
Messina being between 40,000 and 50,000. In 1771 
nearly a quarter of the population of Moscow died of it, 
or more than 50,000 people. In the century just ended the 
plague has been confined principally to the East, although 
during the second and third decades repeated outbreaks 
occurred in the Balkan peninsula and the regions border- 
ing on the lower Danube and the Black Sea. In 1815 it 
appeared on the Eastern coast of Italy, but was restricted 
to a small district. This was its final appearance in that 
country. A small epidemic was observed in Greece in 
1828. The plague appeared in Malta in 1818, and in 1816 
it extended to certain of the Ionian islands. Again, in 
1820, the plague appeared at Majorca, whither it had 
been brought from the Barbary coast. Owing to favor- 
able conditions on the coast of Northern Africa the plague 
has repeatedly appeared at Tunis and Algiers, and has 
generally shown a tendency to linger. The plague of 
1784 lasted for fifteen years. Between the years 1816 and 
1821 the disease again manifested itself in these cities, and 
again in epidemic form in 1836 and 1837. In 1885 there 
was an outbreak of such degree of severity in Cairo that 
the deaths equalled in number the entire adult popula- 
tion. Subsequent to this it ceased to prevail to any ex- 
tent in Africa. It disappeared from Asia Minor, Syria, 
and Palestine in 1848, and from Egypt in 1844. Reports 
of the presence of the plague from time to time were 
made from Dalmatia (1840), Constantinople (1841), Cana- 
ry Islands (1852). Since 1850 the disease has oscillated 
now east, now west, between the Red Sea and the Pacific, 
in China, India, Arabia, Persia, Mesopotamia, Russia, Cas- 
pian Sea, Afghanistan, Tripoli. There have been since 
1850 but nineteen years when it was not recorded in one 
or the other of these countries. 

For a short period, near the middle of the last century, 
nothing was heard of the plague, and it seemed unlikely 
that there would be any repetition of the periods of ex- 
tensive prevalence, or pandemics, which had character- 
ized the disease in former times. It is true that after 
a season of great scarcity of food in the northwestern 
provinces of India, the plague appeared in 1815 and con- 
tinued until 1821, reappearing in 1836, and again in 1837 
in Pali, and that, according to, Hirsch, it has never dis- 
appeared entirely from the southern slopes of the Hima- 
layas since 1823, where it has raged at an altitude of 
16,300 feet. Its ravages in these mountain districts have 
been so great that some settlements have been wholly 
destroyed. The last outbreak to occur on European soil 
was that of 1878 and 1879, upon the banks of the Volga. 
Tropical Africa has never suffered from the plague. 

The Present Epidemic.—In 1892 the Chinese Govern- 
ment, in the course of some military operations, moved 
certain stores and materials by caravan, from Yunnan, 
which was the endemic focus of the disease, to Longtcheu. 
The disease made its appearance in the latter place in 
1893, and was thence conveyed by trading junks to Can- 
ton and Hong-Kong, in which cities it was recognized as 
epidemic plague in 1894. From Hong-Kong it was con- 
veyed by sea to Bombay, Kerachee, and Poonah. Wy- 
man estimates that as a result of this epidemic outbreak 
there were 220,907 cases in Bombay presidency alone, with 


eT 


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Bubo Plague. 
Bubo Plague, 





the enormous mortality of 164,083. It also prevailed in 
Calcutta, Amoy, Formosa, Alexandria, and the port of 
Kobe in Japan. In 1899, Nieuchwang, in China, was 
invaded, and the epidemic soon gained a foothold, the 
domestic animals dying in great numbers and infecting 
the surroundings and the soil. It again made its ap- 
pearance in Europe in Oporto, Portugal, in August, 
1899. Some not well-authenticated cases at Plymouth 
and Southampton, England, have been reported within 
the past few months by the public press as having oc- 
curred, but through the vigilance of the sanitary authori- 
ties the disease has not been able to extend its influence 
outside of the small area directly connected with the ship- 
ping. There has been noticed, however, at Southampton 
an epidemic among dogs which was so fatal and infec- 
tious that in a short time the town was nearly cleared of 
its canine population. From this source the disease has 
since spread to many other parts of England, and the 
epidemic is receiving much attention from the veterinary 
physicians.* In October, 1899, the plague appeared 
at Santos, Brazil. This outbreak, as noted by Wyman, 
marks an important epoch in plague literature, as fur- 
nishing the first recorded instance of the occurrence of 
the disease in the Western hemisphere. The outbreak 
occurred after the arrival of a ship from the infected port 
of Oporto, which lay alongside the dock in Santos, and 
within a short time there was an extensive mortality in 
July and September among rats, preceding the appear- 
ance of cases among human beings. On the 18th of No- 
vember, 1899, the British steamship J. W. Taylor, from 
Santos, arrived at the quarantine station, New York, 
with two cases of bubo plague on board, and reported 
having lost one man at sea from the same disease. Ow- 
ing to the prompt and effective action of the United 
States quarantine officials in disinfecting the ship and 
cargo, no spread of the disease occurred. A few suspi- 
cious cases in the Chinese quarter have occurred at San 
Francisco, Cal., but as the sanitary authorities were alert 
and took the necessary steps to control the disease, no 
communication from these cases has been observed. + 

The recent acquisition of the Hawaiian Islands and the 
Philippines by the United States, among other advan- 
tages, has given us the rather questionable one of having 
the first veritable epidemic of plague in territory under 
our flag. In the latter part of December, 1899, plague 
broke out in the Chinese quarter of the city of Honolulu. 
As a result of the most vigorous measures for its extinc- 
tion, including the application of the torch (with the un- 
expected result of the destruction of a large portion of 
the city), the deportation of the population from the in- 
fected quarter, and the establishment of a cordon prevent- 
ing all communication between them and those outside, 
the epidemic has not spread, and as a result of thorough 
disinfection comparatively few cases have since occurred. 
The plague subsequently broke out with decided viru- 
lence among the filthy huts of the Chinese quarter of 
Manila. The military authorities, however, at once 
adopted active measures to prevent its spreading and to 
limititscourse. The St. Petersburg plague board reports 
recently that bubo plague is prevalent in Assyr, Mecca, 
and Jeddah, and that, accordingly, last year’s Mussul- 
man pilgrimage to Mesopotamia was prohibited. A re- 
port from Major Blair D. Taylor, United States Army, in 
regard to the progress of plague in Honolulu, dated Jan- 
uary 15th, 1900, states that up to that date there had been 
34 cases, with 27 deaths. The following week there were 
12 new cases and6 deaths. Plague has disappeared from 
Kobe, Japan, but is active in Osaka, taking the form of 
a lung disease which proves very fatal. At the present 
time the epidemic of 1899-1900 seems to be on the decline 
in the East and has gained no foothold in Europe or 
America. General Wyman believes that, with the rigid 
application of the ordinary principles of sanitary science 
and with the means now at our disposal for the prophy- 
laxis and cure of the malady, it seems extremely doubt- 


* Journal of the Amer. Med. Assn., March 3d, 1900, p. 568. 
+ Tbid., March 24th, 1900, p. 763. 











ful if the plague will ever secure a decided foothold in 
the United States. 

Accidental Propagation.—Incidental to the recent out- 
breaks of the plague was the unfortunate communication 
of the disease to several physicians who were engaged in 
making bacteriological investigations. The Japanese 
Commissioner Aoyama, who accompanied Kitasato to 
Hong-Kong in 1894 by direction of the Japanese Govern- 
ment, contracted the disease by inoculation incurred dur- 
ing a post-mortem examination, but fortunately recov- 
ered, although one of his assistants died of disease 
contracted in the same manner. More recently, in 1898, 
the disease appeared in Vienna, in Professor Weichsel- 
baum ’s institute, in which inoculation experiments were 
carried on upon guinea-pigs with material obtained from 
Bombay by a commission appointed by the Imperial 
Academy of Sciences of Vienna. Dr. Miiller, who was a 
member of the commission, unfortunately fell a victim 
to his zeal for science, and a laboratory attendant named 
Barisch also died; two nurses were also attacked by the 
disease. The commission was successful in restricting 
the spread of the disease by adopting extremely active 
measures. The Lancet for October 29th, 1898, states that 
“as soon as the first case of plague was clearly recog- 
nized, the plague commission permanently closed Profes- 
sor Weichselbaum’s institute. All the animals used for 
experiments were killed and cremated, and the drains 
of the institute were disinfected. Dr. Nothnagel’s clinic 
was cleared and disinfected, and the medical men and 
nurses belonging to it were isolated; the public were 
refused access to the General Hospital; all the medical 
men and the nursing staff were kept indoors, and some 
supposed febrile cases were transferred, from the institute 
and Professor Nothnagel’s clinic, to the Infectious Hos- 
pital. Barisch’s wife and brother were also admitted to 
the Infectious Hospital and received prophylactic treat- 
ment.” These measures were completely successful, and 
abruptly terminated an outbreak that had startled the 
entire civilized world. 

The Disease in Lower Animals, and their Agency in 
Spreading the Plague.—Concerning the matter of the part 
played by the lower animals in spreading the epidemic, 
our knowledge is still incomplete. Dr. Sticker, of the 
Vienna Commission, states that rats and mice are active 
carriers of the contagion. Preliminary experiments have 
shown that pigeons, hens, geese, and swine are insuscep- 
tible to the disease, while dogs, cats, sheep, goats, cows, 
and horses react to the infection by at least a transitory 
morbid state that ends in recovery. Monkeys are highly 
susceptible, especially the so-called sacred ape, and they 
may play an important part in the epidemics of India. 
Surgeon-General Sternberg, in reference to this subject, 
says: “ We have learned that certain of the lower animals, 
including rats and mice, are very susceptible to infection, 
and that they play an important part in the propagation 
of the disease, also that the germs are found not only in 
the blood and in pus from suppurating buboes, but also 
in the discharges from the bowels of infected individuals. 
This being the case, it can readily be seen how important 
a strict sanitary police is in arresting the spread of an 
epidemic. As in other filth diseases in which the germ 
is present in the excreta of the sick, insects, and especially 
fleas and house flies, probably play an important part in 
the spread of the disease.” * 

Modifying and Predisposing Agencies.—Poverty, filth, 
physical and social wretchedness have become so gener- 
ally recognized as predisposing causes to the plague that 
Cabiadis termed it misertée morbus, thus perpetuating a 
name given to the plague of 1665, in London, which was 
called “the poor’s plague” (Wilson). The bad hygiene 
observed in the poorer class of dwellings, especially in 
tropical countries, not only favors the propagation of the 
epidemic by vermin, as already mentioned, but it also 
lowers the vital resistance of the individual and renders 
him more liable to infection than if he belonged toa grade 


*‘* History and Etiology of the Bubonic Plague,’’ Philadelphia Med. 
Journ., April 7th, 1900. 


507 


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Bubo Plague. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








higher in the social scale. The season of the year has 
some influence upon the development and course of the 
plague, but it has been remarked that the influence is 
not the same in different countries. The epidemics in 
London reached their height in midsummer and declined 
in the fall months. In Constantinople also the disease 
becomes dormant in winter and becomes active as the 
summer heat increases. In the epidemics of extreme 
Northern Europe, the disease has been equally prevalent 
in winter and in summer, while they lasted. Egypt and 
Mesopotamia, however, follow a different course; in 
Cairo the epidemics have always ceased upon the recur- 
rence of the hot weather of June. 

A marshy soil is favorable to the spread of plague, re- 
peated outbreaks having occurred in the valley of the 
Nile, the marshy regions of the lower Euphrates and 
along the Caspian and Black seas ; but dampness and low 
elevation are not essential, since it has flourished in the 
mountainous districts of Arabia and on the slopes of the 
Himalayas, at a great elevation. Both sexes and all 
ages are liable to the infection, although young adults 
furnish the greater number of victims. Depressing influ- 
ences, especially debilitating diseases, increase the indi- 
vidual susceptibility. Occupation has little influence, 
although it has been observed that oil carriers, dealers in 
oils and fats, and, to a less degree, water carriers and bath 
attendants are less liable to contract the disease than oth- 
ers. It is noted by Dr. N. F. Arnold, U. S. N., that 
those inhabitants of Chinese cities in which epidemics are 
in progress who live in boats suffer little. This is proba- 
bly due to the fact that communication between the rats 
and other animals inhabiting them and those of the land 
is not easy (Philadelphia Med. Journ., April 7th, 1900, p. 
789). The plague is to a certain extent self-protective; 
second attacks, if they occur, are of less severity than 
were the first. 

Incubation Pertod.—The period of time which elapses 
between exposure to infection and the development of 
the disease is comparatively short. Prus, in a report 
drawn up for the French Academy of Medicine in 1844, 
declared that the plague had never shown itself among 
compromised persons after an isolation of eight days. It 
appears that from three to six daysis about the rule. 
Cabiadis sets the incubation stage at three days, but occa- 
sionally it lasts only twenty-four hours. Hirsch, from ob- 
servations on the Astrakhan epidemic, concluded that the 
average period was five days, very short or very long 
periods being seldom observed. Recent observations by 
Haffkine and Simond agree in showing that the incuba- 
tory period may be as short as twelve hours, but, on the 
other hand, that, in a number of cases observed in a de- 
tention camp, over six per cent. occurred as late as the 
ninth day, and 1.73 per cent. as late as the eleventh day. 
Wyman justly remarks that this point has an important 
bearing on quarantine measures at ports of arrival, for it 
does not bear out the theory that the period of incubation 
is such that all cases which are to occur will occur on 
the voyage, since a fair proportion of the cases developed 
in a period which exceeds the average duration of a trans- 
Atlantic passage in these days of fast ships. 

Relative Danger of Propagation by Fomites and Mer- 
chandise.—With regard to the transmission of the disease 
by fomites and the dangers of spreading an epidemic by 
merchandise from an infected locality or from a ship hav- 
ing plague on board, it is fortunate that the vitality of 
the bacillus, apart from the animal body, is limited, its 
virulence being rapidly lost under conditions of heat, 
light, exposure to sun and to the air. In fact, this is in 
accord with every-day laboratory experience, where the 
greatest difficulty is found in keeping cultures of the 
plague bacillus in virulent condition. Wyman further 
says that “under ordinary conditions of laboratory 
growth, in the presence of uniform temperature, on fa- 
vorable nutrient media, and kept from the influence of 
strong light, a culture of the plague bacillus, virulent to 
rabbits, will in two or three days so deteriorate that it is 
no longer pathogenic for the very susceptible mouse. 
Passage through the bodies of animals, repeated at short 


508 











intervals, seems to be necessary to preserve the virulence 
of the bacillus. These conditions removed, its viability 
is short, and it either perishes altogether or becomes a. 
saprophytic organism. It therefore would seem justifi- 
able, in the present state of our knowledge, to assert that. 
the relative danger from merchandise as a carrier of in- 
fection is slight, and that the greatest danger is to be ap- 
prehended from mild cases of the disease, unrecognized, 
little dangerous in themselves to the person having it, 
but as capable of spreading virulent contagion as is mild 
varioloid of communicating and imparting a virulent, 
fatal type of smallpox.” 

Symproms.—Of the three varieties or clinical forms of 


_ the plague which are usually recognized, (1) the bubon- 


ic, (2) the pneumonic, and (3) the septiceemic, the former 
is the most frequent and may be considered as the type. 
In cases of this ordinary grave or bubonic form we have 
present a highly contagious fever, setting in suddenly, 
attended with constipation, with a rapid, feeble pulse, 
with dizziness and delirium, with injected eyes, with a 
dry tongue, with noises in the ears and deafness, with 
defective urinary secretion, with starting of the tendons, 
with watchfulness or stupor, and with red patches and 
purple spots scattered over the surface of the body. 
Such is the graphic language used in describing the dis- 
ease by Da Costa, to which he adds (as distinguishing it 
from typhus), nausea and vomiting, a pale face, an 
alarmed despairing look of the countenance, hemoptysis, 
and, above all, the buboes and carbuncles in different 
parts of the-body, and the clearing mind when they mani- 
fest themselves. Moreover, the disease is of much shorter 
duration than typhus. Death generally takes place be- 
tween the third and the fifth day, or convalescence sets 
in on the sixth or the seventh day, or early in the second 
week. It may, however, be protracted by a long-continu- 
ing suppuration of buboes. 

J. C. Wilson divides the course of the attack into four 
stages: (1) invasion, (2) intense fever, (8) fully developed 
localizations, (4) convalescence. The first stage is ushered 
in by a feeling of lassitude with pains in the loins and ex- 
tremities. Extreme bodily debility, fulness and throb- 
bing pain in the head, with dizziness and mental weakness, 
are complained of. The patient’s expression is dull and 
stupid, and he responds but slowly or awkwardly to 
questions. His face is pale, eyes languid, his gait weak 
and staggering, as if inebriated. No distinct rigor is 
noticed, but shivering occurs, and nausea, vomiting, and 
diarrhcea may appearearly. This stage begins suddenly 
and may last from a few hours to a day or more. It is. 
followed by the febrile stage, which may be ushered in 
by a chill, more or less severe but commonly the latter. 
The lassitude and headache now become more marked. 
The temperature rises to 102°-104° F., or, exceptionally, 
to 107.6° F. The pulse is rapid, 120 to 180, the skin hot 
and dry, and the patient complains of fever and thirst. 
The eyes become sunken and injected as the case con- 
tinues, the tongue is coated with a grayish pasty mass, 
the teeth and lips are covered with sordes, the vomiting 
often continues. Active and noisy delirium, with great 
restlessness, or mild delirium, tending to stupor or coma, 
now appears. Bloody crusts collect on lips and nostrils. 
The pulse grows feeble, small, often very irregular, the 
lips become bluish, the extremities cold, and there is im- 
pending collapse. The enlargement of glands may now 
be noticed, with tenderness and swelling of the superficial 
lymphatic vessels. A sudden fall of temperature, often 
to several degrees below the normal, now occurs, fre- 
quently attended by a profuse, strong-smelling sweat. 
The pulse falls to 100 or below, and the mind clears. 

The third stage is characterized by suppuration and 
great enlargement of the glands of the groin, or upper 
part of the thighs, less frequently in the axilla or near 
the angle of the jaw. As this usually does not occur 
in fatal cases, suppuration is looked upon as favorable. 
The buboes may appear as early as the second day, some- 
times as late as the fifth day, exceptionally they are ab- 
sent altogether. Carbuncles, though less common tham 
buboes, are also likely to appear at this stage, especially 


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Bubo Plague, 
Bubo Plague, 








on the legs, buttocks, or the back of the neck, but they 
are not necessarily fatal, as the slough may soon sepa- 
rate, the gangrene being of limited extent. Boils also 
are occasionally seen. The appearance of petechie is 
regarded as unfavorable; they may be detected only in 
the neighborhood of the buboes, or may appear in great 
numbers all over the body, giving the cadaver a livid hue 
(from which character the name black death probably 
was derived). Extensive ecchymoses may also appear 
just before death. 

The fourth stage, that of convalescence, begins about 
from the sixth to the tenth day, and may be delayed by 
prolonged suppuration or by relapses. Among special 
features to be noted among this class of cases is the mat- 
ter rejected from the stomach, which at first is simply 
gastric mucus with bile or later a coffee-colored fluid; 
hematemesis may occur. Bleedings from the nose, lungs, 
bowels, vagina, and bladder have also been observed. 
Such cases generally terminate fatally. The urine may 
contain albumin and blood, hyaline and granular casts are 
commonly found; it also frequently contains indican; the 
quantity voided is diminished or suppressed in grave 
cases. The temperature record is not characteristic: it 
remains at 102-108.5° F. for about three days; it then 
becomes nearly normal or subnormal, and may rise again, 
if septic processes supervene. The blood becomes leuco- 
cythemic, but the red cells are not diminished in number. 
The blood contains the plague bacillus, in the great major- 
ity of cases. In some, especially early in the epidemic, 
the disease progresses with such intensity and rapidity 
that the characteristic symptoms have not time to develop; 
the whole duration of the attack is only a few hours. In 
this, which is called the fulminant form, convulsions and 
coma, with the rapid formation of petechix and vibices, 
precede the fatal termination. This form is most likely 
to occur in the aged. ~ 

The pneumonic form of plague occurs principally in 
India. Whereas, in the ordinary bubonic form, the in- 
fection apparently enters the body by means of some 
wound, abrasion, or bite of an insect, in this form the 
lungs appear to be the door of entrance. Pneumonic 
plague cases occurring during an ordinary epidemic, ac- 
cording to Harris and Arnold,* are all fatal, usually 
within the first four days, and without any other symp- 
toms than fever, cough, bloody expectoration, pain in 
the chest, and the symptoms of the digestive and circula- 
tory disturbance noted above. 

The pnewmonic form was prominent in the epidemic 
known as the black death. Dr. Calmette reports that he 
has observed it in the recent epidemic in the city of 
Oporto, Portugal, and that in pulmonary plague there 
are no buboes, but the cases are marked at the outset by 
a profound depression of the vital powers, by violent 
vomiting, cadaveric paleness, a rapidly failing pulse, and 
death within afew hours. W. C. Hossack, in the British 
Medical Journal, February 10th, 1900, described a peculiar 
form of plague pneumonia. Its onset is insidious, and at 
the end of five or ten days the symptoms may be very little 
marked, while the physical signs are scarcely recognizable. 
Intelligence is unaffected, head symptoms are wanting, 
and death, when it comes, is apt to be quite unexpécted. 
The pulse is the most important diagnostic point; it is 
disproportionately quick and feebie. As arule, there are 
no enlarged glands, unless late in the disease, and every 
case proves fatal. They are recognized, by Hossack, as 
a form of pneumonic plague. What has been termed the 
septicemic form is regarded, by Sternberg and others, as 
a secondary phenomenon, which occurs only in very se- 
vere and usually fatal cases. Arnold says that a bare ten 
per cent. of all cases will reach the septiceemic stage. 
Such cases as present no buboes have probably received 
infection either through the respiratory, genito-urinary, 
or digestive passages. The same observer reports having 
seen several cases that presented conclusive evidence of 
the last mode of inoculation. 








*“ Bubonic Plague with Clinical Notes,” Philadelphia Med. Journ., 
April 7th, 1900. 


» 

















In cases of the ordinary type an early symptom is the 
presence of pain and tenderness on pressure in the ingui- 
nal region. The onset is often marked by convulsive 
tremor or shivering, without sensation of cold, a stagger- 
ing gait, confusion of mind, dizziness and headache, 
with a dull expression of countenance, great prostration, 
and rapid appearance of typhoid state. In children, cer- 
vical adenitis is more common than inguinal. 

From personal observation of the plague in London in 
1665 and 1666, Dr. Sydenham furnished the following 
clinical description : ' 

“The first attack is almost invariably ushered in by 
chills and rigors (such being also the accession of inter- 
mittent fevers), which are followed by violent vomiting, 
by pain in the region of the stomach, like that of the 
pressure of a screw, burning fever, and its usual crowd 
of concurrent symptoms. These affect the patient with- 
out intermission, until either death itself or else the fa- 
vorable breaking out of buboes or of parotid abscesses. 
Hereby the morbific matter becomes eliminated, and re- 
lieves them from the appalling crises. 

“Occasionally it happens that the disease lights upon 
the patient without any premonitory signs of fever 
whatsoever, so that, even whilst engaged in his common 
business, a man may be suddenly struck down,—an 
eruption of crimson blotches being the only forerunner of 
his quickly coming death. It is important, however, to 
remark that death, thus sudden, rarely happens, except 
during the beginning of epidemics of more than ordinary 
severity. In years when the disease has been sporadic, 
and during its remissions and decline, they have never 
been observed. It happens also that at times tumors 
may break out without either fever or any other impor- 
tant symptom as their precursors; although I suspect, for 
my own part, that chills or shivers, in some slight de- 
gree or other, and more or less perceptible, invariably 
precede. Those to whom this happens may walk about 
in public as usual, and attend to the common duties of 
life like healthy men, taking no thought of regimen.” 

The German National Board of Health has issued re- 
cently a circular to physicians, containing official instruc- 
tions regarding the plague, from which the following 
graphic description is extracted : * 

The outbreak of the disease proper is preceded by las- 
situde, depression, pains in the lumbar region, increased 
thirst, and diminished appetite. It frequently begins 
quite suddenly. Stinging, burning, or dull pains at the 
point which corresponds then or later to the bubo, the 
inflammation of the glands or the pneumonia, may be the 
first manifestations of the disease, soon accompanied by 
chilliness amounting to a rigor, and consecutive fever. 
The latter may exist for several hours or days before the 
local manifestations develop. The commencement of the 
disease is almost invariably accompanied by a sensation 
of vertigo in the head, which may increase to resemble 
a severe intoxication, with the external indications of ex- 
treme stupor, and loss of control over the limbs, and then 
pass away. Nausea or vomiting frequently accompanies 
the vertigo. When the patient reaches the physician the 
clinical picture in severe cases is usually fully developed. 
The patient produces the impression of a drunken man: 
the vacant stare; the face bloated, flabby, expressionless ; 
the extremely bloodshot eyes; the thick, stammering 
speech, and uncertain, staggering gait. This impression 
is enhanced by the abrasions and bumps caused by the 
stumbles and falls of the patient. The tongue looks as if 
it were whitewashed with lime, or is occasionally red and 
knobby like a raspberry. The skin is dry over the entire 
body and burning hot, or it is merely hot on the face and 
trunk, while the pulseless limbs are already cold and cov- 
ered with a sticky sweat. The respiration is labored or 
sighing; the heart beat is much accelerated; the arteries 
are relaxed; the radial pulse is dicrotic, full or already 
thready, near extinction, while the heart beat is still vigor- 
ous. Put to bed, the patient lies dormant in extreme ex- 


* Miinchener med. Woch., January 2d, and Journal Am. Med. Assn., 
February 3d, 1900. 


509 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





haustion, whispers low or talks confusedly to himself or 
tosses restlessly on the bed with loud delirious ravings, or, 
if he is not prevented by the attendant or fastened to the 
bed, gets up and wanders restlessly about ina wild frenzy, 
and makes efforts to escape. With careful scrutiny it is 
possible to detect the local disease focus even in the first 
hours, and thus approach the correct diagnosis. <A 
freshly swollen gland and a pustule on the skin are the 
indications of commencing inflammation of the lungs, and 
belong to the developed clinical picture of the plague, 
“which can thus appear as gland plague, skin plague, or 
lung plague. Plague of the alimentary canal has hither- 
to been established only in animals. The gland plague 
or bubo usually appears in the inguinal region, but also 
frequently in the axilla and in the neck, especially with 
children. In a few cases it has been noted on the back of 
the head, on the elbow, the popliteal space, the anterior 
or posterior ear glands, the hyoid glands, etc. Frequent- 
ly the superficial glands are only slightly inflamed; the 
disease process seems to have jumped them and affected 
the deeper glands, the second or third class glands, which 
develop into buboes. For instance, the femoral glands 
may be unaffected, while a large iliac or lumbar bubo 
may be palpated like an appendicular tumor through the 
abdominal wall; ora cervical gland may be only slightly 
swollen, while an area of dulness in the clavicular region 
and symptoms of compression in the cervical organs may 
reveal the formation of a bubo in the upper portion of 
the thoracic cavity. The separate enlarged glands can 
be distinctly palpated in the bubo, or the inflammation of 
the interstitial tissue may have bound them into a thick 
bunch which can only be vaguely distinguished from the 
surrounding tissues, and is frequently surrounded by 
doughy cedema extending far around and involving the 
skin. The sensibility of the bubo to pressure is usually 
much more than the spontaneous pain, so that the pa- 
tient, by favoring the bubo by the position of the limb, 
experiences no pain. A small bubo is frequently not 
even noticed by the patient and his attendants, so that 
every gland that can be reached should be carefully and 


repeatedly investigated by the physician. Plague pus- . 


tule and carbuncle are rare in comparison to the bubo. 
_ They begin with a small spot like a flea’s bite anywhere 
on the body. Thespot smarts sharply and soon develops 
into a larger or smaller blister with a cloudy fluid. The 
pustule either stops at this stage, or the subjacent tissues 
harden and soon become transformed into a deep carbun- 
cle, progressing to a gangrenous ulcer. Inflamed lymph 
vessels frequently lead from the pustule to the nearest 
cluster of glands, and a bubo may then develop in them. 
A bubo may also develop in the vicinity of a carbuncle. 
Buboes, pustules, and pneumonia may appear from the 
first, at the commencement of the disease, sometimes be- 
fore the fever, or they may become evident a few hours 
or days afterward, seldom later than the third day. In 
all forms of the plague the early weakness of the heart 
is noticeable. In all, symptoms of irritation in the ali- 
mentary canal are evident at first, with sensitiveness to 
pressure in the upper abdomen and cecal region, violent 
vomiting, later also the passage of black fecal masses. 
With considerable regularity there have also been observed 
a slight degree of tympanites: a soft, palpable, or percus- 
sionable swelling of the spleen, and traces of nucleo-albu- 
min and serum-albumin in the urine. Vomiting of blood 
or blood in the urine is rarer. A diphtheritic affection of 
the tonsils is frequently noted early.” There is almost 
constantly more or less conjunctivitis, which is frequently 
and rapidly complicated with keratitis and may lead to 
the complete suppuration of the eye. Punctated or 
striped hemorrhages in the skin and mucous membranes 
have been noted with varying frequency in different epi- 
demics. In the course of the disease the lymph vessels 
beneath the buboes may become involved in the inflam- 
mation, and new buboes may develop elsewhere in the 
body. 
Morrarity AND ProGnosis.—There is no other epi- 
demic disease which owns a mortality rate so high as 
this. It has been already intimated that the virulence 


510 











and prognosis of the plague are influenced by social and. 


especially sanitary conditions in the community visited, 
and are also affected by the season of the year. As in 
other infectious diseases, cases exceptionally occur of 
very mild form, and in which the incubation stage may 


be unduly prolonged, these cases being important factors. 


in disseminating the epidemic, although scarcely sick 
themselves. Others occur which are overwhelmed with 


the poison and die in a few hours. The mortality of the 
recent epidemic in China has been stated to be as high as. 


98 per cent.; that in India is 75 per cent. among natives; 
among Europeans it is said by Arnold to have never ex- 
ceeded 60 per cent., and is usually much less. The Ma- 


_Trine Hospital Service’s issue for December 22d of its. 
Public Health Reports gives some startling figures of the 


mortality of the present outbreak up to August 1ith, 1899; 
namely, to mention only a few, that there had been in 
the Belgaum district 29,300 cases, with 22,042 deaths; in 
the Dharwar district 38,754 cases, with 31,307 deaths; 
and in the Nassik district 20,162 cases, with 15,480 deaths. 
The septiceemic and pneumonic forms are most fatal. If 
the necrotic material in the buboes makes its way through 
the overlying tissues and skin and evacuates itself, the 
patient’s. chances of recovery are generally admitted to 
be improved. If, on the other hand, the material in the 
buboes becomes diffused into the tissues, and is not evacu- 
ated, death from septicemia quickly follows. The prog- 
nosis is greatly improved if modern sanitary and thera- 
peutic measures are available and are early instituted. 

DraGnosts.—The clinical features which distinguish 
the plague have just been considered. Although typical, 
fully developed cases could scarcely escape recosnition, 
it is important for the protection of the community that. 
the diagnosis should be made at the earliest possible mo- 
ment. Suspicion of impending danger may be aroused 
by the occurrence of a great mortality among rats and 
mice; it has been observed that rats sometimes leave a 
locality in great numbers before the plague manifests. 
itself in man. There may also be unusual mortality 
among domestic animals. A bacteriologic examination 
of these animals might thus give early information of the 
presence of the plague bacillus and anticipate the out- 
break in man. In the human subject errors may be 
made in the milder cases of the bubonic form and in the 
pulmonic and septiceemic forms, but a bacteriologic ex- 
amination properly carried out will clear up the diagno- 
sis. The method pursued by Harris and Arnold is, in 
the bubonic form, to open a gland involved, under due 
antiseptic precautions, and plant some of the contents on 
any ordinary culture medium. Cover-slip preparations. 
are also at once made, stained, and subjected to micro- 
scopic examination. In most cases, the latter procedure 
will at once determine the true nature of the case, as in 
addition to the morphologic characters of the bacilli 
their very number serves to distinguish them, for in no 
other disease are so many bacteria present. In the septi- 
ceemic form the blood should be examined in the same 
manner, and, if the bacilli are not found in the cover-slip- 
preparations, they will develop in the culture. An ex- 
amination of the sputum in plague pneumonia is at once: 
suflicient to place the diagnosis beyond all doubt, as this. 
material always contains the bacilli in great numbers— 
oftentimes in pure culture. 

Morsip ANATOMY AND HistoLogy. — Post-mortem 
rigidity and lividity appear early. The temperature 
often increases after death (108° F. in some instances). 
Petechiz usually, and carbuncles occasionally, are ob- 
served. In about half the cases, the lymph nodes of the 
groin first show the disease: in the remaining half, the ax- 
illa is affected in about fifty per cent. The superficial 
nodes appear to be first affected, but the disease quickly 
extends to the entire chain of glands to which the one first. 
affected belongs. All the other lymph nodes of the body 
may be invaded, but especially those of the mouth, 
throat, intestines, and mesentery. The tissues around the 
nodes are softer and may show hemorrhagic foci. The: 
nodes, or lymph glands, are very much increased in size. 
On section, the node substance is quite firm if the proc— 


Ese 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bubo Plague, 
Bubo Plague. 





. 


ess is recent, or the contents may be semi-fluid and muci- 
laginous, the material resembling lard. The cut surfaces 
often present a grayish, red color, with darker areas of 
hemorrhage, or the entire contents are of a dark red color. 
Other glands in distant portions of the body are enlarged, 
but do not present any hemorrhagic foci, except in cases 
of relapse. Around the nodes the tissues are swollen, 
the blood-vessels are engorged and contain pest bacilli; 
these are not found, however, in the tissues or lymphat- 
ics, although the latter are distended with lymphoid cells. 
Unless the necrotic process extends through the capsule, 
the tissues show no other change. Harris and Arnold 
found that in those instances in which the node has just 
been attacked, or in which the disease is of a mild charac- 
ter, there is evident increase in the number of cells within 
them, the vessels are dilated, and the lymphatic channels 
contain many bacilli. In advanced cases, no differentia- 
tion is possible; all the gland contents now consist of a 
finely granular material, which is colored pink when 
stained by hematin and eosin, or by the method of Van 
Gieson. Intermingled with this granular material there 
are quite a number of cells and some cellular débris. If 
the section be stained by the toluidin blue and glycerin- 
ether method, or by toluidin blue followed by eosin, this 
granular material is found to consist of countless myriads 
of pest bacilli, they constituting, in many instances, more 
than one-half of the entire contents of the node. The 
same authors insist upon the importance of the presence 
of mast cells, as they have never seen them in any other 
lesions of the lymph nodes. It is suggested that their 
function is to elaborate an antitoxin, as they never ap- 
pear to be phagocytic, like the hyaline cells, but it was 
observed that around many of the mast cells there is 
a zone in which no bacilli are seen. There are also a 
few plasma cells and a few polymorphonuclear leuco- 
cytes. When the gland softens and breaks down, it is 
due to a process analogous to cheesy degeneration of tu- 
bercles; therefore it is obviously wrong to speak of the 
process as a primarily suppurative one. If, however, 
any of the organisms of suppuration subsequently reach 
the diseased area, or a mixed infection occurs, a true 
suppuration will ensue. Lymph nodes, in parts of the 
body at a distance from the original foci of the disease, 
show only macroscopic swelling and a somewhat darker 
color than is normal. On microscopic examination, the 
cells of which the nodes are composed are found to be 
apparently somewhat increased and the blood-vessels 
dilated. In severer cases, and in relapses, these vessels 
usually contain bacilli, but they are not found in the 
gland substance ordinarily. 

Inngs.—The plague causes broncho-pneumonia, but 
more of the lung tissue is involved than is commonly the 
case in the ordinary forms of this disease. There is occa- 
sionally observed a fibrinous pleuritis with the pneumonia. 

Spleen.—The spleen is large, dark colored, and soft. 
There are numerous hemorrhagic areas in its substance. 
Its vessels are greatly dilated. Many of the cells show 
degenerative changes. This organ always contains the 
bacilli, often in great numbers. 

The Avdneys may be either somewhat enlarged or nor- 
mal in size. There is hyperemia, with areas of hemor- 
rhage; especially between the Malpighian pyramids. The 
capsule is easily removed and the cortex is thickened and 
quite friable. The cortical cells are granular and many 
have degenerated and lost their nuclei. Hyaline substance 
resembling that found in the normal thyroid tubules is 
found in the uriniferous tubules. Areas of hemorrhage 
are occasionally seen between the collecting tubules, but 
there is no evidence of nephritis. In all the blood-vessels 
(which are enormously dilated), both in the Malpighian 
bodies and elsewhere, are found numerous pest bacilli. 

The Liver is somewhat darker in color than normal, 
owing to hyperemia and dilatation of capillaries. The 
liver cells show signs of degeneration and are irregular 
in form and swollen, with disappearance of the nuclei in 
many. 

Intestines and Stomach show hemorrhagic foci and the 
lymph nodes are enlarged. 














The Brain and tts membranes are congested, and, rarely, 
fibrinous meningitis, or meningo-encephalitis, is met 
with. This condition of the brain is more often found in 
cases of the fulminant form in which death occurs within 
a few hours after inoculation. 

The hemorrhages found in the various organs, according 
to the same authorities, are not caused by the mere pres- 
ence of the bacilli, but they are the effects of a poison or 
poisons produced by bacilli. The instance is given, 
which was reported by the German Pest Commission, of 
a woman suffering with the pest who gave birth to a 
dead child, and although its body was entirely free of 
the bacilli, the hemorrhages were very numerous in its 
organs. The leucocytosis, which is so constant in the 
plague, may be frequently made out by sections of the 
tissues—the white cells being evidently increased in the 
blood that is present in the blood-vessels. A mixed infec- 
tion frequently occurs: streptococci, diplococci, and dif- 
ferent varieties of staphylococci may be found in various 
lesions or structures; generally, however, they appear 
late, or in the agonal period, and in such cases do not 
influence the result to any material extent. It is proba- 
ble, however, that when recovery takes place they are 
active in causing eruptive diseases of the skin and pro- 
longed suppurations of glands and carbuncles. Paraly- 
ses of certain muscles result from the occurrence of 
hemorrhages into the meninges and spinal cord. 

TREATMENT.—At the present day attention is particu- 
larly concentrated upon the use of Haffkine’s prophylac- 
tic and Yersin’s anti-pest serums. The best recent 
authorities appear to be agreed as to the great value of 
these agents. It is understood that, as Wyman insists, it 
is necessary to draw a sharply defined line between the 
serum therapy and serum prophylaxis of a disease. In 
the case of plague the difference is not merely one of 
degree but of kind. The serum which may be successful 
in protecting against the plague may be powerless to 
cure it when once the disease has manifested itself. For 
the cure of plague, according to Wyman, there is at pres- 
ent but one accredited remedy, viz.: the curative or anti- 
toxic “anti-pest” serum of Yersin and Roux. 

The preparation of the Yersin serum is, in brief, as fol- 
lows: Horses are treated with progressively increasing 
doses of the toxins of plague, prepared by subjecting 
virulent bouillon cultures of the B. pestis to a degree of 
heat which insures their sterilization. These injections 
at first have a very profound effect upon the horse, but 
in time a certain immunity is conferred, and his blood se- 
rum is found to have a very decided effect in preventing 
the infection of animals when these are subjected to inoc- 
wations of cultures of the organism after the usual labor- 
atory methods. Usually the process does not stop here, 
but is carried on to the production of true anti-pest serum, 
preventive and curative, whose further preparation is as 
follows: When reaction to the increasing doses of toxin 
has practically ceased, toxins of the same nature are 
administered intraperitoneally and intravenously, and 
these are supplemented by the intravenous injection of 
toxins prepared with a special view to rendering soluble 
the toxin which is enveloped in the dead bacterial body. 
If necessary, this is supplemented by the intravenous 
injection of live bouillon cultures, and bleedings are prac- 
tised and experiments made with the serum both against 
living, virulent cultures and against the precipitated tox- 
ins of the organism. When the serum has reached a 
point of strength when a dose of 75 c.c. will protect a 
mouse of 25 gm. weight against living cultures and a 
three times mortal dose of toxin, the serum is considered 
to have acquired full antitoxic power, and is not only 
protective or prophylactic, but also antitoxic or curative. 

A French commission, after an investigation made 
upon mice, monkeys, and human beings, during the epi- 
demic in Oporto, reported that the value of the anti-pest 
serum is incontestable. In cases treated with it the mor- 
tality was only fourteen per cent., while in those not so 
treated it was at least seventy per cent. These cases 
were of the pneumonic form. When exposure to the 
plague infection continues, it is recommended by Roux 


% 511 


Bubo Plague. 
Bubo Plague. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





that these inoculatious should be repeated every thirty- 
five to forty days, but the reports of Simond show that 
they should be practised more frequently, viz., every 
fourteen or twenty-one days. It should always be borne 
in mind that these inoculations do not in any way take 
the place of general hygienic measures. The technique 
is thus given by Wyman: 

General Technique.—The injection should be adminis- 
tered in the subcutaneous connective tissue of the flank, 
the abdomen, or the back, and should be practised under 
the usual antiseptic precautions. The region where the 
remedy is to be injected should be washed with a solu- 
tion of carbolic acid (five per cent.) or solution of mercu- 
ric chloride (1 to 1,000). A large antitoxin syringe should, 
if possible, be employed, and before use it should be 
nearly filled with cold water and then submerged in 
water which should be brought to a full boil and main- 
tained at that temperature for fifteen minutes. Having 
been emptied, it should be allowed to cool before being 
filled with the serum, as heat has an injurious action on 
the remedy, and the syringe may be clogged by the co- 
agulation of albumen. In the absence ‘of an antitoxin 
syringe, an ordinary hypodermic syringe may be em- 
ployed in its stead, care being taken as to the steriliza- 
tion as above, and, the syringe having been filled and 
emptied, the remainder of the dose determined upon may 
be administered without removing the needle by detach- 
ing the syringe and filling its barrel the requisite number 
of times, the syringe being screwed or otherwise joined 
to the needle in situ. This obviates the necessity for 
multiple punctures, always disagreeable, and is an impor- 
tant point in the treatment of children. 

(a) Administration for Prophylactic Purposes.—W hen 
a case of plague manifests itself in a house or on board 
ship, 10 c.c. of the serum may be administered to all 
persons exposed to the contagion. The injection is 
not accompanied by any inconvenient or disagreea- 
ble after-effects. It should be repeated in ten days 
in order to prolong the immunity, and in a badly in- 
fected locality the injections should be repeated several 
times. 

(0) Administration for Curative Purposes.—The cura- 
tive action of the serum is the more efficient the earlier in 
the disease the injection is practised. Large doses should 
be administered, 30 to 50 ¢.c., rather than smaller doses 
successively administered. Under the influence of the 
serum the fever decreases and the swelling of the glands 
(the buboes) rapidly diminishes. If this amelioration is 
not produced promptly, a second and even a third dose 
should be administered until the fever and the gen- 
eral and local symptoms disappear. This is important, 
for so long as the bubo remains, especially if suppura- 
tion supervenes, the patient is liable to secondary in- 
fections. 

The Haffhine prophylactic is intended solely for proph- 
ylactic purposes, and is not to be used after a_per- 
son has already been exposed to the infection. Under 
antiseptic measures, the dose of 1 c.c. is administered hy- 
podermically, and, when the constitutional reaction has 
subsided, the dose may be repeated. A slight fever for 
two days with temporary enlargement of neighboring 
glands is observed following the inoculation. The im- 
munity does not continue long over thirty days and inoc- 
ulations may be repeated. 

The inoculations made by Haffkine in Bombay were 
quite successful. In the first experiment 8,142 persons 
were inoculated. Of these only 18 subsequently con- 
tracted the disease and 2died. Among 4,926 persons in- 
oculated a single time at Dharwar 45 were subsequently 
attacked and 15 died, while among 3,387 persons in 
whom a second inoculation was made only 2 were at- 
tacked. Atthe same period, the rate of mortality among 
those who held back from the inoculation rose to an un- 
paralleled height, the deaths being 657 to 1,000 per week. 
The results elsewhere were equally good. The follow- 
ing table is excerpted from Surgeon-Captain Leumann’s 
report. The conclusions to be drawn from it are self- 
evident. 


512 






































3 galsze| 2.3| 23 

~ Sal 8s lo 2 ae © 23 

Census |/2eS3S8| S88 |Facslaas 

Dates. of Hubli. |GSES) SES |PuSslza8 

B°3s| 255 |psesiags 

eke! = Ses] a5 

2 &'s|/ 288] $8] So 

s kof-<} 

Five weeks, from May 
llth to June 14th,| Fell from 
1 BOR. eta aiteavnted eee 50,000-47,427 | 44,573 | 2,854 47 1 
Week ending (1898) 

JUNO 21Stie. oe eae 47,082 41,494 | 5,588 22 3 
JUNE SOLD ceive slewierere 47,485 | 39,042 8,443 29 1 
SULLY: DEN ioe stoi «inswietess 46, 537+ 36,020 | 10,517 55 6 
JULY. LZ! vars eenee 46,518 33,255 | 13,263 34 6 
JUlye 19th cerca ese 45,240 29,716 | 15,524 82 7 
‘JULY 26th. sees vey ae 24,112 | 19,697 100 15 
AL UBE 20 ntl crersie's 707 21.081 | 22,676 140 16 
August Sth scence: 168 15,584 | 27,184 212 19 
rAUpust 6th the. cock 40,441 10,685 | 29,756 386 61 
AUGUSL 280 scene ee 39,400 6,367 | 33,033 371 41 
August 30th ........ 38,210 4,094 | 34,116 328 28 
September 6th ...... 38,382 2,731 | 35,469 adi, 34 
September 13th ..... 38,408 1,116 | 37,292 138 47 
September 20th ..... 39,142 ~ 937 | 38,205 106 55 
September 27th...... 39,315 603 | 38,712 58 20 














The government of India is now making a prophylae 
tic from a vegetable culture medium which appears to be 
equally successful. The Lancet’s Calcutta correspondent 
wrote (January 27th, 1900): 

“Tn order to meet the religious scruples of a large sec- 
tion of the natives, experiments have for some time past 
been conducted in order to ascertain whether or not the 
plague prophylactic obtained by growing the bacilli of 
plague in a medium manufactured from wheat was as 
effective as that made in the ordinary manner from meat. 
For rabbits at least, the wheat-peptone vaccine is as effec- 
tive as that prepared from meat peptone. Only one ex- 
periment has been made, but there is no reason to sup- 
pose that human beings will react differently. It is 
suggested that publicity be given to this experiment, so 
that those communities which have religious scruples 
against the use of vaccine prepared from goats’ flesh may 
be made aware that they can now be protected by the 
use of the wheat-peptone prophylactic. The new mate- 
rial is ready for distribution.” 

In some experiments made to determine the efficacy of 
the different constituents of Haffkine’s prophylactic, C. 
Balfour Stewart found that the sediment contains bacte- 
ricidal properties, and that the filtrate alone is capable of 
conferring immunity or of modifying the attack. 

Prevention of Epidemics.—The observations of sanitary 
authorities all over the world agree in one respect, and 
that is that the plague isa thoroughly preventable disease 
under conditions imposed by modern medical science, 
and that if these precautions can be freely carried out an 
epidemic will be impossible. As recommended by Roux, 
the attention of the sanitary authorities is devoted at the 
outset to the lower animals, the entire destruction of rats 
and mice being advised, and the cremation of their bodies, 
It is suggested that since the discharges from the nasal 
chambers of infected rats contain the plague bacilli in 
nearly pure culture, this may be one method of the ex- 
tension of the disease. Since dogs and cats eat rats and 
mice, the propriety or necessity of quarantining or de- 
stroying these also must be considered. In the human 
subject, besides attention to ordinary hygiene, the use of 
Haftkine’s prophylactic on a large scale is advised. 

Lord Curzon, the Viceroy of India, recently before 
starting for a thorough inspection of the sanitary arrange- 
ments of the infected districts, took the precaution of 
having himself and entire party inoculated with the 
prophylactic serum. “A measure,” he said, “which 
changes the death rate of from 70 to 80 per cent. into one 
of from 15 to 20, even in those who are attacked after 
submitting to it, to say nothing of the large proportion 
who are completely protected by it, is one w hich no sen- 
sible man can afford to neglect.” 

The value of the anti. plague inoculation bie just 
been investigated by a government commission in India, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


which has carefully reviewed the entire subject and has 
reported that under the safeguards and conditions of ac- 
curate standardization and sterilization of the vaccine, 
together with the precaution of sterilizing the syringe in 
each case, the inoculations should be encouraged wher- 
ever possible and in particular among disinfecting staffs 
and the attendants of plague hospitals.* Lustig and 
Galeotti have used a nucleo-proteid as an immunizing 
substance, which they claim has marked advantages over 
Haffkine’s prophylactic serum. Its efficacy has been 
proved by experiments upon animals. It is innocuous as 
regards man, being free from the toxic substances found 
in all cultural liquids used in their entirety. They make 
the specific charge against Haffkine’s liquid that it easily 
becomes contaminated and there is no guaranty of the 
sterility of each separate bottle. + 

Experience has shown that the doses laid down in the 
instructions for the use of the plague prophylactic by M. 
Haffkine require revision. This fact has been taken ac- 
count of by the sanitary authorities in India, and an offi- 
cial order has been made in relation thereto. The Lancet’s 
special correspondent says (February 3d, 1900, p. 345): 
“Tt has been found that children are less affected by inocu- 
lation than adults and can be given proportionately larger 
doses. Accordingly new rules have been promulgated 
and official instructions for the use of the plague prophy- 
lactic have been sent out. Considerable improvement has 
been effected in the matter of packing and fitting up the 
bottles. At one time this appears to have been carried 


out very insecurely and many bottles of the fluid were 
found to have undergone decomposition. 
dosage is now ordered: 


The following 





IF THE DOSE MARKED ON THE 
BOTTLE IS— 

2.5 C.C. 5.0 ¢.c. 
then give— then give— 
0.5 @.¢. Ibe oer 
it oe 9 oe 
1.5 oe 3 io 
Ps oe 4 oe 
Pipa ins Ya 











It is thought that persons over fifty years of age should get 0.25 c.c. 
less for each decade above that age. 


“The official instructions contain the following para- 
graph indicating the usual symptoms of plague inocula- 
tion: ‘The symptoms commence, as a rule, three to five 
hours after inoculation and consist chiefly of swelling 
and pain at the seat of inoculation and of a rise of tem- 
perature. The pain is felt particularly on movement of 
the part. The fever is accompanied by general discom- 
fort usual to this condition. No treatment of the symp- 
toms is required beyond applying ice for the relief of 
headache, if any is felt, and enjoining some rest. Gen- 
eral symptoms subside after twenty-four to thirty-six 
hours; the pain at the seat of inoculation lasts for three 
or four days, disappearing gradually; a painless indura- 
tion remains for some time longer. It is desirable to 
produce a rise of temperature to at least 102° F. If the 
reaction is less marked the operation may be repeated 
three or four days later with the same or an increased 
dose, according to the result of the first inoculation. 
There is no harm in leaving a longer interval between 
the two inoculations. No changes in diet or occupation 
are necessary, beyond if possible insuring some rest. 
Bathing in the openair should be avoided for some days. 
A simple purgative may be given twenty-four hours 
after the inoculation.’ ” 

Both the anti-pest serum of Yersin and Roux and the 
Haffkine prophylactic are now prepared in the hygienic 
laboratory of the United States Marine Hospital service 
at Washington, D. C. 

In India investigations have also been made in the 
treatment of plague with the poison of the cobra, admin- 


* Brit. Med. Journ., February 24th, 1900, p. 461. 
+ Brit, Med. Journ., No. 2041, p. 311. 
Vou. I1.—83 


Bubo Plague, 
Bubo Plague, 


istered hypodermically, and diluted with glycerin. A 
dose of 1 mgm. was given, afterward increased to 2 mgm. 
Experiments upon monkeys were said to have given 
good results. Deane reports a mortality of 54 per cent. 
in 500 cases treated in this manner as compared with the 
average mortality of 70 to 80 per cent. (Lancet, July 8th, 
1899, p. 121). 

Turning now to the materia medica, the drugs to which 
we naturally look for assistance in treating sucha typically 
infectious disease are the antiseptic and bactericidal 
agents. In fact J. M. Alkinson reported (in the Laneet, 
December 9th, 1899) a case of bubonic plague treated with 
large doses of carbolic acid with the recovery of the pa- 
tient. Dr. Alkinson was induced to use carbolic acid in 
plague by the successful employment of large doses in the 
treatment of influenza and tetanus. The patient, a man 
of thirty-eight years, was admitted to the Government 
Civil Hospital, Hong-Kong, June 9th, 1899. Three days 
previously he had been exposed to contagion and the 
fever appeared two days later, or the evening before ad- 
mission. After a preliminary calomel purge, gr. iij. 
(0.2 gm.) of carbolic acid were given every few hours, 
but this not being sufficient he was given a mixture 
of pure carbolic acid gr. xij. (0.75 gm.), syrup of ginger 
Zi. (or 4 c.c.), and chloroform water 3 vi. (180 ¢.c.). Of 
this one ounce (30 c.c.) was given four times the same 
evening. On the following day the headache was much 
better, there was no evidence of toxic action, the urine 
was not blackened by the acid. A bubo was now found 
in the groin. The medicine was continued every two 
hours during the day. The patient’s pulse and tempera- 
ture had fallen on the 13th to 72 and 99.8° respectively. 
On the 15th the dose was reduced to gr. ij. (0.13 gm.) 
twice daily, and on the appearance of urinary symptoms 
was finally discontinued June 26th. During the acute 
stage, six ounces of brandy were given in twenty-four 
hours and the diet was liquid. The patient in three days, 
from June 10th to 12th, took over two hundred grains 
(18.33 gm.) with the result of lowering temperature, al- 
laying vomiting, and relieving nervous symptoms. 

There are other antiseptics less toxic than phenol to 
the human system, which can be given in larger doses, 
such as creosote, creosotal, guaiacol (and its benzoate or 
carbonate), betanaphtol, iodoform, resorcin, sodium hy- 
posulphite, etc. The affected glands may be painted with 
pure guaiacol, or anointed with iodoform ointment or 
iodol dissolved in oil (gr. xx. to cod-liver oil, Zi.). If the 
glands are accessible, they. may be extirpated or de- 
stroyed with the galvano-cautery.* 

The imperative necessity of scrupulous antisepsis 
should be impressed upon the patient an¢ all his attend- 
ants; the sputum, the cedema fluids, the urine, and all 
other discharges should be promptly mixed with chloride 
of lime solution, and, with all dressings, clothing, etc., 
destroyed by fire with the least possible handling or delay. 

In order to guard a community against the introduc- 
tion of an epidemic it was well said by Prof. Max von 
Pettenkofer that three things are essential to success. 1. 
A rigidly enforced quarantine to exclude the fomites or 
materies morbt. 2. By means of improved hygiene, per- 
sonal cleanliness, diet, and other precautions, the indi- 
vidual should so far as possible be rendered immune from 
or less liable to the infection. 3. The locality should be 
purified from sewage and all filth that may form disease- 


* “ Encouraging results have followed surgical treatment in cases of 
bubonic plague. In a report to the Surgeon-General of the Marine 
Hospital service, Acting Assistant Surgeon W. Havelburg states that 
the clinical registry of the Paulo Candido Hospital, Rio Janeiro, 
Brazil, during the period from June Ist to August 31st, 1900, shows 
that there were 221 plague patients treated by extirpation of the in- 
fected glands, of whom 45 died, giving a death rate of about 20.8 per 
cent. And of 143 patients with solitary infected buboes, treated in 
the same manner, 23 died, showing a death rate of about 16 per cent. 
The diagnosis in all the above cases was confirmed by two bacterio- 
logical examinations, one before removal to the hospital, and the 
other after admission to the wards. Sero-therapeutic treatment was 
instituted in a number of other cases, but the effect of operating dis- 
played such favorable results that injection of serum in the others 
was deemed unnecessary. The necropsy reports in the cases that 
died showed buboes that were inaccessible to operations, being scat- 
tered in the mesentery, or deeply situated in other tissues.”,-—Journ. 
Am. Med. Assn., January 19th, 1901, p. 185. 


513 


Buchu. 
Buena Vista Springs. 








breeding centres, pure water only should be used for 
drinking by the community and various similar precau- 
tions should be taken. Not only should the sick-room 
be disinfected, but the house should be similarly cleansed 
and the whole neighborhood made as clean as possible by 
the sanitary authorities. The free use of disinfectants to 
the discharges from the patient and to the surroundings is 
now regarded as an imperative duty and the directions 
given by the sanitary authorities are most explicit and 
comprehensive. The methods followed by the United 
States Marine Hospital service, and by the French and 
German governments are summarized in the report of 
General Wyman, already freely quoted from. 

A few words may be permitted to correct a popular 
error to which attention has been called by Dr. James 
Edmunds* of London. The impression prevails among 
a rather large proportion of the profession and the com- 
munity that alcohol has a certain antidotal power against 
infection, and that, if when epidemic disease prevails, it 
will act as a prophylactic and confer a certain degree of 
immunity upon those who are under its influence. Alco- 
holic drinks, therefore, are often publicly recommended, 
when a community is threatened with an epidemic. 

Whatever may be the result of such a course in other 
infectious diseases, experience does not warrant the view 
that it would be of any avail when plague is imminent. 
On the contrary, intemperance is now generally recog- 
nized as constituting or favoring a predisposition to the 
disease. Sydenham’s observation is here very much to the 
point. “Certain it is,” he says, “that the free use of wine, 
and other strong preservatives, taken at stated hours and 
in the way of regimen, has brought the disease upon 
many persons who in all probability would have remained 
safe and sound otherwise.” 

As the therapeutic and prophylactic problems relating 
to the plague are at the present day taken out of the 
province of the private medical practitioner, on account 
of the very important interests that are involved, and as 
the problems are now being studied seriously by the 
sanitary authorities of the various governments of the 
civilized world, they can have only an academic interest 
to the members of the profession in general and need not 
be dwelt upon further. The reader is referred to the 
publications of the national departments, and particularly 
to those of the United States Marine Hospital service, for 
detailed information on these topics. 

John V. Shoemaker. 


BUCHU.—Short Buchu. “The leaves of Barosma 
betulina (Thunberg) Bartling et Wendland, and Barosma 
erenulata (L.) Hooker (fam. Rutacee)” (U. 8. P.). A 
third species, B. serratifolia 
Willd., “ Long Buchu,” was 
also once official, but was 
dropped because of its in- 
feriority. The British Phar- 
macopeeia rejects also the 
second-named species, 
which is greatly lacking in 
uniformity and which is 
now but little collected. 
There are about fifteen 
species of this genus, all 
natives of South Africa. 
The drug was in use by the 
Hottentots at the time of settlement by the whites. Its 
introduction to America was in the form of a notorious 
quack medicine, and was afterward adopted upon its 
merits by the profession. 

The leaves of B. betulina, the best variety, are mostly 
one-half to three-quarters of an inch long and two-thirds 
as broad or more, occasionally broader than long. They 
are abruptly contracted into a short, narrow basal por- 
tion, che broad upper portion being irregularly sub-ro- 
tund, the apex blunt, often recurved, the margin sharply 





Fic. 1055.—Buchu Leaves. a, B. 
crenulata; b, B. betulina. 
(After Baillon.) 





os toon and the Plague.’’ The Indian Lancet, December Ist, 1899, 
p. 472. 


514 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





and finely dentate. They are very thick, brittle when 
dry, smooth and somewhat shining, slightly papillose, and 
of a yellowish-green color. Against the light they are 
pellucid-glandular-dotted, with larger marginal glands. 
They have a strong mint-like odor and a warm, aromatic, 
and mucilaginous taste. 

B. crenulata varies from oblong to oval or obovate, 
usually a little broader than our figure, and is often 
twice as long as the other, and less blunt. The margin 
is crenulate. It is also thick and greenish-yellow, and 
has similar pellucid glands. 

B. serratifolia is markedly different from the others, 
being of a bright green color, thin, sub-three-nerved by 
the elongated basal pair of veins, narrowly oblong or 
Jance-linear, sharply serrate, the teeth and sinuses curved. 
The leaf is about as long as the B. erenulata. There is 
a very large gland at the obtuse apex. 

There is no adulterant of the official buchu, but when 
long buchu was official, the leaves of Hmpleurwm sercu- 
latum Ait. were used for that purpose. They are distin- 
guished by the very acute apex and the straight, incised, 
salient, longer toothing. 

Composition. — Official buchu contains 1 to 1.5 per cent. 
of volatile oil, long buchu half as much. There are also 
resin, gum, and a little of the bitter glucoside barosmin, 
believed to be the same as hesperidin. 'The oil contains 
a camphor-like body, often called buchu camphor (dio- 
sphenin ©C,.Hi.O2). There is but little of this in oil of 
long buchu, but that contains much of a body to which 
the peppermint-like odor is due. 

Action AND UsEes.—Buchu acts locally as a mild stom- 
achic. Absorbed, it possesses the ordinary diffusive 
stimulant properties of volatile oils, its special point of 
action being the kidneys, by which it is excreted. Its 
diuretic properties are mild, but it is distinctly sedative 
and astringent to the urinary organs, as well as slightly 
antiseptic. Henbane is often combined to increase the 
sedative effect. It is a mild expectorant. The fluid ex- 
tract is official, and the dose is 1 to 2 c.c. (fl. 3 4 to 4). 

Henry H, Rusby. 


BUCKBEAN.—Bogbean. Menyanthes. The herb of 
Menyanthes trifoliata L. (fam. Gentianacee). A widely 
distributed bog herb, with a creeping perennial rhizome, 
and thickish bright-green leaves, but which become very 
thin in drying. They arise from long, sheathing peti- 
oles. These leaflets are nearly entire, oblong or ovate, 
blunt, about 8 cm. long and half as wide (one and one-half 
by three inches). They have a disagreeable odor when 
fresh, which disappears upon drying: the taste is bitter 
and nauseous. The white or pinkish flowers are borne in 
an upright, spike-like raceme at the end of the rhizome, 
and are very beautiful, 

Buckbean grows in cold swamps and moist places in 
Europe, Asia, and America, and has naturally been long 
known and used in medicine, but is now very little called 
for. Its bitter principle, menyanthin, was separated in 
1860 by Kromayer as a white, amorphous, bitter powder, 
and showy to be a glucoside—sugar and a liquid oil, 
“menyanthol,” being the result of its decomposition. 

In moderate doses it is a simple bitter tonic, similar to, 
but less agreeable than, the other Gentianacese. In large 
doses it is cathartic, and sometimes emetic. Dose, as a 
tonic, 1 or 2 gm. (15 to 30 grains). W. P. Bolles. 


BUCKEYE. A:SCULUS. — Horsechestnut (fam. Hip- 
pocastanacee). A genus of about a dozen species, of 
America and Asia, growing mostly north of the Equator. 
The bark and seeds of 4. Hippocastanum L., native of 
Asia, but largely cultivated for ornament in all temper- 
ate countries, have been much used in domestic practice 
in the treatment of malaria and rheumatism. Both con- 
tain considerable tannin, but the activity appears to re- 
side in the bitter glucoside esculin (CisHieOo+1.5 HzO) 
which is crystalline, white, soluble in water and alcohol, 
and antiperiodic in fifteen-grain doses. 

The seeds of the red buckeye, dv. Pavia jee of the 
southern United States, are reported to have caused fatal 


, Buchu, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ’ gicna Vista Springs. 





cases of poisoning in children, the symptoms being those 
of poisoning by saponin. It is even said that the former 
species has acted similarly. H. H. Rusby. 


BUCKTHORN.—FPrangula. “The bark of Rhamnus 
Frangula L. (fam. Rhamnacee), collected at least one 
year before being used” (U.S. P.). This is a very large 
shrub or small tree, growing throughout Europe and in 
adjacent Asiaand Africa, and sparingly naturalized near 
New York City. The wood is very fine-grained, and its 
charcoal is largely utilized for powder-making, for which 
the bark must be first removed. The latter thus results 
as a by-product. It is largely employed in domestic 
veterinary practice, in the fresh or recently dried condi- 
tion. It is then a sharply irritating cathartic or even 
emetic, but its griping properties are greatly mitigated 
by being kept. It occurs in strongly curved quills, 
which are commonly more or less flattened by pressure. 
The bark is very thin for the size of the quill (about 1 
mm.=,; inch). The outer surface presents two forms, 
the one nearly black, the other dark-gray. Both are 
commonly marked by numerous transversely elongated 
white dots, and are somewhat warty-roughened, but 
never fissured or scaly. The inner surface, bright yel- 
low when first collected, becomes successively dark yel- 
low, brown, reddish, and nearly black with keeping, this 
being a fairly good way of recognizing its age. Its frac- 
ture is weak but not brittle, and is slightly fibrous. It 
has a slight characteristic odor and a bitter taste. 

Composition.—W ith resin and asmall amount of tannin, 
the important constituent of frangula is the yellow 
glucoside frangulin, or rhamnoxanthin (C2:H2 Os) and 


its products emodin (C;5Hi003) and tscemodin (Cy;HsO,). - 


The development of all three of these substances proceeds 
as the dried bark ages, and coincidently the drug be- 
comes a milder cathartic or laxative. Emodin and Iso- 
emodin belong to the class of Anthraquinones, some one 
of which appears to give the properties to one large class 
of laxative drugs. Emodin. derived both from rhubarb 
and from frangula, is on the market. It is insoluble in 
water, little soluble in alcohol, but dissolves readily in 
Caran solutions. It is not used medicinally in its own 
orm. 

Properties and Uses.—Frangula can be used as a Ca- 
thartic in doses of 4 to 8 gm. (3i.-ij.), but, like cascara 
sagrada, it acts much better as a laxative in doses of 
one-fourth or one-third these amounts. The fluid ex- 
tract is official. Owing to its less mild and uniform ac- 
tion, frangula has almost entirely given way to cascara 
sagrada as a laxative. 

The genus contains some seventy-five species, mostly 
in the north temperate zone, and gradually decreasing 
southward, in the mountains, a few in the south temper- 
ate zone. Many of them have a similar composition 
and action to that here described. R. Cathartica L. has 
especially been so used, both the bark and the fruits 
(buckthorn berries) having been used as cathartics from 
ancient times. The bark of at least one species, R. 
Wightii, of India, is a strong astringent. 

LTlenry H. Rusby. 


BUDDING.—One of the methods of asexual reproduc- 
tion in the animal kingdom as well as in the vegetable 
world. 

It differs from fission (g. 2.) in that the offspring pro- 
duced from the bud has never formed an integral part of 
the parent organism, but arises as an outgrowth of some 
part of the parent. 

In its simplest form, as in the case of the fresh-water 
hydra (Fig. 1056), the process is as follows: Certain cells 
of the wall of the hydra grow and multiply, forming a 
hollow outgrowth on the side of the parent (a). As this 
enlarges and develops, tentacles appear at the outer end, 
and a mouth is formed (a@’). Later, communication with 
the digestive cavity of the parent is cut off, and the 
young hydra feeds itself, and at a still later stage be- 
comes separate from the parent. 

In other cases the buds remain permanently attached, 


and thus are formed colonies, or stocks of greater or 
smaller size and complexity, often supported by a skele- 
ton. Such are the coral stocks and many others. One 
example from the protozoa is shown 
in Fig. 1057, and one from the polyzoa 
in Fig. 1058. 

Buds may be formed at various 
places on the par- 
ent or colony. Very 
frequently they 
grow from the side 
of the parent—lat- 
eral budding, as in 
hydra and most cor- 
als; or on the top— 
apical budding 
(Fig. 1057). Some- 
times buds are 
formed from stol- 
ons developed from 
the ccenosarc of the 
colony (Fig. 1058, 0) 
or from the cceno- 
sare directly. 

A variety of apical budding, called axial, consists in 
the production of new segments, which may remain per- 
manently united, as in most worms, or become detached, 
as in the tape-worm. 

In some cases internal buds are produced, as in echino- 
coccus (q. v.), and in the redia of the fluke-worms. 

Closely united with this last method is the formation 
of germs, or unfertilized eggs, from organs correspond- 
ing to the ovary (parthenogenesis, 
q. v.), Which develop into animals 
like the parent, as in the produc- 
tion of drone bees, plant lice, etc. 





Fie. 1057.—Dino- 
bryon, an Infu- 
sorian (greatly en- 
larged). Showing 
apical budding. 





Fig. 1056.—Hydra 
(enlarged). Show- 
ing buds, a, a’. 





Fic. 1058. —- Fredericella, 
a Polyzoan (much en- 
larged). Showing adult 
bud, a, and stolon, b. 


Fic. 1059.—Syncoryne, a hydroid. A 
nutritive zodid with medusa (repro- 
ductive) buds (a, a’, a") in various 
stages of development. 


A variety of this method, pedogenesis, consisting of 
the production of germs from animals still in the larval 
form, is exemplified in certain flies, as Cecidomyia, 
Miastor. 

In some cases the buds of a colony are of different 
forms and functions. This is best seen in the hydroids, 
in which the feeding zodids are of a different form from 
the reproductive zodids (Fig. 1059, a, a’, a’). This 
method of budding leads to colonial division of labor. 

HH, A, Birge. 


BUENA VISTA SPRINGS.—Logan County, Kentucky. 

Post-OFFi1cE.—Russellville. Springs Hotel. Accessi- 
ble vii Louisville and Nashville Railroad (Memphis 
branch) and Owensboro and Nashville branch to Russell- 
ville, thence by stage six miles to springs. The stage 
meets the train which leaves Russellville for the springs at 
8 A.M. 

This resort is located in a beautiful and picturesque 
region, interspersed with lofty hills, deep gorges, beau- 
tiful dells, and majestic native forests. The hotel has 
been rebuilt, and the guests will now find a large and 


515 


Buffalo Lithia Sp’gs, 
Burns and Scalds. 


commodious building, which will meet all the require- 
ments of modern cultivated tastes. The springs, two in 
number, are situated in the lawn in front of the hotel, 
where they rise from their subterranean recesses, and 
flowing forty feet, empty into the creek. The following 
qualitative analysis of Spring No. 1 was made by Dr. L. 
P. Yandell, professor of chemistry and physiology in 
the University of Louisville: 

Sulphureted hydrogen gas (abun- 


dant). 
Carbonic-acid gas. 


Magnesium sulphate. 
Calcium sulphate. 
Calcium carbonate. 
Magnesium carbonate. 


Dr. H. A. Utley’s analysis of Spring No. 2: 
Magnesium sulphate. Sodium phosphate. 
Magnesium carbonate. Tron phosphate, 
Magnesium phosphate. Iron chloride, 
Potassium carbonate. Calcium carbonute, 
Potassium phosphate. Free carbonic-acid gas. 

Sodium carbonate. 

The waters have been highly recommended by Ken- 
tucky physicians in liver disorders, malarial affections, 
rheumatism, skin diseases, anzemia, general debility, and 
other conditions. Various amusements, in the way of a 
tennis court, croquet grounds, billiard tables, swings, and 
walks over the hills and through the gorges are at the 
option of the visitor. James K. Crook. 


BUFFALO LITHIA SPRINGS.—Mecklenburg County, 
Virginia. 

Post-OFrricE.—Buffalo Lithia Springs. Hotel. 

Accress.— Via Southern Railroad to Clarksville, thence 
eight miles by private conveyance to springs. Also via 
Atlantic and Danville (branch line), which delivers pas- 
sengers immediately at the springs. 

These celebrated springs occupy a central position in 
the section of country known as the Buffalo Hills, a 
broken, rolling district, having an average elevation of 
five hundred feet above the sea level. The hotel is open 
from June 15th to October 1st. The buildings are on the 
cottage plan and sufficient for the accommodation of two 
hundred and fifty guests. Among the attractions of the 
place is a well-appointed bathing establishment, afford- 
ing ample facilities to visitors for mineral-water baths. 
The springs are three in number, and are designated re- 
spectively 1, 2, and 3. 

They have been analyzed by Prof. William P. Joury, 
of the Maryland Institute, Baltimore. We append the 
analysis of Spring No. 2, which is richest in mineral 
ingredients: 





trace. 


ONE UNITED STATES GALLON CONTAINS: 





Solids. Grains. 
MAS NER SIT] PALO Rare cecerelotahese oleinisitverataieieleraolare 0.88 
ATH IMINUIN SUI PHATE serctervercialaretavetelelelswlatelsielereieiers 9.07 
Galen Sulphate inci cwstssicierceis scieieistsicle creole eis 33.06 
POtassitlM sCaTDONALe sh oe ves iceniecie che.cieremeterie 29.30 
Caleium: DicaTDONATC: 4 i.< sce sale kic'eis 0! clarereleictore 14.96 
Aithium Hicarbonate rset sccetsrelsisiisiciels cielawicls 2.25 
TVODVHICATDOMALO chante icletarersielaeterieitatete entaraerets 30 
Banya DICATWOMALC ier.e ovelereiisteisls stare eteta ts erere aletete 1.%5 
SOCIAMCHIOTIAE Jecrenleite cane cine ceeaeie eimai 4.92 
Silica ChloridGsey cramer cui dents cetatereetenteee 1.87 
Phosphoric acid ane Traces 
TOCING Aaa ceoeienieetiee cele hate oe 
AELANIC INATCET Parsee eictesoierercalsiareumeraratavele efayerierareye Small amount. 

TOG BG Fics ocvoracs ca sin a eveionot ate totaal choral otois era 98.36 

Gases. Cubic inches. 
SulpPHureted Ny GTOLENM tw «.ciarvieratelerctovatalicts Weletetesleisriareveler 8.30 
CarDOmiGeacid...i.s sreic steiecceccla aw cieusie se Oe sinter estore ounions orate ayers 59.20 


This analysis shows what might be termed an alkaline- 
carbonated-aluminous-lithic-calcic mineral water. It 
possesses sufficient iron to give it ferruginous properties, 
but hardly enough to class itas a chalybeate. The water 
undoubtedly possesses valuable medicinal properties. 
The analysis would show it to be antacid, diuretic, and 
tonic. It has gained a wide reputation, especially in the 
treatment of the uric-acid diathesis, gout, rheumatism, 
renal calculus, stone in the bladder, and nervous and 
gastro-intestinal disorders. Spring No. 3 is a decided 
chalybeate, containing 3.77 grains of bicarbonate of iron 
to the standard gallon. It is also somewhat purgative in 


516 


‘ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








its action. On account of a heavy precipitate it is not 
offered for shipment, as are the waters of Nos. 1 and 2. 
These latter have an extensive sale throughout the 
country. James K. Crook. 


BUGLE.— Ajuga reptans L. (fam. Labiate). A hairy 
European annual, with a rosette of spatulate, finely ser- 
rate leaves near the ground, and an upright, slightly 
leafy stem. The flowers are small and blue, labiate, but 
with very small upper and larger lower lips. Stamens 
four, didynamous, with divergent anthers. The leaves 
are Official in France; they have a slightly bitter and 
astringent taste, but little odor, and no valuable medical 
properties. Dose indefinite. 

. The genus contains about thirty species, a number of 
which have had their day as medicines. Ajuga Chame- 
pitys Linn. (ground pine) grows also in this country. It 
is more aromatic than bugle, and reputed to be “stimu- 
lant, diuretic, etc.” W. P. Bolles. 


BULPISS.—An affection of the skin occurring in the 
northeastern part of Nicaragua and called by the natives 
“bulpiss.” The word is derived from “buluy,” in the 
language of the Mosquito Indians meaning spotted, and 
“piss” meaning gray—terms that appropriately describe 
the indivdual affected. The disease was first described 
in notes sent by Dr. Otto Lerch from Central America to 
Dr. Isadore Dyer of New Orleans asking for a diagnosis 
of this unusual affection. The notes were published in 
the New Orleans Medical Journal, 1894-95. Bulpiss ap- 
pears to be an endemic disease affecting every tribe in- 
habiting this part of Central America, attacking any in- 
dividual irrespective of age, sex, or general condition. 
Cases in very early infancy are, however, rare. It causes 
no disturbance of the general functions of the body. 
There appear to be several varieties, two distinct: (1) 
Black bulpiss; (2) white bulpiss. 

The disease commonly starts on the hands and feet, 
spreading gradually and becoming more marked on the 
knees, abdomen, neck, and face. 

The lesion is a minute reddish papule appearing in 
crops; they break up gradually, disappear, and leave dis- 
colored spots, the pigment of which finally disappearing 
too, leaves behind a dirty, whitish, dry, scaly patch with 
a partly discolored and slightly elevated broad margin— 
the white bulpiss. These patches are round or oval in 
shape with irregular border. In the black bulpiss the 
lesions are of a greasy black color, the affected skin hav- 
ing the appearance of being painted, the patches grad- 
ually drying and shrivelling. The only and common sub- 
jective symptom in both forms is that of itching, which 
occurs as the disease comes out and after bathing and at 
night. The disease is not hereditary. It is contagious 
and the duration seems indefinite. It is more than prob- 
able that it is parasitic in nature, as might be inferred 
from the remedy commonly employed—the red oxide of 
mercury ointment. Charles Townshend Dade. 


re BURDETT MINERAL WELLS.—Caldwell County, 
exas. 

Post-OFFIcE.—Luling. Hotel. 

Access.—Via San Antonio and Arkansas Pass Railroad 
to Burdett Switch, where carriages meet trains for the 
springs during the summer season. The location is seven 
miles north of Luling, on the Galveston, Harrisburg and 
San Antonio Railroad. 

Only one well is in use. The water has been employed 
for medicinal purposes for thirty years. According toa 
qualitative analysis made in 1877 by H. W. Johnson, of 
Boston, Mass., it contains the following acids and bases: 


ACIDS. BASES. 
Sulphuric acid. Calcium. 
Carbonic acid. Magnesium. 
Silicic acid. Aluminum. 
Hydrochloric acid. Manganese. 
Boric acid. Strontium. 
Phosphoric acid. _ Iron. 

Potassium, 
Sodium. - 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 


Buffalo Lithia Spgs, 
Burns and Scalds, 





We cannot positively classify this water from the 
above ingredients, but it appears to belong to the class 
of alkaline-chalybeate waters. Je is... 


BURDOCK. LAPPA.—“ The root of Arctiwm Lappa L. 
and of some other species of Aretéwm (fam. Composite),” 
U.S. P. Burdock is a native of Europe, but is common 
everywhere as a garden weed. It is a rank-growing, 
bitter, disagreeable plant, from 1 to 2 metres (three 
to six feet) in height, with a stout, branching stem, and 
great, coarse, heart-shaped leaves. The flower heads 
are clustered along the stem and branches; they are 
rather small, and look like miniature thistles. The in- 
volucre is ovoid and green; its scales are numerous, 
imbricated in several rows, with spreading, sharp, stiff, 
inwardly hooked tips. Flowers are tubular and perfect, 
rose-purple. 

The root is the official portion, and should be gathered 
at the end of the first season, or the beginning of the 
second; it is biennial, fleshy, and usually simple. When 
dried, it is in gray-brown, wrinkled pieces, as large as 
the thumb, and 20 or 30 cm. long (eight to twelve inches), 
often split, to facilitate drying. The hairy bases of leaf 
stalks may remain attached to its upper end, or there 
may bea cottony or woolly bud at the crown. Internally 
it is light brown, with a rather thick bark, a distinctly 
radiated woody zone, and a white, often broken or 
missing pith. Odor slight; taste mucilaginous and 
slowly bitter. 

Burdock contains znulin, mucilage, nine per cent. of 
fat, a slight amount of amaroid, lappin, and a little 
tannin. Its inulin, which is in large amount, up to forty- 
five per cent., and its fat well adapt it to use as a food, 
and it is said that many cultivated varieties of it exist 
in Japan for this use. It is an old medicine, whose 
reputation depends upon pureempiricism. As an altera- 
tive and an antisyphilitic it is still occasionally used, but 
is more called for as an ingredient in proprietary medi- 
cines than in serious medication. Dose from 2 to 4 gm. 

A fluid extract is official. Burdock fruit, a small, 
black, curved, rough, seed-like akene, is much less used, 
but much more efficient. It contains a considerable 


amount of bitter glucoside and pungent resin. Its ac- 
tion appears worthy of investigation. The dose is 1 to 2 
OM (ST. XV. bO’ XXX. ); W. P. Bolles. 


BURLINGTON.—Vermont, a city of 14,590 (census of 
1890) inhabitants, is situated in the northern part of Ver- 
mont, upon Lake Champlain, at an elevation of 377 feet 
above sea level. On the east are the Green Mountains, on 
the west is the Lake, and beyond this are the Adirondack 
Mountains. The climate is salubrious, not excessively 
cold in winter, nor excessively hot insummer. The mean 
relative humidity for the year is 68.2 per cent. There 
are frequent high winds, but no fogs. The proportion 
of bright and sunny days is said to be large. The mor- 
tality is 16.38 per thousand. The soil is generally dry 
and sandy. 

The outdoor attractions are, in summer, yachting, 
rowing, canoeing, swimming, riding, driving, bicycling; 
in winter, sleighing, coasting, tobogganing, snow-shoe- 
ing, skating, and ice-boating. The University of Ver- 
mont is situated here. The accommodations are good, 
there being first-class boarding-houses and two fair 
hotels. 

The annexed table shows the various climatic condi- 
tions of this place. 


CLIMATE OF BURLINGTON, VT. LATITUDE, 44° 29’; LONGITUDE, 
73° 15’. PERIOD OF OBSERVATION, TEN YEARS. 























January.| July. | Year. 
Temperature (Fahrenheit scale)—- 

AVGLAE OL NOTMAN so c'.00 cps nee cicicicee seis 18.9° 70.9° 44,8° 
AVErage Gaily TANGO... cc csevsecveccee 18.5 19.0 
Average Of Warmest .....scceseeseeeees 27.4 80.1 
AVETAGE: OL COLDER iS hires oe cnleaiettbines » 8.6 61.1 
Msi TO UIN OFM IGMOSG wis sjejdrneicis sci cic/elviaiese 51.0 96.0 
MInimMunY OF OWESE <ofi vec t ec cc cece nscs —24.8 47.0 

















January.| July. Year. 

Humidity— 

Average mean relative ..........e.eee08 72.3% 66.1% | 68.2% 
Precipitation— 

Averagerin INCHES scsmecsisere Werte + tcc oe 1.90 3.76 28.48 
Wind— 

Preval ling: GILOCLION:. «ste semtalestenis clersiare 8s. S) 8. 

Average hourly velocity in miles ....... 8.3 5.7 7.2 
Weather— 

Average number of clear days ......... 3.2 tel 63.3 

Average number of fair days........... 12.7 16.2 153.4 

Average number of fair and clear days. 15.9 23.3 216.7 





NoTE.—If the above table is not understood, the reader is referred 
to an explanation of the terms under the article Baltimore. 


Edward O. Otis. 


BURNET.—Radiz Pimpinelle. This name is applied 
to the roots of Pimpinella saxifraga L. and Pimpinella 
magna L. (fam. Umbellifere), both of which are wild as 
well as cultivated in Europe. They are small tapering 
roots similar to and of the size of small carrots. They 
contain the ordinary constituents of the roots of this 
family, volatile oil, resin, gum, and a bitter principle, and 
are used like the related aromatics, the dose being 0.5 to 
2.0 gm. (gr. Viij. to xxx.). H. H., Rusby. 


BURNS AND SCALDS.—Burns are injuries produced 
by fire or dry heat and scalds are the results of the ap- 
plication of hot fluids or moist heat. Clinically the results 
of these forms of injury are very much the same. The 
degree or severity of the burn varies according to the 
degree and duration of the heat and the capability of the 
solid or liquid for retaining caloric. Burns or scalds 
may be caused by the rays of the sun or by contact with 
fire, boiling water, oils, heated or molten solids, caustic 
alkalies, or concentrated acids; the amount of injury 
caused varying from a simple erythematous blush to the 
charring of a limb or part. The effect also varies ac- 
cording to the mode of application of the heat. To 
quote Wilson: “In degree, heat may be feeble but pro- 
longed, or it may be strong and instantaneous, strong 
and continued for a brief period, or strong and continued 
for a long period.” 

The flame of burning ether or alcohol, if momentarily 
brought into contact with the living skin, causes a 
superficial burn, while the contact of burning sealing 
wax or boiling oil, the capacity of which to retain caloric 
is greater than that of water, because of its greater 
density, gives rise to much more serious injury. Molten 
metal when it simply strikes the skin causes vesication ; 
but if it gains access to and surrounds a limb, complete 
charring and destruction of tissue occur. 

A scald, even if severe, may leave the hairs uninjured, 
and from this circumstance it may often be diagnosticated 
from a burn; but when the liquid is hot and dense the 
hairs are often destroyed as in burns. 

Concentrated acids and caustic alkalies, either in solid 
or in liquid form, act with great power on the soft tissues, 
and so cause injuries of the most serious character. 
Burns from this cause may be distinguished by the 
absence of vesication and other symptoms which are 
present when fire has been the cause. 

Phosphorus acts energetically, causing deep and rapid 
burns and inflammation of surrounding tissues, and fatal 
results have attended its improper handling. Surface 
burns from lightning stroke present about the same ap- 
pearances as burns from other sources. The skin is red- 
dened and blistered, and the hair is singed or entirely 
destroyed. 

Burns from nitric acid produce yellowish stains or 
patches, while sulphuric acid and caustics generally 
cause reddish or red-brown discoloration. 

Sunburns are generally so slight as to, require only a 
brief notice, yet occasionally a person having a tender 
skin may suffer severely from only a brief exposure to 
the sun. This burn is characterized by diffuse redness 
of the exposed part, with more or less smarting pain. 
The face, neck, forearms, and hands are usually affected. 


bait! 


Burns and Scalds, 
Burns and Scalds, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Grave symptoms sometimes arise when a large surface 
(two-thirds) is implicated, and a case has been reported 
in which death occurred from violent dermatitis, with 
gangrene, following sunburn. 

Burns are usually classified as of the first, second, or 
third grade. Dupuytren’s division into six degrees is 
too complicated, and, though it was for a long time in 
vogue, it has been generally discarded by modern writers. 
The following classification is that of Thomas George 
Morton, and is the one generally accepted: 

BurNs OF THE Frrst DEGREE.—Characterized by 
erythema, irritation, and inflammation of the skin with- 
out vesicles. 

BuRNS OF THE SECOND DEGREE.—Vesication, inflam- 
mation of the skin, and formation of vesicles and bulle. 

BuRNs OF THE THIRD DEGREE.—Eschars; gangrene, 
superficial or deep, involving the skin or the subcutane- 
ous tissues; carbonization of a part or of the entire body. 

ProGnosis.—The prognosis depends upon the depth 
of the injury and its extent, upon the susceptibility of 
the skin to the action of heat, and upon the general 
characteristics and physical condition of the patient. 
Burns of the first and second degrees generally result 
favorably, the patient recovering rapidly ; in those of the 
highest degree, however, when the surface involved is 
very extensive, the prognosis is more grave; and even 
burns of the first degree may prove fatal when a great 
extent of surface is involved. It is generally accepted 
that, if one-half or even one-third of the surface has been 
burned or scalded, death, from some physiological cause 
as yet not clearly explained, will be inevitable; and this 
usually happens during the first twenty-four or forty- 
eight hours. I think, however, that much depends upon 
the patient’s previous physical condition and mental 
equilibrium. In two cases which came under observa- 
tion during my service in Bellevue Hospital, the burns 
involved more than half of the entire surface of the body, 
in varying degree at different points; but these patients 
both recovered. One of them was a strong and healthy 
engineer, the otherarobust Italian laborer. On the other 
hand, even slight burns, in aged and enfeebled subjects, 
are sometimes a cause of death through shock. In all 
these cases, therefore, a guarded prognosis should be 
given. In burns of the third degree, which result from 
the application of intense heat, the prognosis will depend 
not merely upon the depth of the burn, but also upon 
the part of the body involved, and upon the age, sex, 
and temperament of the patient. 

Symproms.—In burns of the first degree there is more 
or less redness of the skin, which disappears on pressure, 
and which is accompanied by swelling and pain. This 
continues for a longer or shorter period, and then the epi- 
dermis is exfoliated and the natural conditions are re- 
stored. Recovery generally ensues in a few days and no 
permanent injury results. The constitutional symptoms 
are usually slight. Sometimes there is, however, an 
irritative fever, and if a great extent of surface has heen 
injured, and if the patient is very susceptible, shock may 
be quite marked and even death may result. 

In burns of the second degree the pain, redness, and 
swelling are more marked than in the first degree, and, 
the hyperemia being greater, there is a tendency to exu- 
dation, and vesicles are formed. These, when large in 
size, are called bulle. They either come on at once or 
form in a few hours. The serum is usually transparent, 
though sometimes it may be discolored by blood. Usu- 
ally, along with the formation of the vesicles, the skin 
proper receives no damage, but sometimes suppuration 
and ulceration may take place. The constitutional 
symptoms vary according to the extent and severity of 
the injury. Shock is almost always present, and death 
results in some cases simply from this cause. Sometimes 
there is found a congestion of all the viscera, and death 
may result from cerebral effusion with delirium. With 
the rise in temperature, albumin is commonly found in 
the urine, and during the period of reaction ulceration of 
some portion of the mucous membrane of the bowel fre- 
quently occurs. 


518 


Burns of the Third Degree.—In this group are classed 
all cases of gangrene resulting from burns affecting the 
skin or subcutaneous tissue. Now, according to the in- 
tensity and duration of the heat, the skin alone, or the 
muscles, nerves, blood-vessels, and bones also, may be 
destroyed even to carbonization. This latter is, fortu- 
nately, a rare occurrence, but it sometimes happens that 
portions of limbs are entirely burned off while the indi- 
vidual is inadrunken stupor or is suffering from epileptic 
coma. The constitutional symptoms are, as may be 
supposed, severe. If reaction occur at all, the symptoms 
become at once quite grave, in proportion to the extent 
of the injury. Insome cases death soon takes place from 
coma, due to cerebral congestion. The lungs, kidneys, 
ahd other organs are intensely congested, and this period 
of inflammation, so called, extends from the period of 
reaction to the beginning of exhaustion, during which 
time the dead tissues are being thrown off by suppura- 
tion. This exhaustion is sometimes increased by hemor- 
rhages from the necrotic tissues. In all cases of burns of 
the third degree renal congestion is constant and gives 
rise to albuminuria. 

THE COMPLICATIONS of burns may involve either the 
brain, or the respiratory tract, or the intestines. Cerebral 
irritation often appears quite early, and inflammation 
may follow and be accompanied by violent delirium. 
Convulsions and coma may occur in a fatal case. 

Laryngitis, bronchitis, or pneumonia may occur from 
burns or scalds, the first frequently following the inhala- 
tion of hot steam. idema may be excessive, requiring 
tracheotomy in order to avert impending death from 
dyspnea. Bronchitis and pneumonia are frequently ob- 
served to follow burns of the chest and neck. 

Intestinal ulceration is one of the peculiar results of 
severe burns, and follows the intense congestion of the 
digestive tract that sometimes takes place. The intes- 
tinal lesions are present in varying degrees, from the 
simplest gastric irritation and diarrhcea to severe inflam- 
mation of the stomach and intestines, going on to duo- 
denal ulcer, perforation, and death. 

TREATMENT.—This varies in accordance with the 
severity of the injury. The indications are: First, to re- 
lieve the pain and overcome the shock; secondly, to 
guard against congestion and inflammation of the internal 
organs; and thirdly, to counteract the exhaustion incident 
to sloughing and suppuration. 

Local Treatment.—In burns of the first degree there are 
usually no marked constitutional symptoms, but the 
local ones may be quite severe. These may be relieved 
by local applications of olive oil, vaseline, oxide of zine, 
or other ointments of asoothing nature. Powdered bicar- 
bonate of sodium is a most excellent application, and in 
simple burns it often affords great relief when freely 
dusted over the affected surface. Other alkaline applica- 
tions may be used, among which a mixture of linseed oil 
and lime water, called “carron oil,” may be mentioned 
as having long been popular. Flour, starch, white 
lead, paint, or any substance that excludes the air and 
makes a coating for the nerve filaments that have been 
irritated or uncovered will relieve the pain. Molasses 
has been used when nothing better could be found at 
hand in a case of emergency. The addition of carbolic 
acid to any of the ointments, or vaseline, or oil, is of 
much advantage, as it relieves pain and thoroughly dis- 
infects any discharge that may occur. It produces a 
certain amount of surface anesthesia, and, as carbolic 
acid is absorbed but feebly from any mixture with an oil, 
the danger of poisoning is not great. The urine should, 
however, be watched for any trace of the acid, as cases 
of such poisoning have occurred. An ointment made of 
boric acid and vaseline—e.g., in equal parts—is of great 
service, as it allays pain and is perfectly safe. These 
remedies may be spread upon lint or old muslin and laid 
upon the burned surface, the parts being then enveloped 
in layers of cotton batting and all held in place by a 
roller bandage. ; 

In burns of the second degree, in which we have vesi-— 
cation and inflammation of the skin, with the formation 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Burns and Scalds, 
Burns and Scalds, 








of bulls, it is absolutely necessary that the injury should 
be regarded as a wound and treated accordingly; 7.e., 
the burn should be rendered aseptic and kept so, if pos- 
sible. It is well to bear in mind that only one part of a 
burned patient should be exposed at a time, in order to 
avoid surface chilling. Vesicles and bulle should not 
be broken, but should be punctured at their lowest point 
and their contents allowed to drain off, and care should 
be taken that the cuticle should not be rubbed off, as it 
affords an excellent protection for the excoriated surface. 
The burned surface should be thoroughly cleaned; any 
cinders or any portions of clothing or charred material 
should be carefully removed, and the part should be 
rendered as aseptic as possible by washing and by the 
application of solutions such as mercuric chloride (1 to 
10,000 or 20,000), aluminum acetate, ete. After these 
have been washed off with warm, decinormal salt solu- 
tion, the burned surface may be covered with sterilized 
rubber tissue, which in turn is to be covered by a thick 
layer of sterilized gauze that is held in place by a roller 
bandage. When the inflammation of the skin is intense, a 
wet dressing of aluminum acetate or of ichthyol solution 
(three to five per cent.) should be applied and kept con- 
tinually moist. Such an application will tend to relieve 
the pain and to render the burned surface aseptic. The 
rubber-tissue dressing, with its thick covering of steril- 
ized material, acts as a substitute for the destroyed in- 
tegument; it excludes the air and makes an excellent and 
painless covering. If now the wound has really escaped 
being infected, it will rapidly become covered by a re- 
newed epithelial surface. 

The dressings need not be changed oftener than every 
second or third day, unless the amount of discharge is 
very great or the odor quite marked. 

It is quite proper to mention here the method of treat- 
ment of burns of the body, as well as of one extremity, 
by immersion. The clothing of the patient being re- 
moved or cut away, the limb or limbs or the entire body 
may be placed in a bath of decinormal salt solution, which 
should be maintained at a temperature of about 100° F. 
and not allowed to drop below 98.5° F. In cases of ex- 
tensive burns, in which both legs and portions of the body 
have been involved, the placing of the patient in a bath 
of this character produces great relief, particularly as 
regards the pain and the amount of shock. The solu- 
tion, which should completely cover the burned part, 
gives immediate ease, as it excludes the air; and, further- 
more, if the temperature of the bath be raised sufticiently, 
there will be provided a most efficient remedy for the 
condition of shock. This form of bath not only cleans 
the injured portion of the body thoroughly, but at the 
same time renders it aseptic and maintains it in this state 
for a certain length of time. From time to time, as the 
solution becomes fouled, it will be necessary to renew it. 
The patient should not be removed from the bath until 
ail sloughs have been separated and the denuded surface 
is ready for grafting. Propped on rubber air pillows, 
the patient may sleep or rest in the bath without danger. 
Provision must be made, however, for maintaining the 
temperature of the bath, and for keeping up its proper 
saline proportions. 

In burns of the third degree, I would mention the fact 
that sometimes it will be found advisable to resort to an 
early amputation. The adoption of this course is indi- 
cated when the area burned is so extensive that the sub- 
sequent suppuration might prove too great a drain upon 
the patient’s strength, or when this area occupies such a 
position that even if perfect healing should take place the 
remaining cicatrix would be constantly exposed to ulcera- 
tion through the effects of abrasion or would seriously 
interfere with the use of the limb. 

When the sloughs have separated, the ulcerated sur- 
faces beneath are soon covered by florid granulations, 
which may require astringent applications or strapping 
with adhesive plaster. The treatment now becomes that 
of a simple ulcer, and may be guided by the same rules. 
Much good may be accomplished and deformity be 
avoided by keeping the various parts carefully separated, 





and by maintaining them in an appropriate position 
either by fixation on splints or by some proper mechanical 
appliance. 

In the ulcerative stage skin-grafting is at times of 
great service, and large and indolent ulcers may be made 
to heal quite readily by this means (see article on Skin- 
grafting). Eventransplantation of skin, as recommended 
by Wolf, may be employed with advantage in certain 
cases. If the patient, for example, has a large denuded 
surface, grafting becomes imperative; and the method 
of Thiersch is the best one to employ under these circum- 
stances, provided the patient can be confined to bed in 
proper quarters. If, however, this is impossible, the 
epidermization of the denuded surface may be materially 
hastened by employing the method of engrafting por- 
tions of corns or callous portions of the skin upon the 
exposed granulating surface. As the details of this pro- 
cedure are given in a later volume it will not be necessary 
for me to mention them in this place. 

Treatment of Burns from Corrosive Acids, Caustic Al- 
kalies, etc.—The corrosive or mineral acids which most 
often cause burns are sulphuric, nitric, and muriatic. 
In burns from these acids the application of water is to 
be avoided, as it causes, when mixed with the acid, a 
great and sudden rise of temperature. The proper treat- 
ment is to apply whiting or levigated chalk, which 
causes brisk effervescence, and at once neutralizes the 
acid; after this the part may be washed off with water. 
If this is done promptly, no more serious injury will 
result than a faint erythematous redness, accompanied 
by a slight sensation of smarting. Should by chance 
any of these substances be splashed into the eye, the 
organ should be well bathed in lime water, and sub- 
sequent inflammation should be treated in the usual 
manner. 

The caustic alkalies are soda, potassa, ammonia, and 
quicklime. These act by suddenly abstracting moisture 
from the tissues. A fresh burn of this nature should be 
treated with vinegar, or with any other mild acid, which 
neutralizes the alkali, and forms with it an unirritating 
salt. A burn of the eye should be treated in the same 
way, care being taken to dilute the acid to a proper 
degree. 

The treatment of shock from burns or scalds should be 
the same as when this condition arises under other cir- 
cumstances. (See article on Shock.) 

When reaction has commenced, a generally supporting 
plan of treatment is in order. Thirst, which is usually 
intense, should be allayed by small lumps of ice placed 
in the mouth, or by occasional sips of carbonated water. 
Constipation is quite common during the first two or 
three days following a burn, and a laxative enema 
affords the best means of relief. The gastric and intes- 
tinal disturbance often calls for treatment. The diar- 
rhea during exhaustion due to the profuse suppuration 
is best treated by opium combined with astringents, and 
by pepsin and bismuth. The diet should be simple but 
nourishing, and absolute rest is to be enforced. 

John McG. Woodbury. 


BURNS AND SCALDS, THE MEDICO-LEGAL RE- 
LATION OF.—The application of a moderate degree of 
heat to the surface of the body acts as a stimulant to 
the activity of the cutaneous transpiratory system, 
through its effect upon the capillary circulation. If the 
heat be raised beyond this degree, and to one incom- 
patible with the integrity of the tissues, there results 
what has been denominated a burn or scald. Such dif- 
ference of designation is based upon no special difference 
of character, but upon the nature of the causative agent. 

For all practical purposes it is not essential to make a 
distinction between burns and scalds, yet it is sometimes 
important to decide upon the cause of the lesion observed. 

DEFINITION.—A bu7n is an injury resulting from the 
application to the body of a highly heated substance, 
flame or radiant heat. A scald is an injury produced by 
the application of a liquid, at or near the boiling-point. 

CLASSIFICATION.—Burns are most simply classified ac- 


519 


Burns and Scalds, 
Burns and Scalds, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





cording to the severity of their injurious effects. 
may accordingly be considered as: 

I. Burns involving the skin and subcutaneous cellular 
tissue only. A 

II. Those which extend their injurious effects to the 
muscles, nerves, and blood-vessels. 

III. Burns involving in their effects the internal organs 
and bones. 

IV. Those in which the preceding classes are variously 
combined. 

Class I. In this are included those burns in which a 
short contact with a heated body, or with water at or 
near the boiling-point, causes redness or scorching of the 
skin and considerable pain, leaving no permanent mark. 

Class II. In the least severe cases the cuticle is destroyed 
in its entire thickness, and the injured parts are covered 
with yellowish-gray or brownish eschars. The skin sur- 
rounding the burned surface is reddened and, immediately 
or after a few hours, blisters are formed. Such cases 
heal without deformity and leave a shining cicatrix. In 
the severer cases the subcutaneous cellular tissue, the 
muscles, and the nerves are destroyed. Blackish eschars 
form which are without sensation and, ultimately, are 
thrown off by the process of suppuration, leaving a 
granulating surface. The surrounding tissues are red- 
dened and usually a greater or less amount of vesica- 
tion exists. In the healing process, the resulting cica- 
trices of the skin adjacent are prone to contract and 
produce deformity which in some cases, especially when 
affecting the head or extremities, demands extensive sur- 
gical interference. 

Class III. So severe are the effects of burns of this 
class that the result is rapidly fatal. They are usually 
caused by an exposure to flame or to intense heat, more 
or less prolonged, and not only involve the lesions al- 
ready noted, but also a charring or carbonizing of the 
parts exposed. ; 

Causes Indicated by Appearances.—Burns of any inten- 
sity may be produced by a heated body, according to the 
degree of the elevation of its temperature and the period 
during which contact is maintained. The shape and 
size of the object are often indicated by the burn. These 
appearances may vary from a simple reddening of the 
skin to a complete charrring of the parts.” At the tem- 
perature of the boiling-point, 100° C., metals are capable 
of producing redness, vesication, and other effects. Partly 
fused solids cause burns of greater severity than sub- 
stances which can be readily removed from contact with 
the body, since, by their adhesion to the skin, they are 
prone to tear away portions of the derma in their re- 
moval. Such burns resemble, in their appearance and 
effects, those produced by solid bodies. They are less 
regular in outline, however, and are usually more severe 
on account of the high temperature of the agent causing 
them. Burns of this character are characterized as scalds. 

Boiling water produces scalds which may be so slight 
as to produce moderate redness only, or be so extensive 
as to develop quite characteristic effects. Such special 
effects are an ashy hue of the skin, with a sodden ap- 
pearance, and the formation of -blisters. While these 
features are usually characteristic of scalds by hot water 
or steam, they are sometimes with difficulty distinguished 
from burns by other agencies. Blackening of the skin 
never occurs in burns caused by boiling water. Gan- 
grene sometimes develops in cases which are not neces- 
sarily fatal. Scalding with hot water, though sometimes 
demanding legal investigation, is usually accidental. 
Severe and fatal burns of the mouth, fauces, and larynx 
are occasionally seen, from the inhalation of steam or 
from swallowing boiling water. These usually occur in 
children who attempt to drink fluids from teapots or tea- 
kettles. 

Burning oil produces burns similar to those by molten 
metals. ; 

Flame causes a scorching of the surface which is char- 
acteristic. In burns from this source the hairs upon the 
injured part are scorched and often upon those parts ad- 
jacent. This serves to distinguish burns from this cause 


They 


520 


from scalds from boiling water or steam, or by boiling oil, 
or by a hot body. 

Petroleum and its derivatives produce burns similar to 
those caused by flame, but in addition to the scorching 
the parts burned are blackened and more deeply injured 
than by flame alone, since the clothing usually holds the 
burning agent in contact with the body. The odor 
peculiar to the substance is ordinarily noticeable. 

Acids and corrosive agents cause severe burns. Besides 
injuries accidentally occurring, wilful injuries by the use 
of such means sometimes require investigation. While 
no fatal case from this cause is recorded, malicious attacks 
by throwing “ vitriol” (strong sulphuric acid), have oc- 
casionally occurred, resulting in loss of sight and severe 
disfigurement. 

The appearances of a burn by a mineral acid are easily 
distinguishable from those caused by heat. The eschar 
of a burn by an acid is soft, and sloughs readily, while 
that caused by heat is hard and tough. Around the site 
of the burn no redness, blackening, scorching of the 
hairs, or blisters occur, and the color of the burn is uni- 
form. Thestain upon the surrounding parts often affords 
means of distinguishing the agent which has caused the 
injury. Sulphuric acid produces a dark brown stain, 
nitric acid a yellow, and chlorohydric acid a brownish- 
yellow stain. The clothing also furnishes similar evi- 
dence by discolorations, and by a chemical analysis of 
the fabric. A post-mortem burn by an acid is not dis- 
tinguishable from an ante-mortem burn, unless a vital 
reaction has occurred. 

Liffects of Burns.—These are local and constitutional. 

1. Local Effects. Redness, blisters, destruction of the 
cuticle, scorching of the hair, and roasting of portions of 
the body occur, according to the extent and severity of 
the burn. In some severe cases, all these appearances. 
are to be seen on the same body. Within a short time 
after the occurrence of a burn a special line of redness 
appears between the part burned and the uninjured skin. 
This red dine is caused by highly congested vessels and, in 
some cases, becomes a medico-legal sign of much impor- 
tance. listers may be single or multiple; some of these 
may be unbroken, others may be ruptured and their 
serum may have flowed out upon the surrounding parts. 
In some cases the skin, made dry and brittle by the heat, 
develops cracks and fissures by the movements of the pa- 
tient. These most frequently occur in the vicinity of 
the joints. Occasionally these fissures resemble incised 
wounds, and it becomes necessary accurately to establish 
their character. Their depth depends upon the depth of 
the burn. In the more superficial cases the skin only is 
fissured, leaving the subcutaneous fat exposed, which 
may partially melt and flow out upon the sides of the 
fissure. In such cases the blood-vessels may usually be 
seen stretching across the crack, not having been de- 
stroyed in consequence of their elasticity. They should 
always be carefully sought. In severer burns the vessels 
are involved and break with the opening of the fissure.* 

Should it become-necessary further to differentiate be- 
tween such a fissure and a wound made by a sharp instru- 
ment, the condition of the edges of the fissure, whether 
clean-cut or ragged, and the presence or absence of uncut 
vessels and evidences of hemorrhage upon the surround- 
ing parts, will complete the differential diagnosis. It 
must be remembered, however, that incised wounds and 
wounds from the action of fire may be found upon the 
same subject. Each wound noted, therefore, must be 
specially examined as toall its characteristics of position, 
depth, shape, and other features. 

2. Constitutional Effects. The constitutional effects of 
a severe burn are manifest in the condition ef “shock,” 
which is induced by all sudden and severe injuries. The 
predominating symptoms are pallor, with coldness of the 
surface of the body, a feeble pulse with chills, and a ten- 
dency to collapse. In cases which are quickly fatal, ob- 
structed respiration supervenes, and death from coma 
follows. Occasionally, convulsions precede death; while 


* Casper, ‘‘ Forensic Medicine,” i., 301, 314. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





in cases not immediately fatal, a reaction, more or less 
marked, occurs. 

Causes of Death.—Death may follow from cerebral 
congestion or effusion before any reaction is apparent. 
Pulmonary congestion and cedema, with pleural effusions, 
occur in other cases, death supervening before the ap- 
pearance of any evidences of reaction. Such fatal result 
usually takes place within the first two days; while, in 
some cases, the issue is immediately fatal from the pros- 
trating effects of the intense pain. During the two 
weeks succeeding the infliction of the burn, the period 
of inflammatory reaction occurs, in which the case may 
terminate fatally, from the development of inflammatory 
conditions of the thoracic and abdominal viscera, with 
or without ulcerative processes in some organ. 

Death may be due to one or more of several conditions, 
arising from important modifications of visceral organs. 
Such modifications result from the intimate relation ex- 
isting between the sympathetic nervous system and the 
spinal cord, and that of the nervous supply of the sur- 
face of the body and the internal organs. These changed 
conditions may induce death immediately, or after an in- 
terval. The conditions immediately fatal are those which 
cause death by asphyzia, through deprivation of air, or 
by suffocation from inhalation of carbon monoxide and 
carbon dioxide, produced by combustion. 

Death may result from syncope or collapse, induced by 
nervous shock and pain. A fatal issue, after a short 
interval, may be caused by cerebral congestion and effu- 
sion; by bronchitis, or pneumonia with congestion or 
cedema of the lungs; by inflammation of the intestines, 
causing peritonitis and ulceration ; by gangrene or septi- 
cemia or by exhaustion resulting from prolonged pain 
and suffering. 

From a medico-legal standpoint it may be necessary to 
determine the extent of a burn which must, necessarily, 
prove fatal. While burns and scalds are not legally 
classed as wounds, they are included among injuries 
dangerous to life. It must be remembered that upon 
their evtent, rather than upon their depth, is the danger 
dependent. Destruction of a considerable portion of the 
transpiratory tract, or the suspension of its function by 
an extensive superficial’ burn, is far more fatal in its 
tendency than a deep burn of a limited portion of the 
body. The character of the burn, whether single and 
continuous or multiple and in small patches on various 
parts of the body, is an important consideration. The 
part affected has a very direct relation to its fatality. 
Burns of the extremities are less fatal than those of the 
trunk; while burns of the genitals and the lower portion 
of the abdomen are especially so.* 

The physical condition of the person has a very pro- 
nounced influence. Burns in females and children of 
highly nervous organization, render an unfavorable prog- 
nosis necessary. It may be stated that a burn involving 
two-thirds of the surface of the body is necessarily fatal, 
but a small area of injury of even one-fourth of the sur- 
face has proved fatal. Such a general statement is quite 
as scientific as an attempt to define an exact area of 
square inches. 

Period at which Death Occurs.—As previously stated, 
death may occur almost immediately from direct effects, 
or after a period of five or more weeks. Death, in the 
majority of cases, occurs during the first five or six days. 

How long a person may have survived the infliction of 
the burn is sometimes a most important question. The 
probable time which has elapsed is indicated by the pres- 
ence or absence of suppuration. The development of 
this condition, if existing, would indicate a period of two 
days or more, since inflammation and suppuration would 
not begin, ordinarily, before the third day. Intestinal 
inflammation or ulcerations, which usually require sev- 
eral days for their development, would also afford sug- 
gestions as to the time elapsed. 

Post-mortem Appearances.—Exzternally, the examination 
of a burned body calls for a special note as to the sex, 


* Tidy, “ Legal Medicine,” ii., 99. 


Burns and Scalds, 
Burns and Scalds, 





probable age, and every condition bearing upon the 
identity of the individual. The burned parts should be 
carefully examined as to the condition and extent of the 
injury. The presence or absence of redness, blisters, 
charring, and fissures should be particularly noted and 
the area of the burned surface carefully computed; as 
also the relation of the burned portions to uninjured sur- 
faces, and whether the line of separation be sharply 
marked or gradually fade into the surrounding skin. If 
blisters are present they should be examined in order to 
note whether they be full or empty, and as to the char- 
acter of their contents, whether consisting of a clear or a 
turbid and colored serum. 

Internally, the examination sometimes reveals no 
lesions, such persons usually dying from shock or from the 
intensity of the pain. Ordinarily the mucous membrane 
of the trachea and bronchial tubes is congested and, 
when asphyxia or suffocation has caused death, dark, 
sooty or smoky mucus is found in the respiratory tracts. 
In many cases the serous membranes of the abdomen, 
thorax, and brain are found to be reddened. The sudden 
inflow of blood from the surface of the body, caused by 
the local lesions, also gives rise to peritoneal, pleural, and 
ventricular effusions. 

Should the body have been so badly burned as to be 
charred or even incinerated, the bony portions usually 
remain in considerable part, and it is possible to deter- 
mine the sex from the shape of the pelvis, and to estimate 
the age from the length and development of the bones 
and by the lower jawand teeth. Evenif largely reduced 
to ashes, portions of the bones, sufficient to determine 
their character, can be detected by careful sifting. 
Special articles of identity are usually to be found among 
the ashes. Buttons, articles of jewelry, false teeth and 
filled teeth, discovered, have been sufficient to establish 
identification. A chemical analysis of the ashes may 
sometimes afford valuable evidence, in cases of suspected 
poisoning, with burning to conceal the crime. While 
volatile and organic poisons may be dissipated by the in- 
tense heat, some agents used in poisoning are not so 
affected, and might be detected. 

When the body is not completely roasted and charred, 
the possibility of the existence of wounds should lead to 
a careful examination for them, and for fractures of the 
bones; their accidental occurrence, however, must be re- 
membered. If the body be cremated the evidence of 
previous violence is destroyed, and an opinion upon the 
subject could not be formed. 

The period of time necessary to cremate the body may be- 
come an important question in cases in which such cre- 
mation has been resorted to for concealing crime. In the 
“Druse case” it was definitely ascertained that, in less 
than ten hours, a human body was cremated in a stove 
by burning with pine shingles. 

Was the Burn Ante Mortem or Post Mortem ?—It be- 
comes important to decide, in some cases, whether the 
burns noted are of ante-mortem or post-mortem occur- 
rence. The decision of this question is largely dependent 
upon the presence or absence of true d/isters, since vesi- 
cation is an almost constant lesion in burns occurring dur- 
ing life. The blister is formed by the separation of the 
cuticle from the derma by the effusion of an albuminous 
serum, the surrounding skin being of a bright or coppery 
red color. The occurrence of blisters may be almost 
immediate or it may be delayed for many hours, accord- 
ing to the occurrence or non-occurrence of a vital reac- 
tion. In cases of shock, or of great depression of the 
vital powers, accompanying insensibility, death may 
supervene before vesication can appear. The absence 
of blisters would not, in such case, be a determining 
factor. 

Blisters are more likely to occur when the burn has 
resulted from the application of steam, a scalding fluid, 
flame, or by burning clothing, rather than from the ap- 
plication of a highly heated body. In the living body, 
if the elevated cuticle of the blister be removed, a bright 
red base is exposed; in the dead body, no red base ap- 
pears. The blister produced during life contains a yel- 


521 


Bursz. 
Burs, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





lowish, highly albuminous serum.* If the blister be 
unbroken this is present; but if the cuticle be broken 
evidence of the existence of the blister is found upon the 
sides and the parts adjacent. The blister produced post 
mortem usually contains air only, but if its contents are 
fluid they are not a true serum. The cuticle in such 
blisters is elevated by the vaporization of the fluids of 
the tissues beneath it by the heat applied. It is possible 
in some conditions to produce such blisters immediately 
after death. Leuret+ and Champouillon,} succeeded in 
producing in dropsical subjects, a few hours after death, 
blisters containing a reddish fluid, slightly albuminous; 
but such blisters could be distinguished from true blisters 
produced ante mortem. Wright publishes similar ex- 
periences. The experiments of Woodman and Tidy § 
lead them to corresponding conclusions, while Chambert, 
Taylor,|| Jastrowitz,4{ and others conclude that, while 
blisters having fluid contents can sometimes be produced 
within tw enty- -four hours after death, such blisters lack 
the essential features characteristic of those produced 
during life. 
direction, has led the writer to adopt the conclusion that 
a true blister cannot be produced post mortem. 

A more important anatomical feature of the burn than 
the blister is the condition of the skin surrounding the 
burn. The skin of the burned part appears dry and 
parchment-like, of a dusky red color, and is surrounded 
by an area of grayish-white skin bounded by a deeply 
marked ved line. The general redness of the burn is 
transient, disappearing under pressure, but the red line 
ds permanent and does not disappear under pressure, and 
remains after death. This line of redness is developed 
during life, and is essentially a vital process, thus be- 
coming of great significance from a medico-legal point 
of view.** 

Vesication and the formation of the line of redness are 
vital processes, requiring time for their development; 
yet the absence of these conditions requires a most care- 
ful scrutiny of the circumstances attending the burning, 
as to the existence of shock or profound insensibility, 
before the adoption of a decision that the burns noted are 
post mortem. 

In cases of multiple burns upon the same body, the 
question of simultaneous production can be decided by 
the presence of the same symptoms in all. 

Spectroscopic investigation of the condition of the 
blood in burns thus far. has failed to develop constant 
or purely characteristic appearances. Lack of uniform- 
ity in changes noted, in such examinations, and the 
limited series recorded have not yielded sufficiently posi- 
tive results upon which to decide questions which may 
arise. ++ 

Some of the spectroscopic analyses of the blood, in 
such cases, have shown the presence of dark bands in the 
spectrum, not encountered in that of normal blood; such 
bands, however, have not been uniformly noted. Many 
modifying considerations must be entertained in such 
examinations, such as the differing intensity of the heat, 
the length of exposure to it, as well as other elements of 
variation. 

Wertheim {t+ calls attention to the increased number of 
leucocytes and the presence of melanin and hemoglobin. 
With these observations, those of Hoppe-Seyler agree. 
Ponfik, $$ on the contrary, is doubtful of the constant pres- 
ence or the significance of these conditions. Seliger and 
others have noted appearances similar to those described 
by Wertheim. 

The bright color of the blood observed by Falk ||| and 
others is contrary to that noted by some observers who 








* Kossack: Friederich’s Blatt. f. gericht. Med., 1877, Heft iii., 210. 
+ Annales dhygiéne, 1885, ii., 387 

an Annales d@hygiéne, 1846, i., 320. 

§ “ Forensic Medicine,” 1877, p. 886. 

| ‘* Medical Jurisprudence,”’ "am. ed., 1880, p. 408. 

TV ierteljahrsch. f. gericht. Med., Bd. xxxvi., Heft i., 1880. 

** Casper: ‘“* Forensic Medicine,”’’ iv., 299. 

++ Schjerning-Eulenberg’s Vierteljahrs. f. gericht. Med., xli., 44. 
+¢ Wien. med. Presse, 1868, pp. 309-605. 

§§ Berliner klinische Wochenschrift, 1876, No. 17; 1877, No. 46. 
|| ** Die Verbrennungen und Ver briihungen.” 


522 


An extended series of experiments, in this ‘ 





have described it as being of a dark, venous hue. 
These differing conditions may, in some cases at least, 
be explained by the mode of death. When the fatal 
issue has resulted from suffocation, caused by the de- 
privation of oxygen and by the respiration of the prod- 
ucts of combustion, the color of the blood would be 
dark or venous; while in case of death by apnoea, in- 
duced by an atmosphere containing an excess of carbon 
monoxide, the color of the blood would probably be 
bright or arterial. 

Spontaneous Combustion.—The possibility of the occur- 
rence of “spontaneous combustion” of the human body 
has been occasionally discussed, and a number of cases 
have been popularly reported. Its serious considera- 
tion here, as a scientific fact, is not entertained. The 
term “spontaneous combustion” igs a misnomer. The 
burning of the body cannot be accomplished without 
contact with fire. 

The possibility of an “increased combustibility ” of 
the human body, under certain conditions, has been re- 
cently maintained, and that, under such circumstances, 
the application of flame causes its rapid combustion. 
Dr. Hava, of New Orleans, has urged the existence of 
such a condition.* His experiments on animals and one 
or two cases observed in the human subject, apparently 
sustaining his position, have led him to claim the possi- 
bility of “an increased combustibility ” of the human 
body, as the result of a gradual, progressive, and constant 
accumulation of carbon monoxide for many years, and 
its consequently rapid combustion on exposure to flame. 

Enoch Vine Stoddard. 


BURSA, LIST OF.—A knowledge of the exact loca- 
tion of burse is of great importance with reference to 
diagnosis. Unfortunately the subject has been some- 
what neglected by descriptive anatomists. While some 
bursee have received names and are accurately described, 
others are but seldom mentioned, and authors differ as 
to their nomenclature. In the following list, which has 
been carefully compiled from various sources, an en- 
deavor has been made to describe and name all the burs 
which have been found in the human body, omitting 
only those which are merely accidental. The figures 
show the situation of the principal bursze in the most 
important surgical regions. 

HeEav.— Bursa galew capitis. Between the aponeurosis 
of the occipito-frontalis and the pericranium, directly 
over the occipital protuberance.! Only in aged subjects. 

B. sacculi lachrymalis. Between the lachrymal sac and 
the internal palpebral ligament.? Rare. 

B. trochlearis oculi. -In the pulley of the superior 
oblique. Constant. 

B. capsule oculi. Between the capsule of Tenon and 
the globe of the eye. Usually imperfect. Hyrtl® cites 
cases of effusion into the sac. 

B. circumflext palati (Rosenmiiller). Where the tendon 
of the tensor palati turns around the hamular process. 

Burse masseterice. 'There appear to be several burs 
between the masseter and the subjacent structures. 
Rosenmiiller mentions one between the two portions of 
the masseter, and one between the masseter and the 
external pterygoid. Hyrtl*+ mentions one between the 
muscle and the temporo-maxillary articulation. Nan- 
crede supposes that these may become continuous, and 
when inflamed form a cystic tumor reaching to the base 
of the skull. 

B. spine sphenoidee. Uyrtl® states that when the 
temporo-maxillary joint is unusually large a bursa oc- 
curs between the spine of the sphenoid and the joint 
capsule. 

B. angult mandibult. 
jaw. Rather rare. 

B. sublingualis. Between the tongue and the mucous 
membrane, outside the genio-glossus. Frequently called 
Fleischmann’s bursa, from its discoverer. Some deny 
its existence.’ Tillaux has frequently found’ it, and be- 


Subcutaneous over angle of the 


* The New Orleans Medical and Surgical Journal, April, 1894. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





lieves that acute ranula is caused by a rupture of Whar- 
ton’s duct into it.® 
B. prementalis (Fig. 1060). Subcutaneous at lower 
border of the symphysis of the chin. Quite constant.°® 
Necxk.—B. digastrici posterior (Rosenmiiller). Between 
the posterior belly of the digastric and the sterno-mastoid. 













B. preementalis, , 


B.  digastrica 
anterior. 


B. stylo-hyoidea, 
B. thyr. lateralis. 


B. subhyoidea... 
B. preethyroidea. 


B. crico-thyro- 
thyroidea, 





Fig. 1060.—The Principal Bursz of the Neck, in Front. 


B. digastrict anterior (Rosenmiiller) (Fig. 1060). Where 
the tendon of the digastric passes through the fascia 
binding it to the hyoid bone, or through the stylo-hyoid 
muscle. 

B. stylo-hyoidea (Fig. 1060). Under the insertion of the 
stylo-hyoid and the hyoid bone. 

B. suprahyoidea (Verneuil). Between the upper sur- 
face of the hyoid bone and the genio-hyo-glossi. Rare. 

B. subhyoidea (Fig. 1060). Between the hyoid bone + 
combined insertion of sterno-hyoid, omo-hyoid, and 
stylo-hyoid muscles, and the thyro-hyoid membrane. 
Larger in men than in women. Often called Boyer’s 
bursa. 

B. sterno-hyoidea (Rosenmiller). Between the inser- 
tion of the sterno-hyoid and the hyoid bone.?° 

B. prethyroidea (Fig. 1060). Between the skin and the 
upper part of the thyroid cartilage in old subjects. 
Often wanting. 

B. thyroidea lateralis (Gruber !') (Fig. 1060). Between 
the inferior constrictor and the greater cornu of the 
thyroid cartilage. Found in five cases out of fifty. 

B. crico-thyro-thyroidea (Calori '*) (Fig. 1060). Between 
the lateral lobes of the thyroid body and the crico-thy- 
roid. 

B. thyro-trachealis (Calori) (Fig. 1060). Between the 
isthmus of the thyroid body and the trachea. Usually 
single and median; there may be one on either side. 
Most common when the pyramid of the thyroid body is 
well developed, especially when it is attached to the 
hyoid bone. 

B. musceuli thyroidei. Between the levator thyroidei, 
when that muscle is present, and the thyroid body. 
Calori figures one in a case of goitre. 

B. omo-hyoidet. Between the sterno-mastoid and the 
middle tendon of the omo-hyoid. Mentioned by Nan- 
crede, but not generally noticed by authors. 

Bb. aortico-tracheales (Calori). Between the aorta and 
the trachea. A large one extends from the origin of the 
innominate to the left carotid, and from the upper border 
of the arch to the bifurcation of the trachea. A second 
one is described as posterior to this, also a small one 
which extends between the left carotid and the trachea. 
Some one of these was found in thirteen out of forty ex- 
aminations. If the pericardium extends upward, the 
large aortico-tracheal bursa is small. 

B. vertebre prominentis. Between the skin and the 
spinous process of the seventh cervical vertebra. Nan- 





Burse, 
Burs2,. 


crede states that this is quite large, and may inflame 
from pressure of a heavy overcoat. 

Trunk.—B. subclavia (Rosenmiiller). Within the 
fibres of the rhomboid ligament.'* Not constant. May 
simulate a costo-clavicular articulation, of which, in- 
deed, it seems to be the beginning. 

B. submammaria. Between the mammary gland and 
the pectoralis major. Rare, but interesting, as it may 
be involved in a case of mammary abscess. 

B. anguli sterni. Subcutaneous over the angle be- 
tween the first and second pieces of the sternum. In 
carpenters and cabinetmakers. 

B. hyper-viphoidea. Subcutaneous over xiphoid cartil- 
age. Usual in shoemakers and rachitic children. 

B. suprapubica. Beneath the pubic attachment of the 
rectus abdominis. Duval!‘ reports that inflammation of 
this has been known to occur as a sequel to croupous 
pneumonia. Not mentioned by authorities generally. 
Schreger mentions a subcutaneous bursa at the side of 
the suspensory ligament of the penis. 

B. coste prime. Between the muscles of the back 
and the tuberosity of the first rib. Mentioned by Nan- 
erede. It is probably rare, as the principal authorities 
omit it. 

B. sacralis (Luschka).. Over spinous process of fourth 
or fifth sacral vertebra, or over the articulation of the 
sacrum and coccyx. Usual in old subjects. 

B. coccygea (Luschka). Between tip of coccyx and 
sphincter ani. Common.!® 

B. phrenico-hepatica anterior (von Brunn!*), Between 
the left lateral ligament of the liver and the under sur- 
face of the diaphragm in front. Found in 31 cases out 
of 64. Its enlargement might simulate a diaphragmatic 
hernia. 

B. phrenico-hepatica posterior (von Brunn). Between 
the same structures behind. Found in 2 cases out of 64. 

SHOULDER.—B. trapezii. Between the aponeurotic 
part of the trapezius and the base of scapular spine (3 
times in 12, Synnestvedt). 

B. latissimi dorsi. Between the latissimus dorsi and 
the inferior angle of the scapula. Recent observers 
(Henle, Heineke, Synnestvedt) do not find this. 

B. spine scapula ; 

B. supracromialis. These are subcutaneous, found in 
those who carry burdens. 

B. infrascapularis, Between 
the scapula and the chest wall. 


the inferior angle of 
Usually between sub- 









. coraco-clav, Media. ......sse.e8 caeieren 


. coraco-clav. lateralis .......e+e+e B. fossz infraclav. 
. subscapularis ........eeeereeee B. v. pect. min. 
. Subcoracoidea ........eee6 


supracromialis .......e+ 
. Subdeltoidea .......... 


. intertubercularis, 


. subt. teret, 
maj. 


oH DP bbe e 


B. subt,. latiss. 
dorsi. f 


Fig. 1061.—The Principal Bursz about the Shoulder. 


scapularis and serratus magnus. May be of considerable 
size, and by crepitation, when inflamed, simulate crepi- 
tant rales or pleuritic fremitus.!" 

B. subdeltoidea (Fig. 1061). Between the under surface 


523 


Burs2z. 
Burs, 





of the acromion + structures arising therefrom (lateral 
portion of coraco-acromial ligament, deltoid muscle) and 
the capsular ligament of the shoulder joint.'® Constant. 
Many authors describe the upper part of this bursa sepa- 
rately as B. subacromialis. This portion may be sepa- 
rate, but it usually communicates, and the whole should 
be considered as a single large multilocular bursa. 
Rarely communicates with the joint. Its inflammation 
may simulate dislocation of the biceps tendon (Nancrede). 

B. coraco-brachialis (Monro). Between the lateral part 
of the subscapularis and the short head of the biceps ++ 
coraco-brachialis. Sometimes communicates freely with 
B. subdeltoidea. Also known as B. subcoracoidea. 

B. coraco-brachialis minor (Gruber). Under a rare 
muscle, which arises from the anterior and internal part 
of the coracoid process. 

B. fosse infraclavicularis (Gruber) (Fig. 1061). Be- 
tween two layers of the coraco-clavicular fascia (costo- 
coracoid membrane), in front of the coracoid process. 
Frequent (1 in 8), more common in women. 

B. coraco-clavicularis media (Gruber) (Fig. 1061). Be- 
tween the conoid and the trapezoid ligaments. Frequent 
(1 in 2). May simulate a coraco-clavicular articulation. 

B. coraco-clavicularis lateralis (Gruber) (Fig. 1061). 
Between the coracoid process and the trapezoid ligament. 
Occasional (1 in 5). 

B. subtendinea pectoralis minoris. Under insertion of 
pectoralis minor. Rare (1 in 80 or 40, Gruber). 

B. vaginalis pectoralis minoris (Gruber) (Fig. 1061). 
Around tendon of pectoralis minor. Rare (1 in 10). 

B. subscapularis (Fig. 1061). Between the subscapula- 
ris and the neck of the scapula. Constant. It always 
communicates with the joint, and may properly be con- 
sidered as a diverticulum of the capsule. 

B. subcoracoidea (Gruber) (Fig. 1061). Between the 
upper edge of the subscapularis and the B. subscapu- 
laris.1° Found 10 out of 12 times (Synnestvedt); in two 
of these cases it communicated with B. subscapularis. 

B. subtendinea subscapularis (Synnestvedt). Between 
the tendon of the subscapularis and the capsule (2 times 
in 18). 

B. intertubercularis (Henle *°) (Fig. 1061). Surrounding 
the tendon of the long head of the biceps in the groove 
of the humerus. Constant. Always communicates 
with joint cavity, and should be considered as a diver- 
ticulum of the capsule. 

B. infraspinata (Rosenmiiller). Between upper edge 
of infraspinatus and scapular spine (2 in 3, Synnestvedt). 

B. subtendinea infraspinata. Between tendon of in- 
fraspinatus and capsule (4 in 14, Synnestvedt). 

B. subtendinea teretis minoris (Gruber). Under the 
tendon of the teres minor. Rare. 

B. subtendinea teretis majoris (Fig. 1061). Between the 
tendon of insertion of the teres major and the latissimus 
dorsi. Constant. 

B. subtendinea latissimi dorsi (Fig. 1061.) Between the 
tendon of the latissimus dorsi and the humerus. 

B. subtendinea pectoralis majoris. Between tendon of 
pectoralis major and B. intertubercularis + tendon of 
latissimus dorsi (4 in 12, Synnestvedt). 

B. intermuscularis pectoralis majoris (Synnestvedt). 
Between the clavicular and thoracic portions of the 
muscle, 

Evsow.—B. radio-bicipitalis (Rosenmiiller). Between 
the tendon of the biceps and the inner surface of the 
radius. Constant, often double. 

B. ulno-radialis (Jancke). Between the tendon of the 
biceps + radial tuberosity and outer surface of ulna + 
muscles of that region. Of considerable size. Frequent 
(1 in 4, Gruber; 3 in 6, Synnestvedt). 

B. subtendinea brachialis. Between the tendon of in- 
sertion of the brachialis anticus and the coronoid process. 
Rare. The older anatomists (Fourcroy, Jancke, Koch) 
describe a bursa between the brachialis anticus and the 
interosseous ligament. 

B. flecoris digitorum sublimis (Gruber). In the tendon 
of origin of the flexor sublimis, or between it and the 
pronator radii teres. Very rare (1 in 200). 


524 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


B. palmaris longi. Between the origin of the muscle 
and the joint capsule. Very rare. 

B. subcutanea olecrani (Camper). Between the skin 
and the periosteum of the olecranon. Constant in adults. 

B. subtendinea olecrant. Above the olecranon, and in 
front or at the side of the triceps tendon. Frequent (3 in 
5); constant in old subjects. 

B. intratendinea olecrant. Within the tendon of the 
triceps. Quite frequent (7 in 12, Synnestvedt). 

B. humero-tricipitalis. Between the anterior surface 
of the triceps and the fat covering the lower end of the 
humerus. Rare (1 in 12, Synnestvedt). q 

B. retro-epitrochlearis. Between the triceps +- ulnar 
nerve behind, and the posterior surface of the internal 
condyle +- median surface of capsule infront. Very rare. 

B. anconet (Rosenmiiller). Between the anconeus and 
the capsule (1 in 4 or 5). May communicate with B. ex- 
tensoris carpi ulnaris or with joint (Henle). 

B. epicondyli (Schreger). Between the skin and the 
external condyle of the humerus. Rare (1 in 60). 

B. extensoris carpi ulnaris (Jancke). Under origin. 
May extend under the extensor communis. Frequent 
(1 in 8 or 4). May communicate with the joint and also 
with B. anconei. 

B. extensoris carpi radialis brevioris (Monro). Between 
the common origin of the extensor carpi radialis brevior 
+ the extensor communis digitorum and the head of the 
radius (1 in 6 or 7). 

B. epitrochiet (Schreger). Between the skin and the 
inner condyle of the humerus. Rather frequent (1 in 5). 

Wrist AND Hanp.—B. ulnaris subcutanea. Over 
styloid process of ulna. Not constant (8 in 11, Syn- 
nestvedt). 

B. radialis subcutanea. 
Rather rare. 

B. dorsalis carpiea subcutanea. 
2 cases. 

B. vaginalis eatensoris carpi ulnaris (Fig. 1062). A 
small sheath. Reaches to the base of metacarpale V. 

B. v. extensoris minimi digiti (Fig. 1062). A small and 
separate sheath. 

B. v. extensorum communis et indicis (Fig. 1062). Large. 
Extends farther toward the fingers on the ulnar side. 

B. 2. extensoris longi pollicis (Fig. 1062). Runs obliquely 
across the next. 

B. v. extensorum carpi radialorum (Fig. 1062). In 
groove on back of radius. Single above, divides below. 


Over styloid process of radius. 


Schreger found this in 


Yor Be v. ext. longi pollicis, 


— { B. v. ext. carpi radial- 
orum. 






B. v. extens. carpi! __ 
ulnaris. 


Post. annular lig....-~ 


ite v. abd. long. et 


B. v. ext. min. dig.. ext. brev. pollicis, 


iv 


B. v. ext. com- 
munis et indicis. 





FIG. 1062. 


B. subtendinea extensoris carpi radialis longioris. Under 
the tendon at its insertion into metacarpale II. (4 in 20, 
Synnestvedt). 2 

B. subtendinea extensoris carpi radialis brevioris. Under 
the tendon at its insertion into metacarpale III. (18 in 20, 
Synnestvedt). 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Bursz, 
Burse, 





B. vaginalis abductoris longi et extensoris brevis pollicis 
(Fig. 537).—Surrounds these tendons from the dorsal 
surface of the radius to the outer edge of the wrist. 

B. subtendinea flexoris carpi ulnaris (Fig. 1063). Under 
the tendon at its insertion into pisiform (6 in 30 Synnest- 
vedt). 

B. tendinosa ulnaris (Michon) (Fig. 1063). The usual 
arrangement of this extensive sheath is to surround the 
tendons of both the superficial and deep flexors as they 









B, v. flex. carpi radialis. ...-~~ 


be B. subtend. flex, 
x carpi ulnaris, 


B, tendinosa radialis........ ----..,Ant, annular ligt. 


- B, tendinosa ulnaris, 


Fig. 1063. 


lie in the wrist and palm, sending a diverticulum down- 
ward upon the tendons of the little finger. Schiller?! 
describes this bursa as double, the sheath for the tendons 
of digits IV. and V. being separate from those of digits 
II. and III. Holden * reports a case in which this bursa 
communicated with the wrist joint. It does not usually 
communicate with the radial bursa,®* but many varieties 
are found.*4 


B. vaginalis flexoris carpi radialis (Fig. 1063). In the 
groove of the trapezium. 
B. tendinosa radialis (Michon) (Fig. 1063). Extends 


from an inch above the anterior annular ligament to the 
base of the second phalanx of the thumb, upon the tendon 
of the flexor longus pollicis. 

Bb. dorsales subcutanee. Between the skin and the ex- 
tensor tendons on the ulnar side over the metacarpo- 
phalangeal joint (Synnestvedt found them in digit I., 40 
per cent.; digit II., 53 per cent.; digits III. and IV., 66 
per cent.; digit V., 27 per cent.). 

Bb. dorsales subtendinew.—Between the tendons and the 
capsules of the metacarpo-phalangeal joints. Quite 
constant. Frequently communicate with joint. When 
not found a diverticulum of capsule takes the place 
(Theile, Synnestvedt). 

Bb. volares articuli-metacarpo-phalangeit. Between the 
skin + subcutaneous fat and the flexor tendon with its 
fibrous sheath. Found by Schreger in all the digits, by 
Synnestvedt only in digits I., II., and III.; most fre- 
quent in digit ILI. 

Bb. volares phalangis prime. Between the skin and 
subcutaneous tissue and the flexor tendon with its-sheath 
in front of the first phalanx. Found by Synnestvedt in 
_ but two instances, in digit II. and digit III. 

Bb. vaginales flecorum propriorum (Fig. 1063). Special 
sheaths for the flexor tendons of digits II., III., and IV. 

Bb. intermetacarpo-phalangea. Between‘ the heads of 
metacarpales II., III., IV., and V. 

Bb. interossea. Between the tendons of the interossei 
muscles and the metacarpo-phalangeal joints. Gruber? 
finds two sets of these, one under the part of the tendon 
that extends to the dorsal aponeurosis, the other under 
the part which communicates with the phalanx. 

_B. metacarpea ulnaris (Synnestvedt). Between the 
skin and the head of the fifth metacarpal. Found in 8 
out of 15 cases. 





Bb. phalangea dorsales. Over the articulations. Quite 
constant over the first series; less so over the second. 

Hir.—B. iliaca anterior. Subcutaneous over the an- 
terior superior spine of the ilium. 

B. subiliaca (Hyrtl). Under the tendon of the ilio- 
psoas, covering the ilio-pectineal tubercle, the anterior 
surface of the pubis, and the capsule of the hip joint. 
This large and constant bursa is sometimes multilocular 
and frequently (6 in 14, Synnestvedt) communicates with 
the hip joint. 

B. subtendinea iliaci. Between the tendon of insertion 
of the ilio-psoas and the femur. Not constant. 

B. subtendinea pectinei. Between the insertion of the 
pectineus and the femur + lowest fascicles of the iliacus. 
Frequent (8 in 14, Synnestvedt). 

B. trochanterica superficialis. 
trochanter major. Usually small, but sometimes multi- 
locular. Rather frequent (4 in 13, Synnestvedt). 

B. trochanterica profunda. Between the tendon of the 
gluteus maximus and the posterior and external portions 
of the great trochanter. Large and constant; frequently 
multilocular. 

Bb. gluteo-femorales. One or more between the tendon 
of the gluteus maximus and the femur. Quite constant. 

B. gluteo-fascialis. Between the tendon of the gluteus 
maximus and the origin of the vastusinternus. Constant. 

B. glutei medii anterior. Between the anterior portion 
of the tendon of the gluteus medius and the great tro- 
chanter. Nearly constant (12 in 15, Synnestvedt). 

B. glutet medit posterior. Between the posterior por- 
tion of the tendon of the gluteus medius and the pyri- 
formis. Usual (10 in 15, Synnestvedt). 

B. glutet minimi. Between the gluteus minimus and 
the anterior surface of the great trochanter. Large and 
nearly constant (14 in 15, Synnestvedt). 

B. supra-acetabularis. Between the reflected tendon 
of the rectus and the upper edge of the acetabulum (5 in 
16, Synnestvedt). 

B. pyriformis. Under the distal insertion of the muscle 
Infrequent (3 in 12, Synnestvedt). 

B. gemellorum (Synnestvedt). Between the gemelli 
and the joint capsule. Found once only. It communi- 
cated with B. circumflexa. 

B. ovalis obturatoris internt. 
the obturator and the gemelli. 
Synnestvedt). 
cumflexa. 

B. circeumfleca obturatoris internt. 
and the lesser sciatic notch. 

B. subtendinea obturatorisinterni. 
and the capsule of the hip joint. 
cate with last (Quain). 

B. obturatoris externt (Synnestvedt). Between the ob- 
turator externus and the joint capsule. Infrequent (2 
in 18). 

B. quadrati femoris. Between the quadratus femoris 
and the trochanter minor + tendon of ilio-psoas. Con- 
stant. 

B. subcutanea tuberis ischit. This is described by some 
(Hyrtl, Nélaton) as directly under the skin over the 
tuberosity of the ischium. It is probably rare. The 
three following are often mistaken for it: 

B. musculi glutec in tubere ischit. Between the lower 
border of the gluteus maximus and the tuberosity of the 
ischium (5 in 12, Synnestvedt. ) 

B. semitendinoso-bicipitalis in tubere ischii. Between 
the tendon of the united semitendinosus and biceps and 
the tuberosity. Constant. 

Bb. semimembranose in tubere ischit. Two of these 
are found between the tendon of the semimembranosus 
and the quadratus femoris. One is quite constant (9 in 
12), the other infrequent (2 in 12, Synnestvedt), 

B. iliaca posterior. Subcutaneous over the posterior 
superior spine of the ilium. 

KneEep.—B. condyli interni ; 

B. condyli externi. Subcutaneous burse over the pro- 
jecting condyles (Figs. 1064 and 1065). 

B. prepatellaris subcutanea (Fig. 1064), 


Subcutaneous over the 


Between the tendon of 
Rather frequent (5 in 13, 
Communicates sometimes with B. cir- 
Between the muscle 


Between the tendon 
Rare. May communi- 


In the sub- 


525 


Burs2. 
Burs. 


cutaneous connective tissue in front of the patella. This 
is quite common (18 in 20, Synnestvedt; 165 in 400, 
Gruber), and is usually confounded with the next. It 
may be of considerable size. 

B. prepatellaris subfascialis. Between the fascia in 
front of the patella and the aponeurosis of the extensors. 
Not so frequent (9 in 20, Synnestvedt; 28 in 400, Gruber). 







B. subcruralis. 





B. condyli externi. . - + aes. B. condyli interni. — 


B. prepatellaris| __ 
subcutanea. 


B. subpatellaris. . — — -- | B. gastrocnemi- 


alis interna. 


B. preetibialis. ~ — B. tibialis interna. 


Fig. 1064.—The Principal Burse in Front of the Knee. 


B. prepatellaris subaponeurotica, Between the apo- 
neurosis and the anterior surface of the patella. Found in 
9 out of 20, Synnestvedt; 23 in 400, Gruber; 10 out of 
12, Schreger. This division of the prepatellar burs is 
that of Gruber. The three here described rarely coexist, 
and when they do, they usually communicate. 

B. subcruralis (Fig. 1064). Between the tendon of the 
extensor quadriceps and the lower part of the anterior 
surface of the femur above the patella. This is always 
present, and invariably communicates with the joint, 
except occasionally in very young children. 

B. intermuscularis extensoris cruris. Between the 
tendons of rectusand the crurzus. About an inchabove 
the patella. Rare (2 in 55, Synnestvedt). 

B. patellaris externa. Between lateral expansions of 
the tendons of the quadriceps femoris and the patella. 
Rare. 

B. patellaris lateralis interna. In a similar situation 
on the inner side. Synnestvedt mentions two varieties, 
one superficial and one deeper. 

B. preligamentosa. Between the fascia and the liga- 
mentum patelle. (Found by Synnestvedt in 6 out of 15.) 

B. pretibialis (Fig. 1064). Between the fascia and the 
tuberosity of the tibia. Usual in old subjects. 

B. subpatellaris (Fig. 1064). Between the ligamentum 
patelle and the anterior surface of the tibia. Constant 
and large. May occasionally communicate with the joint, 
though Synnestvedt has never seen this, and thinks the 
reported cases erroneous. 

B. subtendinea sartortt. Between the tendon of the 
sartorius and the internal condyle of thefemur. Rather 
rare (2 in 15, Synnestvedt). 

B. sub ligamento interno (Synnestvedt). Between the 
internal lateral ligament and the capsule (11 out of 21). 

B. tibialis interna (Fig. 1064). Between the expansion 
of the lower internal ham-string tendons (semitendinosus, 
gracilis, sartorius), and the long internal lateral liga- 
ment.?° Constant. It occasionally blends with B. gas- 
trocnemialis interna, and through that communicates 
with the joint. 

B. tibialis subcutanea (Schreger). 
upper end of tibia. 
vedt. 

B. tendinis poplitet. Between the external lateral liga- 
ment and the tendon of the popliteus. Not constant (5 
in 16, Synnestvedt). Occasionally communicates with 
joint. 


Subcutaneous over 
Not found by Gruber or Synnest- 


526 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


B. tendinis bicipitis (Fig. 540). Between the external 
lateral ligament and the tendon of the biceps. Near] 
constant (21 in 26, Synnestvedt; 191 in 200, Gruber). It 
occasionally communicates with the joint. The external 
popliteal nerve is in relation to it. 

B. subtendinea tensoris fascia late (Synnestvedt). Be- 
tween the ilio-tibial band and the capsule. Found in 3. 
out of 19, once communicating with joint. 

B. fibuluris subcutanea (Schreger). Subcutaneous over | 
upper end of fibula. Not found by Gruber or Synnest- 
vedt. 

B. supracondyloidea interna (Fig. 1065). Between the 
inner tendon of the gastrocnemius and the femur. 
Nearly constant. May communicate with joint. 

B. gastrocnemialis interna (Figs. 1064 and 1065). Be- 
tween the inner head of the gastrocnemius and the semi- 
membranosus. It is behind the internal condyle and over 
the neighboring capsule. Large and constant. Sometimes 
multilocular. In adults it usually communicates with 
the joint. Synnestvedt describes the lower part of this 
as a separate bursa, under the name of B. semimem- 
branoso-gastrocnemialis. 

B. semimembranosa (Fig. 1065). Between the expansion 
of the semimembranosus tendon and the inner condyle of 
the tibia. Usually closed. Constant. 

B. gastrocnemialis externa. Between the external head 
of the gastrocnemius and the capsule. Rare. 

B. bicipito-gastrocnemialis. In the popliteal groove 
between the prominence of the sesamoid bone in the 
head of the gastrocnemius and the biceps tendon. Very 
rare. 

B. poplitea (Fig. 1065). Between the popliteus and 
the joint capsule + external tuberosity of tibia. This 
always communicates with the joint, and is properly a 
diverticulum of the capsule, occasionally (1 in 10, Lenoir) 
it also communicates with the cavity of the superior 
tibio-fibular articulation. 

ANKLE AND Foot.—B. malleoli externa ; 

B. malleoli interna. Subcutaneous over the malleoli. 
Not constant. External more frequent. 

B. vaginalis extensoris longi digitorum ; 

B. v. extensoris longi hallucis ; 

B. v. tibialis antici (Fig. 1066). 
these muscles. 


Around the tendons of 
Not infrequently the sheath of the ex- 







B. supracondyloidea int. . 

B. condyli interni....... - 

F —| B. condyli ex- 

, rni. 

le | B, tendinis bi-- 
cipitis. 

“{ ~~-B. poplitea. 


B. gastrocnemialis int... .— 


B. semimembranosa..... 


Fic. 1065.—The Principal Bursz Behind the Knee. 


tensors.extends somewhat higher up than is shown ir 
the figure. 

B. sinus tarsi (Gruber). Between the fascia which 
binds down the extensor longus digitorum and the head 
of the astragalus. Quite frequent (5 in 12, Synnnest- 
vedt; 97 in 174, Gruber). May communicate with joint. 

Bb. sub musculo pediwo. Under the extensor brevis 
digitorum. Usuallytwo. Found by Synnestvedt Zin 16. 
; Bb. tarsiea subcutanea (Schreger). On dorsal surface of 

oot. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Burse, 
Burse, 





ry 


B. vaginalis tibialis postict (Fig. 1067). Surrounds the 
tendon as it lies back of the internal malleolus. 
as v. flecoris longi digitorum ; 

v. flecoris longi hallucis (Fig. 1067). Surround the 
Reon behind the internal malleolus and extend into 
the sole. 

B. postealcanea superficialis. 
the deep fascia. Not constant. 

B. postealeanea profunda (Fig. 1067). Between the ten- 
don and the posterior surface of the calcaneum., Con- 
stant. Has cartilage on two of its walls, viz., over the 
bone, and a thin layer coating the anterior surface of the 
tendon. 

B. subcaleanea (Lenoir*’), Between the inferior sur- 
face of the calcaneum and the plantar fascia. Constant. 

B. subtendinea tibialis antici (Fig. 1066). Under the 
tendon at its insertion upon cuneiforme I. (5 in 12, Syn- 
nestvedt). 

Bb. abductoris minimi digiti (Synnestvedt). One be- 
tween the abductor and the sesamoid bone of the peroneus 
longus; another between the muscle and the tuberosity 
of metacarpale VY. Rare. 

B. subtendinea peronet tertii (Hyrtl) (Fig. 1066). Under 
the tendon at its insertion upon head of metacarpale V. 
Not constant. 

B. subtendinea extensoris longi hallucis. . Between the 
tendon and the head of metacarpale I. Small and rather 
rare, 

B. vaginalis anterior extensoris longi hallucis (Fig. 1066). 
i hed metatarso-phalangeal joint I. About one inch 
ong 

B. v. peronet. Sheathes the peroneal tendons behind 
the external malleolus. Single in the middle, it divides 
above and below. 

Bb. dorsales subcutanew. Several of these are described 
by Schreger and Synnestvedt. One over cuneiforme L., 
one over head of metacarpale I., and occasionally over 

other projections. 

Bb. dorsales subtendinee (Synnestvedt). These occur 
in similar situations as those of the hand, and agree with 
them in form and size. 

B. vaginalis peronei longi. Sheathes the tendon as it 
lies in the groove of the cuboid. A small bursa is some- 


Between the tendon and 







B. v. tibialis antici........ eae Seamer = fae 


B. v. ext. longi hallucis. . 
B. v. ext. longi digitorum ......._ 


B. subtendinea tibialis antici.._- 
B. subtendinea peronei tertii. __/7 


B, v. anterior ext. long. 
hallucis. t-. 


Fig. 1066.—Synovial Sheaths on Back of Ankle and Foot. 


times found under the tendon where it turns around the 
outer side of the cuboid, and another under its insertion 
upon metatarsale I. 

Bb. plantaris metatarso-phalanget (Schreger). These 
occur at the articulations. 

B. plantaris in capitulo ossis metatarsi I. (Lenoir) ; 

B. plantaris in capitulo ossis metatarst V. (Lenoir). 
These are well-known burs between the skin and the 
points of greatest pressure. 

Bb. intermetatarso-phalangee. These are usually 
found in old subjects, between the toes, in the region of 
the metatarso-phalangeal joints. The three inner are 





most constant (No. 1, 95 per cent. ; 
No. 38, 95 per cent. ; No. 4, 28 per cent., 
casionally communicate with joints. 

Bb. interossea. Between the interossei and the meta- 
tarso-phalangeal joint. Rarely communicate. 

Bb. lumbricalium. Under the lumbricales and laterally 
to them. Rare. 

B. abductoris minimé digiti. 


No. 2, 98 per cent. ; 
Gruber). Oc: 


Between the abductor of 







B. v. flex. long. digitorum-=-— 
B. v. tibialis postici......-- _ 


Internal annular lig’t ... .- 


B. v. flex. long. hall. . 
B. postcalcanea profunda, : 


Fic. 1067.—Synovial Sheaths of Inner Side of Foot. 


the little toe and the head of metatarsale V. Rare (1 in 
14, Synnestvedt). 

Bb. phalangea dorsales (Schreger). 
constant as those of the hand. 

Besides the general treatises on anatomy, and the 
publications cited in the foot-notes, the following works 
have been specially consulted in the preparation of this 
article : 


These are not so 


Monro, A.: A Description of all the Bursz Mucosze of the Human 
Body. Edinb., 1788 

Rosenmiiller, J. C.: Alex. Monroi icon. et descr. burs. mucos. corp. 
hum. Lipsiz, 1799. This is far more valuable than the original 
work of Monro, being considerably enlarged and improved. 

Schreger: De bursis subcutaneis, Erlangen, 1825. 

Gruber, W.: Die neue Bursa mucosa sinus tarsi. 
St. Petersbourg, tom. xv., No. 1, 1856 

Gruber, W.: Die Bursz mucosz prepatellares. 
St. Petersbourg, Nos. 10 and 11, 1857. 

Gruber, W.: Die Knieschleimbeutel, eine Monographie, Prag., 1857. 

Gruber. W.: Die Bursz mucosz der Spatia intermetacar po-phalangea 
et intermetatarso- -phalangea. Mém. des say. étrang. de St. Peters- 
bourg, tom. viii., 1858. 

Gruber, W.: Die Oberschulterhakenschleimbeutel, eine Monographie. 
en aA Gee Imp. des Sciences de St. Petersbourg. ser. vii., tom. 
iii., No. 11. 

Gruber, W.: Die Bursz mucosz cubitales, eine Monographie, Mém. de 
ee) Imp. des Sciences de St. Petersbourg, 1866, ser. vii., tom. x., 
N 


Bull. phys. math. de 
Bull. phys. math. de 


Todd, J.: Cyclopzedia of Anatomy and Physiology, article Bursa. 

Sée, M.: Dictionnaire oe ee des sciences médicales, article 
Bourses séreuses, Paris, 1867. 

Heineke, W.: Anatomie und Pathologie der Schleimbeutel und Sehnen- 
scheiden, Erlangen, 1868. 

Synnestvedt, A. S. D.: En anatomisk beskrivelse af de paa over-og un- 
derextremiteterne forekommende Burs mucos, Christiania, 1869. 

Nancrede, C. B.: Injuries and Diseases of Bursz, in the Int. Encycl. 


of Surgery, vol. ii., pp. 691-733. Frank Baker. 
1 Ayrtl: Oest. Zeitsch. f. pract. Heilk., vii., 47, 1861. 
2 , Rodrigues : Annal. d’Ocul., Juillet, 1845. 
3 Topogr. Anatomie, 7 Aufi., }. 225. 4 Op. cit., i., 415. 

5 Op. cit., i., 363. 6 Hiser’s Report, ii., 6, 1841. 

7 Sappey : Anat. Descriptive, second edition, iv., 67. 

8 Tillaux: Anatomie topographique, third edition, 320. Cf. C. O. 
Weber in Virchow’s Archiv, vi., 511, Berlin, 1854. 

® Richet: Anat. Medico-Chirurg., third edition, 398. 

10 Luschka: Anat. des menschl. Halses, 140. 

11 Archiv fiir Anat. u. Physiol., Leipsic, 1875, 590. 

12 Mem. della Acad. di Bologna, ser. 3, 1874, v., 335. 

13-Henle: Banderlehre, 2 Aufl., 68. 

14 Gazette des HOpitaux, Mai, 1854, p. 250. Nancrede cites this with 
approval. 

1© Luschka: Anat. des menschl. Beckens, Tiibingen, 1864, p. 28. 

16 Zeitsch. f. Anat. und Entw., vol. i., 205, 1875-76. 

17 Terrillon : Arch. gén. de méd., Par., 1874, ii., 385-403; also ibid., 
1877, ser. 6, xxx., 

18 Cf. Henle: biindertebre, 2 Aufl., 64. 

19 Henle: Muskellehre, 2 Autl., 182. 

20 Banderlehre, 2 Aufl., 75. 

21 Deutsche med. Wochenschr., 1878. 

22 Manual of Dissection of the Human Body, fifth edition, 385. 

23 Tillaux: Anatomie Topographique, third edition, 568. 

24 See Sappey: Anat. Descr., ii., 3 

25 Die Burse mucosze der Spatia intermetacarpo-phalangea, St. 
Petersburg, 1859. 

26 Henle: Banderlehre, 152; Muskellehre, 284. 

27 Recherches sur les bourses muqueuses sous-cutanées de la plante 
du pied, etc. Presse médicale, Paris, 1837, i., 49-53 


527 


Burse, [drate. 
Butyl Chloral Hy- 





BURSA. (SURGICAL.)—The pathological lesions of 
burs that demand surgical relief are those which follow 
traumatism and various forms of acute and chronic in- 
flammation. Of the large number of burs and synovial 
or bursal sacs in the body, a certain few, by reason either 
of their situation or of their structure, are especially prone 
to cause trouble. These alone will be mentioned in this 
article, although the lesions discussed in connection with 
them may also be found in other less well-known burse. 
The affections of other synovial sacs, which are really 
only larger burse, will not be considered here because 
their importance demands that they be separately 
enumerated. Such are the synovial linings of joints, 
and the serous linings of the larger cavities existing in 
the skull, spinal column, thorax, abdomen, and scrotum. 

AcutgE Lestons.—7raumatism.—A fall upon the elbow 
or knee may cause a contusion of the subcutaneous bursa 
marked by pain and tenderness, with only slight redness, 
heat, and swelling. Often the traumatism will give rise 
in addition to an effusion of serum and sometimes to a 
hemorrhage into the bursal sac. Under such circum- 
stances there will be, in addition to the signs noted above, 
that of a well-marked rounded tumor, not attached to 
the skin. If the bursa is filled with serum, it will be ex- 
quisitely fluctuating, though less so if filled with blood. 

Treatment.—The affected part should be kept quiet 
even though to accomplish this end splints or rest in bed 
are necessary. A mildly antiseptic light wet dressing 
should be applied, and covered with either cracked ice 
or a hot-water bag. When the pain and cutaneous 
swelling have subsided, a flannel bandage, or straps of 
rubber plaster, will hasten the absorption of serum from 
the bursal sac. 

If rest and pressure do not suffice for the absorption 
of the serous contents, the latter may be evacuated and 
pressure again applied. If the sac refills, it may be 
again emptied and then partly filled with iodine or car- 
bolic acid according to the plan of treatment for hydro- 
cele; or it may be excised. 

If a small blood clot exists, similar treatment, 7.e., by 
cold, rest, and pressure, is justifiable. If the clot is of 
considerable size, it is better to make a short incision, re- 
move the clot, suture the sac and skin, and apply press- 
ure so that the walls of the sac shall remain in contact. 
If the surgeon is not absolutely sure of his asepsis, he 
may leave in a drain of six threads of silkworm gut for 
two days. 

Internal Traumatism.—Another form of traumatism 
occurs from within, that is, through injury of the serous 
surfaces by the overuse of muscles. Asa result the bursal 
sac becomes sore or distended with fluid, or the serous 
membrane becomes dry and its surfaces crepitate when 
they slip on each other. As illustrations of these three 
types of mild inflammation may be mentioned a bunion 
which has become sore from a long walk, the distention 
of the bursa under the tendo Achilles from the same cause, 
and the crepitation of the extensor tendons of the 
fingers and hand but especially those of the thumb, a 
condition which is often produced if a man who has been 
idle for some weeks starts in energetically at moving 
furniture or engages in some other hard labor. The 
swelling and tenderness will be distinct though slight, 
but the chief symptom will be a fibrinous creaking felt 
along the course of the tendons when the least motion is 
imparted to the hand. Sometimes, when the patient has 
been asked to move the hand a few times in order to de- 
monstrate this symptom, it will entirely disappear. 

Treatment.—The treatment of lesions due to trauma- 
tism from within does not essentially differ from that of 
lesions due to traumatism from without. If pain isa 
prominent symptom, and there is little swelling, the ap- 
plication of iodine, either in the form of the tincture or 
in that of an ointment, may give relief, In the case of 
crepitating tendons, a few days’ rest of the hand will ef- 
fect an entire cure; but the patient should be warned 
against a too speedy return to hard work. 

Infection.—Traumatism. may produce or be followed 
by a much more serious condition than those thus far 


528 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


considered, namely, infection. This may be direct and 
obvious, as when the wound opens into the prepatellar 
bursa; or indirect as when the germs introduced by a 
pin-prick in the finger find their way into the serous sacs 
about the flexor tendons. In both instances more or less 
cellulitis will follow together with a collection of sero- 
purulent fluid in the cavity of the bursa. Pus may also 
accumulate outside of the bursal sac; for example, in the 
hand an abscess, starting in infection in the sheath of the 
flexor tendons, may point posteriorly between the heads of 
the metacarpal bones. Under such conditions an anterior 
incision to open the sheath, as well as a posterior one to 
open the point of the abscess, will usually be required. 
This infection of a digital tendon sheath is a very com- 


‘mon one and bears the popular name of felon, which see. 


Treatment.—If the existence of pus is uncertain in any 
of these infective cases, rest and a wet antiseptic dressing 
are permissible. The patient should be kept under close 
observation, and if the process does not improve ina 
day, or if signs of accumulation of pus appear, a suit- 
able incision should be made. A suitable incision is one 
which relieves the tension, evacuates the accumulated 
pus, and allows the escape of pus yet to be formed. The 
mere pricking of a bursa full of pus, and the cutting of 
every felon clear to the bone, are both examples of bad 
workmanship. And drainage requires judgment no less 
than the incision. The comfort of the patient and the 
rapidity of his recovery are best provided for by a wet 
gauze dressing. If the incision has been properly made, 
and the walls of the bursa have been kept apart by 
gauze for a few days until granulation has begun, the 
gauze may soon after be removed from the bursal cavity 
without danger of pocketing, if only drainage is facili- 
tated by a constant moist dressing. For this purpose 
nothing is better, and scarcely anything cheaper, than 
one-per-cent. creolin solution. The gauze may be wet 
with this before it is applied and after that kept wet with 
plain cold water. Such a dressing will keep sweet two 
or three days if necessary. 

Curonic Lrestons.—Repeated Traumatism.—Repeated 
slight injuries may produce chronic inflammation of a 
bursa, with accumulation in its cavity of a serous or 
mucoid fluid, according to the character of the bursal 
lining. Thus in the burse overlying the olecranon and 
patella, the accumulated fluid is usually viscid,—glairy. 
The content of a ganglion may be of the same nature. 

The elbow and knee are so exposed to injuries of all 
sorts that they are often the seat of occupation diseases, 
and hence the names which have been given to chronic 
bursitis in these regions—miner’s elbow, and housemaid’s 
knee. These lesions are by no means, however, confined 
to these two classes of workers. 

The bursa gastrocnemio-semimembranosa sometimes 
fills with fluid as the result of a sudden strain, but the 
trouble is more. often chronic than acute. The patient 
suffers from moderate disability and consults a doctor in 
reference to a smooth tumor lying to the outer side of the 
popliteal space. The symptoms are plain enough if one 
has the lesion in mind, but unfortunately a mistaken 
diagnosis is often made in these cases. 

Another chronic bursitis with accumulation of serous 
or mucoid fluid is usually found in connection with a 
joint, sometimes in connection with a tendon sheath, and 
iscalled a ganglion. It presentsitself as a small rounded | 
tumor, tense, elastic, free from the normal skin, but only 
slightly movable on the deep parts. When cut down 
upon the sac can be readily freed superficially and at the 
sides, but its base is intimately associated with the fibrous 
capsule of the joint, or the tendon sheath, and its cavity 
may or may not open freely into the cavity of the 
normal structures. It is still a disputed point whether 
a ganglion is a bursal outgrowth from the lining of a 
joint or tendon sheath, or is a fibrous tumor, in which 
a cavity has subsequently formed and has then opened 
into the preformed synovial cavity of joint or tendon. 

Treatment.—The old treatment of a ganglion was to 
crush it by a sharp blow with a heavy book, and to apply 
and keep up pressure by a bandage. This treatment 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


will often result in cure in a recent case, but often too, 
owing to the thickness of the wall of the ganglion, rupt- 
ure does not follow the blow. Often, too, the sac refills. 

The certainty of aseptic excision of such tumors has 
rendered the method above described obsolete. When 
the skin has been cleansed and anzsthetized, an incision 
should be made over the crest of the ganglion parallel 
to the long axis of the limb. It should extend one-third 
inch beyond the edges of the tumor. The sac should be 
freed from the skin and at the sides before it is cut into. 
But nothing is gained by its removal entire, and as the 
. operation is made more difficult by this plan of action, it 
should not be followed, but the sac, when freed laterally, 
should be split open and emptied. Any communication 
with joint or tendon sheath will then be manifest, and 
the base of the sac may be easily and surely removed. 
If there is a distinct neck it may be ligated, so as.to close 
the cavity of the joint, or the joint may be closed with a 
suture, or allowed to close of itself. The wound should 
be carefully sutured, and ought to heal quickly without 
drainage. 

Of course there can be no thought of “breaking” and 
“scattering ” a chronically distended patellar or olecranon 
bursa. All such should be excised. The practice of 
making an incision and allowing the sac to granulate use- 
lessly delays the time of complete recovery in non-sup- 
purative cases. It is difficult to aneesthetize the base of 
an olecranon or patellar bursa, so intimate is its attach- 
ment to the periosteum. Hence, unless the patient is 
ready to stand some pain, it is wise to give a general 
anesthetic. 

Productive Inflammation.—Sometimes the chronic in- 
flammation of a bursa is of the productive type, and asa 
result the inner lining of the capsule thickens until the 
cavity is in great part obliterated, its place being taken 
by more or less recent fibrous tissue. It is useless to at- 
tempt the absorption of sucha mass. The whole tumor 
should be excised and the wound sutured. This form of 
bursitis is most commonly found in the prepatellar bursa. 

Tuberculous Inflammation.—Burse are very subject to 
tuberculous inflammation. In a certain number of cases 
in which no history of injury exists a bursa, or more 
often the synovial sheath, will gradually swell up and 
become fluctuating. When opened the sac will be found 
to contain serous or mucoid fluid, and often a large num- 
ber of rice bodies. The contents are similar to those of 
a tuberculous joint in which the trouble began in the 
synovial lining and has not yet progressed to the destruc- 
tion of bone. 

In some of these chronic cases the clinical and bacterio- 
logical examination make the diagnosis of tuberculous 
synovitis an easy one; but it by no means follows that 
every lesion of this sort is tuberculous; even the micro- 
scopical character of some chronically inflamed burse is 
in bitter controversy. That is a question, however, 
which the surgeon may well leave to the pathologist. 

Treatment.—There is only one satisfactory method of 
handling these cases—by excision. If the synovial sacs 
are affected the complete removal of every bit of inflamed 
tissue is out of the question. Still if a major portion be 
removed nature may do the rest. Even though the 
tendons be widely exposed by the removal of the diseased 
tissue, they may remain perfectly movable if the wound 
heals primarily. In general the results which follow 
operation upon the lesser synovial sacs are of a favorable 
character. Hdward Milton Foote. 


BURSERACEA.—A small, but rather important family 
of some sixteen genera and about two hundred species, 
distributed through all tropical and some sub-tropical re- 
gions. A few fruits are somewhat eaten (Protium), and 
some of the seeds yield useful fixed oils. The principal 
value of the family resides in its numerous gum resins and 
oleo-resins, which have from the earliest times been used 
for incense and recognized as important articles of com- 
merce. The best known of them are myrrh, bdellium, 
olibanum, and elemi, which represent the constituents 
and properties of the family. Henry H. Rusby. 


- Von. II.—384 


Bursze. {drate, 
Butyl Chloral Hy=- 





BUTTERNUT. JUGLANS.—“ The bark of the root of 
Juglans cinerea Li. (fam. Juglandacee), collected in the 
autumn,” U. §. P. The butternut is a medium-sized 
tree, with short, freely branching trunk and a light foli- 
age of pinnate leaves. The flowers are monecious: the 
staminate, in lateral drooping catkins; the pistillate few 
together in terminal clusters. It is a widely distributed 
tree, growing in the middle latitudes of North America, 
furnishing a useful cabinet wood, edible fruit, and a fair 
dyeing material. The description of the Pharmacopeia 
is poor, and applies rather to the stem bark. The bark 
occurs in large quills or curved pieces, about one-quarter 
of an inch thick. It is of a dark chocolate-brown 
throughout, the outer surface developing a reddish tinge 
in time. The outer surface is very little, if at all, fissured 
or scaly, but is somewhat warty. The inner surface is 
shreddy with partly detached fibre, in autumn-collected 
bark, but smooth if collected during the spring or sum- 
mer. The fracture is weak and soft, but somewhat 
fibrous, and delicately checkered. It has a feeble odor 
and a bitter, acrid taste. 

It contains a little tannin and volatile oil, fourteen per 
cent. of fat and a large amount of juglon, nucin, or jug- 
landic acid, which crystallizes in deep yellow needles and 
is the active constituent. 

Action AND Usre.—Butternut is a mild cathartic, 
operating, usually, without pain or irritation, well 
adapted to continuous administration, and worthy of 
more frequent use than is made of it. Dose, 1 or 2 gm. 
(gr, xv. ad xxx.). An extract, extractum juglandis— 
dose, 3 to 6 dgm. (gr. v. ad x.)—is the only preparation. 

ALLIED PLANTS.—Juglans regia Linn. is the European 
walnut (Noyer commun, Codex Med.); its leaves are the 
Folia Junglandis of the German Pharmacopeeia; its oil, 
the walnut oil of the market. The rind of the green 
fruits is collected and dried for a stomachic and vermi- 
fuge. It contains the juglon (nucin) above mentioned. 
The leaves are used for “scrofula, rickets,” ete. 

Juglans nigra, the black walnut, has probably similar 
properties to those of butternut. Henry H. Rusby. 


BUTTERWORTH’S MINERAL SPRING.—Kent Coun- 
ty, Michigan. 

Post-OFFIcE.—Grand Rapids. This spring is located 
on Huron Street, in the city of Grand Rapids. Adjoining 
is a commodious bath-house, with suites of rooms on 








separate floors for ladies and gentlemen (Walton). The 
analysis is-by Dr. 8. P. Duffield. 
Solids. Grains. 
SOGIUNG, DICATDONALC veratoeterere cassie acotnticinsersipie ei dueretete netaterare 5.00 
Calcium bicarbonate ese its : 8.34 
Magnesium bicarbonate ....... Ot ae pe COD 
TTOR SI CAT DOUALE iecerailersrerere vielelniacntie 97 
CACTI MCSIL ON Abe yaae sptaiviere alate cisicisiereuieiestsitte claveleicciontaterey e pels 
MPOGTUTT- CHIOTIGCE Potter lerelerenisieinareissisie’s isis bs nice civieaivine cee 12.73 
POLASSIUTN CHIOTIAE ey ore clercinnis alovsseterelalertivselalietereMelereiees clos 9.60 
CalGiimr Chloride oes acm «sles aiclacteamieanelbicesteisieis.s aftetoiste dtp 6.10 
MAG TIGSIUMIIGHIOLIOG csrais aie cielecsisisiereialoureisiy eisieinte/siolecsieiere clei 41.86 
(A TULTHLITIN, ctete aterata sioie.c otelate:cicte ¥evelaictute ele'v ace's/sis\eveerersie o-vecsieuare AL 
UE) pcre JOORGDOD OOS CDLAC ATL 0D GAOL CLARE ODICOCCUOlC 52 
Oigta hiner Cine hic Moc ooGaaSOaUdAO SC OCU OOS ODOOUT DODoOnE 67 
SEOUL ar cletta tare slatsitalatete corctestelow ata siclowt cate ceterere cicia’e ale 167.20 


The water has a considerable resemblance to that of 
Bath, England. It contains, however, a much larger 
proportion of chloride of magnesium. 

James K. Crook. 


BUTYL CHLORAL HYDRATE.—C,H;C1;0, HO. This 
substance, formerly erroneously styled croton chloral hy- 
drate, was introduced into medicine in 1870 by Liebreich, 
but has not met with much favor, and has failed to secure 
official recognition in the United States Pharmacopceia. 
Butyl chloral hydrate is in the form of colorless crystalline 
scales, of an odor and taste reminding of ordinary chloral 
hydrate. It has the disadvantage, as compared with the 
latter substance, of being but sparingly soluble in cold 
water. It dissolves freely in alcohol, in glycerin, and in 
boiling water. 

Butyl chloral hydrate is closely allied, chemically, to 


529 


Byron Springs. 
Cachexia. 





ordinary chloral hydrate and resembles that compound 
in its effects upon the animal system. Its only recom- 
mendation to medical favor lay in its supposed property 
of being peculiarly anodyne to the trigeminal nerve 
(Liebreich), and so of peculiar promise for the alleviation 
of neuralgias of the face and head; but this property 
certainly does not exist to any marked degree. Practi- 
cally, the drug is only a comparatively insoluble, and 
therefore inconvenient, substitute for ordinary chloral 
hydrate. It may be given in doses ranging from 0.30 to 
2.00 gm. (gr. v. to xxx.) in syrupy mixture. 
Edward Curtis. 


BYRON SPRINGS.—Contra Costa County, California. 

Post-OFFIcE.—Byron Springs. 
These excellent springs are pleasantly situated near the 
foot-hills, on a spur of the Coast Range of mountains, 
about 16 miles southeast of Mount Diablo, and 68 miles 
northeast of San Francisco. They are reached by the 
railroad’ line running from San Francisco to Stockton 
and Sacramento vid Martinez. The springs are one mile 
and a half from Byron Station on this line. They lie 
in a small valley leading from the San Joaquin plains. 
The elevation is about 100 feet above tide water, and the 
climate is mild and pleasant. An excellent hotel and a 
number of cottages have been erected for the accom- 
modation of guests. Being only three hours’ ride from 
San Francisco, the place is visited by thousands of people 
every year, and is constantly increasing in popularity. 
The springs are upward of fifty in number, and many 
of them are of great therapeutic value. They range in 
temperature from 52° to 140° F. Within a few feet of 
each other one finds a cold carbonated spring and a hot 
sulphureted spring. The entire basin has the appear- 
ance of being an extinct volcanic crater. The cold soda 
springs probably come largely from the surface water, 
while the hot springs undoubtedly have a much deeper 
origin down in the earth’s crust. Of the fifty or more 
springs only seven or eight are in active use. We pre- 
sent several analyses made by Dr. Winslow Anderson: 


Tne “LIVER AND KIDNEY” SPRINGS. 
ONE UNITED STATES GALLON CONTAINS: 





Solids. Grains 
Sodium CHOVIDE. Gar cioes eic'e vcs a slo's ciee.0's/eiocctsislv vies s ele siveee 622.07 
Potassium CHIOTIAE... 5 ccs aes ep ccs wicters elsiaiyreve ery cleteeiers 33.74 
POLASSHTTHETOMIAG 5 cate 4c otracete vishan's lita cteicisieleranietOate ate cieteetas 79 
POtASSTMM DTOMAIGC iiciin:c calorie sicieicis creieietel svorersievele ciswieilereer Trace. 
Magnesium CHIGTIGG 0... aiaceeojcrotelersieiete/ereievslsielere sts) ctolsisletetale 3.92 
IMABTICRHTTHACRT DOTIALE oa .-isisivice ales cte's sietclelsinie srarelaclenielonya 15.75 
Oaictam CHlOTICG an facie ac ores oi ceranisiers ee eiele eerie eric ates 85.37 
Calcinim' salphates sc. cuscsls cecctrecte s viciereeet terceemest 1.12 
Calelam*carbonate-... duce cas Oae ccesulcc cslacihecrtaanmerae 59 
BariuyyCarhonate.2.2 2 cccve ace cc eiew sales viebie saeco 93 
PETTOUS CATDONALG |. 6:0: viswie s sisiere ou.0'e 0.0 s so.ee sletee siete niet 72 
AMMON iM CHOTIAG!s ow odiecinc ae cc.utloe anou ae che ealesnteres -05 
SiNGCA e527 vviows vie wae eos pea dlee ey cae e oeOn ee mentee 1.00 
OTWANIC MACON. ce ocns sic lenic ccisles creisie tea etree heretics Trace. 

TOGL sain 6 rave soreresvveje aver srsie'e valedstyevete tietele re analv aleve’ sire oilaveiee 766.05 
Free carbonic:acidl gas 2... ccrssences seas 7.82 cubic inches. 
Temperature Of Water.) <<. .ccccccessews vce 66° F. 


Tke analysis shows this water to be heavily impreg- 
nated with saline ingredients. The water is said to have 
a special action on the liver and kidneys, which. fact 
gives the spring its name. It is said to be very useful in 
dyspepsia, chronic hepatic diseases, obstruction in the 
gall ducts, and what is known as “ gin livers.” Its good 
effects are also observed in intestinal atony or torpidity 
of the bowels. The water is diuretic, and is said to have 
been successful in a number of cases of albuminuria. Its 
best effects are observed in alcoholic dyspepsia, and in 
the “rocky” and dilapidated state of the system con- 
sequent upon excessive conviviality. 


Tue “WHITE SULPHUR SPRING.” 
ONE UNITED STATES GALLON CONTAINS: 


Sclids. Grains 
SOLU CHIOTICG 5 i.5 o.6)5,< 01070: ve ele siete wie ste pts visvc enieeeie sees 12.01 
Sodium Dicarbongles cs: coscecc cece news cee cance ete 12.94 
Sodhim sulphate secisriciccivie cs vecieleicie eee overs Cvevesieletee meets 1.34 


530 


Hotel and cottages. ' 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 









Solids. Grains. 
Potassium: CHIOLIAE fy cine sieiais’e. cre vistors ociele ele eetenee «eee Trace. 
Potassium, CATDONALC s;.\ s1cj0'210.0, 010.0 vic.e/e sloisin'e sis oiclelw i tetetate 2.37 
Potassium sulphate ......... sisis)sin s'ninjs\slo/a/e]s\plaie ecolhiatmeeees Trace. 
Magnesinm Chloride 5.02... ccsaciee vesicle siscies cleeslneetnare im 
Magnesium CarbONate olor. secs cc'eisie oi leietalerettsiniats ase ea 
Calcium 'carbonate iis sistas ls ctex's vedlecrctaers ; 1.13 
Calelum: SUIPOALG sn «aie eels ieieerriois cisielerets 51 
Herrous'CarbOnato ne evseescsceone . 8.00 
BIHCAS vactincsen.ttaak 26 
Organic Mattern vs: «slo slels eee ss's Trace. 

DiOUGL S gisteiesate.ciorn ot olathe lei pialelere ois alaloietale cigttemne eens 36.06 
Carbonic acid gas ...........00. .. 21.17 cubic inches. 
Sulphureted hydrogen... .. 5.80 “ 
Temperature Of Water oe. cccvccessvceveone 76° F. 


This will be seen to be a light alkaline-sulphur water, 
with a well-marked quantity of ferruginous salt. Its 
action is tonic, diuretic, alterative, aperient, and antacid. 
It is very useful in affections consequent upon the uri¢- 
acid diathesis, such as rheumatism, gout, glandular en- 
largements, and many forms of skin disease. 


THe “BuAck SULPHUR SPRING.” 
ONE UNITED STATES GALLON CONTAINS: 





Solids. Grains. 
BPOCIM ENIOTIGE sive cctelorcrelo siee wate excel sates shag else tiateetereta 395.00 
SOMINM GSULPHAte, o's: s/'e stoisce'g'ele elo a etvie 1s tolerate eee Trace. 
Sodium bicarbonate) .%.cie< ocscc ccceune steers ele elite tole ~ 
Potassium GhloridG, ... <<less ce feustine sae esieaepieimereete 35.62 
Potassinm SUIPHAte%:.'. <\c.0:c eles vise cinie ciasieles sisteeletineteete Trace. 
Potassium 1OGIGE.¢. vi ccc ewe cs vaginitis ccledeonercets 74 
Potassiuni bromide. oi .cs.ccusiiesnccncenmetes areratorees ed 16 
Magnesitim Chloride .scc.c.s.ccesenss cease eaves aoe 1.00 
Magnesium Carbonate .........ssscccceees alstoide ataletete <r . 
Cakelum chloride. .icncwccccens este sfaialels ora, njerelateltteaate 9.00 
Caicium ‘sulphate..... «cvs c'eis.csls 00s sess ssuennenceenenn 3.20 
Calcium Carbonate «5 :.:0/. cice.crielsiee icistale siete ane teens Aor hs 
Ferrous Carbonate .:...:. is: 01v.0.e vio ois ae apie sie Oe ene 70 
Baritim:carbonate.\:)..<cis'e cles svioaleiieaecnieeas dedcecor .. Trace. 
Ammonium Chloride): < si... + scene cleats aicels anise Cane ne 
SSTTIGE asc 5 wivic o's wluselciarsse org aretersl araterpionewinta toate ieretaitete Deir 1.10 
Organic matter .........0.0 sistainintoloisis bistererete alereeierae stetate Trace 

TOtAL. cre uuneis s Salers ceisler o:nsere 6) sess pote.oreleteimiarstates deen a.cey S0LeOn 
Carbonic acid gas......... ... 20.60 cubic inches. 
Sulphureted hydrogen . ses . 





Temperature of water 


This water contains a considerable quantity of the 
chlorides and carbonates, and is largely diuretic in con- 
sequence. It is also heavily charged with carbonic acid 
gas, and has a fair amount of sulphureted hydrogen gas. 
It is indicated in catarrhal irritation and inflammation of 
the genito-urinary tract, and has proved of service in 
cystitis, Bright’s disease, dyspepsia, and constipation. 
It is largely used for bathing purposes. 

Among other valuable springs at Byron are the “Tron” 
spring, a well-marked alkaline-chalybeate water; the 
“ Hot Salt” spring, having a temperature of 122.3° F. and 
much used for bathing; the “Iron Pipe” spring, and the 
“Surprise” spring. This latter spring is one of the most 
heavily charged saline waters in the world, containing 
15,000 grains of common salt to each United States gallon 
of 231 cubic inches. With other mineral ingredients it 
is known to possess over 18,000 grains—about 40 ounces, 
or 33 per cent. of solid constituents to the gallon. The 
following comparative table of heavy waters shows the 
Surprise spring to be one of the most remarkable known. 


ONE UNITED STATES GALLON CONTAINS: 


rains 
BOB WALCLE.. 2.0.5: eccinyew eee eo 0 0 ol eiercre civ etme ecalalheraietee teint +. 2168.91 
Mono Lake: (Gal.)..c.ciccunis este cleetcewie ccteiece ten aicea ee DID AD: 
Castalian Mineral Spring (Cal.) ..........eceeeeeeees 4,422.25 
Owens Lake: (Cal.) cic ccc cies ssl nile ccsle.e scissile serene 7,000.60 
Syracuse, N: Y. (salt well)}-. <.sscccss>«sceueee cs ATS 0 9,221.00 
Sait Lake (Utah) oi 0.). csciccen pases set eee ...-about 11,000.00 
Dead Sea (Holy Laid) ssc cssle- ce vo evieletties semen . 13,488.10 
St. Clair Springs (Mich:).2...:.+ sce ete cucce een ... 17,704.60 
Clark’s Red Cross Mineral Springs (Mich.) .......... 17,825.77 
Byron’ Surprise Spring. .2. oassus csv ecceeance tenes 18,773.73 


The water is highly diuretic and laxative when taken 
internally, and ought to be valuable for bathing purposes. 
Two large bath-houses have been built at Byron, fitted 
with sulphurous, steam, vapor, and water baths in tub 
or plunge, at all temperatures. The moor or mud baths 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Byron Springs, 
Cachexia, 





Nee ee EEE 


form an important feature of this resort. The hot sul- 
phurous, saline mud has become famous in the treatment 
of obstinate cases of rheumatism, gout, arthritic joints, 
scrofula, and skin diseases. The following analysis 
shows the mineral constituents of this mud: 


ONE UNITED STATES GALLON CONTAINS: 


Solids. Grains. 


SUNSRRURREYINCSH) UOT EGG orc c, cava, 0) cis erhio.e cVoreS ars) €ipleieinte sieis stoletase'sye:e 2 
Sodium phosphate .. A 

Potassium chloride . 
Potassium iodide,... 
Potassium bromide . 
Magnesium chloride 





SNBMPPMESL EET ESAT PIT LELLGS occa! ac a/clo 010 ca,c1t eleisia/sieu aiein csieicie eles s 
MIPMRRPTSEEITACOTAGG thir 5 alciers nle. d/o, sarc. ole Sieidiele o closs eisiinelae a4, are'e 75 
MEET ES EM TULITIA GC icc: coin 00/430 016 ¢.0)8\ bre 0/80 6)0/0 ai518,0[0 bia wo wee aie 36.05 
DPMREIBURTTIGHE LO Lec ciocrcts cove citelesteclcteee cele #8 0.08 ces 3. 
Rab EEn pe PA UNURLPSYLEL LO ota e wyetataratare ca\ ere) ciale) o/h ate aialetarels’ ays (el, sxe. 6|6/e\s 7 
PRMPEBAOHAN INTL OU OTTUOS cic 0s v'ere:s sco veieiecre's 9-6) 0 0c a'e eso 0 be o0.6 Trace. 
RRR iy falg a 1eTo lave ofo\ @.asc/e aI 6 oc ave leg ue caoleiel ors ecarayere-s aielere.s 5.62 
MEARE AUC UCI Watateiatelsniois ciace) va, speisieisw/e'sitfe's) tie (eleie si4\ «la ie\ la 7.384 
CISA 5S S633 OgDbR GAR CACGOO BOCES SSO OOo HOC cen 425.83 
Pree CarpOniC ACID PAS. . 26s ceccccssssnece 17.75 cubic inches. 
Free sulphureted hydrogen..............+ 14.50 eS 
MEMPCTAtUTE Of MUG. ..ccececccecccncscocs 110° F. 


REFERENCES. 


Winslow Anderson: The Mineral Springs and Health Resorts of 
California, 1892. 
J. K. Crook: The Mineral Waters of the United States, 1899. 


James K. Crook. 


CACAO, BUTTER OF.—Oleuwm Theobromatis. Oil 
of Theobroma. “ Cocoa Butter.” “A fixed oil expressed 
from the seeds of T’heobroma Cacao L. (fam. Sterculiacee) ” 
(U.S. P.). The chocolate tree is a native of tropical 
South America, where we have occasionally seen small 
forest areas which consisted almost wholly of it. These 
wild trees only occasionally produce fruit, for which the 
trees are very extensively cultivated in all tropical coun- 
tries. There is great variation in the quality of the seeds 
coming from different regions. Under cultivation, the 
tree grows like an apple tree, which it closely resembles, 
from a distance, in form and general appearance. The 
- oblong-ovate leaves are about a foot in length, thick-and 
rich-looking. The flowers are small and inconspicuous, 
growing in little cymes directly from the bark of the 
branches, or even of the trunk. The fruit, about six to 
ten inches long and half as thick, is oblong-ovoid, coarsely 
ribbed or grooved, so as to look not unlike a narrow, 
pointed melon. It has a thick, hardish rind, like a 
pumpkin or squash, and its color varies through shades 
of yellow, orange, and red to purple. It is filled with a 
whitish pulp, as soft as the flesh of a ripe melon and of 
a very fine texture. The numerous seeds are embedded 
in this pulp and attached toasoft central placenta. This 
pulp forms the basis of a delicious jelly of a beautiful 
purple or wine color. The seeds, after being cleaned of 
the pulp, are knownas raw seeds. In this condition they 
are bitter and astringent and unfit for use. Two methods 
of curing are in vogue. The first is to enclose them in 
tight boxes and allow them to “sweat.” The second is 
to “clay ” them by burying in holes in the earth. Either 
process results in fermentation, by which the outer coat- 
ing is caused to peel off, and they lose their disagreeable 
taste. They are then dried, cleaned, and marketed under 
the name “cacao” (pronounced (kah-kah’-o; or in Eng- 
lish, kay-kay’-o). Venezuelan clayed cacao is probably 
the most highly esteemed and is the most expensive. The 
seeds are about as large as unshelled almonds, oblong- 
ovoid and somewhat flattened, blunt at both ends, of 
some shade of brown, veiny on the outer surface. The 
shell is thin and brittle, the cotyledons friable and fatty. 
The latter are wrinkled, and in good seeds fill the cavity 
loosely, with an irregular, small space in the centre. 
The taste is slightly bitterish, but agreeable. For choco- 
late manufacture, the seeds are roasted and shelled and 
the kernels finely ground into a paste, with or (usually) 
without a very slight addition of water. In the process 





a portion of the oil separates. In the earlier manufacture 
in the United States, this, with frequently an additional 
portion, was removed, making our chocolate dry. We 
have since learned so well from our tropical relatives 
that we not only retain all of this oil, but abstract a por- 
tion in making the poorer grades of chocolate, to add to 
the richer and finer grades. 

The seeds yield almost half their weight of fat, about 
a third as much albuminous matter, considerable starch, 
and about one and one-half per cent. of the alkaloid theo- 
bromine. The shells removed from the seeds yield about 
one per cent. of this alkaloid. They are utilized for the 
preparation of an inferior drink. The use of chocolate 
produces, in a milder degree and after a longer time, the 
cerebral stimulation of coffee. As the latteracts through 
its caffeine, which is methyl theobromine, it would ap- 
pear that some transformation of the theobromine of 
chocolate must occur in the system. 

Cacao butter is obtained irom the seeds by the aid of 
heat, either by pressing with heated rollers or by boiling. 
The cake which remains is ground into “breakfast 
cocoa.” Thecacao butter occurs in cakes of a yellowish- 
white color; has a slight, agreeable odor and an oily 
taste, a little like that of chocolate. Its specific gravity 
is from 0.970 to 0.980. It melts at from 86° to 91.4° F., 
and is soluble in 100 parts of alcohol. It is much sub- 
ject to adulteration with other fats, for the detection of 
which the Pharmacope@ia provides ample tests. The 
peculiarities of this fat are its hardness and its melting 
point, at about the temperature of the body. This com- 
bination renders it exceptionally useful for the making 
of suppositories and bougies. As it does not readily 
decompose like other fats, it becomes a useful base for 
medicaments, and is, for the same reason, frequently em- 
ployed in hot countries as a delicious substitute for but- 
ter. It has no distinctly medicinal action. 

Henry H. Rusby. 


CACHEXIA.—GENERAL PATHOLOGY.—DEFINITION. —- 
The term as now used designates a condition of marked 
anzmia associated with great emaciation. The causes 
of the condition are many. Formerly the term was used 
rather loosely to designate any state of deterioration of 
the general health. This led to its use as a generic term, 
while numerous specific terms designated the causes in 
individual cases; thus, C. canceratica, C. cardiaca, ete. 

ErroLocy.—Cachexia is not associated with the pri- 
mary anzmias, namely, pernicious anemia, chlorosis, 
leukemia, and pseudo-leukemia. In these the general 
bulk of the frame is well maintained, and in some cases 
may be increased. In the secondary ansemias the asso- 
ciated emaciation in grave cases leads to the typical pic- 
ture of cachexia. 

The term cachexia, however, is especially used in con- 
nection with certain diseases. The most generally recog- 
nized types occur in malaria, syphilis, lead poisoning, 
gastric carcinoma, and infantile scurvy. It is well, how- 
ever, to consider all the pathological processes which 
may lead to this state. The condition resulting from the 
removal of the thyroid gland, sometimes spoken of as 
cachexia strumipriva, is a special condition not to be 
considered under the general subject of cachexia. 

In this connection the work of Lazarus* on the sec- 
ondary anzemias has been largely drawn from; his etio- 
logical classification is especially valuable. He divides 
the secondary ansemias into three classes: (1) hypoplastic, 
due to insufficient blood formation; (2) consumptive, 
caused by abnormally extensive destruction of the blood; 
and (8) complex, resulting from a combination of these 
two causes. Of the consumptive anemias the post- 
hemorrhagic isthe purest type. In most cases the patho- 
logical processes are so complex that it is impossible to 
determine whether the hypoplastic or the consumptive 
factor obtains. The examination of the blood gives no 
clew to the cause, asthe hematology of most of the second- 
ary anzemias is practically the same. 


* Ehrlich-Lazarus: “Die Anaemie,”’ II. Abtheilung, 1900. 


531 


Cachexia, 
Cadaver. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Krehl* says that the hypoplastic anzmias are due to 
an injury of some organ concerned in the production of 
a constituent of the blood. It is certain that many 
organs are concerned, and a disturbance of any one of 
these may bring about the result. 

The consumptive anzemias may involve the destruc- 
tion of normally produced blood. Here, also, many 
organs are probably concerned. The production of sub- 
stances necessary for the preservation of the erythrocytes 
in the plasma might be limited, or deleterious substances 
might be produced. As another possibility might be 
mentioned acceleration of the normal destruction, by 
whatever processes that is brought about. 

An evidence of increased destruction within the body 
is an increase in the amount of iron in the liver, spleen, 
and bone marrow. When the anemia is due to loss of 
blood, the amount of this iron is decreased as a result of 
the activity of the regenerative processes. 

The causes of the secondary anzemias may be classified 
as follows: 

I. Hemorrhages. 

II. Insufficient nourishment and bad hygienic sur- 
roundings. 

III. Malignant tumors and other organic diseases, poi- 
sons, parasites, etc. 

I. Hemorrhages.—The loss of blood may occur from: 
(1) the nose; (2) the lungs; (8) the gastro-intestinal tract 
in association with ankylostoma duodenale, ulcus ven- 
triculi et duodeni, malignant tumors, and hemorrhoids; 
(4) the genital tract in women; (5) the bladder; and (6) 
it may also occur in the various forms of hemorrhagic 
diathesis. Considerable losses are compensated for if 
sufficient intervals occur between the hemorrhages. The 
more frequent the hsmorrhages the longer is the time 
required for this compensation, 

Il. Insufficient Nourishment and Bad Hygienic Condi- 
tions.—No satisfactory explanation of the anemia is 
given. Improper food and surroundings (light, air), 
hard work, and mental distress are ordinarily given as 
the causes. Experiments upon professional fasters and 
upon animals have shown that acute and complete star- 
vation does not produce anemia. In the more chronic 
cases, however, it occurs especially when the diet is poor 
in iron-containing foods, of which the most important is 
meat. As these are the most expensive foods, this is 
probably an important factor among the poorer classes. 
In infantile scurvy the cachexia associated with the sub- 
periosteal extravasation of blood is usually a result of 
improper feeding. Malted milk and condensed milk are 
most largely responsible. Animal experimentation and 
the experience of members of polar expeditions in the 
long polar nights seem to show that lack of light does 
not produce anzemia or have any other bad effects. Con- 
cerning the ill effects of polluted air, little is known. 

Ill. Malignant Tumors and Other Organic Diseases, 
Poisons, Parasites, ete.—There is hardly an important 
pathological condition that does not have its effect upon 
the blood and upon the bulk of the frame. The reduc- 
tion in the amount of food in disease of course aids in 
producing anzemia and emaciation. 

In suppurations there is a loss of important materials 
and a considerable additional expenditure of energy. 
The great draft upon the bone marrow is shown experi- 
mentally by the increase of the red marrow, and by the 
relative increase of the neutrophiles — especially the 
mononuclear forms—and the relative decrease of the 
eosinophiles. 

In spermatorrhea, lactorrhaa, catarrh of the air passages 
and of the alimentary tract, the same causes obtain. 

In albuminuria the loss of albumin probably brings 
about a state of hydreemia, and this latter condition no 
doubt exerts a deleterious effect upon the red blood cor- 
puscles. The associated intoxication is also probably a 
factor. 

In fevers the amount of hydrobilirubin in the urine is 
to a certain extent a measure of the destruction of the 


* Krehl: ** Pathologische Physiologie,” Leipzig, 1898, 8. 125. 


532 


red blood corpuscles. Experimentally the simple eleva- 
tion of temperature probably does not increase metabol- 
ism extensively, or alter the quality of the blood. Prac- 
tically, however, the associated intoxication, as in the 
infectious diseases, is probably the important factor. 
The toxins may exert an erythrocytolytic function. 

Diseases of the Digestive Tract. These are among the 
most frequent causes. Limitation of alimentation and 
intoxication operate as factors here. Decreased excre- 
tion of toxins, and possibly auto-intoxication, occur. 

In syphilis the anemia and emaciation are probably 
due to the specific toxin of the disease. 

Tumors. Uncomplicated benign tumors have no effect 
upon the general health. Uncomplicated malignant 
tumors produce marked anemia and emaciation. The 
cause is to be sought in a toxin which increases blood 
destruction and proteid metabolism. 

Animal Parasites. Most of these probably produce 
toxins. The eosinophilia which occurs in connection 
with most, if not all, of the intestinal parasites is to be 
regarded as evidence of this. This is true of oxyuris 
vermicularis. In the case of ascaris lumbricoides the 
mechanical irritation may be a factor. With the echino- 
coccus and the trichina no anzemia occurs. The compli- 
cations seem to be responsible for the anzmia in the case 
of filaria sanguinis hominis and distoma hematobium. 
In ankylostoma duodenale the blood removed by the 
worm is an important factor. In the urine of patients 
infected with this worm is a toxin which produces 
marked aneemia in rabbits. In malaria a toxin undoubt- 
edly exerts an influence in addition to the direct destruc- 
tion of the erythrocytes by the parasites. 

Poisons. In lead poisoning the anzmia is thought to 
be due to the lesions of the stomach and intestines. 
Arsenic probably destroys the erythrocytes directly. 

In any of the above conditions, if there be marked 
emaciation, the condition of cachexia may be brought 
about. 

PATHOLOGICAL ANATOMY AND HistoLoey.—Blood.— 
The condition of the blood is that of a secondary anemia. 
In only a few forms is a special feature noted; as, for in- 
stance, the presence of parasites in the case of malaria. 

Other Organs.—The skin is yellowish rather than white, 
as in the acute anemias. This is to be regarded as an 
expression of the increased destruction of the erythro- 
cytes. The tendency to cdemaand hemorrhages is prob- 
ably due to changes (fatty) in the blood-vessels. _Haemor- 
rhages may occur into the skin, the mucous membranes, 
the central nervous system, and the serous membranes. 
No characteristic changes in metabolism are known. It 
is often impossible to say whether the gastro-intestinal 
disturbances which so frequently occur are primary or 
secondary. 

Certain lesions sometimes spoken of as characteristic of 
pernicious anzemia may also occur in these grave second- 
ary anemias. Such are hemorrhages into the omentum, 
fatty degeneration of the heart, degenerations in the 
brain and spinal cord, and atrophy of the mucous mem- 
brane of the gastro-intestinal tract. Changesin the bone 
marrow consist of an increase of the red marrow. This 
may gradually encroach upon the territory of the yellow 
marrow in the shafts of the long bones. However, the 
hyperplastic marrow has normal histological characters. 

In the emaciation the most important tissues suffer. 
least. The greatest reduction is of the fat; then follow 
the muscles, skin, liver, bones, heart, and central nervous 
system. Theorgans show nostriking histological altera- 
tion. The atrophy of the fatty tissues is described as 
follows by Ribbert.* In cases of marked cachexia the 
fat, especially of the epicardium, may assume an cede- 
matous, gelatinous character. In frozen sections of the 
fresh tissue one sees, in place of the large, closely packed 
fat cells, groups of fat droplets in a clear vascular tissue. 
Under a high power these groups are seen to be con- 
tained within cells which represent the atrophied fat 


¥ hee ““Lehrbuch der pathologischen Histologie,” Bonn, 1896, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cachexia, 
Cadaver. 





cells. If the process is still more advanced they take on 
the character of the ordinary connective-tissue cells. 
Between these are connective-tissue fibres. 
H. 8. Steensland. 
CACHEXIA STRUMIPRIVA. See Thyroid Gland, 
Diseases of. 


CACTACEA.—(The Cactus family.) This strange and 
interesting family of plants occupies as yet a most un- 
certain place in the materia medica. It comprises some 
twenty genera and probably six hundred species, and its 
study is no less difficult for the botanist than for the 
pharmacologist. The plants grow chiefly in desert re- 
gions, being competent to withstand the most extreme 
conditions of aridity, and interest centres chiefly in their 
defensive provisions. The absence of leaves, which are 
usually metamorphosed into spines, protects them against 
desiccation. The succulent nature of their stems causes 
them to be sought by hungry and thirsty animals. In 
times of cattle famine, the spines are burned off and the 
stems then used as fodder, while a wholesome water 
supply can be obtained from cavities scooped out in the 
bodies of some of the thicker species. Against destruc- 
tion from such causes, most of them are protected by 
their armament of spines. Those which lack this arma- 
ture are commonly protected by poisonous alkaloids, and 
attempts have been made to utilize some of these in 
medicine. The important drugs of the family are the 
Cactus grandiflorus and the Mezcal Buttons, which see. 

Their physiological properties are diversified. The 
berry-like fruits are commonly edible, and some of them, 
like the Prickly Pear or Tunya, are of much economic 
importance. Several of them are hosts for the valuable 
cochineal insect. Many succulent plants not related to 
this family are popularly called cactuses. 

Henry H. Rusby. 


CACTUS GRANDIFLORUS.—CEREUs GRANDIFLORUS. 
The flowers of Cereus grandiflorus (L.) Miller (fam. 
Cactacew). 'The stems have also been used. This plant, 
the well-known Night-Blooming Cereus of cultivation, 
is a native of the West Indies, and flowers in August. 
Adulteration with, or substitution by, the flowers of 
Opuntia decumana Haw. is very extensive. The flowers 
of the latter are cup-shaped, about an inch long and 
broad, with stamens one-fourth or one-half of an inch 
in length; while the genuine flowers are eight to ten 
inches in diameter when fully spread out, and have 
stamens two or more inches long. Much of the contra- 
dictory testimony as to composition and properties is 
doubtless due to this irregularity in the drug used, yet 
there is a wide discrepancy of opinion as to the merits of 
that which is genuine. No efforts appear to have been 
made to compare the flowers collected in different stages 
of maturity. The facts here stated, however, appear to 
be fairly well established. Both the stems and the flow- 
ers appear to be active, but the latter more so. An 
alkaloid and a glucoside are claimed, but our information 
regarding them is very meagre and indefinite. The drug 
is a cardiac stimulant of peculiar action. It does not 
affect the stomach nor the centres as digitalis does. It 
increases blood pressure by quickening and strengthen- 
ing the heart beat, through direct action upon its nerves. 
Wilcox, who has studied it extensively, is positive in as- 
serting its value in aortic regurgitation, where digitalis 
cannot be used, but its injuriousness in mitral stenosis. 
He recommends it generally in relative cardiac incom- 
petency and functional cardiac weakness. The dose of 
the fluid extract is 0.6 to 2 c.c. (Mx. to xxx.). 

Henry H. Rusby. 


CADAVER, LEGAL STATUS OF.—Scope of the Sub- 
Jject.—The enactments of State legislatures and the regu- 
lations of sanitary codes in regard to the cadaver con- 
stitute the purely legal side of the subject, and are too 
extensive to be considered in detail. So far as they 
affect physicians, as practitioners, investigators, instruc- 


tors, and medical examiners, they fall within the scope 
of an article suitable for this HANDBOOK. 

Questions involving the cause of déath, and such other 
deductions as only a person possessing expert anatomi- 
cal, medical, and surgical knowledge would be able to 
make from an examination of the cadaver, constitute 
the medico-legal side of the subject. Those matters, 
which can be determined only by an autopsy, have been 
considered in Vol. I under Auwtopsies, Medico-Legal Rela- 
tions of. Besides pathological conditions, the cadaver 
presents certain appearances which form a basis for the 
determination of the fact of death, of the time when it 
occurred, and of the identity of the dead person. 

Legal Aspects.—If we consider the subject from the 
physician’s standpoint, it will be sufficient for us to enu- 
merate the latter’s duties and privileges in relation to 
the cadaver; we shall scarcely be expected to specify in 
detail the statutes and codes that relate to the subject. 
For more detailed information in regard to the latter the 
reader is referred to an excellent article by T. C. Becker 
on the “Legal Status of the Dead Body,” in Witthaus 
and Becker’s “Medical Jurisprudence, Forensic Medi- 
cine, and Toxicology.” 

A death having occurred in a physician’s practice, it 
is his duty to examine the cadaver and verify the occur- 
rence by unmistakable signs presented. (These will be 
discussed further on.) No statute or code requires this 
in so many wards, but the physician’s “Certificate of 
Death” presupposes such examination to have been 
made. 

The “ Certificate of Death” is a record and legal proof 
of death. The form is furnished by the health authori- 
ties, and on its reverse side it contains terse information 
about the legal requirements. The extent to which these 
are either neglected or disregarded in New York, and 
presumably elsewhere, is remarkable. Such neglect is 
frequently responsible for many vexatious occurrences 
that might and should be avoided. 

The attending physician must furnish such a certificate 
within a specified time (thirty-six hours, according to 
the New York Sanitary Code, sec. 180). 

The physician must be officially registered (New York 
Sanitary Code, sec. 5.; Bureau of Records). 

The cause of death must be sufficient, no mere symp- 
tom being given as the sole cause. 

When a cause of death is given which might possibly 
be the result of injury, if such is not the case the certifi- 
cate should make that fact plain. 

If death is due to other than natural causes, the case 
must be referred to the coroner, county physician, medi- 
cal examiner, or justice of the peace, according to the 
law of the State. In doubtful cases the practitioner 
should not furnish the certificate unless authorized to 
do so by the proper official. Such cases are specified by 
statute in the various States. That of New York State 
is very broad. If a person dies from criminal violence, 
or by a casualty, or suddenly while in apparent health, 
or when unattended by a physician, or in prison, or in 
any suspicious or unusual manner, the case must be re- 
ferred to the coroner’s office (chap. 410, sec. 1,778, laws 
of 1882). 

Still-Birth.—The still-born foetus or child at full term 
is certainly a dead human body, having been alive in 
utero; yet the law takes no cognizance of this fact, and 
does not require an inquiry into the cause of death, un- 
less it can be proved that the child was born alive and 
capable of maintaining a separate existence; the decision 
of the former fact being based upon breathing; of the 
latter, upon normal formation and sufficient develop- 
ment. 

The physician or midwife in attendance at a still-birth 
should make a report thereof to the proper authorities, 
In New York, certificates are furnished by the Bureau 
of Vital Statistics, and these certificates require, besides 
other information, a statement of the “cause of death- 
birth, if known.” 

Concealing the birth of a child, which if born alive 
would be a bastard, is punishable in seventeen States. 


533 


Cadaver. 
Cadaver. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











A failure on the part of the physican to make a proper 
return to the authorities in a case of this nature might 
be construed as such concealment. 

Autopsies.—In cases in which the coroner, county phy- 
sician, medical examiner, or justice of the peace has juris- 
diction, an autopsy may be ordered or performed by him 
(county physician, medical examiner, coroner’s physi- 
cian) to ascertain the cause of death. If the body has 
been interred, the coroner, justice of the peace, or dis- 
trict attorney—this duty falling upon a different officer 
in different States—may exhume, take possession of, and 
remove the body or any portion thereof, and submit the 
same to a proper physical or chemical examination or 
analysis to ascertain the cause of death, which in New 
York “will be made on the order of a justice of the 
supreme court of the State, or the county judge of the 
county in which the dead body shall be, granted on the 
application of the district attorney,” etc. (sec. 308, Penal 
Code, subdiv. 3, as amended by chap. 500, laws of 1889). 
When the officials mentioned have no jurisdiction, an 
autopsy may be authorized by husband, wife, or next of 
kin. If no relatives charged by law with the duty of 
burial are at hand, and the deceased has left a will, his 
executors may authorize the performance of an autopsy. 
If the body has been interred, it may be exhumed on 
such authorization with the permission of the health au- 
thorities. 

The removal or disinterment of a dead body without 
authority of law, or consent of relatives, for the purpose 
of selling such body, or for dissection, or for mere wan- 
tonness, is a felony, misdemeanor, and punishable by sen- 
tences which vary in different States. 

The time that should be allowed to elapse before per- 
forming an autopsy is not specified by statute. It is 
best to await the development of unmistakable signs of 
death, the time for which varies in different cases and 
under different circumstances. This matter is discussed 
further on. 

Dissection of bodies unclaimed by relatives or friends 
for burial is permitted by various State enactments. 
Their phraseology varies. In general, they are worded 
so as to include the bodies of criminals executed under 
sentence, those of persons dying in jails, poorhouses, 
asylums, and public hospitals, and those lying in under- 
takers’ establishments—in brief, bodies which would 
otherwise be buried at the public expense. Dissection 
is prohibited in some States, under the following circum- 
stances: if the deceased in his last illness expressed the 
wish that his body should not be used for such a pur- 
pose; if relatives or friends withhold their consent; if 
deceased was a stranger or a traveller; or, finally (in 
Maine), if ten voters object. 

The Powers and Duties of Coroners, County Physicians, 
Medical Examiners, and Justices of the Peace in relation 
to the disposition to be made of a cadaver. A considera- 
tion of the coroner’s inquest, and of the systems which 
have superseded it, although related to this subject, 
would occupy more space than can be spared in the 
present article.* In those cases in which these officials 
have jurisdiction, no disposal may be made of the body 
without their sanction. No person, however, would be 
adjudged as infringing such authority if he were imme- 
diately to cut down a suspended body on the chance of 
life not being extinct, or if he should in some other man- 
ner lay hold of the body in efforts at restoration. 

The wisdom of having an official who is duly author- 
ized, in a suspicious case, to take possession of the 
cadaver, of its effects, and even of the quarters in which 
it is found, while at the same time all other unauthor- 
ized persons are prohibited from disturbing the body, its 
effects, or the quarters in which it is found before such 
official possession is taken, is apparent, when the great 
importance of a proper record of all details in relation 
to the cadaver and its surroundings as first discovered 
is considered. Circumstances which seem at the time to 





* Vide **The Powers and Duties of Coroners and Medical Exam- 
iners,’’ by August Becker, in Witthaus and Becker’s ** Med. Jurisp., 
Forensic Med., and Tox.,’’ vol. i. 


534 








be trivial may prove of prime importance at the trial. 
Expert medical knowledge is very useful in the first ex- 
amination of the cadaver, especially in relation to the 
position which it occupies in the midst of surrounding ob- 
jects; to the disposition of any blood and stains that may 
be present; to rigor mortis, and to other signs upon 
which the time that has elapsed since death took place 
may be estimated. Evidence furnished by one who pos- 
sesses such knowledge is more to be depended upon than 
that given by a layman, and the results of the earlier ex- 
amination are naturally more valuable than those secured 
after the cadaver or surrounding objects have been dis- 
turbed. 

Determination of Death.—Immediate continuance of life 
depends upon respiration, circulation, and innervation. 
Cessation of any one of these functions entails that of 
the others. Clinically death is determined by complete 
arrest of both respiratory movements and heart’s action, 
on examination with the stethoscope. Electro-muscular 
irritability may still continue for a variable length of 
time, not longer than six hours thereafter. Reaction of 
the pupil to light, and spasmodic movements of facial 
muscles, have been noted in cases of decapitation. The 
pupil may react to atropine for as long a time as four 
hours, and to eserin for two hours, post mortem. Re- 
spiratory movements and heart’s action do not necessar- 
ily cease together. Temporary absence of respiration is 
not incompatible with the continuance of life. In the 
new-born, cases are on record in which respiration was 
not established until one and even two hours after birth. 
The heart’s action may be extremely feeble in such cases, 
even inappreciable by the stethoscope. It cannot be 
doubted that respiratory movements may be so shallow, 
and the heart’s action so slow and feeble, that both may 
be inappreciable, though not necessarily arrested. The 
usual clinical determination of death, although correct in 
the vast majority of cases, must therefore be considered 
as entirely inadequate. No grave error is probable, 
however, provided the conditions be kept in mind under 
which the state of apparent death, or one resembling it 
in some of its phases, is produced. 

Apparent Death ; Lethargy ; Catalepsy.—Many stories 
of apparent death, and of burial alive, are entirely imag- 
inary or are based upon certain appearances observed in 
exhumed remains—appearances which may readily be 
explained as effects of the gases of decomposition. <A 
few authentic cases are on record in which life seemed 
extinct, but afterward became evident again. In these 
instances respiratory movements and heart’s action could 
not be appreciated, and muscular relaxation, pallor, and 
marked reduction of surface temperature were present. 
In one case electro-muscular irritability was preserved 
throughout the period (thirty-three hours) of apparent 
death. It is hardly credible that respiration and circula- 
tion were actually arrested. 

Besides the condition of apnoea in the new-born, and in 
cases of submersion in which it is stated respiration has 
been established after a lapse of half an hour or even 
longer, the conditions of lethargy and catalepsy might be 
mistaken for death by the laity, and occasionally by a 
physician, if reliance were placed upon apparent arrest 
of respiratory movements and heart’s action alone. The 
muscular relaxation of lethargy, with apparent arrest of 
respiration and circulation, reduction of temperature, 
and absence of reflexes, may closely resemble death. 
However, there are other signs presented by the cadaver, 
even within a few hours after death, which render the 
decision quite easy. The rigidity of catalepsy, although 
presenting some resistance to passive motion, is readily 
overcome, and after such motion the limb remains rigid 
in the position in which it is placed (flexibilitas cerea). 
When rigor mortis is well established the rigidity does 
not return after it has been overcome. Lethargy and 
catalepsy are phases of the hypnotic condition that occur 
in hysteria. Lethargy may be the last stage of one of 
the acute infectious diseases; it occurs also in epilepsy 
and in the sleeping sickness of Africa, and it may follow 
cerebral injuries. Catalepsy also occurs in melancholia, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


in progressive paralysis, in meningitis, in brain tumors, 
and in apoplectic coma. (For further information, see 
under these headings. ) 

Signs of Death, their Application. — After death the 
body presents certain appearances which are due to 
physical and chemical changes. The character of these 
appearances, their causes, the time of their inception, 
their duration and disappearance, are matters of consid- 
erable importance, both as signs of death and as aids in 
establishing the time of death. Moreover, a thorough 
knowledge of these cadaveric appearances and of their 
relations to different pathological processes is necessary 
if one wishes to avoid drawing unwarranted conclusions. 
In regard to establishing the time of death—often a very 
important medico-legal question—no absolute rule can 
be given, since the cadaveric appearances may be subject 
to variations due to age, sex, constitution, and environ- 
ment of the cadaver, and to the cause of death (namely, 
previous disease, injury, or poison). Consequently, 
great caution is necessary in arriving at a conclusion, and 
all the various conditions must be taken into account. 
It will therefore be best to consider carefully the cadav- 
eric appearances, or signs of death, seriatim, their usual 
chronology, and the variations to which they are subject; 
and at the same time the conclusions which one is war- 
ranted in drawing from these appearances should be 
pointed out. 

Muscular Relaxation. After death a primary period of 
complete muscular relaxation precedes the onset of rigor 
mortis. Some observers have maintained that voluntary 
muscular contraction at the time of death may imme- 
diately pass into post-mortem rigidity (cataleptic rigor 
mortis of Du Bois-Reymond). 

Reduction of Temperature. 'The cadaver loses heat and. 
by evaporation, its temperature sinks below that of the 
surrounding atmosphere. Exceptionally a rise of tem- 
perature occurs post mortem, as after some infectious 
diseases; after cholera, tetanus, and diseases of the cen- 
tral nervous system; after asphyxia; after poisoning 
{accompanied by asphyxia and convulsions), and after 
injuries of the brain and upper part of the spinal cord. 
The temperature may reach 44° C, (111.2° F.), and be 
maintained at this height for from fifteen to twenty min- 
utes. On the other hand, in cases of hemorrhage, drown- 
ing, and exposure to cold, and possibly in those of burns 
and scalds (through a loss of epidermis), the temperature 
is apt to sink rapidly (Hofmann). Within from 8 to 17 
hours (according to Caspar) the body becomes cold to the 
touch. According to Seydeler, a period of from 23 to 38 
hours is required before complete cooling, as shown by 
the use of the thermometer, takes place. Maschka’s in- 
vestigations showed that in anatmosphere of from 8°-15° 
R. (50°-65.7° F.), adult cadavers, lying upon a board or 
mattress, and covered with a sheet or simply naked, be- 
came cold to the touch in from 8 to 10 hours. Only in 
rare instances was a period as long as from 11 to 13 
hours, or one less than 8 hours, required. Cooling of 
the parts takes place in the following order: feet, hands, 
and face, in from 1 to 2 hours; then gradually the ex- 
tremities, chest, back, and belly. The epigastrium, 
axilla, and neck on either side of the larynx are the last 
spots to cool. The abdominal organs may still be warm 
at the end of from 16 to 24 hours after death. The rate 
of cooling is given by Goodhart as 4° F. per hour in the 
first 3 hours; 3° F. per hour in the next 6 hours; there- 
after, a little more than 1° F. per hour. Bowman esti- 
mates the rate to be 2° F. per hour for the first 8 hours. 

Cooling is postponed for a period of from 2 to 3 hours 
by clothing, and for one of from 38 to 4 hours by bed 
covering, hay, or straw. Ina case reported by Maschka 
the body of a person who had died from epilepsy in bed 
was found to be still warm after the lapse of 14 hours; 
and in another case, one of homicide, renorted by the 
same author, the body, covered with horse hair, was 
found to be still warm after 16 hours. 

Obesity may postpone complete cooling for as long a 
time as from 2 to 38 hours. The bodies of those who are 
extremely obese may have the same degree of surface tem- 


Cadaver, 
Cadaver, 








perature 12 hours after death that the ordinary cadaver 
presents after the lapse of 2 hours (Hofmann). In such 
cases one may find the internal organs, 30 hours after 
death, still warm, although, as a matter of course, the 
surface of the body will be cold. 

The cadavers of the new-born and of infants become 
cold in from 5 to 6 hours. 

In ice and snow cadavers of adults may become cold in 
half an hour or an hour; in cold water they become so in 
from an hour and a‘half to two hours. After the human 
body has been in water at 18° R. (72.5° F.) for from ten 
to twenty minutes the surface may already be cold, and 
yet the epigastrium, the axille, and the neck on either 
side of the larynx are likely still to manifest some 
warmth (Maschka). 

With progressive putrefaction a rise of temperature 
has been noted (Mende). 

Evaporation produces changes in the eye, skin, mucosa 
of the lips, and hair. 

Eye.—The globe loses its normal tension, becoming 
flaccid and softer. This is partly due to post-mortem 
sinking of blood, when the head rests in the usual posi- 
tion upon the occiput. The cornea loses its transparency, 
and is thrown into folds by the loss of intra-ocular ten- 
sion. The earliest period in which these changes become 
apparent is from 2 to 3 hours after death. The trans- 
parency of the cornea may be retained for from 10 to 12 
hours, or even, in some cases, for from 24 to 30 hours 
(Caspar-Liman). The protection afforded by closed eye- 
lids favors transparency, exposure favors opacity. The 
cornea becomes opaque earlier in children than in adults. 
All influences favoring putrefaction, as septicemia, pye- 
mia, and an abnormally high temperature of the atmos- 
phere, tend to hasten the occurrence of these changes. 
The average length of time required for the development 
of distinct flaccidity is from 5 to 6 hours; and by this 
time slight opacity of the cornea also usually develops. 
The triangular spots described by Larcher, with base at 
the corneal margin and apex toward the external canthus, 
of a yellowish, bluish, or even black célor;-are= not. al- 
ways present. They may occur from 8 to 5 hours post 
mortem, may also be present between the cornea and the 
internal canthus, and are due to drying of the conjunc- 
tiva and sclera—a change which allows the color of the 
choroidal pigment to become more and more apparent. 

Skin.—W herever denuded of epidermis—whether this 
occurred before or after death, it makes no difference— 
the corium, under the favoring influence of evaporation, 
becomes dry, firm, of the consistence of parchment or 
leather, and light yellowish brown. At a still later time 
the color grows darker, and may even become black. 
Such changes may be apparent in the course of 2 or 3 
hours. In fat subjects the cutaneous fold about the neck 
may be the seat of excoriation from eczema intertrigo. 
From the above changes in drying post mortem, an ap- 
pearance may be produced which simulates the marks 
left by a constricting band. Such a condition has led to 
the mistaken report of strangulation. An incision will 
readily show that the change is confined to the corium, 
there being no evidence of subcutaneous laceration of 
tissue, of hemorrhage, or of ecchymosis. 

Lips.—The mucous surface of the lips may be divided 
into two regions: the narrow vermillion border which is 
adjacent to the skin and is smoother and more intimately 
adherent to the underlying tissues; and the remaining 
larger portion, which is thrown into folds, owing to the 
fact that it is more loosely attached to the submucous 
connective tissue. The latter portion, more especially of 
the upper lip, may become quite dry and black as a mere 
post-mortem change, the condition occurring more fre- 
quently in children than in adults. The line of demarca- 
tion between this dry and black portion and the vermil- 
lion border is under these circumstances quite straight 
and distinct. Such a change may occur as early as 2 to 
8 hours after death. It has been mistaken for the escha- 
rotic effects of acids. 

The hair may become loosened and fall out or be easily 
pulled out, after evaporation of fluid from the hair follicle. 


535 


Cadaver. 
Cadaver. 


Post-Mortem Hypostasis.—With the cessation of the cir- 
culation the skin loses its pink tint and becomes intensely 
pale. In cases of cyanosis (e.g., in asphyxia, pulmonary 
cedema, heart lesions, and alcoholism) a bluish tint may 
be apparent, especially in the skin of the face and neck. 
In cases of carbon monoxide poisoning, and in those in 
which death follows exposure to a low temperature, the 
pink tint of the skin may not only be retained but even 
be exaggerated. The pallor of those portions of the 
cadaver which lie uppermost becomes intensified by con- 
trast with those into the veins and capillaries of which 
the major portion of the blood flows by gravitation. 
The position of the cadaver will therefore determine 
which are the parts that are likely to show this condition 
of hypostatic congestion, When the blood has thus col- 
lected in sufficient amount, spots, streaks, and patches 
appear in the skin of the dependent portions. At first 
they are small, separate, and light red or purple in color, 
but later they become larger, confluent, and dark red, 
blue, or even black in tint. At first, while the blood re- 
mains in the vessels, the color may be made to disappear 
by pressure. Wherever, therefore, the skin is subjected 
to pressure, such spots of color are absent. If the cada- 
ver has been lying upon the back on a flat surface, pale 
areas occur over the bony prominences of the scapula, 
the dorsal spines, the buttocks, and the calf of the leg. 
Ata later period, with the first onset of decomposition, 
the serum takes up blood-coloring matter and transudes 
through the vessel walls, staining the surrounding tis- 
sues. Such spots, then, cannot be removed by pressure. 

Post-mortem hypostasis also occurs in internal organs 
wherever the physical conditions are favorable, namely, 
in the pia mater of the posterior portion of the brain and 
cord, posterior portions of the lungs, stomach, and intes- 
tinal wall, bladder, uterus, and adnexa, when the body 
has been lying upon the back. The kidney, spleen, and 
liver do not present conditions equally favorable for the 
occurrence of such hypostatic congestion. Post-mortem 
transudation of serum into the meshes of the pia-arach- 
noid, and into the pericardial, pleural, and peritoneal sacs 
may occur. Such conditions are frequently mistaken for 
congestion and inflammation, and should not alone be 
relied upon in making such a diagnosis. 

External Hypostasis, or Post-Mortem Spots.—With a 
knowledge, therefore, of the manner in which these spots 
develop, one can readily appreciate that the total amount 
of blood in the body and the degree of its fluidity will 
exert an appreciable influence upon the time when the 
external hypostases will manifest themselves, upon the 
intensity of their color, and upon the extent of their dis- 
tribution. ‘They appear earlier, are more widely distrib- 
uted, and are more intense in color in plethoric than in 
anemic individuals; in those who die suddenly rather 
than in those who succumb to some exhausting disease 
or in whom the lethal agony has been prolonged; and, 
finally, in those who die from asphyxia, from sepsis, or 
from some form of poisoning in which the blood remains 
fluid, rather than in those who die from cholera, from 
tetanus, or from poisoning by arsenic or by strychnine, 
in both of which conditions the blood is less fluid. Ex- 
ternal hypostases usually appear from 3 to 4 hours after 
death, and after the expiration of from 12 to 14 hours 
they become widespread. Exceptionally, they may be 
plainly developed in an hour and a half, but usually a 
period of from 4 to 6 hours intervenes before they can 
readily be distinguished. In some instances they are not 
well marked and extensive until after the lapse of from 
16 to 18 hours. A high temperature, or the artificial 
warmth afforded by coverings (clothing, bedding, etc.), 
causes their earlier appearance and more extensive dis- 
tribution. 

The color of the spots is affected by age, it being usu- 
ally lighter in the new-born and in infants; it is also af- 
fected by poisons, being light red or pink in poisoning 
by carbon monoxide and by hydrocyanic acid and com- 
pounds, and grayish in poisoning by potassium chlorate. 
The light-red tint observed when the cadaver has been 
exposed to cold (as in water, snow, or ice) is ascribed by 


536 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Hofmann to the easier access of oxygen to the blood 
through the moist epidermis, by Blumenstock to the in- 
terference of low temperature with the reducing power 
of the tissues post mortem. 

After excessive hemorrhage, hypostases are late in their 
development and are much less marked, although rarely 
absent. Devergie and Hofmann have observed a few in- 
stances of such entire absence, especially in young sub- 
jects. 

The presence of external hypostases is an important 
and reliable sign of death, and, in addition, of the posi- 
tion in which the body lay when they developed. The 
important fact should also be stated that in an early stage 
these areas of hypostatic congestion may disappear on 
changing the position of the cadaver, and subsequently 
appear in new places, namely, in the most dependent 
portions in the new position. Tourdes ascertained the 
following facts: that, on reversing the position of the 
cadaver, 4 hours after death, the hypostases which had 
already developed, disappeared entirely, and new ones 
appeared in the new dependent portions; that, at the end 
of from 12 to 15 hours after death, the hypostases which 
had developed no longer disappear, but simply grow 
fainter, and new ones appear; and, finally, that 30 hours 
after death these spots grow paler but do not appear in 
new dependent parts on changing the position of the 
cadaver. Otherexperiments have shown that, on chang- 
ing the position of the cadaver 4, 6, and even 12 hours 
after death the hypostases already developed may dis- 
appear, but. that this does not occur after the lapse of so 
long a period as from 23 to 28 hours. 

Rigor Mortis. — After death muscle tissue becomes 
firmer and more resistant to compression and extension. 
Rigidity of the entire muscular system results. This 
rigidity offers a greater or less resistance to the move- 
ment of parts, but the resistance may readily be over- 
come by force. After muscle has been thus stretched, 
there is free mobility, and the rigidity does not return. 
Various theories inregard to the causation of this rigidity 
have been advanced. The discussion of these would be 
too lengthy for the scope of this article. The most plaus- 
ible one ascribes the occurrence of rigor mortis to coagu- 
lation of myosin. 

The time of the inception of rigor mortis, its intensity 
and duration, and the conditions affecting them, have an 
important bearing on the subject now under discussion, 
since rigor mortis affords reliable evidence of death, and 
also aids in establishing the time when it occurred. Rigor 
mortis does not affect all muscles equally at the same 
time. The determination of its presence and the esti- 
mation of its intensity and duration rest upon the degree 
of force necessary to overcome it, ¢.e., in the case of the 
voluntary muscles, to produce free motion in the joint 
or joints with which the given muscle or group of mus- 
cles is related. If this degree of force were measured in 
foot-pounds, there might be more unanimity in the re- 
ports of different observers. As it is, the personal ele- 
ment, which plays a part in the estimation of this force, 
accounts for the more or less considerable variations. 
Maschka reached the following conclusions from a study 
of over five hundred cases: 

Rigor mortis occurs in all cases, no matter what may 
be the cause of death. It is absent only in the decom- 
posed cadavers of still-born infants, and locally where 
muscle is excessively contused, lacerated, gangrenous, or 
the seat of purulent or phlegmonous processes of inflam- 
mation. Rigor mortis does not follow immediately upon 
death in any case; a shorter or longer period of complete 
muscular relaxation intervenes. Strychnine poisoning, 
tetanus, hydrophobia, and hemorrhage cause no excep- 
tion in this regard. 

Rigor mortis usually begins between 2 and 3 hours. 
after death. All the muscles are not affected at the same 
time. The usual order in which the rigor shows itself in 
the different parts of the body is the following: lower 
jaw, neck, trunk, and upper extremities, in which parts 
rigor mortis becomes distinct after the lapse of from 
34+ to 44 hours after death; then the lower extremities 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


become affected, so that after the lapse of from 6 to 9 
hours from the time of death the entire body will have 
become rigid. Exceptionally this order variesas follows: 
lower jaw, upper extremities, neck, trunk, etc.; or the 
lower extremities are affected before the upper; or the 
upper extremity of one side becomes rigid and then that 
of the other side, etc. 

The earlier or later inception of rigor mortis is not con- 
stantly or characteristically affected by the degree of 
‘muscular development, the sex, the age, poisoning, hem- 
orrhage, sudden death, or, with few exceptions, by path- 
ological processes. General hydrops or cedema of an 
extremity delays the development of rigor in that ex- 
tremity until from 4 to 6 hours after death. Paralyzed 
muscles may not show rigidity for 4 or 5 hours after it 
has appeared in the non-paralyzed muscles, although this 
.is not always the case. In amputation stumps rigidity 
is developed later than in other muscles. In very atro- 
phic or fatty muscles rigidity may be entirely absent. 
After acute diseases of the brain and spinal cord the rigor 
appearsearlier. No difference in time of onset is ascribed 
to injuries of the brain and spinal cord which are fol- 
lowed by sudden death. 

The covering of the cadaver, as with clothing, bedding, 
etc., seems to favor the earlier appearance of rigor mortis. 

As regards the time of appearance of rigor mortis, 
there are considerable variations for which no explana- 
tion can be given. Maschka reports a number of such 
cases, in which the conditions, so far as they were ob- 
served, were apparently the same. In one of these cases, 
that of an emaciated tuberculous woman, rigor mortis 
began in three-quarters of an hour after death; in an- 
‘other, in 3 hours; in 4 cases of strychnine poisoning 
the facts were as follows: in a child of seven years, it 
began in half an hour; in 2 other cases, also children, 
and in a male adult, it began at the end of 1% hours and 
2 hours respectively. Rigor mortis begins usually not 
earlier than one-half hour, nor later than 6 hours after 
death. ; 

In regard to the intensity of the rigidity, Maschka was 
unable to find any constant or important difference for 
the production of which special influences could be held 
responsible. 

If the cadaver is not interfered with, rigidity usually 
remains marked, in adults, until after the lapse of from 50 
to 60 hours, and then it gradually disappears, so that noth- 
ing remains of the rigidity after the lapse of from 70 to 
75 hours. In exceptional cases it may last for as long a 
time as 80 or even 90 hours, and then again it may dis- 
appear as early as at the end of 40, 30, or even 20 
hours without special causes therefor being apparent. 
It is evident, therefore, that absolute rules in regard to 
the duration of rigor mortis cannot be laid down; for 
under the same development, mode of death, previous 
pathological processes, and external circumstances, great 
differences in duration have been noted. 

Rigor mortis may still be present when the early signs 
of decomposition—such as green color of the skin of 
the abdomen, the sides of thorax, the neck, and the back 
—appear. When the cadaver swells with post-mdrtem 
emphysema, and the epidermis becomes loosened and 
easily strips off, rigidity will always be found to have 
disappeared. 

In children rigor mortis usually commences at the same 
time as in adults. In the new-born, however, and in 
infants a few days old, it may appear as soon as ten 
minutes after death or not until after the lapse of 14 
or 2 hours. The degree of rigidity is apparently less, 
on account of the small muscular development. The 
duration is also shorter in the new-born—say from 8 to 
10 hours,—yet in some cases it may last for from 36 to 
42 hours, or even—in the case of infants—50 hours. 
In older children, when poorly nourished, the rigidity 
may last only for from 20 to 24 hours, but in the major- 
ity of cases it persists for 40 or 45 hours, and in some 
cases even for 60 or 70 hours. 

Rigor mortis disappears in the different parts of the 
body in the same order in which it begins, the foot being 


Cadaver, 
Cadaver, 


the last part to become freely movable. Yet it is not 
unusual for the rigidity in the jaw and neck to outlast 
that of the extremities (Hofmann). The latter authority 
places the time of inception of rigor mortis at from 2 to 4 
hours after death, and that of complete development at 
from 4 to 6 hours after inception; for the new-born and 
infants, he names earlier periods. According to him, 
the rigidity lasts for from 24 to 86 hours in the new-born, 
and for 40 hours in infants; in adults it is marked for 48 
hours, then gradually disappears, and is absent after the 
lapse of from 72 to 84 hours after death. Rigidity makes 
its appearance earlier after hemorrhage, injury to the 
cervical portion of the cord, poisoning by: acids and 
strychnine, and perhaps in insolation and lightning 
stroke; it either appears later or is entirely absent in 
acute parenchymatous degeneration of muscle (as in 
poisoning by phosphorus and by toadstools) and also 
after sepsis. 

Du Bois-Reymond, Rossbach, and Brinton record in- 
stances in which rigor mortis developed immediately 
after death. From observations upon the battlefield, 
the conclusion has been drawn that rigor mortis may set 
in with the occurrence of death, and thus the facial ex- 
pression and action which existed at the moment when 
death occurred may be preserved. If this conclusion 
were well founded, it might afford important aid in 
determining whether death, in a given case, were due to 
an accidental or inflicted injury, or to suicide. Caspar- 
Liman, Hofmann, and Maschka point out the danger of 
relying upon such evidence, as the positions observed, 
indicating action, may simply have been the result of 
the passive interference of surrounding objects. They 
assert that, so far as their experience goes, complete 
muscular relaxation precedes rigor mortis. This is evi- 
dent from the expressionless countenance of the dead in 
the great majority of cases. Occasionally such a coun- 
tenance does present an expression of mirth, sadness, 
pain, or anger, but to draw any conclusion therefrom 
would be hazardous, since it may simply be due to press- 
ure after death and before rigor mortis has set in, or it 
may be the result of sagging of the lower jaws and of 
open eyelids. In no case of death from apoplexy, so far 
as the writer’s experience goes, can a diagnosis be made 
from a mere study of the facial appearance after death. 
On the contrary, in a case of sudden death from chronic 
interstitial myocarditis, without any brain lesion, the face 
of the cadaver presented the typical picture of hemiplegia. 

In no case of suicide has either Maschka or Hofmann 
found the weapon grasped in the hand of the cadaver. 
Taylor states that he has made such an observation. 
Maschka’s experiments in securing weapons within the 
grasp of one of the hands of the cadaver before rigor 
mortis set in, showed that they either fell out when the 
bands were loosened or that the grasp itself was very 
feeble. The writer has never encountered a case of sui- 
cide in which the weapon appeared to be grasped by the 
hand of the cadaver. 

Decomposition of the cadaver is brought about by the 
invasion of saprophytic bacteria. If the conditions are 
such as to favor their access and growth, decomposition 
will begin earlier and will advance more rapidly. Access 
of air and moisture, and a warm temperature, in so far 
as they are necessary to bacterial life, favor decomposi- 
tion. A cadaver exposed to the open air decomposes far 
more rapidly than when it is immersed under water or 
buried in the soil. If in a given temperature, in the 
open air, a cadaver requires one week or one month to 
reach a certain stage of decomposition, it will require, if 
submerged, double the length of time to reach the same 
stage of decomposition, or four times this period if buried 
under ground (Caspar-Liman). If, however, a body is 
exposed to a current of air, evaporation is favored, and, 
instead of marked or rapid decomposition, mummifica- 
tion may take place. Under these conditions the growth 
of bacteria is interfered with by the lack of water 
Somewhat the same conditions are established when the 
cadaver is buried in dry, sandy soil and at a sufficient 
depth. When burial is just beneath the surface, or in 


527 


Cadaver, 
Cadaver. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





moist clay, decomposition is favored. The various 
methods of embalming all depend for their success upon 
the inhibition of bacterial growth by chemical means 
(bactericides) and, in the older methods, by the exclu- 
sion of air as well. 

Freezing will postpone decomposition indefinitely, and 
low temperatures—above the freezing point—will pre- 
vent decomposition for a considerable length of time. 

Whatever interferes with the cooling of the cadaver— 
as a warm, moist atmosphere, clothing, bedding, etc.— 
favors an earlier onset and a more rapid advance of de- 
composition. 

The condition of the cadaver has a bearing upon de- 
composition. New-born and obese subjects decompose 
more rapidly, since fat is a poor conductor of heat. Pre- 
vious pathological processes have an influence upon the 
condition of the cadaver and thus indirectly upon de- 
composition. Sudden death is followed by earlier and 
more rapid decomposition. Cases of asphyxia, of gen- 
eral cedema, of sepsis, of typhoid fever, of parturition— 
when death occurs during delivery or soon thereafter— 
and of narcotic poisoning are also more liable to undergo 
an early and rapid decomposition. The free use of alco- 
hol, when death occurs during a debauch, postpones the 
onset of decomposition, and cadavers, after poisoning by 
sulphuric acid, remain fresh and odorless, while under 
the same external circumstances other cadavers undergo 
decomposition (Caspar-Liman). This statement is not 
confirmed by the observations of Maschka. 

The bodies of individuals poisoned by carbolic acid 
and corrosive sublimate might be expected to decompose 
later and less rapidly; as a matter of fact, no pronounced 
effect has been. noted. In the case of those dying from 
arsenic poisoning it has been both affirmed and denied 
that decomposition of the cadaver is inhibited. The 
weight of authority seems to be on the latter side. Al- 
though all these substances prevent decomposition when 
liberally applied in embalming, the amount necessary to 
cause death is very much less, and is not applied in the 
same way. 

According to Tourdes, decomposition follows very 
rapidly upon death from lightning stroke; he found 
bluish spots on the integument, and gas bubbles in the 
liver and blood, at the end of twenty-two hours after 
death. On the other hand, Caspar and Liman note no 
unusual difference in two cases observed by them. Hot 
weather and exposure in the open air should be taken 
into account in judging the effects of this agency. 

Decomposition begins in the blood. The red cells are 
broken up and then the serum becomes stained with blood 
pigment and transudes into the neighboring tissues. The 
external hypostases or post-mortem spots become darker 
and confluent, and on incision the tissue is found to be 
succulent and filled with stained serum. A transudation 
between the corium and the epidermis may lift up the 
latter in the form of smaller and larger blebs, or it may 
simply loosen it so that it is easily stripped off. 

With the production of sulphureted hydrogen and the 
formation of sulphide of iron (blood pigment), a greenish 
discoloration of the integument makes its appearance: at 
first in the groin, then on the abdomen and sides of the 
thorax, and, finally, on the neck and face. 

The formation of gas first in the subcutaneous areolar 
tissue of the face, neck, and upper part of the thorax, 
and later in that of the external genitals and extremities, 
as well as in the abdominal cavity, gives the cadaver a 
deformed and gigantic appearance. By pressure of the 
gas which accumulates from decomposition, the contents 
of the stomach may be forced into the cesophagus and air 
passages, frothy blood may appear at the nostrils and in 
the mouth, and the mucosa of the rectum or external 
genitals (in women) may be forced outward. Througha 
post-mortem rupture of the mucous membrane of the 
posterior fornix of the vagina coils of small intestine may 
make their appearance in the latter cavity. The foetus 
has been expelled post mortem by the pressure of gas. 
The abdominal and thoracic walls may undergo rupture 
when decomposition is advanced. The eyeballs may be 


538 





pressed forward, and the cranial sutures may undergo 
separation. . 
Decomposition of the organs commences earlier in parts 
subjected to post-mortem hypostasis, to transudation 
and imbibition of serum, and to easier access of air. The 
facility with which decomposition takes place in an organ 
depends in some measure upon its structure and blood 
supply; it occurs earlier in those organs in which the 
stroma is of a loose character and the blood supply abun- 
dant. Casparand Liman give the following order as that 
in which the different organs undergo decomposition: 
mucosa of the trachea and larynx; brain of the new-born 
and of infants up to one year of age; stomach, intestines, 
spleen (sometimes earlier than intestines); omentum and 
mesentery; liver; adult brain; heart, lungs, kidneys, 


‘bladder, esophagus. and pancreas; diaphragm, aorta 


and larger arteries, and uterus. 

With advancing decomposition the organs become 
softer and more succulent from imbibition of transuded 
serum; their color becomes darker; and the markings on 
section grow more and more indistinct. From progres- 
sive liquefaction the tissues become mushy or pasty in 
consistency, and finally indistinguishable. 

Microscopical examination of decomposing tissue— 
especially the epithelial cells of the liver and kidney and 
the muscle fibres of the heart—shows in the earlier stages 
a loss in distinctness of structure and the presence of 
highly refractile granules in the protoplasm; a condition 
upon which an erroneous diagnosis of ante-mortem par- 
enchymatous degeneration might be made. The gran- 


‘ules are, however, much coarser, and the nuclei, although 


altered, usually do not show a degenerative change ap- 
parently more advanced than that of the protoplasm. 
Later, the tissue becomes more indistinct and cloudy, but 
the parenchyma and stroma can still be made out. Fi- 
nally, no structure can be identified. In decomposition 
of the liver, fat may find its way into the blood of the 
veins, and, by the pressure of the gas of decomposition, 
may pass into the vena cava and right heart. These 
facts have an important medico-legal bearing. 

Since decomposition, in onset and rapidity, is influ- 
enced by so many factors, no absolute rules can be formu- 
lated for determining therefrom the time of death. We 
can, however, after taking all circumstances into account, 
state the minimum and the maximum period that must 
have elapsed—the former more accurately than the latter. 

The following chronology of the signs of decomposi- 
tion, taken from Caspar and Liman, applies to cadavers 
exposed to air in mean temperatures, and is subject to 
variation by the different influences already discussed: 

Green discoloration of the groin and abdomen appears 
at the end of from 24 to 36 hours after death, and with 
it the odor of putrefaction. At this time the eyeball is 
soft, the cornea cloudy and wrinkled. In summer the 
green color may appear as early as at the end of 15 or 
18 hours; in winter it may be absent even after the lapse 
of 4 or 5 days, when the cadaver is exposed to air. 
When the cadaver is submerged, this discoloration may 
not appear, in summer, until after the lapse of from 40 
to 48 hours, and in winter it may be absent even at the 
end of 8 weeks (Maschka). The green color spreads in 
such a manner that, at the end of from 3 to 5 days, the 
entire abdomen and the external genitals may be involved. 
An irregular distribution of smaller and larger greenish 
spots appears upon the back, sides of thorax, neck, and 
lower extremities. Frothy blood may appear at the 
mouth and nose, especially in cases of asphyxia. At the 
end of from 8 to 12 days the whole body is reddish- 
green and darker; the spots become confluent; and on 
the neck; chest, and extremities, the superficial venous 
trunks are marked out, through imbibition, by dark red, 
purple, or bluish streaks. The abdomen is distended 
with gas. The cornea is relaxed and concave, and al- 
though very cloudy, the color of the iris may still be 
made out. In the foetus the cornea is opaque. The 
sphincter ani is patent. The nails are still adherent. 
At the end of from 14 to 20 days it will be found that 
the discoloration is still going on. Blebs containing 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cadaver, 
Cadaver. 





murky red or black serum (methemoglobin) appear, 
or the skin may be denuded of epidermis in places. 
Post-mortem emphysema appears and increases in the 
subcutaneous cellular tissue of the neck, chest, and face. 
The penis and scrotum are increased in size thereby. 
The entire body presents a puffed-up appearance, and 
the features are so deformed that recognition is almost 
impossible. The cornea is opaque and the sclera of a 
dirty red hue from imbibition. The nails are loosened 
and can easily be pulled off. Maggots are present in 
abundance, especially at orifices and folds (as the eyelids, 
mouth, nose, and anus). 

The rapidity with which these changes take place is 
markedly influenced by the surrounding temperature. 
At from 16° to 20° R. (68° to 77° F.) a cadaver will, in 
8 or 10 days, reach a stage of decomposition that would 
require a period of from 20 to 30 days if the temperature 
were at 0° to 8° R. (382° to 50° F.). 

After the lapse of from 1 to 3 or more months the 
greenish, putrid, and emphysematous cadavers cannot, 
with any degree of certainty, be distinguished from one 
another. 

After the lapse of from 4 to 6 months—or at a still 
earlier period if warmth and moisture are present—putrid 
liquefaction of the soft parts sets in. The pressure of 
gas may cause rupture of the putrid abdominal and 
thoracic parietes, and even diastasis of the cranial bones. 
Entire bones, especially of the head and extremities, may 
be laid bare. The optic cavities may be empty. The 
soft parts become progressively changed into a mushy, 
pasty, dark mass in which their identification becomes 
more and more diflicult, and finally impossible. Joints 
may be opened and loosened by beginning destruction of 
fascize and ligaments. Determination of sex by the 
breasts or external genitals may be impossible on account 
of their disappearance. The uterus, however, and prob- 
ably the prostate, may still be identified, and the meas- 
urements of the pelvis will aid in determining the sex. 

The entire disappearance of the soft parts, in adult 
eadavers, requires a period of from 2 to 3 years. Liga- 
ments and cartilage are destroyed after the lapse of 5 
years. Loss of fat from the bones and complete drying 
require 10 years, or even longer (Hofmann). 

Adipocere.—Under certain circumstances, as exposure 
in water or in moist soil, without any or with only a 
slight access of air, the soft parts, instead of undergoing 
putrid liquefaction, become changed into the substance 
called adipocere. Recent investigations show that its 
formation is due to the saponification of fat. (For further 
information on this subject the reader is referred to the 
article on this topic in Vol. I.) 

Identification of the Cadaver.—The strictest attention 
should be given to every detail, even though it may ap- 
pear to be trivial, since there is a sufficient number of 
cases on record in which the identification made by rela- 
tives and friends in good faith, upon view of a well- 
preserved cadaver, has proven to be erroneous. The 
clothing and effects found upon the cadaver often lead 
to identification. They should be accurately described 
and preserved, yet they should not be relied upon to 
the exclusion of other means, since clothing and effects 
may be, and have been, substituted to mislead in identi- 
fication. A good photograph should be taken of an un- 
known cadaver as early as possible and before the head 
has been opened. In addition, an accurate description 
should be recorded, embracing such data as height, 
weight, and build, race, sex, apparent age, shape of head 
and face, complexion, color of hair and iris, condition of 
hands and finger nails, deformities, and special marks 
and peculiar features. 

In the great majority of cases such a description can 
be well made bya layman. When, however, decomposi- 
tion is advanced, or the cadaver mutilated, or burned, or 
only portions thereof are at hand, anatomical knowledge 
is necessary and by means of it many of the above points 
may be cleared up or approximately judged that would 
otherwise remain unknown. 

Race and nationality are determined by well-known 











characteristics, for which the reader must be referred to 
works on anthropology. 

Sex.—In well-preserved cadavers the determination of 
sex, except in cases of hermaphroditism, is readily made. 
Where, however, the body is not well preserved, or where 
parts of the cadaver only are at hand, there are various 
points which may aid in determining the sex. The 
growth and distribution of the hair are usually charac- 
teristic of sex, and yet in exceptional cases they may fail 
to enlighten us upon this question. The long hair of the 
scalp and its arrangement, the absence of hair (except 
fine, downy hair) on the face, the sharp line of demarca- 
tion of the hair upon the mons veneris, and its fine, 
downy character upon the extremities, are characteristic 
of the female. The presence of coarse hair upon the 
face, chest, and extremities, and the prolongation of hair 
from the mons veneris along the median line to the um- 
bilicus, or its more abundant distribution over the belly 
as well, are characteristic of the male. With progressive 
maceration the epidermis, and tovether with it the hair 
and nails, become separated from the cutis and fall off, 
leaving a smooth surface, especially in cadavers that 
have been exposed in the water. Beard and moustache 
may be lost after four or five days of such exposure in 
hot weather, after two weeks in cool weather, and after 
the lapse of a month or more in cold weather. Exposure 
to flame may cause complete disappearance of hair. If 
the hair is thicker, more oily, or arranged in a braid, it 
is more likely to be partially preserved. 

The general external form of the cadaver, or parts 
thereof, may be distinctly of feminine or masculine type, 
yet dependence upon this alone may lead to error. Be- 
fore puberty the male and the female forms are very 
much alike. As regards the breasts, they may be unde- 
veloped or atrophic in the female, and from abundance 
of subcutaneous fat the male breasts may simulate those 
of the female. The presence, at birth, of a mammary 
gland, and of a secretion that can be expressed, is com- 
mon to both sexes. 

The genital apparatus (or characteristic parts thereof) 
is of course the most certain proof of sex. The external 
genitals may have been lost or rendered indistinguishable 
by putrefaction, by maggots or rats, by incineration, or 
by mutilation or removal. The uterus, from its firm con- 
sistence and protected situation, has been recognized in 
cadavers that were far advanced in putrefaction—even 
as late as at the end of nine months after death (Caspar 
and Liman). According to the authority of Hofmann, 
there have been instances in which the cadaver was con- 
siderably charred, with ruptured abdominal walls and 
external charring of the uterus, and yet upon section this 
organ was easily identified through the intact condition 
of the endometrium and arbor vite. The ovaries have 
also been identified after considerable charring of the 
cadaver. The deep urethra, with its caput gallinaginis 
and the deep parts of the corpora cavernosa (crura penis), 
may be distinguishable even when there has been exten- 
sive destruction of other parts of the body. 

Examination of the skeleton or of parts thereof may 
lead to a decision. In the female, the skeleton is smaller 
and the bones are lighter in weight. The thorax is pro- 
portionally shorter and wider, especially in its upper part. 
The curvature of the ribs on the flat in the posterior part 
is more pronounced, the curvature on the edge (down- 
ward) less pronounced, than in the male (Henle). The 
first and second ribs are longer relatively and absolutely 
than in the male (Meckel). The sternum is shorter and 
broader, the difference depending upon the body (gladi- 
olus) of the bone. The xipho-sternal articulation is on a 
higher level (that of the curve of the fourth rib), while 
in the male it is on a line with the curve of the fifth rib. 
The clavicle is less markedly curved, and the entire 
thorax, in proportion to the size of the pelvis, is much 
smaller. The chief difference is to be found in the pelves 
of the two sexes, and this difference is greatest at and 
after puberty. In the female the transverse dimensions 
are greater than the vertical; the ilium is more inclined 
outward toward the horizontal plane; the promontory 


539 


Cade. 
Czrsarean Section, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








of the sacrum encroaches less upon the pelvic inlet; the 
true pelvis is shorter but more roomy, and its outlet is 
absolutely as well as relatively wider; the sacrum is 
wider and shorter, and its curvature less marked; the 
ischiac spines encroach less upon the cavity; the pubic 
arch is wider and less angular, and its edges are everted; 
and the tuberosities of the ischia and the acetabula are 
wider apart. In the male, the entire pelvis is more mas- 
sive, the eminences and depressions for muscular attach- 
ments are more marked, the pelvic cavity is deeper and 
narrower, and the obturator foramina are larger and more 
oval (less triangular) in shape. 

The following average measurements of the true pelvis 
are taken from Toldt, and, in the determination of sex, 
are to be regarded relatively, since individual measure- 
ments may vary markedly in the same sex: 














Part. Diameter. Female. Male 
a 

{ Antero-posterior./118 mm.= 4.72 in.|113 mm.= 4.52 in. 
eee Transverse...... 2 ee aie ae be ‘ ao te 
OpUGUE Sees s 2 St mit a Suc=='4.5 ae 
F {| Antero-posterior.|126 ‘“* =5.04 ‘“ |114 “* = 4.56 * 
Cavity - ) | ‘Transverse ...... 120 “ =48 “1109 “ = 4.36 * 
Outlet {| Antero-posterior. |90-110 ‘* = 3,64.4 ‘** |75-95°* =3-3.8" 
utlet.. 1 | Transverse ...... 110 Seis ead Ls BD aie SOR gee 














Height.—The relaxation of the ligaments and other 
tissues following death, more especially after rigor mortis 
has ceased and decomposition has commenced, taken in 
connection with swelling or emphysema of the scalp, 
might be responsible for a slight increase in height post 
mortem. The mode of measuring the height is as fol- 
lows: The cadaver is laid out straight upon a flat sur- 
face, and the measurement is made between the perpen- 
dicular line dropped from the top of the vertex and the 
plantar surface of the heel, the foot being at right angles 
with the leg. In certain cases it is desirable to estimate 
the total height of a body of which only isolated parts 
are available. The following proportions will be found 
useful as a basis for making such a calculation: The dis- 
tance between the tips of the middle fingers, the upper 
extremities being extended at right angles to the trunk, 
equals the height. If an upper extremity alone is at 
hand, its length doubled plus the distance between the 
two glenoid surfaces would give the height. How much 
should be allowed for this latter distance is difficult to 
estimate. The length of the two clavicles plus that of 
the interclavicular notch—a total which would average 
twelve inches—would be too much, and consequently 
the total height of the body, estimated according to this 
formula, would also be too great. 

Other formule are the following: The length of the 
middle finger is one-nineteenth of the height; the length 
of the forearm, from the tip of the olecranon to the tip 
of the middle finger, is five-nineteenths of the height; the 
upper border of the symphysis pubis is about the middle 
point of the total length of the body, after full growth; 
the length of the lower extremity, from the head of the 
femur to the plantar surface of the heel, is about one- 
half the height (according to Orfila, the lower part, meas- 
uring from the symphysis, is shorter, by an average of 
two and one-third inches, than the upper, especially in 
women); the length of the femur is about one-fourth of 
the total height, after full growth. 

Tables of the relative proportions of the dimensions of 
single bones to the total height are given by Orfila, Toldt, 
and others. For the determination of the total height 
from single bones the age must be known. in excep- 
tional cases the age may be determined from single bones, 
and in such cases comparison of measurements with 
standard tables may be found very useful in estimating 
total height. However, the proportions given above are 
practically as reliable as the data furnished in these 
tables. 

Age.—The most important points upon which estimates 
in regard to age—at least up to the time of complete 
growth—may be based, are the appearance of the centres 


540 


of ossification, the progress which they have made toward 
complete ossification, and their final union with neigh- 
boring centres. In young subjects the examination of 
the teeth warrants important conclusions. The results 
of anatomical investigation are too extensive to be in- 
cluded in the present article. 

Conclusions based upon the height of the cadaver are 
less reliable. If we take 50 cm. as the average height at 
birth, in five years this height will be doubled (100 cm.). 
In the first year the increase amounts to from 1 to 2 cm. 
a month, or from 12 to 24cm. for the year. After the 
first year the increase varies from 7 to 8 cm. for each 
year. During the ten years following the first five the 
height increases to thrice that at birth (7.e., to 150 em.), 
averaging 5 cm. for each year in the ten. At puberty, 
growth is again more rapid, up to the eighteenth year, 
and then again it proceeds more slowly up to the time 
of complete growth; the usual height attained by males 
being from 157 to 180 cm., while that attained by females 
amounts to from 153 to 166 cm. (Hofmann). 

Care should be taken lest premature loss of hair, gray- 
ness, loss of teeth, or marasmus lead one into error in 
estimating age. Thesenile increase in the angle between 
the body and the ramus of the inferior maxilla, the atro- 
phy of the alveolar processes, and the decrease in the 
angle between neck and shaft of the femur are important 
indications of advanced age. 

The general condition of the cadaver—whether obese, 
well, or poorly nourished, or thin or marantic—may af- 
ford important aid in the work of identification. 

The appearances produced by putrefaction should not 
be confused with obesity, or those due to mummifica- 
tion with marasmus or with advanced age. The appear- 
ance of nutrition may be completely changed in cadavers 
after exposure to flame, and due allowance should be 
made therefor. 

In regard to the color of the hair in exhumed cadavers, 
it has been found that it changes to a reddish brown, the 
effect of exposure to putrefactive substances or to the soil. 
Time alone will change the color of dead hair, as may be 
seen in wigs and in the hairof Egyptianmummies. Heat 
causes a change of color toward a reddish tint. 

Special marks for identification—teeth, moles, warts, 
scars, and tattoo marks—should be accurately described. 
Tattoo marks may disappear. According to Caspar, this 
happens once in nine cases; according to Hutin, once in 
ten and a half cases; and according to Tardieu, once in 
twenty-five cases. Soluble pigments are more likely to 
disappear. Even insoluble pigments may be carried 
through the lymphatics and lodge in the peripheral parts 
of neighboring lymph nodes. 

The appearance of the hands and finger nails, or the 
presence of callosities, stains, etc., may warrant a shrewd 
guess as to occupation. Otto H. Schultze. 


CADE, OIL OF.—OLEUM Capinum. Olewm Juniperi 
Empyreumaticum. “A product of the dry distillation of 
the wood of Juniperus Oxycedrus L. (fam. Conifere)” (U. 
8. P.). The British Pharmacopeeia includes “some other 
species ” in the source. 

J. Oxycedrus resembles in general the common juniper 
of Europe, but has larger, reddish-brown, shining fruits 
(1.25 cm. in diameter—0.5 in.). It is an inhabitant of 
the Mediterranean basin, growing in waste places and 
upon stony hillsides. 

Its tar has been used for centuries by the peasants of 
Southern France for the “sheep itch” and other cutane- 
ous affections of their cattle, but its employment in med- 
icine, although occasional and also of old date, has only 
been extensive since its recommendation by the German 
school of dermatologists in the treatment of eczemas. It. 
is prepared by a method similar to that used in the man- 
ufacture of ordinary tar; that is, by distillation per de- 
scensum, in rude stills or ovens, from the bottom of which 
it is collected and then sold without further purification. 
The principal centre of its production is Nimes. ' 

It is a thin tar, often black in mass, but brown or 
brownish yellow and transparent, in thin layers; and is. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Tt 


more fragrant and pleasant in.odor than common wood 
tar, which it otherwise resembles. The tasteis acrid and 
empyreumatic. Its composition is not notably different 
from that of the tars of other conifers. Cadinene 
(C;5H24) is its important odorous constituent. The prin- 
cipal use to which it is put in medicine is that mentioned 
above—for the local treatment of eczema in the scaly 
stage. It is also used in other chronic inflammatory and 
exfoliating skin diseases. It may be applied by rubbing 
in with the fingers or a cloth, or, what is better, with a 
stiff-haired brush. If desirable to dilute it, some bland 
oil may be mixed with it, or it may be made into an oint- 
ment with lard or tallow, or with vaseline. Soaps con- 
taining it are also considerably used. Stockings, gloves, 
and bandages saturated with it aresometimes worn. Be- 
sides its stimulating properties, oil of cade is a good para- 
siticide, an efficient antiseptic, and a local anzsthetic— 
properties which it undoubtedly owes to the creosote 
and similar substances which it contains. It is never 
used internally. W. P. Bolles. 


CADMIUM.— Cadmium Sulphate is the only salt of this 
metal that merits notice in medicinal relation. It was 
official in the United States Pharmacopeeia of 1870, and, 
though dropped im the revision of 1880, it is still consider- 
ably employed. The salt, formula CdS0O,,4H.O, occurs 
in small colorless, rhomboidal crystals, efflorescent on ex- 
posure. It is freely soluble in water, and has a subacid 
and astringent and metallic taste. In properties it most 
closely resembles zinc sulphate, being an irritant astrin- 
gent. Taken internally, it will determine vomiting, 
after the manner of zinc sulphate, and in overdose will 
prove poisonous. Its claim for recognition in medicine 
rests on an alleged peculiar potency in determining the 
absorption of such corneal opacities as are capable of 
undergoing that process—a potency certainly not much, 
if at all, greater than that possessed by the commoner 
salts, silver nitrate or zinc sulphate. 

Cadmium sulphate is generally used in solution of from 
one-half to one per-cent. strength. Edward Curtis. 


CADMIUM, POISONING BY.—Cadmium and its salts 
are comparatively unimportant from a medico-legal point 
of view. Their uses are limited, and they are seldom 
met with outside of the chemical laboratory. The metal 
is employed occasionally in alloys to reduce their fusing 
point, and an amalgam has been used by dentists for 
filling teeth. The most important compounds are the 
iodide and bromide, which are used in photography for 
iodizing and bromizing collodion. The sulphate of cad- 
mium has been recommended, used internally, in the 
treatment of syphilis, rheumatisni, and gout (Grimaud). 
It has been chiefly used externally, however, as an astrin- 
gent and stimulant, in the treatment of conjunctivitis, 
and ulcers and opacities of the cornea. The iodide of 
cadmium, in the form of an ointment, has been recom- 
mended for external use, particularly in the treatment of 
scrofulous enlargement of the glands (Garrod, Guibert). 
The sulphide of cadmium has been used, to a limited 
extent, as a yellow pigment. Excepting the sulphide, 
the compounds mentioned are colorless, soluble in water, 
and possess a disagreeable metallic taste. 

SymprToms.—Preparations of cadmium have given rise, 
occasionally, to accidental poisoning. They appear to 
act as irritants, resembling in general the salts of zinc. 
Sixty milligrams (0.9 grain) of the sulphate, taken inter- 
nally, caused in one hour salivation, colic, and diarrhea ; 
and after four hours, vomiting accompanied by intense 
gastralgia and tenesmus(Burdach). Vomiting, diarrhea, 
vertigo, labored respiration, loss of strength, and cramps 
followed the inhalation of the dust arising from a polish- 
ing powder containing carbonate of cadmium (Sovet). 
Two ladies took an uncertain but small dose of bromide 
of cadmium by mistake for bromide of ammonium. It 
caused severe pain and a burning sensation in the stom- 
ach, accompanied by vomiting and purging which lasted 
for five hours. During a part of this time the pulse was 
imperceptible. There were nocerebralsymptoms. Both 








Cade. 
Czesarean Section, 





patients were confined to their beds for several days, 
during which time their stomachs ‘continued irritable 
(Wheeler). There is only one fatal case of cadmium 
poisoning recorded, so far as the writer has been able to 
learn. The patient, a lad fourteen years of age, took an 
unknown but probably large dose of chloride of cadmium, 
which had been sold for Epsom salts. It caused imme- 
diate vomiting. On admission to the hospital a short 
time after, he was in a state of collapse, with cold, 
clammy skin; radial pulse scarcely perceptible; respira- 
tion feeble, slow, and sighing. There was no stertor. 
The mucous membrane of the mouth was pale and sod- 
den, the tongue greatly swollen. He was apparently 
unconscious, though when shaken and aroused by dash- 
ing cold water upon the face, he replied rationally, in a 
hoarse whisper, to any questions put to him. There was 
extreme restlessness. Deglutition was impeded. Death 
took place in about an hourand a half after the ingestion 
of the poison. At the post-mortem examination the ves- 
sels of the brain were found filled with blood; the left 
lung congested (Mr. J. Hinder, Indian Medical Gazette, 
Calcutta, 1866, i., 156). 

EHeperiments on Animals.—Marmé has studied the 
action of the salts of cadmium by experiments on ani- 
mals. He concludes that the sulphide is non-poisonous. 
Administered to animals with their food for a week, in 
doses of many drachms, it caused no inconvenience. Its 
insolubility in water, weak acids, alkaline salts, and oil 
renders its use as a pigment free from danger. All com- 
pounds of cadmium which are soluble in water or weak 
acids at the temperature of the body are poisonous. 
Taken into the stomach they cause, in small doses, vomit- 
ing; in large doses, all the symptoms of gastro-enteritis. 
If quantities sufficiently large to be poisonous, without 
causing death rapidly, are injected beneath the skin or 
into the blood-vessels, they produce inflammation of the 
stomach and intestines, and frequently hemorrhages, 
erosions, and ulcerations. Small doses injected into the 
blood-vessels are fatal to animals. Thirty milligrams 
(0.5 grain) killed a dog; 16 mgm., a cat; 10 to 20 mgm., 
a rabbit; 30 to 60 mgm. (0.5 to 0.9 gr.), administered 
by the mouth, killed a rabbit weighing 1,500 to 1,800 
gm. (3.3 to 3.9 lbs. avoir.). The repeated absorption of 
small doses may give rise to chronic poisoning, which, 
in animals, is characterized by disturbed digestion, ema- 
ciation, and death. The post-mortem appearances ob- 
served were: a more or less extensive gastro-enteritis, 
sometimes subpleural hemorrhages, infarctions of the 
lungs, frequently fatty degeneration of the liver and 
heart, and diffuse nephritis. Elimination commences 
very soon and takes place chiefly through the kidneys. 
After death, cadmium can be detected in the blood, heart, 
liver, and kidneys. 

TREATMENT.—This should be much the same as in 
cases of poisoning by salts of zinc. Vomiting should be 
assisted, if necessary, by the free administration of warm 
water, with milk or mucilaginous liquids; or the stom- 
ach may be emptied by means of the stomach pump. 
The subsequent irritation may be allayed by the use of 
opium. Marmé recommends, in cases of acute poisoning, 
the alkaline carbonates with white of eggs. The subcu- 
taneous injection of dilute solutions of soda, when em- 
ployed early, was found, in the case of animals, com- 
pletely to arrest the poisonous action of the cadmium 
salts. William B. Hills. 


CACUM, DISEASES OF. See Appendicitis ; Colitis ; 
and Colon, Surgery of the. 


CAESAREAN SECTION.—Cesarean section is a term 
used for operations which remove a foetus from the 
uterus through the abdominal wall, the peritoneal cavity 
being opened in all cases. Historically it is one of the 
oldest of obstetrical operations recorded. 

It is generally supposed to have received its name from 
Cesar, who was believed to have been born by abdominal 
section. But, whether this be true or not, it was per- 
formed many years before his time. Furthermore, the 


541 


Ceresarean Section, 
Cesarean Section. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





name, according to Pliny, was derived from the Latin 
cedare, “to cut,” which makes the term Ceesarean section 
rather meaningless and the use of the capital C inappro- 
priate, but usage gives it a definite meaning and place. 

Until the Middle Ages the operation was largely per- 
formed only to deliver a child when the mother was 
dying. The Roman laws forbade the burial of a preg- 
nant woman until the ch‘ld had beenremoved. The first 
performance of the operation ona living woman which 
is recorded was in 1500 a.p., the operator being a butcher 
named Jacob Nufer, in Switzerland. In Germany, 
Trautmann, of Wittenberg, inaugurated the procedure 
in the year 1610. The patient lived three weeks. 

Until the advent of antiseptic surgery in recent times 
the mortality following the operation was too great to 
encourage its employment in any but extreme circum- 
stances. 

Until the introduction of recent modifications the vari- 
ous steps in the operation were: 1. Section of the abdom- 
inal wall, usually in the median line between the pubes 
and umbilicus. 2. Section of the uterus 77 stu, the in- 
cision being made upon the middle, anterior surface from 
abovedownward. 3. Removalof the child and placenta. 
4. In some cases suturing of the uterine wound, and in 
others leaving it to close by general contraction of the 
uterus; and suturing of the abdominal wound. 

From a historical standpoint the most interesting ques- 
tion has been the treatment of the uterine wound. So 
recent a work as Cazeaux and Tarnier’s, seventh edition, 
1884, states that, “the wound in the uterus requires no 
other attention than that of being well cleansed”; while 
Playfair, third American edition, 1880, considers the 
question of suture “a mooted point.” To Kehrer (“ Ueber 
ein modificirtes Verfahren beim Kaiserschnitte,” Avch. 
Ft. Gyndk., vol. xix., p. 177, Berlin, 1882), Stinger (“ Der 
Kaiserschnitt bei Uterus-Fibromen nebst vergleichender 
Methodik der Sectio-Ceesarea und Porro-Operation,” 
Leipsic, 1882), and Leopold (“Ein Kaiserschnitt mit 
Uterusnaht nach Unterminirung der Serosa und Resec- 
tion der Muscularis”; “Zwei weitere gliickliche Kaiser- 
schnitte,” etc., Arch. f. Gyndk., vol. xix., p. 400, 1882, 
and vol. xxiv., p. 427, 1884), belong the chief credit for 
the improvement in the treatment of the uterine wound 
which has rendered the present splendid results possible. 

The three improvements that have brought the mortality 
of Cesarean section from nearly one hundred per cent. to 
about five per cent. are: antisepsis and asepsis; complete 
muscular and serous suturing; coaptation in the uterine 
wound, and operation at the selected time, instead of 
when patients were mostly moribund, or exhausted by 
long labors; and the Porro hysterectomy. 

Methods of Operating.—The Siinger Cesarean section. 
To Siinger has been awarded the honor of title of the 
simple ceelio-hysterotomy form of Czesarean section. For 
performing this operation the patient is prepared as for 
any abdominal section. The urine should be carefully 
tested, the bowels thoroughly emptied, the abdomen 
washed with green soap and alcohol or ether, and bound 
with gauze (1 to 1,000 bichloride) twelve hours before 
operating. 'The pubes should be shaved, and the vulva 
and vagina made as asepticas possible. This latteris best 
accomplished by first douching with hot bichloride solu- 
tion and by dusting boric-acid powder into all the crev- 
ices of the introitus vagine and the vulva. The urine 
should after this be drawn with a soft catheter. The 
instruments needed are: scalpels, two mouse-toothed dis- 
secting forceps, one dozen artery forceps, scissors, long- 
curved needles, as well as some that are small and short, 
needle-holders, sutures of medium-sized silk, silkworm 
gut, and catgut; two pieces of either solid rubber liga- 
tures or tubing, each about eighteen inches long; several 
pedicle clamps; right and left aneurism needles, and 
one large vulsella forceps. 

When to Operate.—There are some advantages in oper- 
ating when the patient is in labor, the choice moment 
being when the uterus is awakened to active rhythmic 
pains, but previous to any exhaustion. 

There is less liability to failure of the uterus to con- 


542 








tract after section and removal of its contents. The cer- 
vix is also more succulent, and will permit delivery of 
the placenta per vias naturales if that proves best. On 
the other hand, it is difficult to make as thorough prepa- 
ration for operation and perform it before any exhaustion 
of the patient occurs, if the time is decided by the oceur- 
rence of labor, which may be at an inconvenient hour. 
Generally, when the operation has already been decided 
upon, the operator selects his time. This time should, of 
course, be as near term as possible, unless there are spe- 
cial indications to the contrary. 

Steps of the Operation.—The abdominal incision is made 
in the median line, running from one inch and a half 
below the umbilicus to just above the pubes. Usually 


‘the uterus lies in contact with the abdominal wall, the 


omentum and intestines being above and somewhat to 
the left of that body, but it is not wise to assume this 
and cut at one stroke through the abdominal wall. There 
is no need of such effort at speed. 

There are at this stage two methods of handling the 
uterus: one to incise it 77 s¢tw, and the other to lift it out 
of the abdominal cavity and then incise it. The first. 
method can be used when the uterus is free from infec- 
tion and the foetus of moderate size. It has the advan- 
tage of requiring less length of incision in the abdominal 
wall than the second method, and of causing less expo- 
sure and displacement of the intestines. The second 
method has the advantage of more thoroughly keeping 
the fluids from the uterus out of the abdominal cavity, 
and permits better control of uterine hemorrhage. There 
are also two methods employed for the control of hemor- 
rhage. By one the uterus is constricted by means of a 
rubber ligature (this is about one-eighth of an inch thick 
and eighteen inches long), or by rubber tubing, which is 
passed around the lower portion of the uterus, and cither 
tied tight with the knot in front, or a single turn in the 
knot is made and constriction applied according to the 
need during the operation. By the other method an as- 
sistant grasps the lateral attachments of the uterus with 
the thumbs and fingers of both hands and makes com- 
pression of the uterine and ovarian arteries as required. 
The advantages of the rubber constrictor are: that it 
does not require an individual assistant, that it more 
surely prevents hemorrhage, and that it is less in the way 
of the operator than are the hands of an assistant. It has a. 
distinct disadvantage in its liability to cause asphyxiation 
of the child; and it has a tendency to cause partial paraly- 
sis of the uterus, and so favors bleeding by preventing 
uterine contraction after the organ is emptied. A good 
assistant holding the uterus can both estimate the degree 
of compression required and apply it with lessened lia- 
bility of foetal asphyxiation. He can also be of service 
in steadying the uterus for the operator. 

The uterine incision should be a clean cut, which 
should be made at first only large enough to admit two 
fingers, when the opening can then be enlarged with the 
fingers holding it open, and either a bistoury or blunt. 
scissors used for making the enlargement. 

Many different incisions of the uterus have been advo- 
cated, but only one—the longitudinal—can be employed 
with the uterus 7m stfu. Following is a list of the vari- 
ous incisions advocated: the longitudinal middle third 
(Stinger); the posterior surface (Cohnstein); the trans- 
verse lower segment (Kehrer); the transverse fundal 
(Fritsch); the sagittal fundal (Miiller-Caruso); and the 
longitudinal, from fundus to Bandl’s ring (Bar). Origi- 
nality has evidently found its limit in methods of making 
uterine incisions; even the cervical incision of the dis- 
carded laparo-elytrotomy is excluded from the pioneer. 

Of the above methods only those of Bar, Siinger, and 
Fritsch need to be considered. The Stinger incision is 
not rightfully his, as it was performed long before his 
time. The choice between it and that of Bar would de- 
pend solely upon the location of the placenta, if that 
could be determined—which it usually cannot. There is 
less certainty of contraction of the lower portion of the 
uterus, which gives Bar’s incision an advantage for se- 
curing both greater avoidance of hemorrhage and better 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


behavior of the wound when sutured. It is claimed for 
Fritsch’s transverse incision that there is less hemorrhage 
than in the longitudinal incision because the uterine 
vessels pursue a transverse course; also that there is 
least liability of finding the placenta in this region. 
Neither of these views has any special foundation in fact. 
It might be claimed for the method that the risk of infec- 
tion is lessened by having the line of incision run at right 
angles to the abdominal incision, whereby possible infec- 
tion of the latter would be less liable to come in contact 
with the former. Hahn (Centralbl. fiir Gyndkol., Decem- 
ber 9th, 1899) gives asummary of a total of fifty-one cases 
of Cesarean section performed by Fritsch’s method up to 
date. Two died, both from circumscribed peritonitis. 
The summary is inconclusive so far as showing any spe- 
cial advantage over Bar’s incision. In the absence of 
special indications, Bar’s incision is best. 

While the uterus is being incised an assistant should 
endeavor to keep the lips of the abdominal wound closely 
coaptated to the uterus to prevent the entrance of fluids 
into the abdominal cavity. 

There are certain advantages in bringing the uterus out 
of the abdominal cavity before incising it, and likewise 
disadvantages. The advantages are: the uterus can be 
better handled, its contents can be kept out of the abdom- 
inal cavity, and some time can be saved. The disadvan- 
tages are: the long abdominal incision, and the greater 
liability to hernia and to adhesions. 

The disadvantages are subject to control by perfect 
technique, so that the well-known surgical rule can be 
applied, that free incision with perfect technique appeals 
to first-class operators as against the opposite method. 
The method with the uterus brought out should always 
be selected when there is any suspicion of an infected 
uterine cavity. 

The length of the incision of the abdominal wall can 
best be determined in each case. Before drawing the 
fundus out of its bed it is well to pass two long sutures 
through the upper wound. These can be used, after re- 
moval of the uterus from its bed, to hold the intestines 
back in place. When the uterus is drawn out it should 
be covered with warm, sterile cloths. Pads or mats of 
sterile gauze should be packed underneath, to protect the 
abdominal cavity from fluids. In cases of special sepsis, 
in which it is necessary to incise the uterus before ablating 
it in order to save the child, it is a good measure to slip 
a large sheet of pure rubber, properly sterilized and 
punctured, over the entire uterus down to the cervical 
_ portion. It will automatically keep out every drop of 
fluid from the cavity. 

Location of the Placenta.—As the result of unusual 
opportunity and very careful observation, G. Leopold has 
been able to formulate a rule for determining the placen- 
tal site when the uterus has been brought into view by 
abdominal section. There is a constant relation between 
the placental site and the direction of the tubes, the latter 
extending backward when the after-birth is on the an- 
terior wall, and remaining laterally, or rather directed 
forward, when it is on the posterior wall. In some cases 
there isa bulging of the uterus over the site occupied by 
the placenta. These are means of diagnosis which come 
within reach when the uterus has been exposed by ab- 
dominal section, and which can therefore be utilized in 
Cesarean section. If the placenta were thus indicated as 
being upon the anterior middle surface of the uterus, it 
would be well to make the incision transversely across 
the fundus (Fritsch’s incision), or transversely across the 
posterior fundus (Cohnstein’s). 

In making the incision through the uterus the placenta 
must be disregarded once the incision has been started. 
It can either be cut through, or separated if its edge is 
near the wound. The wound being of sufficient size, the 
child is drawn out either head or foot first, whichever 
way proves most convenient. The placenta may then 
either be removed through the opening or, the cord 
dropped back within the womb, be extracted through 
the cervix. 

In the treatment of the uterine wound it is only a mat- 


, 


Ceesarean Section, 
Cesarean Section, 


ter of historical interest that it was formerly thought un- 
necessary to suture this wound. It was thought that the 
uterus, being a contracting compound of variously run- 
ning muscular fibres, would close the wound without the 
assistance of any sutures; but this view has been found 
to be altogether wrong, and no further discussion of it is 
permissible. The opposite treatment, that of water-tight 
suturing of the wound, is now altogether employed. 

To get the most absolute coaptation and impervious 
union of the lips of the wound, Siinger went to the ex- 
treme of advocating the dissection of a thin strip of mus- 
cle from each raw surface of the wound in order that the 
peritoneum could be enfolded on both sides and prompt 
sealing of the wound by peritoneal agglutination thereby 
secured. Even this time-taking and troublesome dissec- 
tion has already become historical. It is found correct in 
aim, but entirely unnecessary, as the same degree of co- 
aptation can be secured by enfolding superficial sutures. 

It should be borne in mind that perfect closure of the 
uterine wound is essential to success, and the method 
employed should not be slighted by any one. 

First, a row of deep sutures of silk should be inserted, 
extensive enough to include the muscle, but not the en- 
dometrium or decidua. These sutures should be placed 
—interruptedly—about 1.5 em. (.65 in.) apart, and should 
emerge at the same distance from the edges of the wound. 
Between these should be inserted a similar series of 
sutures at half the depth of the first set. In inserting 
these sutures care should be taken to have the opposite 
surfaces meet without irregularity in spacing, lest wrin- 
kling result and afford a pocket for infected secretion. As 
the uterus will sustain constant rhythmical contractions 
and relaxations, it is well to tie the sutures a little too 
tightly rather than too loosely. A slight blanching of 
the included tissues is evidence of proper tension by the 
sutures. When both layers of the deep and half-deep 
sutures have been tied, a superficial row, which includes 
only the peritoneum should be introduced. These are 
intended to enfold the peritoneum and bury the other 
sutures. Fine silk should be used. These sutures in- 
clude just enough peritoneum to secure a good hold, and 
run entirely over the deeper layers. They may be either 
interrupted or continuous, following the method of Lem- 
bert in suturing the intestines. The latter method is 
quite as effective as interrupted suturing, and has the 
advantage of saving time. 

As in every abdominal operation, very careful cleans- 
ing of all parts by gauze sponging should be employed, 
the region behind the uterus receiving special attention. 
Hunter Robb advises drawing the omentum down behind 
instead of in front of the uterus in making the final toilet 
of the abdominal cavity, as proving less likely to cause 
omental adhesions and subsequent hypogastric and epi- 
gastric pains after the uterus has contracted. 

In removing the placenta, it is possible, with a little 
care, to avoid bringing the hands in contact with the 
uterine wall by keeping them within the amnion, the pla- 
centa being grasped on its foetal surface with the amnion 
entirely enveloping the hands. 

Irrigation of the uterus after section is not usually 
indicated, inasmuch as this method of operating should 
not be performed if infection has already taken place, the 
Porro method being employed instead. There may be 
circumstances present in the operation interfering with 
perfect asepsis, in which case thorough douching with 
bichloride solution—1 to 10,000—should be employed. 

In the after-treatment of the patient but little variation 
from ordinary management in abdominal operations is 
indicated. Ifthe bowels were not properly—.e., thor- 
oughly—emptied previous to operation (this is pecul- 
iarly liable to be the case in Cesarean section, where so 
many cases are emergency operations), efforts should be 
made to secure thorough cleansing at once. Otherwise 
the second day will be best for the administration of 
cathartics. 

The vagina should be douched after operation to re- 
move blood accumulations, and then treated as in ordi- 
nary labors in which douching is not necessary ; but care- 


543 


Czesarean Section. 
Caffeine, 


ful dressing of the vulva with sterile gauze and cotton 
pads is essential. Voluntary micturition is preferable to 
catheterization. There is a physiological advantage in 
placing the child to the breast at regular intervals, as this 
stimulates the uterus to healthy contraction and favors 
involution. The patient should not be asked, however, 
to feed the child from the breasts, unless she is quite able 
to do so without feeling the drain. 

The patient should be allowed partially to sit up in 
bed after eight or nine days, according to the conditions. 
Toavoid abdominal hernia, it is best not to hurry getting 
the patient on her feet, the fourth week being usually 
time enough. An abdominal bandage, or truss, should 
be worn for a while. 

CasL10-HystERECTOMY (the Porro operation).—In 1876 
a modification of the classical Csesarean section was per- 
formed by Edward Porro, which consisted in ligation of 
the uterine and ovarian arteriesand removal of the uterus 
at the cervix, the stump being brought into the abdomi- 
nal wound and there fixed. 

There are two methods of performing this operation: 
one, the original Porro method, in which the same steps 
as in the method just described, up to the removal of the 
child, are taken, after which the ovarian and uterine 
arteries in the broad ligaments are tied, and the uterus 
then cut away just above the ligature; and the other 
known as the Porro-Miiller method, in which the abdom- 
inal incision is made sufficiently large to permit bringing 
the uterus out of the abdominal cavity before removing 
the child, when the latter, if still alive, is removed by 
opening the uterus; or if the child is dead, or the uterus 
is dangerously septic, the entire uterus is cut away with- 
out opening it. 

When the Porro method—removal of the uterine con- 
tents with the uterus 77 s¢tw—is employed, great care is 
necessary to prevent contact of any of the uterine fluids 
with the abdominal cavity, inasmuch as this operation is 
generally done in preference to the so-called Siinger oper- 
ation because the uterus is believed to be septic. It is 
better, when doing the operation, to ligate the neck of 
the uterus more tightly than is done inthe Singer opera- 
tion, as it is most desirable to avoid flowing into the ab- 
dominal cavity, while there is no need of preserving ute- 
rine tonicity. 

In doing this operation there is no necessity for care in 
making the opening into the uterus, and it is permissible 
to tear the opening with the hand instead of cutting to 
the desired size with knife or scissors. This may save 
some time and lessen hemorrhage. Itis also well to draw 
a pad of sterile gauze down behind the uterus before 
making the incision into it. This will best prevent the 
entrance of fluids into the abdominal cavity. After the 

- uterus has been emptied it should be cut away with scis- 
sors at about one inch above the line of constriction, the 
tubes and ovaries being included. The vessels should 
then be ligated, including those in the stump. The raw 
surface of the stump is next seared with pure carbolic 
acid. The abdominal wound is then sutured down to the 
stump. Knitting needles, or pins six inches or more in 
length, are passed through the stump, including the liga- 
ture, and are protected from cutting into the abdominal 
wall by pads of gutta-percha or closely folded gauze. 
The stump is generally well dusted with iodoform and 
boric-acid powders, though there is a developing ten- 
dency to discard iodoform at the present time. The en- 
tire wound is then covered with sterile gauze pads and 
absorbent cotton. These dressings may require removal 
and fresh ones to be put in their place in two or three 
days, especially if sepsis develops in the stump. 

A modification of this method of treating the stump is 
known as the subperitoneal method, in which, instead of 
bringing the stump into the abdominal wound and fixing 
it there, it is left 77 sitw, and a layer of peritoneum from 
the posterior surface of the lower uterus is dissected free 
from the uterus before the constrictor is applied, and 
then closely stitched over the stump to the peritoneum in 
front. This method requires, in place of the constriction 
ligature around the neck of the uterus, the application 


544 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








of clamps to the vessels in the broad ligaments; then, 
after removal of the uterine contents, the peritoneal flaps 
are dissected loose. The constrictor can then be applied 
without involving the flaps. This method requires more 
time than the older one, but is preferable when feasible. 

Complete Hysterectomy. —'The removal of the entire 
uterus and cervix is necessary in conditions such as can- 
cer involving the cervix. When this is done, instead of 
ligaturing the stump the vessels are tied in the broad 
ligament and the uterus dissected out complete, as in 
ordinary hysterectomies in gynecological work. 

INDICATIONS FOR C@SAREAN SECTION.—Certain cases 
of pregnancy are met with in which the physician has 
the choice of only one method of relief—Ceesarean section. 

Tumors and Diseases.—Tumors of the lower segment of 
the uterus which cannot be removed by vaginal opera- 
tion, and which are of such size as to prevent dilatation 
of the cervix sufficient to permit passage of the feetus, ne- 
cessitate ccelio-hysterotomy. Fibroids are most frequent 
in this list. Ovarian tumors impacted in advance of the 
head, and occupying the pelvic basin to the obstruction 
of the fetus; rarely a dislocated and adherent kidney; 
intestinal displacement; carcinomata of the cervix, rec- 
tum, sigmoid flexure, and vagina, and certain obstructive 
growths following old cases of appendicitis, compose 
most of the abnormalities necessitating Czesarean section. 
Exostoses may also compel the operation. Cicatrices of 
the vagina may be of sufficient size to compel Czesarean 
section. It is not worth while to classify some of these 
obstructions as “absolute ” indicators of Cesarean section, 
because every case offers an individual equation, and 
must be decided by itself. 

It may be that slitting the cervix in some cases of 
tumor, such as myoma, will be less dangerous than Csa- 
rean section; or a tumor of the ovary prolapsed into the 
pelvis may be removed with less danger than a Cesarean 
section involves. In tumors of the lower uterus the im- 
minent danger of rupture of that organ in cervical dila- 
tation must be given much weight. In cicatrices of the 
vagina it may seem feasible to cut and dilate them, but 
they are liable to tear much beyond safe limits in the 
passage of the foetus. 

In all these various indications the general rule prevails 
among experienced operators that a controllable opera- _ 
tion like Ceesarean section is much safer than severe strain- 
ing and mashing of tissue involved in drawing a fetal 
body through an abnormally obstructed vagina. Incisions 
of the cervix or of vaginal cicatrices, with blind traction 
and distention, cannot equal aseptic, clean abdominal in- 
cisions and neat suturing of wounds, even though the 
latter be great in extent. 

Pelvic Contraction and Large Head.—When a pelvis is 
too small to allow passage of the head of the foetus by 
symphysiotomy, or when craniotomy would be as diffi- 
cult and dangerous as a Cesarean section, the indications , 
for the latter operation may be classed as absolute. But 
it is almost useless to define such conditions by fixed 
pelvic diameters. A conjugata vera of but two inches 
would be “absolute,” but between two and one-half and 
three inches it is not possible to classify the indications, 
The only proper method of determining the dimension 
indications for Czesarean section is to learn the relative 
proportions existing between fceetal head and pelvic cali- 
bre; and pelvic measurement is only one-half of the 
problem. 

Contraction of the pelvic canal of sufficient degree to 
render craniotomy as dangerous as Czesarean section is 
one of the rarest abnormalities in obstetrics. The degree 
of contraction which renders the operation of symphysi- 
otomy out of the question should be determined. This 
method of delivery occupies a field limited to such de- 
gree of disproportion as will permit passage of the foetal 
head after section of the pubic joint without necessitating 
a separation of the pubic bones of more than two and 
three-fourth inches. <A greater separation of these bones 
involves such risk to the sacro-iliac joints and the vagi- 
nal wall and bladder as to condemn the operation. Czesa- 
rean section should be the absolute choice in such cases. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Czresarean Section, 
Caffeine, 





Symphysiotomy should be performed only when the 
patient is in labor, and the most useful and the safest 
method of determining how much separation of the pubic 
bone would be required is direct palpation of the head 
and pelvic inlet with the hand in the vagina. Approxi- 
mately indicating by figures the limits, we would state 
that a conjugata vera of three inches and a feetal biparie- 
tal diameter of from three and one-half to four inches 
would not cause too great separation of the pubic joint. 
Wotherspoon delivered a child weighing fifteen and one- 
half pounds with a separation of nearly five inches; and 
the patient recovered, but with a torn vagina, urethral 
fistula, and one-half of an inch separation of the pubic 
bones. Such cases get beyond the control of the opera- 
tor, and are not justifiable when foreseen. 

The comparative mortality and morbidity of Cesarean 
section, induced labor, and symphysiotomy depend, in 
the answer, upon many variable points. Induced pre- 
mature labor is safest for the mother and most danger- 
ous forthe child in cases requiring delivery before the 
thirty-second week. Cvesarean section is most dangerous 
for the mother and safest for the child; symphysiotomy 
is safer for the mother than Cesarean section, and some- 
what more dangerous than induced premature delivery. 
It is less dangerous for the child than the latter method, 
and more so than is Czesarean section. 

The essential operative mortality (that per cent. of 
fatalities which will follow the surgical work of the best 
operators in cases taken at the time most favorable, and 
which must follow present methods of performance in 
these several ways of delivery) must be the foundation 
for selection of method. 

Induced premature labor for dystocia is essentially al- 
ways of the above class, as it is performed voluntarily 
and at the convenience-of operator and patient. The 
mortality is about 4 per cent., but should not be more 
than 1 per cent. higher than pertains to spontaneous 
ordinary labors. Its relative safety for the mother is 
unquestioned. 

The mortality for the child is, and always will be, very 
high. 

Twenty-five per cent. of all babies born die within the 
first year. The death rate within full term for six- 
months time babies is nearly 90 per cent., at seven months 
75 per cent., and at eight months 50 per cent. These 
figures are higher than those given by French writers, 
but they aim to include private as well as hospital cases. 
Induced labor at a period nearer term than eight months 
would not indicate Cesarean section as an alternative 
operation. Efforts have beenmade by Prochownick and 
others to keep the fetal cranial bones soft up to term by 
diet, and soaccomplish delivery without operation. The 
results obtained justify further effort in this direction. 

The essential mortality from symphysiotomy is about 
2.5 per cent.; this in the hands of experienced operators 
and when the method was properly selected. Pinard 
gives 5 per cent. as the mortality of 160 symphysiotomies 
done at the Baudelocque Clinic 1892-1899, excluding 7 
deaths due to outside causes. The writer has operated 
13 times without a death from symphysiotomy. The 
general foetal mortality is given as 14.5 per cent. 

The essential mortality from the Singer Cesarean sec- 
tion can be given only by estimate. Reynolds (“ Obstet- 
rics,” Vol. II., No. 1), taking the cases of Leopold, Everke, 
and himself in which the patients were free from sepsis 
and exhaustion from labor, reports 88 cases with but 2 
deaths which occurred some years ago from operative 
sepsis. In the hands of operators in general we would 
expect a percentage mortality from selected cases of 
about 5. For the children it should scarcely exceed the 
results in normal labors. 

The actual mortality from the Siinger operation is from 
6 to 8 per cent. in the work of the leading operators. 
From all sources the actual mortality from Cesarean sec- 
tion is from 25 to 33 per cent. to-day. From symphysi- 
otomy it is about 10 per cent. The mortality from the 
Porro operation is necessarily higher than from the Siinger 
operation, even in the best of hands, inasmuch as the 


Von, U1 —35 


cause of its selection is often the septic condition of the 
uterus. 

From craniotomy there should be in favorable cases no 
greater mortality than from forceps deliveries. The 
operation is seldom performed until after the forceps 
has been tried severely, and the patient been bruised 
and often infected. In view of the very low death rate 
of other methods, it should not be the primary selection 
of method in the hands of experienced and properly pre- 
pared obstetricians; but it may often be the most expe- 
dient method for the general practitioner, in whose hands 
most labors occur outside of hospitals. 

Given a patient not in labor but requiring induced pre- 
mature labor, symphysiotomy, or Cesarean section to 
secure delivery of a living child, and an obstetrician of 
equal experience in each method and regularly engaged 
in doing abdominal surgery, due regard being given to 
both mother and child, in cases of medium contraction 
not permitting forceps delivery, symphysiotomy should 
be selected. With more marked contraction the Siinger 
Ceesarean section should be preferred. Cases of severe 
manipulation, with the child in good condition, with 
probable infection of the uterus present, call for sym- 
physiotomy in preference to the Porro operation. Sym- 
physiotomy is not affected by infection if the writer’s 
subcutaneous method is employed; Cesarean section is 
markedly affected. If the child’s condition renders . ~ 
livery alive very problematical, further effort with i-: 
ceps and then craniotomy may be best. The @ priori 
argument in cases complicated by tumors and local dis- 
eases is In favor of Cvesarean section. Induced labor is 
generally decided upon by the patient. 

If the physician is not accustomed to abdominal sur- 
gery, he should select symphysiotomy in preference to 
Cesarean section. If he is not accustomed to any surgi- 
cal work, he should choose induced premature labor, or 
perform craniotomy, if he must deliver the patient him- 
self. 

The Choice of Method in Cesarean Section.—The Porro 
method is not only indicated but required in all cases of 
suspected existing infection of the uterus. This is the 
situation in cases in which extensive efforts have been 
made by others to secure delivery by use of the forceps 
or by version; when the amnion has been ruptured for 
hours and most of the fluid drained away; when the 
cervix is swollen and w@dematous, the vagina hot and 
dry, and the vulva swollen; also when tumors and path- 
ological changes are present in the soft parts which in- 
terfere with passage of the foetus; inrupture of the uterus 
at sites difficult to suture, or when it seems safer to doa 
hysterectomy than to suture a jagged wound at any site. 
It may be indicated in very exhausted conditions of the 
uterus with hemorrhage present or threatening. It is in- 
dicated in certain conditions of the very rare occurrence 
of combined intra- and extra-uterine pregnancy. It is 
not indicated as a means of preventing future pregnancy, 
unless the operator is perfectly satisfied that he can per- 
form it with the same degree of safety that he could a 
Singer section. 

Toa physician of comparative inexperience in abdomi- 
nal operations the Sanger Cesarean section is probably 
an easier and safer method than the Porro hysterectomy. 

Hdward A. Ayers. 


CAFFEINE.—TVvhetine. CsHioNsO2,H.0. “A feeble 
basic, proximate principle, obtained from the dried leaves 
of Thea sinensis, Linn. (nat. ord. Ternstremiacee), o1 
from the dried seeds of Coffea arabica, Linn. (nat. ord. 
Rubiacee), and found also in other plants” (U.S. P.). 

“ An alkaloid usually obtained from the dried leaves of 
Camellia Thea, Link, or the dried seeds of Coffea arabica. 
Ginn 4B). , 

It occurs in fleecy masses of long, flexible, white crys 
tals, permanent on exposure, of a silky lustre, having a 
bitter taste, and without odor. Soluble in eighty parts 
of cold water, in two parts of boiling water, and in thirty- 
three partsof alcohol. It isneutral totest paper. When 
ignited it is consumed without residue. A notable fea- 


545 


Caffeine. 
Caisson Disease, 





ture is the unusually large proportion of nitrogen that it 
contains. 

The only official salt is the citrate, which is very un- 
stable and rapidly deteriorates, the alkaloid separating 
and remaining uncombined. When mixed with three 
parts of water, the citrate forms a thick liquid; when 
more water is gradually added the caffeine is precipi- 
tated, but redissolves and forms a clear solution when 
twenty-four parts of water are added. It is a white 
powder, without odor; it has a bitter taste and an acid 
reaction. When burned it chars and leaves a slight ash. 
It is soluble in thirty-two parts of water. 

An effervescing citrate is official in the United States 
Pharmacopeia and the British Pharmacopoeia. The 


former contains one per cent. of caffeine, that of the Brit- | 


ish Pharmacopeeia contains nearly four per cent. 

Caffeine is the characteristic alkaloid of coffee and tea. 
It was discovered and first prepared, in an impure con- 
dition, from coffee, by Runge, in 1820, and shortly after, 
in a state of greater purity, by Pelletier and Robiquet, 
and other chemists. In 1827 Oudry separated an alka- 
loid from tea, which he named theine. This, in 1888, 
was proved by Mulder and C. Jobst to be the same as 
Runge’s caffeine. In 1840 Martius discovered guaranine 
in guarana, and afterward the same observer, and others, 
proved its identity with the alkaloid of coffee. The same 
substance was also found, in 18438, by Stenhouse, in the 
leaves of maté or Paraguay tea, and in 1865, by D. Daniel 
and by J. Attfield, in the kola nuts (Stereulia) of Africa. 
In all these products it appears, moreover, to be the most 
important ingredient. As no two of these plants are 
nearly related to each other, or are even in the same 
order, caffeine may yet be found to be as widely distrib- 
uted in the vegetable kingdom as berberine or buxine. 
It is aninteresting fact that all the above substances have 
been used from a remote time by communities which 
could have had no communication with each other, for ex- 
actly the same purpose, viz., as a stimulating and com- 
forting addition to their daily food; tea by the Chinese, 
coffee by the Arabs, the kola nuts by the Africans, and 
maté and guarana by different tribes of South America. 

For commercial purposes caffeine is prepared exclu- 
sively from tea and coffee; the poorer sorts, that is “tea 
dust” and damaged and inferior grades of either tea or 
coffee, being used. As the price of both these articles 
does not depend at all upon their alkaloidal strength, but 
only upon their appearance and flavor, the cheaper 
grades often contain considerably more caffeine than the 
more expensive ones, and, price apart, are better for this 
purpose. 

The percentage of the alkaloid in the several plants 
varies greatly. It is estimated that tea contains from 
one to four per cent.; coffee, one to three; maté, one to 
two; and guarana about five per cent. 

Caffeine acts upon the cerebral, medullary, and spinal 
centres, primarily as a stimulant and later as a depres- 
sant. Its action is also directed to the muscular tissue, 
improving its tone and contractile power, until ultimately 
it merges into the general depression. 

In small doses, from one to three grains, it produces a 
sense of well-being, and a feeling of increased strength 
and vigor. The cerebral functions become more active, 
the respirations are deeper, the heart beats more forcibly, 
and the arterial tension is increased. The heart at first 
participates in the general stimulation, and there is an 
increase in its frequency and a more rapid pulse. This, 
however, is transitory, as the inhibitory centres are soon 
influenced by the stimulation and produce a slowing of the 
heart’s action, which, with the more forcible contraction 
of the muscular walls, constitutes its most desirable effect. 
The urine is increased, both the quantity and the con- 
tained solids being greater. Tissue change is accelerated, 
and the body temperature rises. This beneficial action 
continues for some days, after which the continued use 
is liable to give rise to signs of cardiac irritation and ex- 
cessive vascular tension. There may be a rapid, hard 
pulse, a feeling of constriction in the chest, dyspnea, 
and labored action of the heart. 


546 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


In larger doses, from gr. v. to gr. viij. or x., the symp- 
toms of over-stimulation are developed early, and if the 
drug is continued, the depression follows rapidly and may 
become very marked. In addition to the cardiac and re- 
spiratory distress, there are insomnia, vertigo, tinnitus 
aurium, flashes of light, mental distress, and delirium. 
As the depressant action replaces the stimulation, the in- 
hibitory control of the heart is lost and there follows a 
rapid, feeble heart beat, which gradually increases until 
contractions cease. The respirations also become shal- 
low, and there follows a condition of asphyxia and col- 
lapse, death being due to respiratory failure. Caffeine is 
an irritant to the gastric mucous membrane, and its con- 
tinued use produces heat and burning at the epigastrium, 
with nausea, which may terminate in pain and severe 
irritation of the stomach and intestines. 

Caffeine was formerly considered only as a cardiac 
stimulant and administered freely, with very little 
thought of any subsequent depression. Later experience 
has shown that this secondary action is of the greatest 
importance, and although often unrecognized, it is a fre- 
quent cause of serious depression, and possibly of death. 
Cases of acute poisoning are rare, and in healthy adults 
the quantity necessary to cause death would be very 
great, but in diseased states its action is much accentu- 
ated. In valvular disease and in conditions in which the 
heart is being overtaxed, even ordinary doses may be 
attended by very serious consequences. The danger is 
not only from large doses, but also from the continued 
use of moderate doses. 

Attention has also been directed to an unfavorable con- 
dition that may arise during its administration, prior to 
any depressant action. This is an over-stimulation and 
irritation of the cardiac ganglia that may terminate in a 
spasmodic contraction of the heart and death. The fol- 
lowing are given as instances of death from this cause. 
In a case of pneumonia, death occurred suddenly, when 
the patient was taking caffeine, three grains three times 
a day. A woman with chronic parenchymatous nephri- 
tis, anasarca, and double pleural effusion had taken small 
doses for some time previous to a sudden fatal syncope. 
In a third case death.took place suddenly, the patient 
being a young girl who had acquired the habit of taking 
frequent doses of gr. iv. or v. In all these cases a post- 
mortem examination was made and the heart found firmly 
contracted, death being due to a condition described as a 
“tetanus of the heart muscle.” 

Caffeine is employed as a cardiac and general stimu- 
lant, as a diuretic, and for the relief of headaches and 
neuralgia pains. Its value as a stimulant is well recog- 
nized, and its rapid action makes it of value in cases of 
sudden weakness and threatened syncope. In addition 
to its value in threatened heart failure, it is most useful 
in chronic valvular disease, to counteract a failing com- 
pensation. It, however, must always be given cautiously 
when the heart is feeble and dilated, or in any form of 
heart disease in which the walls are diseased. In arterio- 
sclerosis it is also contraindicated, as it adds to the al- 
ready high arterial tension. 

The diuretic action of caffeine isalways to be depended 
upon, and is that for which it proves of greatest service. 
It is in a measure due to the increased arterial pressure, 
but caffeine also exercises a direct action upon the renal 
secreting tissue. Itis particularly indicated in the dropsy 
of cardiac disease, and resembles digitalis in its action. 
It acts more rapidly, but has not the same power to 
strengthen the heart and increase the blood pressure. 
For this reason its effects are often better when preceded 
by digitalis, or when the two are combined. When there 
is kidney disease it must be given with care, as the 
stimulation of the renal tissue may aggravate the local 
trouble. In dropsy due to hepatic disease, its action is 
very uncertain. 

Caffeine has not proved of much value in the treatment 
of headaches. In many forms of neuralgia and migraine, 
in the debilitated and nervous, it may prove of service, 
but this is due to the improved tone of the nervous 
system, and not to any anodyne or analgesic property. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


e 


Caffeine, 
Caisson Disease, 








In administering caffeine, the citrate is frequently se- 
lected on account of its greater solubility. When used it 
should have been carefully preserved, and it must be 
given in powder, or dissolved immediately before use, 
as it rapidly decomposes when in solution. The citrate 
is one-half the strength of the pure alkaloid, and gr. 
x.-xy. during the day is the average dose. When an 
immediate effect is required, it may be administered sub- 
cutaneously. A product that is much employed is the 
double salt of caffeine, with soda and salicylic, benzoic, 
or cinnamic acid. It is very soluble and unirritating, 
and furnishes the best solution for hypodermic use. It is 
about one-half the strength of the citrate. These salts 
were proposed as the best means of obtaining the diu- 
retic action of caffeine, but later experiments seem to 
indicate that these combinations are not so serviceable as 
were expected. It has been found that the presence of 
soda and salicylic acid has a tendency to reduce blood 
pressure and to lessen the secretion of urine. This, it is 
thought, must influence unfavorably the caffeine when 
it is thus combined with other drugs. The compound 
salts, however, are very highly thought of and are becom- 
ing more frequently employed. The following formule 
for their preparation are official in the Paris Codex: (1) 
Caffeine, 4; sodium salicylate, 3; distilled water to 10 
parts. (2) Caffeine, 2.5; sodium benzoate, 3; distilled 
water to 10 parts. Beaumont Small. 


CAISSON DISEASE.—This term has inappropriately 
been applied to the whole group of accidents which re- 
sult from working in compressed air. As Snell aptly 
says, the name of a disease should indicate some charac- 
teristic symptom or some etiological factor. This is 
manifestly not the case in the present instance. The 
caisson itself has nothing whatever to do with causing 
the disease which bears its name. As indicated above, 
compressed wir is the causative factor and should be the 
term substituted for caisson. Compressed air tliness, then, 
will include all this class of accidents under discussion. 

In laying the foundations of bridge piers or abutments 
under water, various means are resorted to for displacing 
the water and building a solid basis; one of these meth- 
ods is by means of caissons. The caisson, or caissoon, is 
made of different patterns, but the one with which we 
have to do in the study of caisson disease is like a large 
inverted cylindrical box supplied with apparatus for 
condensing air to such a degree as to expel and keep out 
the water, thus enabling men to work init. When the 
in-rushing water cannot be removed by pumping, other 
means must be resorted to. The method now in vogue 
is the use of an air-tight diaphragm at some point in the 
cylinder. The workmen and material used are passed 
through a small space or ante-room called the “air lock,” 
with which the diaphragm is provided. This chamber 
is furnished with two air-tight doors, an inner and an 
outer, both of which open toward the compressed air. 
When the men have entered this air lock, the outer door 
is closed and compressed air is gradually admitted by 
means of cocks until the air in the lock is of the same 
density as that in the caisson; then the door of admission 
to the latter is opened. In returning, the process is re- 
versed, the air in the lock being gradually rarefied. 

If the fact be borne in nine that the body has about 
sixteen square feet of surface, and that ordinary atmos- 
pheric pressure is about fifteen pounds to the square 
inch of surface, it may readily be understood that an in- 
crease of atmospheric pressure will have some effect on 
the conditions of the interior of the body. The blood is 
driven, by reason of this external pressure, from the 
surface into the bones, cranium, spinal canal, and other 
parts of the body. If this change of location of the 
blood be effected too rapidly, or if too much force be ap- 
plied, the results may be dangerous. 

A number of factors must be considered as entering into 
the production of this disease, in the enumeration of 
which Snell’s order has been followed. Primarily, there 
is the high atmospheric pressure. As would naturally be 
expected, the extent of the illness varies in proportion to 


the degree of this pressure. The length of time of ex- 
posure is also an important factor, the longer the period 
the more severe the symptoms. Ventilation has such an 
important influence on the degree of this illness that 
Snell has formulated the following law: “The amount of 
illness varies inversely with the amount of fresh air sup- 
plied to the compressed airchamber.” Too rapid decom- 
pression should be avoided. Minor etiological factors 
are: fulness of habit, age, organic disease, alcoholism, 
severe exertion after decompression, and unfamiliarity 
with the work, all of which, with the exception of or- 
ganic disease, militate unfavorably for the patient. As 
those with organic disease are generally rejected, obser- 
vatious concerning its effect on this disease are not at 
hand. One sufferer with emphysema, who came under 
the notice of Snell, was always in better health when 
working in compressed air. Temperature and hygro- 
metric conditions of the air lock seem to bear no relation 
to the illness. 

In an essay on “ The Effects of High Atmospheric Press- 
ure, Including the Caisson Disease,” Dr. Andrew H. 
Smith, of New York, describes the symptoms induced 
by entering highly compressed air. These, with a few 
additions, are: (1) Ringing in the ears and impairment of 
hearing; (2) increased frequency of respiration; (8) in- 
crease in the pulse rate to 120, with subsequent fall to 
the normal; the pulse is reduced in volume, and there are 
pallor and sallowness of the skin; (4) the temperature of 
the body, an hour and a half after entering the caisson, 
is elevated about one degree, but when the atmosphere 
within the caisson is warmer than the external air, the 
body heat may rise as high as 101° F.; (5) the skin is cov- 
ered with perspiration, but this is because of the satura- 
tion of the surrounding atmosphere, and not from any 
increase in the amount of the secretion; (6) increase of 
appetite; (7) dysphagia at times; (8) fatigue; (9) increase 
of urine of about normal specific gravity (probably be- 
cause of diminished evaporation from the skin). No al- 
bumin is present. 

The pathological effects mentioned are: (1) Rupture of 
the drum membrane and inflammation of the middle ear; 
(2) epistaxis or hemoptysis; (8) itching of the skin; (4) 
neuralgic pains, which may come gradually or suddenly, 
in the extremities or in any part of the body; when in 
the lower extremities, they are commonly known as 
“bends”; (5) epigastric pain and vomiting; (6) paralysis, 
both sensory and motor, most frequently of the lower 
limbs, but, notwithstanding the paralysis of sensation, 
the pains continue; (7) the cerebral symptoms are: head- 
ache, dizziness, double vision, incoherence of speech, and 
sometimes unconsciousness. These symptoms are usu- 
ally temporary. “Death occurs only in cases which are 
severe from the first, and are marked by symptoms of 
serous or sanguineous effusion about the brain or cord.” 
“The constant lesion in fatal cases of caisson disease is 
congestion of the brain or spinal cord.” “It is the removal 
of the pressure, and not the pressure itself, that is the 
immediate cause of the seizure,” which occurs usually at 
the time when the victims are coming from under the 
pressure, or even some hours subsequently. The blood is 
driven by the atmospheric pressure from the surface into 
the bones and bony spaces, skull, and spinal canal, the 
vessels of which parts become dilated, and when the 
external pressure is removed, they do not readily con- 
tract to their normal size. Lloyd believes the lesion to 
be destructive or necrotic, due to the deprivation of blood. 
Congestion of various organs has been observed. Areas 
of softening in the brain and cord have been described. 

According to Lloyd, the exact pathology of this dis- 
ease is not perfectly clear, and, indeed, as Smith believes, 
it may vary in different cases. Several theories have 
been advanced: congestion followed by, blood stasis; 
lowered vascular tone; revulsive anemia; extreme de- 
struction of body tissues not followed by proper elimina- 
tion; excess of oxygen. 

Much can be done to prevent caisson disease. Due 
precautions should be taken for the thorough ventilation 
of the air chamber, as this is one of the most important 


547 


Cajeput, 
Calamus, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





prophylactic measures. Care and experience will often 
admit of the engineering work being carried on ata much 
higher level than would ordinarily be thought possible. 
The length of time which the workman spénds in the 
compressed air should be intelligently regulated—much 
depending on the degree of pressure. The “locking-out” 
process must be attended to most carefully. The work- 
men ought to be taught how tocare for themselves. The 
following points should be emphasized: the method of 
inflating the ears; hygienic precautions while in the 
chamber; rest, and a warm drink, preferably coffee or 
beef tea, after decompression, together with a change to 
warm clothing. The chamber should be lighted by elec- 
tricity. 

As to curative treatment, the remedy that Smith pro- 
poses for this condition is ergot, with morphine as re- 
quired to relieve pain. Recompression affords the great- 
est relief to the pains if the patient is seen soon after their 
onset. Liniments are approved by some, but discarded 
by others. Bandaging is often efficacious to relieve pains 
in the extremities. Salicylate of soda has been used. 
Inhalation of oxygen has been suggested in view of the 
theory of retained carbonic acid gas. Electricity has not 
met with much success. Complications must receive the 
ordinary treatment indicated in such cases. When ver- 
tigo is obstinate and persistent, tonics seem to afford the 
greatest relief. Charles E. Hackley. 

Emma EH. Walker. 


CAJEPUT, OIL OF.—Olewm Cajeputi. <A volatile oil 
distilled from the leaves of Cajeputa Leucadendron (L.) 
Rusby (fam. Myrtacee). This species is a rather small, 
fragrant tree, with irregularly growing slender branches, 
and a thick, soft, exfoliating bark. The leaves are 
bright, smooth, narrow, entire, pointed at each end, par- 
allel nerved, and often oblique or curved; they are twisted 
upon their petioles so as to stand with vertical surfaces, 
like phyllodia. The tree is a native of numerous islands 
in the Indian archipelago, especially of Borneo, Celebes, 
and Amboyna. It is also extensively found, if a broad 
view is taken of the species, in Australia and on the main- 
land of Asia. Most of the oil is obtained from Celebes, 
and exported by way of Javan or Indian ports. 

Oil of cajeput is extracted on the spot from the fresh 
leaves, which are first softened by maceration in water, 
and then subjected to distillation in rude copper stills. 
It is filled into once-used wine and beer or other Euro- 
pean bottles for exportation. It was first introduced 
into Europe in the early part of the eighteenth century. 

It is a pale green, transparent, mobile fluid, with a fra- 
grant mint or camphor-like odor, and bitterish aromatic 
taste. It has the usual physical properties of the essen- 
tial oils. It is very similar to its near relative, oil of 
eucalyptus, containing the same constituent, cineol, 
along with terpineol and other bodies. Specific gravity 
of the oil, about 0.926. The green tint is generally 
ascribed to some compound of copper received from the 
still, or introduced into the oil intentionally. The color 
may be separated by several methods of rectification, and 
the oil obtained clear and white. 

AcTION AND Usge.—Cajeput has the stimulating prop- 
erties of camphor and the essential oils in general, and 
stands between the most irritant of them, like oil of tur- 
pentine, and the milder mint oils. It is more extensively 
used in the Indies and Eastern islands than here—in some 
places being given for nearly everything, but is particu- 
larly popular for colics, diarrhoeas, and even cholera, as 
well as for chronic rheumatism, chronic vesical catarrh, 
etc. Here it is not often given internally, but has no 
doubt some value in non-inflammatory intestinal disturb- 
ances, where an aromatic stimulant and antispasmodic is 
needed, being in these cases very much like camphor, and 
like this may be very suitably combined with opium. 
Externally it is a mild rubefacient, and a good ingredient 
for stimulating liniments in chronic rheumatism, old 
sprains, etc.; it may be also useful for psoriasis, scaly 
eczema, etc., and is a fairly efficient parasiticide. As a 
stimulant diuretic in chronic vesical catarrh it is as good 


548 





often as large as the 





as most others of its class. Cajeput is the basis of nu- 
merous toothache and earache drops. It is often adulter- 
ated. Dose, from 1 to 5 dgm. (ij. to viij.) dissolved in 
spirit, suspended in mucilage or syrup, or on a lump of 
sugar. There are twenty or thirty drops to the gram. 
W. P. Bolles. 


CALABAR BEAN. — Puysostiema. Ordeal Bean, 
Chop-nut. “The seed of Physostigma venenosum Balfour 
(fam. Leguminose)” (U.S. P.). This plant is a large, 
climbing, perennial vine, with trifolioiate leaves and the 
general appearance of an enormous bean vine. The stem 
is woody below and 


wrist. The showy 
purple flowers are 
nearly as large as 
those of the sweet- 
pea, and hang in 
loose racemes. The 
large pods contain 
two or three seeds 
each. The “beans” 
are very hard, ob- 
long, slightly 
curved or kidney- 
shaped, from 2 to 3 
cm. in length, and 
about 1.5 cm. broad 
(.75 to 1.25 in., by 
.) in.), and covered 
with a roughish but 
shining -chocolate- 
brown or brownish- 
red testa. <A broad, 
shallow, black 
groove or furrow 
extends along the 
convex border and 
around one end of 
the seed; it con- 
tains the raphe. The kernel is exalbuminous and con- 
sists mostly of the two large, white, brittle cotyledons, 
whose faces are concave and enclose an air space which 
enables the entire seeds to float upon water, although when 
broken the fragments are denser than water. The taste 
and odor of the seeds are simply bean-like, and give no 
suggestion of the deadly poison which they contain. 

The plant grows about the mouths of the Old Caiabar 
and Niger rivers in tropical West Africa. It has been 
transplanted to India, Brazil, and other places, where it. 
flourishes. Physostigma is an ingredient of the poison- 
ous mixture which persons accused of witchcraft or crime 
are compelled by the savage chiefs of these African tribes. 
to take as an ordeal or punishment. The draught is usu- 
ally rapidly fatal, unless vomiting occurs. It was first. 
known in England about 1840 as a curiosity and poison, 
but not much employed in medicine 
until Fraser, of Edinburgh, about 1863, 
discovered its specific power of con- 
tracting the pupil, since when it has 
been in rather frequent use by oculists. 
and in occasional use in internal medi- 
cine. Besides forty-eight per cent. of 
starch and about twenty of albuminoid 
matters, with a little oil and gum (sub- 
stances which are contained as well in 
the common bean, and which are en- 

tirely inert), the drug in question con- 
tains three alkaloids, with physosterin, a fatty or choles- 
terin-like substance, which occurs in the Calabar bean 
in common with other leguminous seeds, and which is. 
inert. 

Physostigmine or eserine is the principal alkaloid. 
Calabarine is apparently a derivative of the former, while. 
eseridine can be converted into physostigmine. The 
action of physostigmine dominates that of the drug, es- 
pecially as that of eseridine is very similar. Calabarine 


ol ee 





Fic. 1068.—Calabar Bean Vine; Flowering 
Branch, Reduced. (Baillon.) 





Fic. 1069.— Cala- 
bar Bean, Two- 
Fifths Natural 
Size. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cajeput, 
Calamus, 





acts antagonistically to the others, but is in such small 
amount as not greatly to modify the drug’s action. The 
action of Calabar bean will therefore be discussed under 
Physostigmine. 

_ Except in the form of the alkaloid, calabar bean is but 
little used. It has been rather thoroughly experimented 
with for its depressing action upon the nerve centres in 
various diseases involving central excitability, and espe- 
cially in tetanus; but the results cannot be regarded as 
encouraging. Some benefit has resulted from its use in 
checking the paralysis of insanity, and it often does good 
as an intestinal laxative. We have an official extract, 
the dose of which is .006 to .03 gm. (gr. #5 to 4), anda 
fifteen-per-cent. tincture, the dose of which is .6 to 2 c.c. 
fo x.2O, XXX.). 

Physostigmine or Eserine (C:sH2.Ns302). The chemis- 
try of this alkaloid, and its relations to the bodies asso- 
ciated with it, are but imperfectly known. Formerly, 
the two names were believed to represent two alkaloids, 
but it was subsequently ascertained that one was merely 
an impure form of the other. It is almost always used 
in the form of its salts. The pure alkaloid occurs in the 
form of colorless crystals which are soluble in both alco- 
hol and water, slowly in the latter. They are very hy- 
groscopic and quickly lose their characters if exposed 
to dampness or light. Of the numerous salts, the most 
important are the hydrochloride, sulphate, and salicylate, 
the two last being official. The sulphate (C:;H2:N30.)s,- 
H.S0,, a white or whitish crystalline powder, which is 
the salt most used, is very soluble in both water and alco- 
hol. The salicylate, C:;H2:N;02,C;H.Os, in white crys- 
tals, is less soluble, namely, in one hundred and fifty 
parts of water or twelve parts of alcohol. The hydro- 
chloride, Ci:;H2)N;02HCl, is soluble in water. 

Action.—The physiological action of eserine is power- 
ful and characteristic, and has been very extensively 
studied. Except in large poisonous doses, its chief 
action is upon the secretion and involuntary muscular 
movements, through the cells and fibres, or their nerve 
endings, or both. The secretions of the entire alimen- 
tary system, excepting perhaps the bile, are markedly 
increased, in which particular a close similarity to 
pilocarpine has been noted. The perspiration and tears 
share in this increase. At the same time, the activity of 
the gastric and intestinal muscles is greatly augmented 
also. The effect upon the stomach may be such as to cause 
vomiting, especially by large doses, poisoning being thus 
avoided. More or less nausea is frequent. If vomiting 
does not occur, then purgation may, owing to a similar 
effect upon the intestinal muscles, combined with the in- 
creased secretion. Looseness of the bowels is an ordinary 
symptom. Uterine contractions may be induced. Coin- 
cident with these effects, and evidently of the same gen- 
eral nature, is the contraction of the pupil and ciliary 
muscle. In all these directions, the drug is directly an- 
tagonistic to atropine, and one drug can be used to coun- 
teract the other, to a great extent. Strychnine, while 
directly antagonistic to physostigmine in its central 
effects, strangely enough produces, through the spinal 
centres, many symptoms similar to those produced by 
the latter through peripheral action. In the voluntary 
muscular system, there is increased irritability of the 
fibre, and apparently stimulation of the nerve endings 
also. This produces muscular twitchings among the 
most prominent of the early symptoms of poisoning. It 
is apparently due to bronchial spasm that respiration is 
slightly interfered with. This interference acts asa respir- 
atory stimulant, and the respirations are early increased 
both in number and force. At the same time there is a 
marked rise of blood pressure, though this is quite irreg- 
ular. The heart is continuously and powerfully slowed 
from the start, due apparently to direct action upon it, 
but the beat is strong. There is the widest disagreement 
as to whether primary central stimulation occurs and is 
partly responsible for these symptoms. Whatever may 
be thé primary central effect, depression of the motor 
centresis early and powerful. If the dose has been large, 
and isnot vomited, paralysis may be very sudden. There 





may then be almost no preliminary symptoms, or the 
muscular twitchings may amount almost to convulsions. 
With increasing cardiac slowness, weakness and reduced 
blood pressure supervene; but this effect is not so marked 
as respiratory depression, which is the immediate cause 
of death. 

Usres.—Physostigmine salts have been used, as already 
stated, for the same purposes as Calabar bean, in doses 
of .001 to .008 gm. (gr. gy to +5). Their chief use, how- 
ever, is for instillation into the eye, in solution of one- 
per-cent, strength or weaker. The effect is to produce, 
at the end of a half-hour, a very powerful contraction of 
the pupil, which lasts for ten or twelve hours, and mark- 
edly to decrease intraocular tension, after a brief in- 
crease. It thus becomes of service in overcoming the 
interference with vision induced by the use of atropine. 
Efforts have been made, with some success, to destroy 
iritic adhesions by its use. 

Pseudo-physostigmine is an alkaloid having apparently 
the same composition and properties; it is derived from 
cali-nuts or false Calabar beans, the botanical origin of 
which is doubtful. Henry H. Rusby. 


CALAMUS. SWEETFLAG.—The rhizome of Acorus 
Calamus L. (fam. Aracew). An endogenous perennial 
with a thick, fleshy, long and branched horizontal root- 
stock, and a few very long and narrow (.5 to 1 m.) linear 
equitant leaves. The flowering scape is also long and flat- 





Fic. 1070.—Rhizoma of Acorus Calamus, Showing Cicatrices of Ad- 
ventitious Roots. (Baillon.) 


tened, like one of the leaves, and bears at its apex a 
straight, solid, fleshy, cylindrical spadix from 5 to 10 
cm. long. Flowers perfect, small, crowded. A long, 
leaf-like bract or “spathe” (Bentley and Trimen) arises 
at the junction of the spadix and scape, and, proceeding 
in a straight line, looks like a continuation of the scape, 
while the really terminal spadix is diverted to an angle 
with the axis, and appears to be lateral. Sweetflag is 
indigenous in parts of Asia, as Asia Minor, India, etc., 
and in some parts of Europe and North America, but 
has been so extensively spread and naturalized by human 
intervention that it is found in nearly the whole north 
temperate zone. It grows either in the water or in 
swampy and shady places, and is very variable in size, 
All parts of the plant are slightly aromatic, the leaves 
least so, but for medicinal use the rhizome only is em- 
ployed. It should be gathered in the autumn or spring, 





Fig. 1071.—Transverse Section of the Same. - (Baillon.) 


washed, cleaned, and dried. In Germany it is generally 
peeled or scraped before drying; but while the appear- 
ance is improved by this process, the strength and qual- 
ity are deteriorated, and this is not authorized by our 


549 


Calcification. 
Calcium, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Pharmacopeia. Although it grows in great abundance 
in the swamps of the United States, a large portion of 
what we use is imported from Europe or Southern Russia. 

Calamus comes in pieces of from 10 to 30 cm. or 
more in length, by 1 or 2 cm. in thickness (from 4 to 12 in. 
x 4 in.); it is shrivelled and lightly flattened, marked 
by frequent and very distinct rings and remains of 
leaf scales, and below is covered with the circular scars 
of the roots. It is pale or reddish brown externally, 
white and spongy within. Its texture is very light, 
being traversed by large air spaces separated by only a 
single row of cells. A cross-section shows these as large 
holes, and the walls as a lace-like reticulation, varied 
with occasional woody bundles (see Fig. 1071). The oil 
cells are like those of the general parenchyma, but larger, 
and are generally situated in the angles formed by the 
confluence of three or four of the partitions, as shown in 
the section. 

The principal constituent is the oil, of which it con- 
tains two or three per cent., a yellowish or brownish, 
very fragrant liquid of specific gravity 0.9. It also con- 
tains the glucoside acorin, which is a soft, resinous sub- 
stance, with a bitter, aromatic taste, resin, starch, tannin, 
gum, and a minute amount of the alkaloid calamine. 

Calamus is a pleasant tonic, aromatic-bitter, applicable 
to all the purposes for which such remedies are used. 
Dose, from 2 to 4 gm.; of the oil, from gtt. x. to gtt. xv. 

No other species of Acorus has any special value. 

W. P. Bolles. 


CALCIFICATION.—(Calz, lime; fio, to become.) Con- 
version of tissue into chalky matter by the deposition of 
lime salts. It is not unusual for solid particles, either 
crystalline or amorphous, to be deposited in the tissues 
throughout the body, and when the area so affected is 
large enough to be perceptible, it is said to be calcified 
or petrified. Chemically, calcareous matter consists 
chiefly of calcic and magnesic phosphates and carbonates. 
Calcification should be distinguished from ossification; 
for in the former there is no formation of bone, but merely 
a deposit of calcareous matter. Under the microscope 
the tiny particles look dark and opaque by transmitted 
light, though when in masses they are glistening. Not 
infrequently they look like fat, but are soluble in dilute 
mineral acid, and often give off gas bubbles from the 
decomposition of earthy carbonates. These tissues 
show a change in staining properties, hematoxylin, e.y., 
producing a dingy bluish-violet color. This applies to 
the carbonates and phosphates of lime, not to the oxalate. 
Calcification takes place in various tissues, both in the 
cells and in the intercellular substance; but the type most 
apt to be affected is connective tissue which has already 
degenerated to the hyaline stage and from which the 
nuclei have entirely or almost disappeared. Dying tis- 
sue seems to have a kind of attraction for the lime salts 
in solution in the body, entering into close combination 
with them. However, the process does take place at 
times in tissues which have undergone no apparent 
change, especially in old age when the lime salts are un- 
dergoing more rapid absorption. There is a curious 
affection called myositis ossificans progressiva, in the course 
of which some of the muscular fibres undergo calcifica- 
tion. Again, the myocardium may be affected by the 
same type of degeneration, and the heart-muscle fibres 
become hardened by lime salts. A well-known example 
of calcification is seen in the walls of arteries where it 
follows fatty and atheromatous degeneration and sclero- 
sis. “Calcification of the intima is a common terminal 
process of arterio-sclerosis” (Osler). The coats affected 
are the intima and the media. When the latter is involved 
there occurs what is known as annular calcification, in 
which the artery—most commonly medium-sized—devel- 
ops into a rigid tube. The arteries most apt to be at- 
tacked by calcareous degeneration are the aorta and its 
larger branches, the arteries of the extremities, of the 
brain, of the heart, and of the spleen, as well as disused 
arteries, such as those of a stump and of the senile uterus, 
Veins are sometimes affected, though rarely, the most 


550 


common instance being the walls of the varicose veins. 
The valves and orifices of the heart are a frequent seat 
of this degeneration. Other tissues undergoing this 
change at times are fibrous or fibro-serous membranes, 
e.g., the pericardium, walls of hollow organs, the dura 
mater, pia mater, and choroid plexuses, when it is known 
as “brain sand.” Cartilage, nerves, and various glands, 
organs, and tumors are at times the susceptible part. 
Calcification may occur in tubercle. The cheesy nodules 
in the crypts of hypertrophied tonsils sometimes calcify. 
Calcification of areas of tuberculous lungs results often- 
times in “lung stones” which are afterward expectorated 
(Osler). This form of degeneration is sometimes con- 
nected with other morbid processes. ‘These lime-salt 
deposits may occur in two general ways. They may in- 
filtrate the tissue of an organ which continues to retain 
its original relation to surrounding parts (é.g., calcifica- 
tion of the membrana tympani), or they may incrust parts 
of tissue which are separated from their normal surround- 
ings, or foreign bodies which have entered the body pre- 
viously. In the first instance there results calcification ; 
in the second, concretions or calculi. On the other hand, 
concretions at first free from surrounding tissue may later 
become firmly attached, or calcified tissue may separate 
from its surroundings and become free. 

The Etiology of this degeneration is generally traceable 
to a lowered vitality of the tissues, which may depend 
on various conditions, such as old age or insufficient 
blood supply with slow circulation. But it is not con- 
fined to old age, as it is exceptionally observed in in- 
fancy, as well as in adolescence and middle age. In the 
latter period, it is due to various cachexie, such as gouty 
or syphilitic, while it is always an accompaniment of 
chronic kidney disease. The precedence of other forms 
of degeneration has been noted. Sometimes there is an 
excess of lime salts in the blood. In certain instances 
the tissues are unable to assimilate the fluid in which the 
salts are in solution. In other cases the carbonic acid 
which holds the salts in solution escapes, thus causing 
the deposit. Certain diseases of bone in which its salts 
are rapidly absorbed, or in which there is obstruction to 
renal elimination, are often associated with calcification. 
In the latter case the kidneys are particularly affected. 
The kidney epithelium is especially susceptible in cor- 
rosive sublimate, bismuth, or aloin poisoning (Ziegler). 

The process is attended many times by alarming Symp- 
toms, the nature of which depends upon the location and 
extent of the trouble, eg., apoplexy, angina pectoris, 
aneurism, senile gangrene of the extremities, and various 
forms of cardiac disease. But the symptoms due to sim- 
ple degeneration of arteries are often very indefinite. 
Calcification is at times the sign of cessation of some 
morbid process, as, é.g., in tuberculosis, where the dis- 
eased foci may be rendered inert by the development 
of this degeneration. 

The Diagnosis of this condition may sometimes be made 
by touch, as in the case of a peripheral artery. Calcare- 
ous particles may be discharged from the body; or the 
presence of the degeneration must be inferred from the 
symptoms caused by it. 

Treatment of this condition, particularly when it is 
found to be present in the walls of the blood-vessels, 
consists in forbidding excitement or excesses of all kinds, 
both bodily and mental. Emma E. Walker. 


CALCIUM.—1. GENERAL MEDICINAL PROPERTIES OF 
ComMpounDs OF CaLciuM.—In the group of metallic ele- 
ments represented by the metals of the alkalies and of 
the earths, calcium is distinguished, in its relations with 
the animal economy, by its comparative inertness. The 
medicinal characteristics of lime preparations as a class 
are lowness of diffusion power, and hence difficulty of 
absorption, slight local tendency to repress secretion, 
and slight constitutional tendency to oppose degenera- 
tive processes in tissues. Individually, the calcic com- 
pounds differ greatly in their properties, and thu§ arise 
many individual therapeutic applications, to be noted 
under the several preparations. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


¢ 


2. THE CoMPoOUNDS oF CaLciuM USED IN MEDICINE.— 
The compounds of calcium that enter into the pharmaco- 
peial preparations containing the metal are the monozide, 
hydroxide, carbonate, phosphate, sulphate, hypophosphite, 
chloride, bromide, sulphide (in the preparation sulphurated 
lime), and the compounds, whatever they be, that form 
the substance called chlorinated lime. In the present arti- 
cle will be discussed only the monowide, hydroxide, car- 
bonate, phosphate, and sulphate. For the other com- 
pounds above cited, see, respectively, Hypophosphites, 
Chlorides, Bromides, Sulphides, and Chlorine. 

Caletum Monoxide: CaO.—Calcium monoxide in the 
form of the ordinary “ lime,” or “ quicklime ” of commerce, 
is official under the simple title Calz, Lime. It is offi- 
cially described as “ hard, white or grayish-white masses, 
which, in contact with air, gradually attract moisture 
and.carbon dioxide, and fall toa white powder; odorless, 
of asharp, caustic taste. Soluble inabout seven hundred 
and fifty parts of water at 15° C. (59° F.), and in about 
thirteen hundred parts of boiling water; insoluble in alco- 
hol. Soluble in diluted acetic, hydrochloric, or nitric acid. 
When sprinkled with about half its weight of water, lime 
becomes heated, and is gradually converted into a white 
powder (calcium hydrate or slaked lime). When this is 
mixed with about three or four parts of water, it forms 
a uniform smooth magma (milk of lime). Even at the 
highest degrees of heat lime remains unaltered and does 
not fuse. Its aqueous solution gives an intensely alka- 
line reaction with litmus paper” (U. 8. P.). Because of 
the strong affinity of lime for water, it should be kept in 
tightly closed vessels in a dry place. Lime is obtained 
from some of the varieties of native calcium carbonates, 
or from white marble or oyster shells, by calcining. 

Physiologically the importance of quicklime lies in the 
fact that because of its intense affinity for water it is 
caustic. Toa moist surface it is powerfully escharotic, 
and since the product of the caustic action (slaked lime) 
is a nearly insoluble solid, the action is non-spreading. 

In practice, quicklime is rarely used by the surgeon, 
except in the form of the composite preparation, potassa 
with lime (Vienna caustic), for whose description see 


under Potassium. 


Caleium Hydroxide : Ca(OH),.—Calcium hydroxide is 
the familiar substance, slaked lime, which forms in the 
shape of a white powder as the product of the chemical 
reaction between lime and water. The reaction is at- 
tended by the development of a high degree of heat. 


Slaked lime is not official in the United States Pharma- _ 


copeia under any distinctive title, but the preparations 
into whose composition it enters are defined as prepara- 
tions of lime simply. Slaked lime is a soft, white, bulky 
powder, of a mawkish, alkaline taste, and having the 
solubilities detailed above in the pharmacopeeial descrip- 
tion of lime. Although a powerful free base, it is not 
caustic to living tissue, because of its difficult solubility 
in water. Combining as it does, therefore, the qualities 
of harmlessness and high alkalinity, it is valuable as an 
antidote—so far as antidotes go—in poisoning by acids. 
Especially is it to be selected in cases of poisoning by 
oxalic or sulphuric acid, because of the great insolubil- 
ity of the salts it makes with these several acids. For 
medicinal purposes, proper, slaked lime is used in the 
valuable pharmacopeeial preparation commonly known 
as lime water, but officially entitled Liquor Calets, Solu- 
tion of Lime. This is simply a saturated aqueous solu- 
tion of slaked lime, easily made by any one by stirring 
freshly slaked lime into water—fairly pure water free 
from salts—in any proportion greater than 1 to 750. 
The vessel containing the resulting solution is to be 
kept tightly stoppered, with the excess of undissolved 
lime retained. After the settling of the undissolved 
portion, the clear, supernatant liquor may be drawn 
off in small quantities, for use, by decanting or siphon- 
ing. The object of having an excess of lime lies in 
the fact that lime water has a great affinity for carbon 
dioxide, absorbing this gas from the atmosphere and 
forming with it the insoluble calcium carbonate. By 
such reaction the lime of lime water gradually becomes 


Calcification, 
Calcium, 


exhausted, but by the device of keeping in the containing 
vessel an excess of lime, the water of the solution re- 
charges itself therefrom as fast as it loses strength by 
carbonating, and the solution of lime is thus maintained 
steadily at saturation. Lime water is “a saturated, aque- 
ous solution of calcium hydrate. . . . The percentage of 
calcium hydrate varies with the temperature, being some- 
what over 0.17 per cent. at 15° C. (59° F.), and diminish- 
ing as the temperature rises” (U.S. P.). Although clear 
when first made, lime water, upon keeping, is certain to 
become turbid froin absorption of carbon dioxide from 
the atmosphere, and the formation thereby of calcium 
carbonate. If, however, there be, as above advised, an 
excess of lime in the bottle, the turbidity does not mean 
loss of strength, and a sample so affected is perfectly 
good for medicinal purposes. Lime water is incompati- 
ble with alkaline carbonates, sulphates, borates, salts of 
ammonia and the metals, acids and acidulous salts, and 
astringent vegetable decoctions or infusions. 

Lime water is, of course, alkaline, and at the same time 
is, physiologically, locally bland and soothing to irrita- 
tion, with a tendency to check secretion. Taken inter- 
nally it operates to allay gastric irritability and to control 
diarrhoea, especially when the diarrhoea is caused by acid- 
ity of the intestinal contents. From the conjunction of 
properties named, lime water is an excellent alkaline 
wash in skin disease, and is a standard remedy to subdue 
vomiting and combat the diarrheea of acidity. In its in- 
ternal use by far the best way of giving is in mixture 
with fresh, ice-cold milk. In such mixture, even when 
“half and half” in strength, the disagreeable lime taste 
is almost wholly lost, while at the same time the medici- 
nal efficacy of the lime is enhanced, and the patient is 
nourished by the milk. In obstinate vomiting, indeed, 
nothing surpasses the administration of small quantities 
of ice-cold lime water and milk, frequently repeated, to 
the exclusion of all other medicine and nutriment, both. 
In ordinary cases, the lime water need not be in greater 
proportion to the milk than one part to two, three, or 
four. If the stomach be not too sensitive, such mixtures 
may be administered quite freely; but yet the habitual 
use of lime water in milk, in milk-fed individuals, such 
as infants, is objectionable. For occasional use, lime 
water is so innocent that it is hardly possible to assign 
any exact dose, but a tablespoonful generally suffices for 
a single giving, to be taken in at least an equal measure 
of water or milk. A special application of lime water is 
based on the fact that the tissue of false membranes im- 
mersed in the solution rapidly disintegrates. Hence the 
practice with some to spray the throat, in croup or diph- 
theria, with atomized lime water. In such procedure, 
however, it must be remembered that in the amount of 
spraying practically possible, the quantity of lime water 
brought into contact with the membrane is very small, 
and the duration of the contact short. 

Lime water, although decidedly alkaline, is not readily 
absorbed, and consequently is useless for constitutional 
alkalizing. For such purpose, alkalies of high diffusion 
power, such as the basic compounds of potassium or lith- 
jum, must be used rather than lime. 

Besides lime water, the United States Pharmacopeia 
offers, as a preparation of lime in solution, Syrupus Cal- 
cis, Syrup of Lime. This syrup is made by treating a 
triturated mixture of lime and sugar with boiling water, 
and bringing the solution after filtration to the standard 
strength of 6.5 per cent., by weight, of lime. In this 
procedure the lime and sugar chemically unite, and the 
product, while retaining the alkalinity and physiological 
properties of free lime, is yet much more soluble in water, 
as the percentage strength of the syrup attests. Syrup 
of lime is therefore, medicinally, a sweetened and at the 
same time a strong solution of lime, and may be used 
for the internal applications of lime water, only in much 
smaller dose—one-eighth, namely, of what would be 
given of the latter-named preparation. 

For local application of the soothing properties of lime 
solutions, an excellent and ingenious preparation of lime 
is official in the United States Pharmacopceia under the 


551 


Calcium, 
California, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





title Linimentum Oale’s, Lime Liniment, often called 
Carron oil, from the Carron Iron Works, in Scotland, 
where the liniment acquired great reputation for the 
treatment of burns among the workmen. The prepara- 
tion is simply an admixture, in equal parts, of lime water 
and linseed oil, whereby a lime soap is formed, which 
being insoluble makes an emulsion with the considerable 
excess of the oil prescribed by the formula. The oil, 
however, readily separates from the aqueous portion, and 
hence the preparation should be well shaken each time 
before use. Lime liniment combines the protection of a 
fixed oil with the alkaline and soothing properties of 
lime, and makes an excellent dressing for painful affec- 
tions of the skin, such as burns, both allaying pain and 
promoting healing. It is applied clear. 

Calcium Carbonate : CaCO;.—Calcium carbonate is rep- 
resented in the United States Pharmacopceia by two prep- 
arations. Oreta Preparata, Prepared Chalk, is the native 
article freed from most of its impurities by elutriation; 
and Oaletii Carbonas Precipitatus, Precipitated Calcium 
Carbonate, is the carbonate obtained as precipitated from 
a solution of calcium chloride by reaction with sodium 
carbonate. Prepared chalk is in the form of powder, or 
of little conical pellets, and the precipitated carbonate is 
always in the condition of a very fine soft powder. Both 
preparations are permanent in air, odorless and tasteless, 
and insoluble in water or alcohol, although soluble, with 
effervescence, in hydrochloric, nitric, or acetic acid. 

Calcium carbonate closely resembles slaked lime in its 
properties, but, being a salt, is less strongly alkaline, and, 
being wholly insoluble in neutral fluids of aqueous basis, 
is, locally, absolutely bland. It is medicinally applica- 
ble, in a general way, for the same purposes as lime 
water, and, in addition, because it is a bland, soft, and 
alkaline absorbent powder, it makes an excellent “ dust- 
ing powder” to apply as a dressing to skin affections in 
which the cutaneous surface is moist and tender. Inter- 
nally the carbonate is available as an antidote to acid 
poisoning, especially if the acid be sulphuric or oxalic, 
and is of use to correct idiopathic acidity of the prime 
vie, and to allay nausea and check diarrhea. Being per- 
fectly innocent, either of the forms of the salt may be 
given freely. For ordinary use in digestive derange- 
ments the single dose ranges from 0.65 to 3.00 gm. (gr. x. 
to xlv.). The medicine may be given as a powder, but 
administration in mixture is morecommon. The follew- 
ing pharmaceutical preparations are official in the United 
States Pharmacopeeia: Pulois Crete Compositus, Com- 
pound Chalk Powder. This consists of three parts of 
prepared chalk, two of powdered acacia, and five of 
powdered sugar, mixed. This powder is probably offi- 
cial as the basis for making the next named preparation, 
but yet is itself a convenient chalk powder for direct 
prescription. Mistura Crete, Chalk Mixture. This is 
compounded of two parts of the foregoing compound 
chalk powder and four parts each of water and cinnamon 
water, The sugar and acacia of the compound chalk 
powder dissolve and the slightly viscid solution resulting 
is capable, when shaken, of holding the chalk in suspen- 
sion. The preparation should be freshly made for use, 
and should be shaken each time before dispensing a dose. 
It makes a very convenient basis for diarrhoea mixtures, 
especially in cases of diarrhcea with acidity. It may be 
given in tablespoonful doses. Tvrochisct Crete, Troches 
of Chalk. Each troche contains 0.25 gm. (about gr. iv.) 
of prepared chalk with a flavoring of nutmeg. 

Normal Caleium (Ortho-) Phosphate: Ca3(PO,4)2.—This 
is the phosphate commonly called, for distinction, bone 
phosphate. It is official under the title Caleii Phosphas 
Precipitatus, Precipitated Calcium Phosphate, and is 
made by dissolving the phosphate of bone ash by means 
of hydrochloric acid, and then precipitating it from the 
solution by the addition of water of ammonia. Such pre- 
cipitate, washed and dried, presents itself as “a light, 
white, amorphous powder, odorless and tasteless, and 
permanent in the air. Almost insoluble in cold water; 
partly decomposed by boiling water, which dissolves out 
an acid salt; almost insoluble in acetic acid, except when 


552 





freshly precipitated; easily soluble in hydrochloric or 
nitric acid; insoluble in alcohol” (U. 8. P.). When 
freshly precipitated and still moist this phosphate also 
dissolves wholly in lactic acid. 

Calcium phosphate is an important normal ingredient 
of the animal body, being the calcareous element of the 
bones and teeth. The use of the salt in medicine has 
been its internal administration in conditions of disease 
where there appears to be a deficiency of the substance 
in the proper tissues, either from assumed lack of sup- 
ply or from want of power of assimilation. Such con- 
ditions are illustrated by rickets, mollities ossium, caries 
of the teeth, and possibly by scrofula and phthisis. But, 


_as often happens in medication based on purely chemical 


considerations, the clinical results frequently fall short of 
the expectation, so much so that many practitioners put 
but little faith in the present remedy. Very likely-the 
lack of effect of calcium phosphate is principally due to 
the difficulty of determining the absorption of the salt, 
partly because of the salt’s entire insolubility in other 
than acid menstrua, and partly because of its low diffu- - 
sion power. But inasmuch as the phosphate is wholly 
innocent, locally and constitutionally, it may with pro- 
priety be tried in cases in which it seems indicated theo- 
retically. From 0.65 to 2.00 gm. (gr. x. to xxx.) may be 
given three times a day, larger doses probably being use- 
less through lack of absorption. A convenient form of 
the medicine is the official preparation of the United 
States Pharmacopeeia, entitled Syrupus Caleti Lactophos- 
phatis, Syrup of Calcium Lactophosphate. Precipitated 
calcium carbonate is dissolved in dilute lactic acid, and 
to this solution phosphoric acid is added. After certain 
necessary trituration, the solution of the lactophosphate 
is filtered, sweetened, and flavored with orange-flower 
water, and then brought to standard strength by the 
addition of water. Twenty-five parts, by weight, of 
calcium carbonate is used to make one thousand measures 
of the syrup. Shoulda gelatinous precipitate tend to 
form upon keeping, a fluidrachm of hydrochloric acid 
may be added to each pint of the syrup. The prepara- 
tion may be given in doses of from two to four tea- 
spoonfuls, representing from 0.20 to 0.40 gm. (gr. iij. to 
vi.) of phosphate. 

Calcium Sulphate : CaSO.,2H.O.—This salt is used in 
medical art only in the making of plaster-of-Paris dress- 
ings. Calicum sulphate occurs native in several condi- 
tions, the commonest being the salt combined with two 
molecules of water constituting the substance gypsum. 
The valuable property of gypsum is that when dehy- 
drated and treated with water it recombines with the 
latter, and in such combining sets in a hard, dry mass. 
Gypsum is dehydrated by heat, which should not exceed 
120° C.; for if carried too high (above 204° C.) the gyp- 
sum—called then technically dead-burnt —recombines 
with water but slowly and the product does not solidify. 
As properly dehydrated and pulverized the product is a 
white powder, without odor or taste, called burnt gypsum 
or plaster-of-Paris. Plaster-of-Paris is official in the 
United States Pharmacopeia under the title Caled? Sul- 
phas Exsiccatus, Dried Calcium Sulphate. Mixed with 
two parts of water, plaster-of-Paris makes a soft, creamy 
paste, which in the course of from fifteen to twenty 
minutes gradually stiffens, until at last it sets into a 
perfectly hard and dry mass. During the setting a mod- 
erate degree of heat is evolved (not beyond the range 
perfectly bearable by the human skin), and the mass very 
slightly expands. Applied, therefore, as a casing to a 
limb, the dressing may be perfectly fitted without fear of 
shrinkage upon setting. After setting, the plaster-of- 
Paris neither softens nor dissolves by treatment with 
water, the solubility of calcium sulphate in water being 
only about one part in five hundred. For use in surgery 
the plaster-of-Paris paste may be applied by smearing it 
upon the bandaged limb so as to form a casing, but a far 
better way is to impregnate a flannel bandage thoroughly 
with the dry plaster, roll it loosely, and when the dress- 
ing is to be fitted dip the roller into a vessel of water 
until bubbles cease to be evolved and then apply in the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Calcium, 
California, 





usual manner, but without reverses. Before so apply- 
ing, however, the skin should be protected by a plain 
bandage, or, where appropriate, by a thread glove or a 
stocking. 

Plaster-of-Paris should be kept in well-closed vessels, 
else, attracting moisture from the atmosphere, it will be- 
come partially hydrated. Edward Curtis. 


CALCULI.. See Concretions. 
CALCULI, CUTANEOUS. See Milium. 


CALEDONIA SPRINGS. — Post-OFrricr. — Caledonia 
Springs, Ontario, Canada. Hotel, the Grand Hotel. 

Access.—From Montreal and Ottawa by Canadian Pa- 
cific Railway, or by the Ottawa Navigation Company 
steamers. 


Analysis, by Sterry Hunt. In one thousand parts: 




















: : ae White Duncan or 
Solids. 9 oe ne Sulphur | Intermittent 

IST BRA A> SIMA Sc Spring Spring. 

Chloride of sodium ...... 6.9675 | 6.4409 3.5430 2.2500 

Chloride of potassium....| .0309 0296 0230 0805 

Chloride of calcium ...... ieiets ao ih omagee 2870 

Chloride of magnesium .. tiga Aree le Pickett 1.0338 

Bromide of sodium....... 2150 .0169 0100 

Bromide of magnesium .. Saac Soaliet \ cea 0238 

Iodide of sodium......... 0005 -0014 

Todide of magnesium .... oer ius eeullamaeeetres 0021 

Sulphate of soda......... .0053 0048 .0183 

Carbonate of soda........ 0485 1762 4558 

Carbonate of lime........ 1480 | .1175 2100 | 1264 

Carbonate of magnesium.| _.5262 5172 2940 8672 

Carbonate of iron........ Trace. | Trace. Trace Trace. 

PARTELLUS seplgree Giatsic'e'cs vie sles 0044 sate 0026 

PUMICE eres vleieisiein tale oieisiers oe 6 0310 «0425 0840 .0225 

TeOti 7.3470 4.6407 14.6433 








These springs are carbonated saline, mildly charged 
with carbonic acid gas. There escapes with the water 
of the Gas Spring a large amount of carbureted hydro- 
gen gas. The water of the White Sulphur Spring con- 


tains sulphureted hydrogen equal to about one cubic 
inch per gallon. 


The springs are situated on a level 





CALENDULA. MARIGOLD.—< The florets of Calendula 
officinalis L. (fam. Composite)” (U. 8. P.). These florets 
are strap-shaped, nearly half an inch long, three-toothed, 
hairy upon the tube, of a bright yellow color, pistillate, 
with a two-branched style. The odor is characteristic, 
the taste aromatic and bitterish. They contain a little 
volatile oil and an amaroid, with resin and an abundance 
of the bright yellow coloring matter, Calendulin, which 
is inactive. The drug possesses very slight aromatic- 
bitter properties, but is chiefly used for coloring pur- 
poses. It is now much less used than formerly, and 
will doubtless be omitted from the next edition of the 
Pharmacopeeia. The dose is 1 to 2 gm. (gr. xv. to Xxx.). 

The herb possesses similar properties, but is even 
weaker and contains much more mucilage. It has been 
used similarly, as well as for making poultices. Through 
an error, this, instead of the florets, was incorporated in 
the preceding edition of the Pharmacopceia. 

Henry H, Rushy. 


CALIFORNIA, SOUTHERN.—In this article only a 
brief and general account of the climate of Southern Cali- 
fornia wiil be given, as the principal resorts and sections 
will receive especial mention under their respective heads, 
in regular alphabetical order. 

Southern California is an irregular area of territory, 
equal in extent to England and Wales, lying between 
latitude 35° 40’ and 82° 30’, with a coast line of 380 miles. 
It is bounded on the north by the Tehachapi Mountains, 
which are spurs of the coast ranges and Sierra Nevada; 
on the east by the Colorado River; on the south by the 
Mexican frontier; and on the west and southwest by the 
Pacific Ocean. In the western portion is the southern 
coast range, forming the eastern boundary of the coast 
plain, w hich contains numerous beautiful v alleys, such 
as the Santa Claraand Santa Buena Ventura. This coast 
plain extends for 150 miles, and is from 15 to 25 miles in 
depth. Between the coast range and the Sierra Madre 
and San Bernardino ranges lies the interior plain, 200 
miles in length and from 15 to 30 miles in depth. Here 
is the great. San Gabriel Valley, which has been called 
the Lombardy of America, and numerous lesser valleys. 
“Between the coast plain and the long interior valley, 





Fig. 1072.—Bay of San Diego, Southern California. 


plateau which extends for many miles in all directions, 
the country being open and well cultivated. The Grand 
Hotel is commodious and comfortable. The manage- 
ment is excellent. All modern methods for utilizing the 
waters are at hand, and a physician resides at the hotel 
during the season. There are also a number of boarding- 
houses and cottages on the grounds, all of which are 
under the controi of thecompany. The hotels are open 
from June to October. 

The Caledonia Springs are the best known of Canadian 
mineral springs, and are resorted to by large numbers 
from Canada and the United States, particularly from 
the South. In addition to the water consumed at the 
springs large quantities are bottled and sent to all parts 
of Canada and the United States. Beaumont Smalt. 





the coast range of mountains is broken, and, opposite the 
Los Angeles plains, entirely disappears for a space. The 
whole country becomes thus a great open coast-land fac- 
ing the south, and with the hig h Sierra for a back- 
eround. ”* North and east of the Sierra, or inland range, 
lie the Mojave and Colorado deserts. It is with the resorts 
on or near the coast, or with those in the interior plain, that 
we have especially to deal as climatic stations, such as 
Santa Barbara, San Diego, Coronado Beach, on the coast; 
or, farther inland, Riverside, Redlands, San Bernardino, 
and others. The soil iscomposed largely of disintegrated 
granite, which is sandy and porous, ‘and in many Tocali- 
ties there are also large patches of adobe or red clay. 


* “ California of the South,’ by Walter Lindley and J. P. Widney, 1888. 


553 


California Geysers. 
California, 
































REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


























SAN DIEGO, LATITUDE, 32° 43’; LONG-||SANTA BARBARA, LATITUDE, 34° 28’;/|LOS ANGELES, LATITUDE, 384° 3/5 
ITUDE, 117° 10’, LONGITUDE, 119° 41’, LONGITUDE, 118° 5’. 
Climatic Data. 
Jan. |April.| July. | Noy.| Winter | Year.|| Jan. |April.} July. | Nov.|Winter | Year.|| Jan. |April.| July. | Nov.|Winter | Year. 
Temperature— 
Average or normal ....| 53.6° | 57.7° | 67.1° | 58.2°| 54.5° | 60.4° || 51.2° | 60.5° | 66.8° | 56.0°/54.01°| 60.7° || 54.1° | 58.0° | 71.1° |62.0°| 58.5° | 62.0° 
Average daily range...| 17.8 | 14.1 | 11.6 |18.1 | 16 14.3 || 18 18 19 25 ciowje | LOL 2001.) 20:2) 28.0 aie 
Mean of warmest...... G1.8591/68:82 75.0.0 66: Oul enn cule neat omnes 69.2 | 62.3 «+e || 62.9 | 69.2 | 82 70.7 
Mean of coldest........ 44.5 | 51.2 | 61.9 | 48.7 42.8 | 52 69.7 |53 42.8 | 49 58.9 | 46.2 
Highest or maximum ..| 78 87 86 85 83 86 89 82 82 94 98.1 |86 
Lowest or minimum... .| 32 39 54 33 38 i 44 40 30 39 51.2 |34.2 
Humidity— 
Mean relative.......... 71.2% | 72.4% | 76.4% |66.4%| 70.9% | 72.9% || 71% | 67% | 72% 64% 73% || 62.9% | 70.1% | 69.4% |57.3%| 63.6% | 66.6% 
Precipitation— 
ane in inches ..... 1.85} 0.68] 0.02) 0.70) 6.04] 9.49 || 3.7 1.4 LG WALT | ATi a.9 1.3 .95| 8.65} 18 
Wind— y 
Prevailing direction ...| N.E.| W. W. |N.W.| N.E. | W. Wie N.E.| W. W.. IN. Bal ON Benen vy 
Average hourly velocity 
in Miles Seen eset 5.1 6.6 6.3 5.1] 5.4 5.9 4.3 5.3 5.1 3 4.6 || 5.5 5.4 4.9 4.9] 5.4 5.1 
Weather— 
Average number of 
clear days.:. nse. scn 11.3 | 10.2 8.2 | 13.5 | 33.5 | 122.7 || 24 16 27 13 231 17.5 |10.2 | 10.4 | 18.8 171.3 
Average number of fair 
OAYSick cee vateeas tices D127 419) 6S 10 ease abo 6 3 9 63 8.5 | 12.5 | 19.7 9.3] 26.6 | 144.8 
Average number of 
clear and fair days...| 22.5 | 22.1 | 24.8 | 23.5 | 67.2 | 277.8 || 25 22 30 22 294 26 22.7 | 30.1 | 28.1) 74.5 | 316.1 


























The main features of the climate of Southern California 
are warmth, equability, a large amount of sunshine and 
a small amount of annual rainfall. “Taken as a whole,” 
says Professor Hilgard, “Southern California corresponds 
in its climatic features and adaptation to the Mediterra- 
nean region of Europe and Africa; a grand Riviera with 
a partial background of the desert as well, where the 
date palm and ostrich finda congenial home, and alluvial 
plains equalling in riches the famed delta of the Nile.” 

“Warm winters, comfortably cool summers, very low 
rainfall, and rainfall so distributed as to divide the year 
into a dry and aso-called rainy season, almost unparalleled 
preponderance of cloudless weather, and (in consequence 
of the low latitude) a long duration of the daily sunshine 
in winter—all these are characteristic of every portion of 
Southern California. In comparative humidity of the 
atmosphere lies the chief difference between its coast 
stations and those lying at a greater or less distance from 
its coast line” (Huntington Richards). 

“The warmth and equability of this climate depends,” 
says Dr. C. F. Williams,* “upon three factors: its south- 
ern latitude, its protection by the various mountain ranges 
from cold, northerly or easterly winds, and the influence 
of the Pacific, and especially the warm Kuro Siwo, or 
Black Japan current, which washes the shores of the 
Western States.” 

There exists a certain misapprehension regarding the 
matter of dryness of this climate. For example, as good 
an authority as Lindsay refers to it as “intensely dry.” 
Williams calls ita “dry, warm climate,” and Remodino 
remarks that “every term in the meteorological vocabu- 
lary relative to moisture and dryness has been conscien- 
tiously applied to the region.” The fact is, that the 
coast districts, like all other coast resorts, exhibit the fea- 
tures of a marine climate, one of which is a large amount 
of moisture, and upon this fact, as we know, depend 
the coolness and equability characteristic of such a cli- 
mate. 

If one would find real dryness he must, as Solly says, 
seek it beyond the mountains in the desert country. If, 
however, “he seeks more days of sunshine and opportu- 
nities for outdoor life, with a more equable temperature 
and an average humidity a little greater than that of 
New York or Boston, he can find what he desires at 
Santa Barbara or San Diego.” Even as far inland as 
Riverside, more than 50 miles from the coast, the humid- 
ity is appreciably greater than at Aiken, for example, 
and very considerably greater than at most of the Colo- 
rado, New Mexico, and Arizona resorts. Still further, 
one must bear in mind the fact, as Solly says, “that, in 
spite of the great amount of sunshine during the day in 
California, the foggy and damp nights and mornings 


*** Aero-Therapeutics,”’ 1894. 


504 





























take up a great part of the twenty-four hours.” This. 
authority notes the following observation made by him- 
self at Redlands: “On one occasion when at 4:30 P.M. the 
relative humidity, as indicated by the hygrometer, was 
fifty-five per cent., at 6 p.m. it had increased to eighty 
per cent.” ““The difference between noonday and mid- 
night temperature,” says Kate Sanborn,* “between sun 
and shade, is something to be learned and guarded 
against.” 


RIVERSIDE, 60 MILES FROM THE Coast, 850 FEET 
ABOVE SEA LEVEL. 




















Jan April July Noy. Year. 
Mean monthly temp.. 53.1° 61.2° 77.0° 62.2° | 62.0° 
Maximum temp...... 78.2 89.2 101.2 89.2 
Minimum temp ...... 32.7 39.2 60.5 39.5 
Relative humidity.... 67% 1 56% 2 63% 3 76%4 | 67% 
Precipitation— 
Average in inches 3.27 1.43 1.35 | 10 
Wind— 
Prevailing direction aun. Siete S. W. W. 
Weather— 
Average number of (1890) 
clear Gays.tacne.: 16 20 29 15 208 
Average number of 
Tair: Gays. ese. s 105 
Average number of 
cloudy days...... 14 9 1 10 52 











From July, 1885, to July, 1886, there were 280 absolutely clear days, 
and 38 days of rain or showers. 


1¥For the spring of 1888. 2Summer of 1888. 
4 Winter of 1888. 


3 Autumn of 1888. 


The accompanying tables of climatic data of San 
Diego, Santa Barbara, Los Angeles, and Riverside exhibit, 
so far as such statistics can, some of the principal cli- 
matic features of this region. As there isno government. 
weather station either at Santa Barbara or at Riverside, 
the figures for these places must be considered as only 
approximately correct. A general similarity will be 
noted in the climates of all these places. As one goes 
inland the relative humidity is seen to lessen. The num- 
ber of fair and clear days is very large, the precipitation 
very small, the prevailing winds are from the west, and 
there is no great wind velocity. At Riverside, a distance 
of 50 miles or more from the coast, the maximum tem- 
perature, especially in summer, is seen to increase. A 
peculiarity of this climate, not indicated in climatic 
charts, is the great difference between the character of 
the atmosphere during the day and during the night. At 
night the humidity is greatly increased, an example of 
which has already been noted in the case of Redlands. 
This increase of moisture by night renders the air chilly 





*** A Truthful Woman in Southern California,” 1895, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


z 





California, 
California Geysers, 








and raw, and in many cases would prevent the free ad- 
mission of night air into the sleeping-rooms. Even dur- 
ing the day this chilliness is experienced in passing from 
the sunshine into the shade, and when the wind blows. 

Another peculiarity is the frequent night fog, present 
not only on the coast, but extending many miles up the 
valleys. These fogs, which are most prevalent during 
the spring and summer, appear about nightfall and dis- 
appear during the early forenoon. Occasionally they 
persist during a part or the whole of the day. The an- 
nual mean average number of foggy nights at Los An- 
geles, for thirteen years, was 57. In 1891 there were 22 
fogs in San Diego, 12 in 1893, and 26in 1894. At Santa 
Barbara there were 73 fogs in 1894. 

The rainfall, which is small in any event, except on 
the highest summits, occurs in the winter, which is the 
rainy season. This rainy season, however, varies very 
greatly from year to year. Sometimes the rain is delayed 
for weeks, and then it may rain continuously for days. 
One cannot predict from the annual average precipitation 
what the rainfall will be for any single year. For in- 
stance, Los Angeles has a normal precipitation of 18 
inches, but in 1881 it was 5.6 inches, and in 1884, 40.5 
inches. The normal of San Diego is 10 inches, but it has 
had a minimum of 3.71 inches and a maximum of 25.97 
inches. The heaviest rainfall occurs in the months of 
December, January, and February. Even January, how- 
ever, may be a very dry month. In the desert regions 
there is almost no rain. Thus, for instance, at Indio the 
annual average for nine years was 2.32 inches. It is to 
be remembered, as Solly points out, that even in the 
rainy season the monthly rainfall is not usually more 
than the normal monthly rainfall for Eastern cities, and 
there are longer periods of fine weather. “The welcome 
rains,” he continues, “bring a vivid green to the brown 
valleys and hills, and the beautiful ‘ procession of flow- 
ers,’ Which continues from December to May, enraptures 
Eastern visitors.” 

Regarding the winds there is one point which the tables 
do not show, and which, as Widney says, most impresses 
the observer in his study of this meteorological factor, 
and that is, their regularity. One can be assured that 
at certain seasons of the year the wind will blow from a 
certain quarter, and rise atacertain timeeach day. Fur- 
ther, he knows that if the wind blows from a certain 
quarter, certain climatic conditions will follow: if it 
blows from one direction a moist atmosphere and rain 
will result; if from another, a dry atmosphere, cold in 
winter, hot in summer; if from still another, there re- 
sults clear, cool weather with moderate moisture. 

Much has been written about the great variety of cli- 
mate to be found in Southern California. For instance, 
Dr. Edwards writes* thus: “ Within a few hours from 
any given point one may obtain the climate to his liking.” 
Such sweeping statements are manifestly misleading, for 
where in any inhabitable locality in Southern California 
can be found the cool, dry air furnished in the elevated 
plains of Arizona, New Mexico, or Colorado, at such re- 
sorts as Tucson, Santa Fé, and Colorado Springs? 

In addition to the favorable climatic conditions of this 
marvellous section of country, there is the fascinating 
charm of beautiful and diversified scenery—sea coast and 
mountain—with varied and luxuriant vegetation. 

A great variety of fruits of both tropical and temperate 
regions are produced here: oranges, lemons, grapes, figs, 
olives, guavas, piheapples, pears, peaches, and straw- 
berries all the year round. Riverside has its famous 
Magnolia Avenue and orange groves; Sierra Madre its 
vineyards; Santa Monica its ostrich farm; and San Diego 
its beautiful Coronado Beach, which Charles Dudley 
Warner calls, in “Our Italy,” “An unique corner of the 
earth.” The temperature of the sea water is 60° F. or 
more throughout the year, so that one can enjoy sea 
bathing at any time of year. There are also abundant 
opportunities for hunting, fishing, camping, riding, and 
almost every kind of outdoor diversion, If we consider 





*** Two Health Seekers in Southern California,” 1897. 





all this, and the fact of an almost continuous sunshine, 
we can understand how outdoor life becomes a delight 
hardly imaginable until realized. 

Here, also, one cannot only take the open-air treat- 
ment, but, while doing so, can, if strength permits, oc. 
cupy himself in making a new home, and in light and 
pleasing work in garden and vineyard. As Dr. Richards 
says: “Southern California is not only a good winter resi- 
dence, but a health-giving and health-restoring home for 
residence all the year round.” 

Formerly—and to a large extent at the present time— 
Southern California was considered one of the most favor- 
able resorts in this country for pulmonary tuberculosis, 
and probably more invalids suffering from this disease 
frequented this region than any other class. Moreover, 
no discrimination appears to have been made regarding 
the stage or condition of the pulmonary trouble suitable 
for this climate. In the writer’s opinion, this will not be 
so much the case in the future, since experience is prov- 
ing more and more conclusively every day that the sana- 
torium treatment of consumption is affording the best 
results, and that the situation of the sanatorium, climat- 
ically considered, does not make so much difference, 
provided pure air, a dry soil, freedom from high winds, 
and a reasonable amount of sunshine are assured. Almost 
every State can offer these simple climatic conditions, and 
hence can have its own sanatorium, 

This plan, moreover, possesses the further advantage, so 
much emphasized by the German phthisio-therapeutists, 
that the consumptive is treated under a climate like that 
in which, if cured, he will continue to live. 

There are no published statistics known to the writer 
of the results of treatment of consumption by the South- 
ern California climate, so that no comparison is possible 
with the results of other resorts and of sanatorium treat- 
ment. That this climate offers excellent opportunities 
for the open-air treatment of phthisis no one will deny, 
but that there is any striking advantage in it over that of 
many other resorts there are no statistics at hand to prove. 

In the writer’s opinion, Southern California, in the 
future, will be visited not so exclusively by consump- 
tives as heretofore, but by the large class of invalids re- 
quiring a mild, equable, sunny climate, with ample op- 
portunity for outdoor life and diversion; such as the 
feeble from age or inherited weakness, convalescents 
from various acute diseases, those suffering from malaria, 
catarrhal affections, chronic bronchitis, renal and cardiac 
diseases, scrofulous children, and those individuals who 
are in the quiescent state of pulmonary tuberculosis 
without pyrexia. Finally, to this list must be added 
that increasingly large number of persons who desire to 
escape the inclemency of a Northern winter. 

The conditions for which this climate is unfavorable or 
doubtful are phthisis with acute symptoms, certain dis- 
eases of the nervous system, laryngeal phthisis, eczema, 
asthma, and rheumatism. 

There has been much exaggerated and immoderate 
writing on the climate of Southern California, not infre- 
quently from selfish and commercial reasons, as also from 
superficial and inadequate knowledge. One physician 
writes of San Diego that it presents “all the factors req- 
uisite ina perfect climate.” Another, writing of Pasa- 
dena, says that it is “the greatest all-the-year-round- 
health resort in the world,” aud so on. 

Such wild statements, generally made without any 
accompanying meteorological data, seem quite unneces- 
sary in regard to a climate which in fact and truth pos- 
sesses so many points of excellence as does that of 
Southern California. Edward O. Otis. 


CALIFORNIA GEYSERS, THE. — Sonoma County, 
California. Hotel and cottages. This marvellous region 
is located in the northeastern part of Sonoma County, 
about 100 miles north of San Francisco, 16 miles from 
Cloverdale, and 26 miles from Calistoga. Formerly tour- 
ists rode on horseback for many miles to visit this realm 
of fumaroles and solfataras, which is situated about 1,700 
feet above the sea level; but, thanks to the push and 


555 


California Poppy. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 









































Calorimetry. 
ANALYSIS OF WATERS FROM SEVERAL SPRINGS AT THE CALIFORNIA GEYSERS. 
, a aps | & B eps 3 me) we | Pm) a MICOS mleo + 
& 2 hn so go Bo aoe, Ba ° BSo "Sto Ss oo $3 wo ES go nee 
awe | SEX) ES ES |SSES|(ae8| ESS | SSS | Ses (SEwSlaess| $2 
Contents per United States Gallon, | B25 | SER | Br mo, |b | Sao) Beas, | Cas aan Pinks eogr| Fk 
Expressed in Grains. dae) Sse | oe ga late Qesee! age 8a] cae Besa 2ogda saat 
S75 |FSe| Sf | Be [sseclgo | PES | See | S78 asesisess| (28 
a B| *8 | <& jFo<e) 5 S/4g8| 8 8) 4 8 /@g a/neoe a 
Potassium bisulphate..............ee00 7.53.| 0.42 1.14 
Potassium sulphate ......5....0c.seseee woe OK Soap Ban Ae 30n 0.21 rf 
Sodium bisulphate-.............ssseseee 53.91 | 39.82 9.62 5.14 Aha saree Risers ago 17.12 eats 98.16 
FLUE SEDI Pl AUC eraser relecotelevstolriereveratere hereraiays Ane Sut acct he 3.15 3.23 ceils 3.29 ane 2.36 
Sodium carbonates Anacae viecleleistesicle acietety one Fase Rislele AGS sieae eaters 1.40 
Calcium silpliate:-sanneasteiecnnee meer avy 6.98 4.44 3.81 5.84 1.10 3.32 fais 6.42 8.72 65 4.36 
Galetam Carbonate o.rc00+ «cease emcmenre ratte Revere aon Bissacs aes act ane 7.35 
Calcium Silicatercnen cent -bemadeuctintente ; Ac 10.18 
GaleiumPOrate cena tere se eect bac wore Meee nitior 4ecic 58np iooe Soup eats 6.62 
Magnesium sulphate .............000eee 40.73 | 9.62 91.29 | 34.49 | 16.66 2.52 sitet 59.33 | 41.12 wane 39.09 
Magnesium carbonate.............0..0- erie aes tae ‘isles nosis siereie 15.47 
Magnesium silicate ............s00+s0000 aoe a 15.46 
Magnesiumuborateen i stee ts 5 crests ett: Eaters Mets inate eo eek eres aver 17.31 
Tron sulphate Grins cwenswsecoere seeoece 12.25 16.63 7.34 .08 11 ALAC ; 28.81 16 
TOM: GAY DOMAUEC TE). ccisoistais aleloisie.cle'state'slesatore AGC betes iiviad cai Sets Sans 12 OF 
Alumintmesulpnateaencesceuchenenciie 82.02 2.04 20.62 63.82 Sons 20 Bains et 22.78 | 118.78 2.39 | 31.16 
Alnminasaeaces neete coma mcr neteide trea Rees 27 Rhee Sade 89 tase Li 18 
Free sulphuricacid)erceescnectree cess 31.82 154.37 6.45 es; At SoS on 32.30 5.75 110.64 
Hydrochloric aeid mrcrctsstitttestase tte 1.19 . ‘ 
Silicic acid wacthnace ose cnn ees 41 16.50 | 4.87% 21.11 17.2 3.50 | 17.25 .99 5.42 | 12.25 | 18.08 8.63 | 12.88 
Sulphureted hydrogen.................. Sat. Sat. Sat. Sat. Sat. Rietehe Rett Sat. Sat. Sat. Sat. Sat. 
BOTIC AGIA A asaitoriates acto sia eiele a creretstete acne meets Str. Traces Ae S05 aaa an* Str. Traces, 
Who] t Gaeemaionws sckanarine sano dacs 195.95 | 63.52 | 819.22 | 1388.81 | 29.62 | 47.58 7.12 | 33.39 | 150.20 | 221.26 | 38.12 | 296.24 




















enterprise of our Western civilization, it may now be 
reached in a comfortable six-horse stage from the termini 
of the Cloverdale and Calistoga railroads over excellent 
mountain roads. It is a good plan to go by way of 
Cloverdale and come back by way of Calistoga, as all the 
grandeur and beauty of the surrounding country may 
thus be seen. The following entertaining account of a 
visit to the geysers is taken from Dr. Anderson’s work: 

“Leaving Cloverdale after luncheon, comfortably 
seated in our stage, with an experienced and accommo- 
datingly communicative driver, who takes pleasure in 
pointing out the many objects of interest, we soon cross 
the Russian River and commence the ascent. The hills 
and mountains are robed in evergreen verdure of indig- 
enous flora, gigantic oaks, and towering pines. Here 
and there the huge boulders and rocky cliffs stand out in 
bold relief, and as we wind up and around the mountain 
sides, with the Pluton River many hundred feet below, 
basking and smiling in the afternoon sun, and rippling 
along its moss-covered banks and bright-pebbled bottom, 
with here and there a miniature cascade and waterfall, 
we feel that words cannot describe the grandeur of the 
scenery. ; 

“As we gain in altitude the view becomes more and 
more extended, until our eyes leap with vivid interest 
from peak to peak and valley to valley for miles around, 
feasting upon the beauties of nature. Some two or three 
miles down the cafon, before we reach the geysers, our 
attention is called to the large white or yellowish-white 
banks across the cafion. They are known as sulphur 
banks, and consist of deposits of sulphur and cinnabar, 
with incrustations of salts of sodium, potassium, magne- 
sium, sulphur, etc. . Near these sulphur banks are 
found the famous Indian Springs, at which Edwin For- 
rest camped for one season and was completely restored 
to health.” 

The waters are diuretic, laxative, and antacid, and are 
valuable in dyspepsia, torpidity of the liver and bowels, 
and in renal and cystic diseases. (See table for analysis.) 

Near by are the real “Indian Mud Springs,” which 
are highly extolled in the treatment of chronic rheuma- 
tism, gout, arthritis, and synovitis, and scrofulous and 
cutaneous contaminations. (See table.) 

“ . , After a few more horseshoe curves have been 
passed and several more magnificent landscapes have 
been mentally photographed on the brain, we reach the 
geyser resort. The many cosey cottages, the hotels and 
grounds, are situated in a leafy dell on the side of the 
mountain opposite the Geyser Cafion. The huge oaks 


556 




















and pines‘afford pleasant shade to the commodious ve- 
randas as we sit and enjoy the pure, dry, invigorating, 
and exhilarating mountain air and picturesque scenery 
which surround us on every side.” 

The geysers are wonderful and picturesque exhibitions 
of the nearly extinct volcanic forces slumbering beneath 
the romantic “Devil’s Cafion.” The region covers an 
area of about four hundred acres, most of the activity, 
however, being confined to the “Devil’s” or “Geyser” 
cafion, comprising about sixty acres. Collectively, the 
springs, hot and cold, flow about one hundred thousand 
gallons daily. 

From the foregoing analyses (see above) made by Prof. 
Thomas Price it will be observed that at the geysers can 
be found probably as great a variety of mineral waters as 
at any other place on the continent, or perhaps in the 
world. When the inprovements now contemplated are 
carried out, the “geysers” will be one of the world’s 
greatest sanatoriums. 

There are other geysers in various parts of California, 
but they have not so far reached any great importance as 
health resorts. Near Litton’s Station, in Sonoma County, 
some few miles from Geyserville, is a pleasant resort 
known as the “Geyser Spa” or “Soda Springs.” The 
surrounding country is picturesque, and the climate mild 
and salubrious. A large number of people go to Geyser 
Spa every year. The waters are highly esteemed for 
their antacid, diuretic, and aperient properties. The fol- 
lowing analysis was made by Dr. Winslow Anderson in 
1888: 


ONE UNITED STATES GALLON CONTAINS: 





Solids. Grains. 
Sodium CHOPIG GS: <<<. a/cce ape cress cals clerepers intel ecel state leteete ener 8.93 
Sodium: CATDOMALE.« .0.cn 2 1 cle sls stalalate «cise kk elee eee 4.97 
Sodium bicarhonate. ss ...5:0100.ccl ociips vie ecicle sacle cieeteiete 21.16 
SOMIUM SUlPHAtLE), ss: ais.0 0jecorsievesefoye/«: vier" oleveteiete:e oleate eae 2.60 
POSSUM CALDOMATE ww arsjetatateie eralaters ae eteneters Ria esieeeeanl Trace. 
Magnesitimt DiGATDODAtC icc cicieincietstaretatstetersietateleiets easier 9.03 
Magnesium stilphate vice. ccccines site sec enteenn ivaawenaae 1.14 
Calcium carbonate aeecicnw sec comes sishers telgiacatelementenieng 4.90 
HELLOUS CAL DOM ALG nus « celee seiaelciete aloes ayhieielsWasteeret 2.09 
SHIGA ass v.clc sie oate sarcae poles areialeteeoiere viele tre mates sae 3.75 
Organice thatter’...;4iscesceceis cues oe sea ened egies Trace. 

Total SOAS: v...<0cea noite ea(soie acim aeiente wena 58.57 


Carbonic acid gas, saturated. 


A previous analysis made by Bauer and Price yielded 
results almost identical with Anderson’s.  - 
James K. Crook. 


CALIFORNIA POPPY. See Eschscholtzia. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


é 


California Poppy. 
Calorimetry. 





CALIFORNIA SELTZER SPRINGS. — Mendocino 
County, California. These springs are pleasantly located 
in the Coast Range, 12 miles from Cloverdale. The sur- 
roundings are picturesque, and the climate salubrious. 
There are comfortable accommodations for visitors. 

On analysis the Seltzer Spring was found by Anderson 
to be composed as follows: 


ONE UNITED STATES GALLON CONTAINS: 





Solids. Grains. 

BAIR TIRENTEETIOET LG ons hese s\cis.24 <injsiais) siarays: 14i0/s}0:0\n,6.0je\6: 0,5 ©, (oaths 17.15 
PHSPEEEEIPATN CATON ACC cers clei cisichvicts tie isse.e tlersiavele sie Se nietee 53.00 
PRPERECHUY ODAC cence ce cictelstcipusiertis's « «ele e/sicjels e's'a/eaefo.el ate Trace. 
Magnesium carbonate....... ROU COBDS ASAT bite COA Dee ae 44.60 
ENS ET OU SNC vols ele niciaieialsieisinixin's a0, eseielo(ele\sicleis einieiaie.e al Trace. 
SPMCUIPIVICHT DONATES o sicccsiecanc's oc sdecveeteccncsecsaads 72.40 
SMT PU TEBE LECT farsi rores eto cin oies\5, svole'olassloierose,016efa\ololeisis seers 'o) ate Trace. 
Bee ea a Re Fa eaccter aly (ous, rae) ofa sheliscle, ere ie eNGl0' 0 k.d-s.5 0 Ooi nvevensvece Trace. 
BE CREEEINS CR PEAS Taleo: ons setae cies hse. cle sive usiciee tis Baie ela gies eiaels% 187.15 
PORES CLE DONIC ACI DAS. o:0'e cist oiciele Se viele cise as.cee 18.00 cu. in. 
PRETIUOLALIITS OL, WAL? sinc viciccielerctlsvislassiee seine e vie 57° F. 


The waters are sparkling and quite palatable. They 
have a diuretic and aperient action, and are beneficial in 
dyspepsia with acid eructations, constipation, acid states 
of the urine, cystitis, etc. They belong to the alkaline- 
carbonated class. James K. Crook. 


CALISAYA. See Cinchona. 


CALISTOGA SPRINGS.—Napa County, California. 
These valuable springs are situated 9 miles south of 
Mount St. Helena. Thereare two sets of springs, one in 
the city of Calistoga and the other just outside the town. 
They are very similar in chemical composition. There 
were at one time an excellent hotel and many fine cot- 
tages at the springs, but since the fire in 1868, which de- 
stroyed the former and several of the latter, the resort 
has changed hands many times, and has been allowed to 
run down. It issaid that the present proprietor contem- 
plates fully restoring the once handsome resort. 

The mineral springs number some twenty or more, and 
range in temperature from 75° to 186° F. They are used 
for drinking and bathing purposes, and have acquired 
considerable reputation. The following analysis of the 
water of one of the springs at Magnolia Hotel was made 
by Dr. Anderson: 


ONE UNITED STATES GALLON CONTAINS: 





Solids. Grains. 
RrMIGPIVSTTCTIEOVACLE ete cieteie'e:svele o!: choice siciovsias eraialelde os 6's eie'ele ois 20.76 
AMM AID SET OTA TC a cleieretsieve bie hve bie's v1 eim1e olelale’s <ipeieisiols cleo 5.10 
BURT IUEPIESAT IVECO ere tislslels,<.cisie o'vie s'e's(cisteta «lain teiaietelsie\e i's :b,¢ 1.75 
ENCED INES FOCLEULO tere tavere tris cious'es e.scce.s\clstbrereraaieisace.s 4/0 w/s\eiete e aie 16 
PPE MMUNLESELOCEC Coc onis an itic ve sicir tmisteie ai's'ere olere slervre oie vele“ere Trace. 
EPHESUS DEA UC wij cre iene lvisieyis ciitele* <ie/s\cle'c eisle orale aie's 2.90 
CHAITCIITT NA AVE gO Ene qpge es GOD OOEBODOCURO DOOCCOOOOneTE 5.57 
MGRICRRIa TEMPER T LES TAS St et ote ca. a ots choles e:asis'e' sins alele\e 6p xis(eleisivie o's .63 
ARRIVE  Reotel cca. o\etove cots Fever nisievsis sloinelela rove e sigeen «bss AT 
RECA m ea acie’. (ci ciatehers s sicuiee yi esiewis.e RasAMon npaorOun Ss 4.55 
MOUSE IUAGGOL) vic) osieie'sisie sigs «sive cco e\ecisie.e'e e viejo o.vie'e,v'6 Trace. 

PR PIE Saptce gle cleo eaie eicisicic’s wie ie cvs eleiess cioleie oiesne sie 41.89 
Free sulphureted hy@rogen 2aS.........eseeeeevees 4.75 eu. in. 
Temperature Of Water ....cccsccccncencesvcecsvens 95° F. 


The following analysis shows the mineral ingredients 
of the Hot Swimming Pool on the grounds of the late 
Senator Stanford: 

ONE UNITED STATES GALLON CONTAINS: 


Solids. Grains 

BURNT ERAS TO TEICTRCL Gtr eiclee in clas sistercle siecais'c, oon et 'e/oraces ore 019 a/a's 23.07 
PneTITT OLY DONEC i alaisc civ cieisieie ei cies vsclvlcnieicieree olVsiwiald sie 2.19 
GUI BUIPNALCs osc se ccc celectrcrcsnenessagecrseds 6.92 
Pera t AP EAT ENA ASCLL LO seis tare ic cistete s/e'ciaialols sisi a\sisisis eiejsinioatei's oisiniers's 13 
RAEN AL OPETITNI EOL LICLO (o cis: ots c 6, eleVsla/e (0) secois 6 o\o{nvtin a oidjsr0,016 a'p\e,e'si0,» 2. 
PEARSE CAT DODALO ere <lcisieie c's vlsic\a'ela o'>. c's) efelafe.e\elo.e)sisieies 76 
Magnesium sulphate........+.+-.s05+ mdalecsclt Beceninns 1.16 
Magnesium CHIOTICE.......ccccecsccerescscesevevecees 40 
MANCINI CHIGTIGE. . 2.050 cccccc cles cccreccevcvevccvece 96 
Calcium sulphate...........cccccscccvcs ASOOAOC AE CCT 1.25 
FELTOUS PPOLOKIGE, ....25.0ccccccccccrcecccnersssencss 45 
IMPANIDANCSE ss obeys viois oo vine vie sicinle vice nisieivin vin vie-0 se .010 eens Trace 
BAUER otto kcistrisininls Har Wasleiieise sirienmewnsneeis.e 6 ot 
ATL rad cine a Cotesia’ ounia.sioie svi ei'tls Wal aus| ortlercls)e.e.s\0© oie 3.61 
OTAANIC MAtter........cecvccevecsecssscseccveccscrers Traces. 

MS AITHO MUN core iaians circle aiainviclslc nits o'o aihie'elee uv ee cessive 41.98 
Sulphureted hydrogen Zas..........sseeeseeveveees 6.30 cu. in. 
Temperature Of Water ........2ceeeeecsceeenenene 121.6° F. 


The springs have gained considerable celebrity in ob- 
stinate cases of syphilitic contamination, rheumatism, 
ete. James K,. Crook. 


CALLOSITAS.—( Callus, Hardened Skin).—SyYNoNnymMs. 
—Callosity; Tyloma; Tylosis; Callus; Keratoma; (F7.) 
Durillon. 

DeEFINITION.—A circumscribed thickening and weld- 
ing of the horny layer produced by intermittent friction 
or pressure. 

Jallosities are congenital or acquired. The congenital 
callosities, however, are now usually discussed separately 
under the heading of Keratodermia or Tylosis Palme et 
Plante. The latter are diffuse or circumscribed kera- 
tomata, usually symmetrically distributed over the palms 
or soles, or over both, springing from an apparently nor- 
mal skin or surrounded by a red areola. Arsenic from 
prolonged use often causes a similar condition. 

Peculiar symmetrical horny hypertrophies are some- 
times associated with certain neuroses or unknown con- 
stitutional conditions; these are often preceded by mild 
inflammatory symptoms. The so-called syphilitic kerato- 
dermias should probably be placed with the latter class. 
The term callosity is more properly applied to the acquired 
form, which is essentially a result of external irritation by 
friction, by ¢ntermittent pressure, or rarely by chemicals. 
Continuous pressure or friction causes active inflammatory 
reaction, either vesiculation, or pustulation, or slough- 
ing. The result of this milder trauma is best seen upon 
the hands of mechanics, oarsmen, wood-choppers, and 
those whose occupations necessitate this irritation, as 
yellowish or yellowish-brown, circumscribed, round, or 
irregularly shaped flat or raised patches of thickened skin 
that are hard and resistant to the touch. They occur 
usually over the bony prominences or burs, and spring 
from apparently normal skin. 

Callosities may occur upon any portion of the body 
subjected to the exciting factor. The feet, next to the 
hands, are most frequently affected, due to walking bare- 
foot or to badly fitting shoes. 

This thickening of the horny cells is an effort of nature 
to protect the more delicate underlying structures. His- 
tologically there is probably no actual increase in the pro- 
duction of epithelial cells but a “welding” (Unna) to- 
gether of the pre-existing horny cells by the friction, into 
a homogeneous horny mass; thus the cells normally 
thrown off are retained, producing an apparent increase 
and an actual thickening. Except in those cases in 
which the condition results from a more violent trauma, 
no marked inflammatory symptoms, aside from a slight 
dilatation of the vessels, are seen. 

The acquired callosities can be differentiated from the 
keratodermias by the history and symmetry of the latter, 
though it must be remembered that in those who are 
particularly susceptible, very little friction may produce 
a marked callus. 

The syphilitic conditions of the palmsand soles usually 
begin in the centre and not over the bony prominences, 
spread peripherally, and at some points the horny layer 
is often split up or undermined. 

The treatment of callosities is first to remove the cause, 
whatever that may be. To soften and remove the thick- 
ened horny layer salicylic acid is the remedy par excellence. 
It can be used in form of a plaster (10 to 20 per cent.) or in 
flexible collodion (3 ss.-3i.). Either should beapplied for 
several days, when the affected part is immersed in very 
hot water for several minutes and the dead, macerated cells 
removed by gently scraping with a curette or dull knife 
blade. This procedure is repeated as often as necessary 
until the skin is reduced to its normal thickness, when a 
mild tar application will effectually complete the cure. 

William A. Hardaway. 


CALORIMETRY (L. calor, heat + Gr. pétpov, meas- 
ure) is the name applied to the process of measuring the 
heat given off from any body or substance; and a calo- 
rimeter is an instrument for making such measurement. 

Animal calorimetry is determining the heat produced 


557 


Calorimetry. 
Calorimetry. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





and the heat given off by an animal. This is accom- 
plished either by indirect or by direct calorimetry, each 
of which will be described in its proper place. A respi- 
ration calorimeter is one which is so arranged as to allow 
the inspired and the expired air to be analyzed at the 
same time that direct calorimetric observations are made. 

The unit of measure for heat in calorimetry is the calo- 
rie.* This is the amount of heat required to raise 1 gm. 
of distilled water 1° C.+ 

In work involving small amounts of heat this is com- 
monly used, and is often spoken of as a small calorie. 
Another unit, often called simply “calorie,” is the amount 
of heat required to raise 1 kgm. of water 1° C. This is 
called a large calorie (or sometimes a great calorie) to 
distinguish it from the small calorie. It is used when 
larger amounts of heat are to be measured. One large 
calorie =1,000 small calories. When the term “calorie” 
is used in connection with physiological experiments, the 
large calorie is generally meant. It will be so used in 
the present article. Other heat units in terms of different 
thermometer scales and different quantities of water were 
formerly employed in calorimetry, but their use is now 
being fast given upin favor of the calorie or large calorie 
—a change which is highly desirable for the sake of uni- 
formity. In engineering the B. T. U. (British thermal 
unit) is still widely employed even in papers of unques- 
tioned scientific standing. Its use in physiology was, 
for the most part, abandoned a decade or more ago. 

In physics and in chemistry calorimeters are mostly 
used for determining the specific heats of different sub- 
stances, for determining the heat of various combustions, 
and for determining the latent heat of fusion and of vapor- 
ization. It is not within the scope of the present article 
to discuss these methods or the instruments involved. 

In the sciences more closely allied to medicine, calorim- 
etry is used to study the phenomena of animal heat and 
its regulation in the healthy body—physiology; to study 
the same in fever—pathology; and to study the effect of 
drugs and poisons which influence body temperature— 
experimental pharmacology. The classic researches with 
the calorimeter in these fields will be discussed in the 
respective sections of this article, which for convenience 
of reference will be divided as follows: 

§ 1. Introductory and historical. 

$2. Indirect calorimetry. 

3. Direct calorimetry. 

4. Description of calorimeters employed in classical 
i 

5 


MUTT 


dical researches. 
. Calorimetry in physiology. 

3 6. Calorimetry in pathology. 

§ 7. Calorimetry in experimental pharmacology. 

$1. InrRopucToRY AND HisTorrcAL.—Our modern 
conception of animal heat, viz., that it is produced by 
the slow oxidation of combustible materials in the body, 
first became possible with the establishment of our pres- 
ent theory of combustion, which dates back to the last 
quarter of the eighteenth century, and is dependent 
chiefly upon the brilliant researches and conclusions of 
Lavoisier (1772-94). Prior to that epoch, there was a 
perfect chaos of speculative theories regarding animal 
heat. Haller taught that this heat was produced by the 
friction of the blood in the heart and in the vessels; that 
every heart beat put the tissues on a stretch, that be- 
tween the heart beats they rebounded by their own elas- 
ticity, and all these motions produced heat by friction. 
Summing up he says: “ De cordis primo insito calore nulla 


On 


m 


AW 1A 


a, 


*Tt is interesting to note that among physicists and chemists one 
sometimes meets the spelling calory and the pronunciation caléry or 
ca’/lory. Among physiologists the original spelling calorie is re- 
tained (this statement is made after consulting all the available text- 
books of physiology), as is also the pronunciation caloree’ in conformity 
with the spelling and older pronunciation. Lexicographers seem to 
prefer the spelling calory, but give both calory and calorie as cor- 
rect. 

+ Since the specific heat of water varies at different temperatures, 
this would be more accurately stated as the amount of heat required 
to raise 1 gm. of water from 15° C. to 16°C. See Berthelot, ** Thermo- 
chimie,’’ Paris, 1897, vol. ii., p. 5. 

¢ When very minute quantities of heat are to be measured, the 
micro-calorie is sometimes used. A micro-calorie is .001 small calorie. 


598 


dubitatio superest.” Van Helmont attributed animal heat 
to a vital spirit. Descartes ascribed it to a fermentation 
of the blood in the cavities of the heart. Hamberger 
held that the heat of the body was comparable to the 
heat of adunghill. All these theories had their followers 
at the time the combustion theory entered the field—the 
theory of Haller being, probably, the dominant one. 

Animal heat soon came in for its share of investigation 
in connection with the general question of the origin of 
heat which was occupying the attention of investigators 
in England and in France at the epoch referred to. 

The first calorimetric researches on animals were made 
by Crawford in Edinburgh, and an account of them was 
published (1779) in a pamphlet entitled “Experiments 
and Observations on Animal Heat and the Inflammation 
of Combustible Bodies, Being an Attempt to Resolve 
These Phenomena into a General Law of Nature.” In 
this work Crawford clearly secures for himself and for 
England the priority in calorimetric observations on ani- 
mal heat, and the title of his pamphlet, as well as the 
matter it contains, leaves no doubt as to his position in 
ascribing animal heat to an oxidation of combustible sub- 
stances in the body. 

Crawford’s work has not received the recognition it 
deserves, and, even in English books, one occasionally 
sees the statement that Lavoisier was the first to use the 
calorimeter in experiments on animal heat. Lavoisier* 
had already, in 1777, from his analyses of expired air, 
published the fact that in the lungs the air lost oxygen 
and took up carbon dioxide; but his calorimetric observa- 
tions were first published + in conjunction with Laplace 
in ne year following the appearance of Crawford’s pam- . 
philet. 

Unfortunately, Crawford used the nomenclature of the 
old phiogiston theory to which English scientists still 
clung, but he measured the heat given off by guinea-pigs, 
and he also analyzed the air they breathed during the 
experiment, and his conclusions, translated into the lan- 
guage of modern chemistry, may fairly be given as fol- 
lows: Both CO, and H,O are given off by the animal from 
its lungs. The blood brings back from the capillaries a 
combustible material for which the oxygen has a great 
affinity. Theoxygen unites with this and produces heat 
which the blood distributes through the body. The heat 
is produced in the process by which the O is transformed 
into CO, or H,O. “Animal heat seems to depend upon 
a process similar toa chemical elective attraction.” Con- 
sidering that the whole theory of chemical affinity was 
then in its infancy, one can hardly expect a more defi- 
nite statement than this from a pioneer series of experi- 
ments. 

It will be seen that Crawford places the seat of com- 
bustion in the blood in the lungs. In this he takesa 
view expressed by Lavoisier, two years before, although 
Lavoisier, contrary to the way he is generally quoted, 
clearly states the possibility that there may be only a 
gaseous exchange in the lungs, the true oxidation taking 
place farther back—a position now universally held to be 
the correct one. 

§ 2. InpDrREcT CALORIMETRY.—“ Indirect calorimetry ” 
is the name given to the method by which the heat pro- 
duced and the heat given off from the body are not meas- 
ured directly, but are calculated from the amount of oxy- 
gen used, and the amount of oxidized waste products 
given off from the body during a given period taken in 
connection with the body temperature. This method 
yields accurate results when the experiments are contin- 
ued uninterruptedly for a considerable time—say twenty- 
four hours—and when cognizance is taken of the com- 
position of the ingesta and of ali the waste products 
thrown off by the lungs, skin, kidneys, and intestines, and 
the temperature of the body is also carefully recorded. 
In many experiments the observers have considered only 
part of the waste products, and the experiments have 
been of short duration—one hour or less. While such 





*** Mem. de l’Acad. des Sciences,” 1777, p. 183. 
+ Op. cit., 1780, p. 355. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Calorimetry, 
Calorimetry, 








investigations may throw light on certain isolated points 
in connection with the chemical changes in the body, it 
must be said that any conclusions drawn from them, 
applying generally to the heat phenomena of the animal, 
are untrustworthy. This becomes apparent when we 
consider the nature of the chemical changes productive 
of heat which go on in the body. 

The greatest amount of heat made in the body is pro- 
duced by the oxidation of food, which is prepared for 
absorption by the digestion processes and then carried by 
the blood to the lymph which bathes the cells of the dif- 
ferent tissues. These living cells then slowly burn the 
combustible parts of the food, and throw the waste prod- 
ucts back into the lymph surrounding them, from which 
the said waste products are taken up by the blood and 
carried to different organs for removal—the excreting 
organ depending on the character of the waste. The 
food which is thus burned consists mostly of carbon, 
hydrogen, and nitrogen, witha certain amount of oxygen, 
but not enough to cause its complete combustion, so that 
to burn it, as is done in the cells, requires the use of a 
considerable quantity of the oxygen which we breathe. 
It must not be forgotten, however, that the oxygen in 
the food itself is just as potent as the oxygen we breathe 
for forming oxidized waste products. So it is clear that 
unless we know how much oxygen the food contains we 
cannot use the oxygen taken up in the lungs as an accu- 
rate measure of oxidation. 

Again, it is a well-known law in chemistry that when 
a highly complex molecule breaks down into more stable 
ones, there is a certain amount of energy liberated, and 
this energy is apt to take the form of heat. Now the 
food contains a large number of these highly complex 
molecules which break down into simpler ones and give 
rise to heat. The oxygen in the food is in different com- 
bination in different kinds of food, and the same oxidized 
end-product of the breaking down of one food may rep- 
resent a very different amount of heat from that which 
it represents inanother. This hasadirect bearing on the 
“heat equivalent ” of different food-stuffs. 

From the above it must be seen that a determination of 
part or even all the oxidized waste products will not give 
satisfactory data from which to calculate the heat pro- 
duced in the body, if the waste products alone are taken 
into consideration. 

Some experiments have been made in which calcula- 
tions of the heat produced have been made only from the 
CO, excreted. It is true that of all the elements of the 
food whose oxidation gives rise to heat, carbon is the 
most important, and it is also true that CO, is the chief 
waste product of such oxidation. It must further be 
granted that the amount of CO, given off by the lungs 
forms a rough and general index to the total amount of 
oxidation in the body, but this method is unreliable as a 
quantitative measure of heat produced, chiefly for the 
following reasons: 

(a) There is always more or less carbon in food which 
is not oxidized all the way down to COs, but stops at 
intermediate stages. The amount of carbon thus incom- 
pletely oxidized varies under different conditions which 
are not easy to control or to recognize. This partial 
oxidation gives rise to heat, and there is no CO, to show 
for it. 

(b) The oxidation of the hydrogen in food gives H.0 
as its end product. The amount of heat thus produced 
is considerable, and there is no CO, to show for it. 

(ec) The amount of CO, thrown off by the lungs de- 
pends toa large degree upon the depth of respiration, 
owing to changes in the partial pressure of CO: in the 
pulmonary alveoli. With shallow respiration an animal 
can store up a large quantity of CO, in the blood, and 
give this off if the respiration becomes deeper, so that 
for experiments of short duration a very considerable 
error may be introduced simply by the animal changing 
the depth of its breathing. 

(d) The condition of an animal, with regard to food, 
has a profound influence on both the heat produced and 
the CO, excreted, but they do not vary quantitatively 





together. Thisis shown by the following table compiled 
by Rosenthal * from the experiments of Senator and Lie- 
bermeister: 








CALORIES OF HEAT 








PRODUCED PER HOUR. 
Animal in Senator’s experiments. 
Measured by Calculated 
calorimeter. from COg. 
DOG As TOSI Oh ve trerscncieicie cleierers'e a clala olaversis 12.6 11.2 
STALVIN Gs ccievocvee cecaieecale Swe steve te 10.9 10.24 
during digestion .......... Actvern 18.9 16.0 
Dog By fasting so ian cee vetie vecie cei cere 16.5 14.1 
« during digestions. . ins ecc esc eece 19.4 15.4 
DOSIO. Tasting ensuecclcnemeniecite: dentine 16.9 10.24 
SIALUINS ae aineiteirsleteciseaennnn cr ont 15.3 9.6 
during digestion oe riers. oe ens 22.0 12.2 








It may be seen at a glance that the difference between 
the amount of heat measured directly by the calorimeter 
and the same value calculated from the CO, is consider- 
able, and that this difference varies with the food. The 
figures in the table are for one hour only, so that the error 
for a day might be twenty-four times ss great. 

Indirect calorimetry becomes accurate only when a 
careful analysis is made and the temperature recorded of 
everything (food, drink, air, moisture, etc.) which enters 
the body (ingesta); and the same is done for everything 
which leaves the body (egesta). The difference between 
the potential energy of the ingesta and of the egesta will 
represent the energy which the body availed itself of, 
and temperature records of the body will show how much 
of this has taken the form of heat. Such observations 
are excessively laborious—far more so than direct calo- 
rimetry. When made in connection with direct calorim- 
etry, however, they are exceedingly valuable, and to such 
experiments we owe one of the most important discoveries 
in modern science, viz.: that the human body obeys the 
law of the conservation of energy just like an inanimate 
machine—or, in other words, the fundamental laws of 
physics and chemistry dominate vital phenomena with 
all the rigor that they exercise in the inorganic world.+ 

Nearly all experimenters in the field of indirect calo- 
rimetry have employed modifications of the apparatus 
used by Regnault and Reiset,t or by Voit,$ in the classi- 
cal researches of these authors. For an excellent résumé 
and criticism of this work, with references to original 
papers, the reader is referred to an article by Zuntz on 
“ Respiratory Exchanges ” in Hermann’s “ Handbuch der 
Physiologie,” Leipsic, 1880, vol. iv., part 2, pp. 118-129. 

§ 3. Direct CALoRIMETRY.—Direct calorimetry con- 
sists in placing the body emitting heat in an appropriate 
apparatus (calorimeter) which will measure the amount 
of heat given off. 

Two widely different classes of observations in the field 
of calorimetry are of interest tous inmedicine. The one 
relates to the heat equivalent of foods, or, in other words, 
to determining the value of the different food-stuffs as 
energy-producers in the body; the other relates to the 
study of the animal body itself by means of the calorim- 
eter. ; 

Each class of researches demands different methods and 
different instruments. Those of the former class will be 
briefly touched upon here, while those of the latter will! 
be more fully described. 

The older method of determining the heat equivalent 


* Rosenthal, *‘ Hermann’s Handbuch der Physiologie,” 1880, vol. iy., 
part ii., p. 374. 

+ To be strictly exact, it must be said that the experiments in ques- 
tion have come up to ninety-nine per cent. of absolute accuracy. 
Considering the complexity of the experiments and the probable error 
involved, this is sufficiently close to warrant the above statement. 
For a fuller discussion of this interesting question the reader is referred 
to Rubner, “ Calorimetrische Methodik,”’ Marburg, 1891; Rubner, “Die 
Quelle der thierischen Wiarme,”’ Zeitschrift fiir Biologie, 1893; Rosen- 
thal, *‘Calorimetrische Untersuchungen,” Arch. fiir Physiologie, 1894 
and 1897; Atwater and Rosa, ‘“‘A Respiration Calorimeter,” etc., ** Re- 
port of Storrs (Connecticut) Experiment Station,’’ 1897; and Atwater 
and Rosa, and Rosa, * Physical Review,” 1899 and 1900. 

+t Regnault and Reiset, Ann. de chim. et de phys., 1849, (3), xxvi. 

§ Voit, Zeitsch. f. Biol., xiv., p. 122. 


559 


Calorimetry. 
Calorimetry. 





of a given food was to dry it carefully and then mix a 
known quantity of it with some chemical which would 
furnish oxygen, such as nitre or a mixture of potassium 
chlorate and manganese dioxide. This made a sort of 
gunpowder, which was detonated in a closed vessel sur- 
rounded by water, and the heat given off was measured 
by the rise in temperature of the water. 

An improved method, suggested by Frankland, was 
first practically applied by Berthelot in a special calo- 
rimeter which he devised. This is known as the bomb 
calorimeter, and is made so as to contain the food to be in- 
vestigated, with oxygen at a very high pressure (seven to 
twenty-five atmospheres). The food isignited by means of 
a platinum spiral heated white hot by an electric current. 


Berthelot found that in such an atmosphere the food was. 


completely oxidized. The bomb is immersed in water, 
and the heat given off is estimated from the rise in tem- 
perature of the water. There are many forms of calo- 
rimeters used for such determinations, but one of the two 
principles here outlined is at the bottom of all of them. 

These methods give accurate and valuable results. 
They are applied not only to studying the heat equiva- 
lent of foods, but are also used to determine the heat 
equivalent of partially oxidized waste products from the 
body, such as urea. It must not be forgotten that we 
utilize only part of the potential energy of many of our 
foods, so that to rate the value of different foods as di- 
rectly proportional to the figures in tables giving their 
heat equivalents would be a grave error. We are suffi- 
ciently acquainted with the metabolism of most of them 
to make a fair estimate of their true value as energy lib- 
erators in the body, but sn adequate discussion of that 
question would be too voluminous to be attempted here. 

Turning our attention now to the subject of direct 
calorimetric observations on animals, we may describe 
the process as follows: An animal is placed in one of the 
forms of calorimeter to be described in § 4, and the heat 
given off from the animal is determined in calories. This 
is known as the heat dissipated. If the temperature of 
the animal is the same on entering and on leaving the 
calorimeter, the heat produced must just equal the heat 
dissipated, for the animal brings out with his body just 
as much heat as he took in, and the heat dissipated while 
in the calorimeter must be exactly equal to what was 
produced there. If the temperature of the animal is 
higher on leaving than on entering the calorimeter, it 
shows that in addition to the heat dissipated and recorded 
by the calorimeter, there was an extra amount formed 
sufficient to raise the temperature of so much weight of 
animal so many degrees. In accordance with the laws 
of physics this extra amount may be found by the fol- 
lowing formula: 

x=wdh. In which— 

x = the extra heat formed and not recorded by calo- 

rimeter. 
w = weight of animal. 
d = the difference in the animal’s temperature between 
entering and leaving the calorimeter. 

h = specific heat of animal’s body. 

The total heat produced is then found by adding the 
value of z to the amdunt of heat dissipated. 

If the temperature of the animal falls while in the 
calorimeter, it shows that the heat dissipated and recorded 


by the calorimeter represents not only the heat actually | 
produced by the animal while in the instrument, but also» 


a certain amount of heat which is represented by the 
cooling down of so much weight of animal through so 
many degrees. In this case we 
amount of heat found by the above formula from the 
amount of heat dissipated and recorded by the calorim- 
eter, to get the true amount of heat produced during the 
time of the experiment. 

Direct calorimetry furnishes the most reliable means of 
studying variations of heat production in the body, and 
by this method, and this method only, can we solve a 
number of interesting problems, notably those connected 
with fever. The temperature alone is a very unsafe 
guide. It has been shown over and over again, by direct 


560 


must subtract the | 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





experiment, that we may have high fever, while the ani- 
mal or man is producing dess heat than normal, and it has 
been shown, also, that certain antipyretics will lower the 
temperature while the production of heat in the body is 
far above the normal. 

The temperature of the body depends upon two factors, 
und may be influenced by either of them separately or by 
both together. These factors are heat production and 
heat dissipation. In warm-blooded animals the balance 
is arranged so as to keep the temperature constant. If 
more heat is produced, for any reason, there is a corre- 
sponding increase in heat dissipation so that the temper- 
ature remains about the same. If more heat is dissipated 
more heat will be produced so as to keep the balance 
even and the temperature constant. If the balance is 
disturbed, as during fever, it is clear that we cannot tell 
in which factor the trouble lies by such an instrument as 
the thermometer, which only records the balance between 
them. These questions will be discussed more fully in 
the later sections of the article, and are only introduced 
here to show the importance of direct calorimetry in medi- 
cine. 

Some of the objections urged against experiments of 
short duration in indirect calorimetry will also apply to 
direct calorimetry. The metabolism of the body is be- 
wilderingly complex, and transient commotions produced 
by causes beyond the observer’s perception may give 
results which would be totally inapplicable to calcula- 
tion of averages, and which multiplied by the time suffi- 
cient to extend them to days would lead us to serious 
errors (see p. 559). 

§ 4. DESCRIPTION OF CALORIMETERS EMPLOYED IN 
CuiassicAL MepicaL REsEARCHES.—As the study of the 
heat equivalent of foods is usually taken up with chem- 
istry rather than with medicine, and as the field is large 
enough to make a monograph by itself, it is deemed ad- 
visable to omit here a description of the apparatus and 
methods employed in this line of research. Those inter- 
ested will find an excellent treatise on the subject in 
Atwater’s “ Methodsand Results of Investigations on the 
Chemistry and Economy of Food” (U. 8. Dept. of Agri- 
culture, Bulletin No. 21, 1895). 

The fundamental object of all calorimeters, for animals, 
is to register the amount of heat given off by the animal 
placed within them. This is done in different ways in 
different instruments, and the various kinds of calorim- 
eters may be classified, according to the means used to 
measure the heat, as follows: 

(A) Fusion (ice) calorimeters. In these the heat is 
made to melt some solid (usually ice), and the amount of 
heat is calculated from the quantity of the substance ° 
melted. 

(B) Vaporization calorimeters. In these the heat is 
made to volatilize a liquid, and the amount of heat is 
measured by the quantity of liquid volatilized. 

(C) Water calorimeters. In these the heat is taken up 
by water, and measured by different methods according 
to the instrument. 

(D) Air calorimeters. In these the heat is taken up by 
air and measured by different methods, according to the 
instrument. 

(#) Respiration calorimeters. 

Each accurate calorimeter, whatever its form, must be 
calibrated. This is done by producing within it known 
quantities of heat, approximating those it will later be 
used to measure, and noting how accurately (and some- 
times how rapidly) the calorimeter will register this heat. 
The known quantity of heat is usually produced by 
burning, within the calorimeter, a given quantity of hy- 
drogen, alcohol, or some pure oil, or by passing an elec- 
tric current of known strength through a coil of known 


resistance. The heat produced is calculated from the 
formula: 
B= Px Race 


In which H= the heat produced, I= the strength of 
the current in amperes, R = the resistance of the wire in 
ohms, and & is a constant, which, to give the value in 
calories per hour = .864. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Calorimetry. 
Calorimetry. 





This is the latest and most accurate method, and serves 
admirably to give varying amounts of heat through the 
range in which the calorimeter would be called on to 
register the heat of animals, including man. 

Class A: Fusion Calorimeters.—The only calorimeter 
of this class employed in animal calorimetry was the ice 
calorimeter of Lavoisier and Laplace.* It consisted of 
three metal cylinders, placed one within the other, with 
spaces between them. The animal (guinea-pig) was 
placed in the innermost cylinder, and the space between 
this and the middle cylinder was filled with ice, which 
was melted by the heat given off by the animal. The 
space between the middle cylinder and the outer cylinder 
was also packed with ice to prevent heat from the out- 
side from reaching the ice in the space next the animal 
cylinder. The water from the ice melted by the animal 
was collected and weighed and the heat calculated by 
multiplying this weight by the latent heat of fusion. 

This is a very accurate form of calorimeter, but it is 
not well adapted to animal experiments, as the animal is 
kept in surroundings of an abnormally low temperature, 
and this seriously affects its production and dissipation 
of heat. The researches of Lavoisier and Laplace are 
classical, in being the second to employ the calorimeter, 
and the first to give valuable results of extended observa- 
tions which were stated in terms of the modern combus- 
tion theory. In these experiments the animal was fur- 
nished with air, and the O used and the CO, given off 
were determined. 

Class B: Vaporization Calorimeters.—Calorimeters of 
this class were used by I. Rosenthal and by Neesen.+ 

I. Rosenthal + devised a calorimeter in which he used 
a fluid witha boiling point near that of the ordinary room 
temperature, ora fluid with a boiling point a few degrees 
below the normal temperature of the animal. The fluids 
which he recommendsare acetic aldehyde, CH;,CHO, with 
a boiling point of 21° C., and ethyl ether, (C:H;).0, with 
a boiling point of 34.9° C. 

The calorimeter consisted of an inner cylinder, in which 
the animal was placed, and an outer cylinder containing 
the liquid to be volatilized. The whole was surrounded 
by a water bath kept carefully at the temperature of the 
boiling point of the liquid in the outer cylinder. Thus 
no heat could either be gained or lost by the liquid in the 
outer cylinder except such as came from the animal in 
the inner cylinder. The heat from this source was all 
spent in volatilizing the aldehyde or the ether, and from 
the quantity thus volatilized the amount of heat given 
off by the animal could be determined. By filling the 
outer cylinder with ice the instrument could be used as 
an ice calorimetey, and thus, as Rosenthal pointed out, 
according to the material used the heat dissipated could 
be determined for temperatures of 34.9°, 21°, or 0° C. by 
the same apparatus. This calorimeter, as constructed, 
could be used only for small animals, such as mice, or 
for isolated organs, such as muscles. 

Class C: Water Calorimeters.—The water calorimeter 
was the first employed in animal calorimetry (see account 
of Crawford’s researches, § 1). From that time (1778) 
to the present it has been the favoriteform. After Craw- 
ford it was used in the classical researches on animal heat 
by Despretz,§ and by Dulong, || and on fever by Senator, | 
and by Wood. ** 

In its simplest form, a water calorimeter consists of a 
tank containing a definite amount of water into which is 
plunged a water-tight metal box containing the animal. 





ee and Laplace, “*Mémoires de l’Academie,’’ Paris, 1780, 


p. 369. 

+ See Richet’s ‘* Dictionnaire de Physiologie,’ Paris, 1897, vol. ii., p. 
405. The writer was unable to find a reference to Neesen’s original 
article. 

tI. Rosenthal, Arch. fiir Physiol., 1878. 

§ Despretz, Ann. de chim. et de phys., 1824, vol. xxiv., p. 337. 

| Dulong, Ann. de chim. et de phys., 18438, p. 140. In 1822, the 
Paris Academy offered a prize for the best experimental researches on 
animal heat. Despretz and Dulong were competitors and Despretz 
won. The work of the two was contemporaneous, but Dulong’s paper 
Was not published until 1843, after his death. 
ae ‘* Untersuchungen tiber den fieberhaften Process,” Ber- 

, 1875. 

** Wood, ‘* Smithsonian Contributions to Knowledge,” No. 357. 


WAI, IO ty 





The animal is supplied with air by tubes entering and 
leaving the box. The heat given off by the animal raises 
the temperature of the water, and, knowing the weight 
of the water and the increase in temperature, the amount 
of heat thus given off can be calculated in calories. In 
text-books, the calorimeter of Dulong is generally de- 
scribed, but in the present article the Reichert calorimeter 
is chosen as a type of this class. This instrument com- 
bines all the simplicity of the older forms with the accu- 
racy and convenience of modern improvements. It has 
been used by Reichert * in his researches on animal heat, 
on fever, and on drugs. 
The calorimeter consists of a metal box A, for the ani- 
mal, and a larger metal box surrounding the box A, the 


CT 


TAS 
A) 
Dy 
y.') 
ZY) Y 
ad 


( 
yn 
~ 
Ww 
WD 
WO’ 
= 






( 
e 









































KK 























AN 
SN 


























m 







































































































































PT 
MU = 



























SS 
i ( SE 











Fig. 1073.—Reichert’s Water Calorimeter. 


space between the two metal boxes being filled with 
water. The whole isenclosed in a wooden box, the space 
between the outer metal box and the wooden box being 
filled with shavings SH, to prevent the radiation of heat. 
At the right of the figure is an opening from the exterior 
into the box A. This is for putting in and taking out 
the animal. During the experiment it is closed by a 
wooden plug fastened with clamps to the wooden box. 
The tubes HN and #X are for the entrance and exit of 
air, and each is furnished with a thermometer as shown 
in the figure. Another thermometer, (7, registers the 
temperature of the water. Sis a stirrer to mix the water 
thoroughly so as to be sure that the temperature recorded 
is the temperature of the whole mass of water. The ar- 
rows show the direction of the air current through the 
animal box. 

Ott + devised a water calorimeter of sufficient size to 
take aman. The inner chamber, to receive the patient, 
was cylindrical in form, and the air, as it was drawn from 
this chamber, passed through a lead pipe coiled in the 
water and thus gave off its heat to the water. The water 
was slowly stirred by a mixer driven by an electric motor. 

D’Arsonval’s compensating calorimeter, of constant 
temperature, is another form of water calorimeter, al- 
though the principle involved in the measurement of 
heat is different from that of the calorimeter last de- 
scribed. t 

This instrument is shown in Fig. 1074. It consists of 
two cylinders, of thick copper, enclosing a space between 


* Reichert, University Med. Mag., 1890, vol. ii., p. 173, and “American 
Text-Book of Physiology,’’ 1896, p. 586. 

+Ott, New York Med. Journ., 1889, vol. xlix., p. 343; also Journ. 
Nerv. and Ment. Dis., 1890, vol. ene 348. 

+ D’Arsonval, Arch. de Physiol., 1890, p. 612. 


: 561 


Calorimetry. 
, Calorimetry. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Through this space run two spirals of metal tub- 
-ing like the worm of a still. These spirals are shown in 
cross-section in the figure. One of these spirals connects 
the inner chamber of the calorimeter with the outside air. 
‘The air is aspirated through the calorimeter, passing in 
by a tube on the left, as shown by the arrow in the figure, 
and out, by the spiral, tothe exterior. In passing through 
the spiral it gives up its heat to the petroleum with which 
the space between the cylindersis filled. The other spiral 
opens, at both its ends, on the exterior. It conducts a 
stream of cold water which is made to flow through it. 
The space between the copper cylinders, enclosing the 
spirals, is filled with petroleum because of its mobility. 
When the heat of the animal warms this petroleum it ex- 


them. 


pands, and exerts pressure on the apparatus shown in the . 


figure to the right of the calorimeter. This is arranged 
to control the flow of water through the cold-water spiral. 

When the calorimeter is working this makes a sensitive, 
automatic regulator. If the temperature of the petro- 
leum tends to rise the pressure exerted by its expansion 
causes more cold water to flow, and this immediately 
reduces the temperature of the petroleum to the point for 




































































































































































spiral. On the surface of the water is a float which rises 
as the water in the cylinder rises. This float is attached 
to a lever which has on its short arm a counterpoise 
weight for the float, while the long arm is made to write 
on a cylinder driven by clockwork. Since the rise of 
the lever is directly proportional to the amount of water 
flowing through the spiral, and since this is directly pro-. 
portional to the heat given off by the animal, it follows 
that the ordinates of the curve written by the lever will 
be directly proportional to the heat which we wish to 
measure. The abscissas will be in terms of time, and will 
be proportional to the speed of the drum. By regulating 
the length of the lever and the speed of the drum a curve 
may be obtained which can be read in terms of calories 
for any convenient unit of time, minutes, hours, days, 
etc., without further calculation. A more elaborate re- 
cording apparatus with electrical contacts is figured and 

described by D’ Arsonval (Arch. de Physiol., 1890, p. 616). 

The same author has described a more convenient but 

less accurate calorimeter based on a modification of the 

one just described (op. ezt., p. 620). 

One of the most recent, as well as one of the most elab- 
orate and perfect water calorimeters, is that of 
Atwater and Rosa.* 

In this calorimeter experiments, lasting sev- 
era! days, have been conducted on man. 

The principle involved is practically the 
same as that of D’Arsonval’s compensating 
calorimeter (Fig. 1074); the heat being removed 
by coils of pipe carrying cold water through 
the chamber where the man is placed. Fora 
full description of this instrument and methods 
employed, the reader is referred to the original 
papers. A more condensed description of the 

~ apparatus is given under the head of Respira- 



































> tion Calorimeters at the end of this section. 
Calorimetry by Baths. The study of heat 
phenomena in animals by baths has found a 
place in medical literature chiefly through the 
classical researches of Liebermeister,+ and his 








pupils Kernig, Hattwig, and Gildemeister. 


























The method here employed was to place the 





























patient in baths of different temperatures, and 



































to calculate the production of heat from the 




















= t0" il = 

















—=— _ gain or loss of heat by the patient and by the 











water under different conditions. This pro- 











cedure presents certain crudities and sources of 





Fig. 1074.—D’Arsonval’s Compensating Calorimeter of Constant Temperature. 


which the instrument is set. (Fora description of this 
regulator in detail, see Arch. de Physiol., 1890, p. 614.) 
The cold water is furnished from a tank, and is made to 
enter the calorimeter at a known temperature. <A tank 
filled with ice furnishing water at 0° C. is the arrange- 
ment recommended. The temperature of the water on 
entering the calorimeter, the temperature on leaving it, 
and the amount of water passed through being known, 
the amount of heat given off by the animal can easily be 
calculated in calories. It is found by experience that the 
water leaves the spiral through the petroleum at the 
temperature of the petroleum, and when this is kept at 
the room temperature, as it should be, the amount of 
heat given off by the animal is directly proportional to 
the amount of cold water required to keep the tempera- 
ture of the petroleum constant. If, therefore, the amount 
of cold water flowing through the spiral be recorded con- 
tinuously throughout the experiment, we can not only 
calculate the total amount of heat given off by the ani- 
mal, from the beginning to the end of the experiment, 
but we can tell whether there was any variation in the 
rate at which this heat was given off, by finding, from 
the record, the variations in the rate with which water 
flowed through the spiral. 

A simple form of apparatus for registering the flow 
through the spiral is shown in the figureas placed on the 
floor under the table. It consists of a cylinder (shown in 
section in the figure) which receives the outflow from the 


562 





error Which have been pointed out by nearly 
every special investigator in the field, but it 
has lately been defended by Lefevre,t who 
employed it in some experiments of his own. The re- 
searches of Lefevre are of interest in showing some inter- 
esting points as to the rapidity with which the heat-regu- 
lating mechanism adjusts itself when the patient is placed 
in acold bath. They also show that this mechanism is 
neither as sensitive nor as efficient in an ape as it is in 
man, but they fail to convince one that the method is 
trustworthy for obtaining absolute values of heat dissi- 
pated or produced. Most of his observations were of 
short duration—five to twenty minutes. 

Leyden§ employed the bath method in his researches 
on fever which are classical. In his experiments a part of 
the body, usually a leg, was immersed in water in an ap- 
paratus somewhat resembling a plethysmograph, and the 
heat given off to the water measured. In many of Le- 
fevre’s experiments the patient was placed in a sitz bath 
and only part of the body covered by water. 

Class D: Air Calorimeters.—The first air calorimeter 
was used by Scharling.|| This consisted of a closed box 
placed in a room of constant temperature. When aman 





* Atwater and Rosa, ‘‘ Report of Storrs (Connecticut) Experiment 
Station,” 1897 ; also Atwater and Rosa, and Rosa, ‘* Physical Review,” 
1899 and 1900. 

+ Liebermeister, Deutsches Arch. f. klin. Med., v., pp. 217-234; xX., pp. 
ae an ; also ‘‘Handb. d. Path. u. Therap. des Fiebers,” Leipzig, 

o/ 5 p. he 

+ Lefevre, Comptes rendus, Soe. de Biol., 1894-96. 

§ Leyden, Deutsches Arch. f. klin. Med., v., p. 273. 

| Scharling, Journ. f. practische Chemie, 1849, vol. xlviii., p. 435, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


~ 


Calorimetry. 
Calorimetry. 





was put in the box, the temperature of the air in the box 
rose, and from this rise the heat given off by the man 
was calculated. A calorimeter of practically the same 
principle was used in the early experiments of Vogel, 


il 





Fig. 1075.—D’Arsonval’s Differential Calorimeter. 


of Sapalsky and Klebs, and of Hirn; and in the later re- 
searches of Kaufman,* who speaks of it as simple and 
precise. 

In most of the later forms of air calorimeters, the prin- 
ciple of measuring the heat by a rise of temperature of 
the air has been discarded, and the expansion of air 
caused by the heat given off from the animal has been 
used as an index. This gives a more convenient and 
more delicate method of measurement. 

One of the simplest calorimeters constructed on this 
principle is the siphon calorimeter of Richet.+ This con- 
sists of two double-walled hemispheres of metal, fitting 
upon each other so as to make a globe. They are con- 
nected by a hinge, so that the upper hemisphere may be 
thrown back like the lid of a box. When closed they 
are fastened by an ordinary clasp. The air space be- 
tween the two walls of each hemisphere is connected by 
a tube with a large bottle of water, arranged like a wash 
bottle, in such a way that when the air between the walls 
of the hemispheres expands it forces out a volume of 
water equal to the expansion of the air. When an ani- 
mal is placed in the globular box formed by the two 
hemispheres, the heat given off by the animal causes the 
air to expand in the way just described. This expansion 
is measured by the amount of water forced out of the 
bottle, and the amount of heat given off by the animal is 
thus determined. 

U. Mosso t¢ used a calorimeter constructed on the prin- 
- ciple of the above. The water, forced out of the bottle, 
passes into a balanced recipient after the manner of the 
registering apparatus of Mosso’s plethysmograph. This 
is an ideal arrangement, for a continuous graphic record 
can thus be kept of the rate of heat dissipation through- 
out the experiment, and if for any reason the animal 
should absorb heat, instead of giving it off, this would 
be recorded as well. 

Differential Avy Calorimeters. The principle involved 
in differential air calorimeters is to have one closed air 
space affected by the heat of an animal, while another 
similar air space is kept ata constant temperature. These 
air spaces are connected with an appropriate recording 
apparatus, and the heat given off by the animal is calcu- 
lated from the difference in expansion of the two. 

The simplest form of differential air calorimeter is 
D’Arsonval’s$ compensating differential calorimeter, 
shown in Fig. 1075. 

This instrument consists of two calorimeter chambers 
8and 8’. Each of these chambers has a double wall en- 
closing an air space, 9 and 9’. These air spaces are con- 
nected by a rubber tube, 10 and 10’, with the registering 
apparatus. This consists of a lever balance, 1, from each 
arm of which is suspended a cylinder, 2 and 2’, closed 
at the top, the lower end dipping into tanks of fluid, 3 





* Kaufman, Comptes rendus, Soc. de Biol., 1896, p. 201. 

+Richet, Comptes rendus, Soc. de Biol., 1884, pp. 707-715; also Arch. 
de Physiol., 1885, vol. vi., p. 237. 

t Mosso, Arch. Ital. de Biol., 1890, vol. xiii., pp. 467-471. 

§ D’Arsonyal, Arch. de Physiol., 1890, p. 785. 





and 3’. These tanks are connected by a tube, 5, so that 
the level of liquid is the same in each. The tubes, 4 and 
4’, rise above the surface of the liquid. When the air in 
the space 9 or 9’ expands it passes into the cylinder 2 or 
2' respectively, and buoys this cylinder up, thus 
raising the arm of the lever 1. To one arm of the 
lever is attached a straw, 6, terminating in a writing 
point which records on a cylinder, 7. This cylinder 
moves by clockwork, and can be made to go so 
slowly that continuous records of a day or a week 
may be obtained. 

When an animal is introduced into one of the 
calorimeter chambers, 8 or 8’, the heat given off 
causes the air in 9 or 9’ to expand, and this expan- 
sion is registered as above described. The empty 
calorimeter chamber is under exactly the same con- 
ditions except for the presence of the animal, and 
registers on the opposite arm of the lever, thus 
giving a compensating effect for the instrument 
minus the animal. The curve recorded is due to 
the difference which is produced by the animal, and is in- 
dependent of barometric changes, room temperature, etc. 

This instrument is classical and is often referred to. It 
is theoretically excellent, but it possesses practical dis- 
advantages which render it unfit for accurate scientific 
research, as the writer has found from personal expe- 
rience (see also D’Arsonval, Arch. de Physiol., 1890, pp. 
787 and 789), 

The most complefe and accurate air calorimeters are 
those of Rubner* and of Rosenthal.t These eminent in- 
vestigators have spent years in perfecting their respective 
instruments, and each, notably that of Rubner, has been 
used in extensive and valuable researches. These calo- 
rimeters are too elaborate to be described in detail lrere. 
A complete description of the latest improvements will 
be found in the original papers of Rubner and Rosenthal 
referred to above. 

The fundamental principle of these two calorimeters 
is the same. Each consists of two closed air spaces, one 
of which is warmed by the heat from the animal, while 
the other is immersed in a bath which is kept at a con- 
stant temperature by an automatic regulator. Rubner 
measures the expansion of the air by an apparatus similar 
in principle to that employed by D’Arsonval and shown 
in Fig. 1075. Rosenthal connects the two air spaces, 
respectively, with a U-manometer, which will respond 
at once to any difference of pressure on the two sides. 
Connected with the air space on one side, there is an in- 
genious piston arrangement by which air can be forced 
in, soas to make the pressure on the two sides of the 
manometer equal. This is driven by an electrical device 
which is set in motion the moment the liquid in the manom- 
eter changes level. The amount of pressure thus ex- 
erted is registered automatically, so that a complete 
graphic record may be kept of how much pressure was 
necessary to equalize exactly the pressure exerted by the 
air expanded by the heat from the animal, and thus this 
heat may be calculated. 

Haldane White and Washburnt have described a 
compensating differential air calorimeter in which the 
animal is placed in one side while a hydrogen flame is 
kept burning in the other. The enclosed air spaces of 
the two sides are connected with the opposite arms of a 
manometer. The hydrogen flame is so regulated that it 
shall give off exactly as much heat as the animal, as shown 
by the liquid in the two branches of the manometer re- 
maining at the same level. The amount of hydrogen 
burned is estimated and the heat produced by the flame 
calculated. This exactly equals the amount given off by 
the animal, since the heat produced in each calorimeter 
chamber is the same. 


Anemo- Calorimeter of D’ Arsonval.§ Most of the calo- 





*Rubner, ‘‘ Calorimetrische Methodik,”” Marburg, 1891; also ‘‘ Die 
Quelle der thierischen Wirme,” Zeitsch. f. Biol., vol. Xxx., 1893-94, 
pp. 73-142. 

+ Rosenthal. ‘ Calorimetrische Untersuchungen,” Arch. f. Physiol., 
1897, pp. 170-209. 

* Journ. of Physiol., 1894, vol. xvi., p. 127. 

§ D’Arsonyal, Arch. de Physiol., 1891, p. 364. 


563 


Calorimetry. 
Calorimetry. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 


rimeters above described are cumbersome, many are suit- 
-able for experiments on small animals only, and none of 
them can be conveniently adapted to the clinical study 
of fever in the hospital. To obviate these disadvantages 
D’Arsonval attacked the problem of devising a calorim- 
eter which should fulfil the following conditions: 

“1. To be set up in any room in a hospital. 

“2. To be light and easily portable. 

“3. To allow the calorimetric observation to be made 
rapidly—say in five minutes. . 

“4 “To be set up over the bed of a patient and give 
automatically continuous records in the form of a curve 
without requiring the presence of some one to watch the 
apparatus.” 





The calorimeter which, he claims, meets all these re- 


quirements is shown in Fig. 1076, } 

The principle of the calorimeter is very simple. The 
heat of the body causes the air to rise. This creates a 
current which passes through the chimney and sets the 
anemometer vane revolving. The more heat, the stronger 
the current and the more rapid the revolution of the vane. 


X 
\ 
\ 
\ 


tito 


pettttde 











Fig. 1076. Fig. 1077. 


Figs. 1076 AND 1077.—D’Arsonval’s Anemo-Calorimeter. 


Fig. 1076.—Calorimeter. Description: 1, The subject of the exper- 
iment; 2, cylinder of woollen stuff fixed to a disc of wood, 3, and 
kept from collapsing by the hoops C and C’; part of the cylinder is 
cut away to show the subject; 4, conical chimney bent near its end ; 
5, opening of chimney with anemometer attached. The anemometer 
is shown, on a large scale, to the right (Fig. 1077). 

Fic. 1077.—Anemometer. Description: 1, Lever for throwing the 
vane in connection with the recorder; 2, vane composed of eight 
aluminum fans; 3 and 4, hands of recorder; 5 and 6, binding posts 
for wires to odograph ; 7, button for putting the hands back to 0. 


The heat given off was found to be directly proportional 
to the square of the number of revolutions of the vane 
in a unit of time. 

Each instrument has to be graded separately by placing 
in it some source of heat which gives off a known quan- 
tity ina giventime. Itcanthen be calculated how many 
turns of the vane represent a given number of calories. 
The numbers are convenient for calculation; for example, 
in D’Arsonal’s own instrument eighty revolutions per 
minute represent 21.6 great calories per hour. 

One would hardly suppose, @ priori, that such a crude 
arrangement would give accurate results, but the figures 
obtained by D’Arsonval while calibrating it would seem 
to leave no doubt as to itsreliability. Asasource of heat 
he employed a ferro-nickel spiral heated by an electric 
current. The error in the record of the anemometer was 
2 revolutions in 2,400, and 5 in 3,600, so that it was prac- 
tically exact. 

The instrument has no time-loss in recording. Within 
one minute from the time a man enters the calorimeter 
the vane has attained its maximum velocity, and two 
minutes after this suffice for an observation, so that a 


564 








whole experiment can be made in three minutes—a desid- 
eratum often important in clinical work. 

The accuracy of the records of the anemo-calorimeter 
is independent of the room temperature. The vane re- 
volves from a current of air which depends upon the dif- 
ference in temperature between the air entering and the 
air leaving the calorimeter. This difference is constant 
for the same source of heat whatever may be the temper- 
ature of the air entering, ¢.e., the temperature of the air 
of the room. zx 

In his laboratory, D’Arsonval uses a wooden box with 
a glass door instead of the woollen curtain, of the port- 
able form, shown in the figure. 

Laulanie * used an anemo-calorimeter, and found that 
the heat produced runs closely parallel with the oxygen 
consumed. 

_When it is desired to make observations continuing for 
a considerable time, the apparatus is connected with a 
Marey odograph,+ and the record is taken on a revolving 
cylinder. With the calorimeter thus arranged over his 
own bed, D’Arsonval made observations on himself dur- 
ing sleep. 

Class E: Respiration Calorimeters.—A respiration calo- 
rimeter is one which is so arranged that the air taken in, 
and the air breathed out, by the animal can be analyzed; 
in other words, it is one which permits observations to be 
made by the method of indirect calorimetry and of direct 
calorimetry at the same time. 

Nearly all the water calorimeters and air calorimeters 
have been arranged in this way. The most elaborate in- 
strument of the kind is one recently perfected by Atwater 
and Rosa (see Water Calorimeters) with the assistance of 
funds supplied by the United States Department of Agri- 
culture, and of the State of Connecticut. The descrip- 
tion here given of this calorimeter is taken (condensed) 
directly from one of the papers by the original authors. t 

“The Apparatus.—The name here used for the appa- 
ratus, ‘respiration calorimeter,’ is suggested by the fact 
that it is essentially a respiration apparatus with appli- 
ances for calorimetric measurements. As a respiration 
apparatus it is similar in principle to that of Pettenkofer. 
The calorimeter is essentially a water calorimeter, that 
is to say, the heat evolved in the chamber is measured 
by a current of water. The appliances for measurement 
of both the respiratory products and the heat given off 
from the body differ in some important respects from 
those of any other apparatus with which we are familiar. 

“The apparatus includes, first of all, a room or cham- 
ber in which the subject remains during the experiment. 
The chamber is furnished with a folding chair and table 
for the man’s use during the day, and a folding bed on 
which he sleepsat night. When the experiments involve 
muscular work, a stationary bicycle, especially arranged 
for measuring the work done, is also introduced. Light 
enters through a window so that the occupant can see to 
read and write. Ventilation is provided by a current of 
fresh air, maintained by a pump specially devised for the 
purpose. This pump not only keeps up a constant cur- 
rent of air, but also measures its volume and withdraws 
samples regularly and accurately for analysis. The air 
is made to enter the chamber at the same temperature as 
when it goes out, so that the quantities of heat brought 
in and carried out by this ventilating current are the 
same. Arrangements are provided for passing food and 
drink into the chamber and for removing the solid and 
liquid excreta. Arrangements described beyond prevent 
the passage of heat through the walls of the apparatus. 

“The heat given off from the body is carried away bya 
current of cold water which passes through a series of 
pipes inside the chamber. Houses are warmed in winter 
by a current of water which is heated in the basement 
of the house, and passes through pipes and radiators in 
the different rooms. The heat thus radiated from the 
water into the room keeps the air of the latter at the de- 





* Laulanie, Comptes rendus, Soc. de Biol., 1896, p. 5. 

+ Marey, ‘* Methode graphique,”’ Paris, 1878, p. 183. 

¢ Atwater and Rosa, “ Report of Storrs (Connecticut) Experiment 
Station,” 1897. 


REFERENCE-HANDBOOK OF THE MEDICAL SCIENCES. raha Cae 


Calorimetry, 








Fic. 1078.—Respiration Calorimeter. General view. 


sired temperature. In like manner the house might be | absorbers inside the chamber of the respiration calorim- 
cooled in summer by a current of cold water. In this | eter. By regulating the temperature of this water cur- 
case the radiators would become absorbers. The heat | rent as it enters, and also its rate of flow, it is possible to 
would be taken up from the air of the room by the cold | carry away the heat just as fast as it is generated, and 
water and carried away. Exactly this is done by the |! thus maintain a constant temperature inside the chamber. 


















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Fig. 1079.—Horizontal Cross-Section of Respiration Calorimeter, 


565 


Calorimetry. 
Calorimetry. 





The amount of the outgoing water and its temperature 
are measured, thus determining the heat carried away. 

“ A general idea of the apparatus can be had from Figs. 
1078 and 1078. Fig. 1078, froma photograph, isa general 
view of the principal parts of the apparatus, though the 
pump and aspirators used for moving, measuring, and 
sampling the ventilating air current and the refrigerating 
machine are not shown. In the centre is the large cham- 
ber which is surrounded by sheathing of wood. At the end 
of the chamber, on the right, is shown a glass door which 
servesalsoasa window. In the foreground, near the cen- 
tre and at the right, are the pipes through which the ven- 
tilating current of air passes. At the right of the window 
and just below it are the arrangements for cooling and 
for measuring the current of water which brings away the 
heat from the interior of the chamber. . At the left, in 
front of the large brick pillar, is a table at which an ob- 
server sits torecord the temperature of the interior of the 
apparatus and of the currents of air and water, these 
temperatures being measured by electrical thermometers. 
Behind the brick pillar is the refrigerating machine, not 
shown in the picture. The object of this is to cool the 
brine, 7.e., a solution of calcium chloride contained in a 
large tank in the centre foreground. The tank is sur- 
rounded by a wooden casing. The ventilating current 
of air, before it enters the chamber, is passed through 
copper cylinders which are immersed in brine in this 
tank, and thus cooled to a temperature of from —19° to 
—22° C., or from —2° to —8° F. At this very low tem- 
perature nearly all the water is removed from the air, so 
that it enters the chamber quite dry. Just before enter- 
ing, at the right of the glass door, it is warmed to the 
temperature of the interior of the chamber. On coming 
out it passes once more through copper cylinders in the 
cold brine, and thus the larger part of the water which 
has been imparted to it by the respiration of the man in- 
side the chamber is frozenand removed. The air pump 
is at the right and the aspirators are at the left of the 
position occupied by the camera in taking the photo- 

raph. 
en The Respiration Chamber.—The internal construction 
of the chamber and the arrangements for regulating the 
temperature are shown in horizontal section in Fig. 1079. 

“The chamber proper is practically an apartment with 
double walls of metal, the inner wall being of sheet cop- 
per and the outer one of zinc. The interior is 2.15 m. (7 
ft.) long, 1.92 m. (6 ft. 4 in.) high, and 1.22 m. (4 ft.) 
wide, the corners being rounded. It thus hasa little less 
than 28 square feet of floor space. The cubic content is 
not far from 4.8 cubic metres or 175 cubic feet. The 
inner wall is made of large sheets of copper, the seams 
being soldered so that when the windows and other open- 
ings are closed the chamber is air tight, and the only air 
which enters or leaves is that of the ventilating current. 
Outside this copper wall is one of zinc. Between the 
two metal walls is an air space(A) of 7.5cm. (3 in.). In 
this space stands a wooden framework to which the two 
metal walls are securely attached. This metal chamber 
is the calorimeter proper. In order to protect it from 
the fluctuations of temperature of the room in which it 
stands, it is enclosed within three concentric walls of 
wood. Between the zinc and the innermost wooden wall 
is an air space (B) of 5 cm. (2 in.), between this wall and 
the next is a third air space (C) of 5 cm., and finally be- 
tween this and the outer wall is a fourth air space (D), 
likewise of 5cm. The wooden walls are made of matched 
pine covered with sheathing paper. The outer one is 
double with sheathing paper between. The air in the 
spaces A and C is ‘ dead air,’ while that in the spaces B 
and D can be kept in constant circulation by means of 
rotary fans in boxes outside. Each of the spaces B and 
D is continuous around the sides and over the top and 
bottom of the calorimeter, and each communicates with 
its fan box by means of one passage extending from the 
top of the air space to the top of its fan box, and another 
from the bottom of the air space to the bottom of the fan 
box. We may thus look upon these air spaces as shields 
guarding the interior space occupied by the calorimeter 


5966 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





from changes in temperature without. They thus ren- 
der necessary aid in accomplishing a fundamental object, 
namely, the keeping of the temperature of the air in the 
space B the same as that of the interior of the chamber. 
When these temperatures are the same there will be no. 
passage of heat through the walls, either into or out of 
the chamber. 

“The outer air current (D) is used for the coarser regu- 
lations of temperature. In the middle of the dead air 
space (C) is a wall of sheathing paper intended to more 
effectually prevent the external temperature from affect- 
ing that of the calorimeter. 

“ The walls are provided at the right with glass doors or 
windows. At Ein Fig. 1079 isa cylinder of copper which ' 


- passes through the walls of the chamber and also through 


the encasing walls of wood. This cylinder, which is 15 
cm. (6 in.) in diameter, serves for passing food and other 
materials into and out of the calorimeter chamber, and ig 
here called the ‘food aperture.’ It is closed at the ends 
by caps aand b. The outer (2) is screwed tightly to the 
cylinder so as to make an air-tight closure. Outside of 
this is a box or cover (c), made of wood and filled with 
cotton or other non-conducting material, the purpose 
being to prevent the passage of heat through E. 

“ Measurements of Temperature. The measurements of 
temperature are made in part by mercury thermometers, 
but mainly by electrical methods. The electrical meas- 
urements of temperature are made by use of either the 
German silver-iron thermal junctions or by resistance coils 
of fine copper wire. - Provision is made for connecting 
these with a D’Arsonval galvanometer especially con- 
structed for the purpose by Mr. O. 8. Blakeslee, mechan- 
ician of Wesleyan University. The electrical thermome- 
ters permit measurements of .01° C. or less. 

“ Temperature of Air Inside the Chamber. Inasmuch 
as the temperature of the air is not the same in different, 
parts of the chamber, and it is desirable to know the 
average or resultant temperature of the whole, the at- 
tempt is made to learn the latter by the use of a series of 
five electrical thermometers at places near the sides, top, 
and bottom. These consist of resistance coils of copper. 
wire connected with a slide wire Wheatstone bridge and 
the galvanometer outside. The measurements are so del- 
icate that even slight movements of the person inside, 
such as rising from the chair, reveal themselves to the 
observer outside by the immediate rise in the thermomet- 
ric reading. 

“ Regulation of Temperature of Ingoing Air. In order 
that the ventilating current of air shall not carry out of 
the chamber any more or any less heat than it brings in, 
the temperature must be the same when it enters as when 
it leaves. Accordingly the incoming air, which leaves, 
the brine tank at a very low temperature, is warmed, 
before its entrance to the chamber, to the temperature of 
the outgoing air. The devices for this purpose are such 
that the difference of temperature of the incoming and 
outgoing currents can be kept inside of .01° C. In actual 
experiments the positive and negative differences are 
made to counterbalance each other. 

“Arrangements for Preventing the Passage of Heat 
through the Walls of the Calorimeter. The difference be- 
tween the temperature of the copper wall and that of the 
zinc is measured by a system of thermo-electric junc- 
tions, in three hundred and four pairs, distributed over 
the sides, top, and bottom, one-half of the junctions (iron- 
German silver) being in close thermal contact with the 
copper wall and the other half (German silver-iron), with 
the zinc wall. The difference of temperature of the two, 
walls is made as small as possible by warming or cooling 
the air in the space B, and the positive and negative dif- 
ferences are made to counterbalance each other. Thus, 
the corresponding movements of small quantities of heat, 
inward and outward also counterbalance, and the cham- 
ber neither gains nor loses heat through the walls. 

“For the measurement of the differences of tempera- 
ture, as well as for the warming and cooling, the walls, 
of the calorimeter are considered as divided into four sec- 
tions, viz.: (1) the top; (2) the upper half of the sides or 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Calorimetry, 
Calorimetry, 





‘upper zone’; (3) the lower half of the sides or ‘lower 
zone’; (4) the bottom. The systems of thermo-electric 
elements for heat measurements, wires for warming and 
of water pipes for cooling, are each divided into corre- 
sponding sections. 

“The Observer's Table. This is shown in Fig. 1078 at 
the left, in front of the brick pier. A shelf fastened to the 
pier and shown on the right of the latter, behind the table 
in the picture, holds the galvanometer and scale. The 
scale is seen in the picture at the front end of the shelf 
over the table. The galvanometer is at the other end of 
the shelf, two metres from the scale and obscured by the 
pier. On the table are the switches to bring the various 
circuits into connection with the galvanometer, and with 
them the Wheatstone bridges, and the banks of electric 
lamps for varying the heating currents. 

“With the aid of the devices thus briefly described an 
experienced operator at the observer’s table can easily 
control the temperature of B and make it follow the vari- 
ations of the interior of the chamber very closely. When 
the rate of generation of the heat in the chamber is rea- 
sonably uniform and the temperature is nearly constant, 
the deflection of the image on the scale at the observer’s 
table can usually be kept within one division of the scale, 
which means an average difference of temperature be- 
tween the copper and zinc walls of less than .01° C. In 
ordinary experiments the difference is generally kept 
within this limit and seldom reaches .05°. The differ- 
ences are both positive and negative, and are easily made 
to counterbalance each other during shorter periods and 
during the whole experiment. 

“ Measurement of the Heat Carried Out by the Water 
Current. The principle here employed is simple. The 
chamber neither gains nor loses heat by the air current 
nor through the walls. The current of cold water which 
passes through the heat absorbers inside the chamber is 
caused to enter ata temperature generally but little above 
the freezing point, and to flow out at such a rate as to 
absorb and carry off the heat just as fast as it is gener- 
ated inside theapparatus. The temperature of the water 
is measured as it enters and as it comes out. The mer- 
cury thermometers are shown at G and H in Fig. 1079. 
The electrical thermometer indicates the difference of 
temperature between the incoming and outgoing water 
currents by the difference of resistance of two coils of 
thin copper wire, of which one is in each pipe at the 
place of entrance or exit from the calorimeter. The dif- 
ference is measured by a Wheatstone’s bridge on the 
observer’s table. The mass of water is measured auto- 
matically by the apparatus shown below and at the 
right of the window of the respiration chamber in Fig. 
1078. 

“From the mass of the water which has passed through 
the absorber in a given time, and the rise in temperature, 
the quantities of heat brought out are readily calculated. 
To this is to be added a certain amount of heat which is 
carried away with the water vapor produced in the ap- 
paratus. This is practically the difference between the 
water vapor in the incoming and outgoing air. From 
the amount of this vapor, and its latent heat at the tem- 
perature of exit, the amount of heat it carries out is easily 
computed. 

“ Metre Pump for Regulating, Measuring, and Sampling 
the Ventilating Air Current. 
for analysis, aspirators of 150 litres capacity were em- 
ployed at the outset and are still used. The measure- 
ments with these have been found quite accurate.* The 
most satisfactory arrangement we have found, and one 
which serves the threefold purpose of maintaining the 
air current, measuring its volume and delivering aliquot 
samples of convenient size for analyses, is an apparatus 
designed and made by Mr. O. S. Blakeslee, and appro- 
priately designated by him as a ‘metre-pump.’ The 
air coming from the discharge pipe escapes into the 
room, but by a special device the air of each fiftieth 





* See ‘‘ Report of the Storrs Station for 1896,” p. 91, and ** Bulletin 44 
of the Office of Experiment Stations of the United States Department 
of Agriculture,” p. 19. 


For taking samples of air. 


stroke is diverted into a receptacle, from which it is being 
constantly drawn for analysis. 

“ Cooling Apparatus. It is desirable that the ventilating 
current of air shall enter the respiration chamber as dry 
as possible. To this end it is cooled to a temperature of 
—19° to —22° C. (—2° to —8° F.), by passing through 
copper cylinders which are immersed in brine in the tank 
shown in Fig. 1078. The brine is cooled by use of an 
ammonia refrigerating apparatus.* The airafter passing 
out of the cylinder is warmed before entering the cham- 
ber in the way described. On coming out of the cham- 
ber the air current is again passed through copper cylin- 
ders immersed in the brine, and thus practically all of 
the water which has been imparted to it within the 
chamber is removed. The same brine is used for cooling 
the current of water which passes through the absorbers 
and conveys away the heat from the chamber. 

“ Analyses of Air, Determinations of Carbon Dioxide and 
Water. The methods used for these purposes are essen- 
tially the same as described in the ‘ Report of the Storrs 
Experiment Station,’ and ‘ Bulletin 44 of the Office of 
Experiment Stations of the United States Department 
of Agriculture,’ above referred to. It will therefore suf- 
fice to say here that the larger part of the water is caught 
in the copper cylinders, immersed in the cooling brine as 
above described, and its amount found by weighing. 
The residue of the water of both the incoming and out- 
going air current is determined in samples by passing 
through U-tubes containing pumice stone and sulphuric 
acid. The carbonic acid is in like manner determined by 
passing through U-tubes containing soda lime. 

“In the ordinary experiments the determinations of 
water, carbonic acid, and heat are made for periods of six 
hours.” 

§ 5. CALORIMETRY IN PuysioLocy.—Heat Centres.— 
In§ 3 it was pointed out that the temperature of the body 
depended upon the balance between two factors: heat 
production and heat dissipation. We know that heat 
dissipation is dependent chiefly upon three factors: the 
supply of blood to the skin, the sweat, and respiration. 
The more blood in the vessels of the skin the more heat 
will be radiated off; the more sweat formed the more 
heat will be lost by the temperature of the sweat and by 
evaporation; the more vigorous the respiration the more 
heat will be lost in the expired air and by evaporation 
in the air passages. Each of these functionsis dominated 
by a special centre or set of centres, the vaso-motor, the 
sweat, and the respiratory centre, respectively. The 
question has naturally arisen, How is it with heat produc- 
tion? We know that the nervous system controls the 
chemical activities of the tissues—is there a centre which 
dominates this control? If so, how? Are there centres 
which cause an increased oxidation of food with increased 
production of heat? Are there centres which inhibit this 
oxidation and thus decrease heat production? Are there 
specific nerves through which such centres act on the tis- 
sues? It is in the experimental investigations relative to 
these questions that the calorimeter has been most em- 
ployed in physiology. 

The method of experiment has usually been to produce 
a lesion of the central nervous system, or to stimulate a 
definite area; and to note the effect on the animal’s tem- 
perature, or to measure the effect on heat production and 
heat dissipation by direct or by indirect calorimetry. 

It is obviously not within our province to undertake 
a critical review of all the work done on a specific sub- 
ject, such as heat centres. Besides, our information is 
at present in a state more or less chaotic, as has always 
been the case with work of this kind on the central ner- 
vous system. We need only recall the confusion which 
existed fifteen or twenty years ago regarding experi- 
ments on “localization” in the cortex, of the centres of 
motion, and of the special senses, to get a fair idea of 
the present condition of our knowledge regarding heat 





* See description of the arrangements for cooling in ‘* Report of the 
Storrs Experiment Station for 1896,’ p. 92, and ‘* Bulletin 44 of the 
Office of Experiment Stations of the United States Department of 
Agriculture,’ p. 22. 


567 


Calorimetry. 
Calorimetry. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





centres. The outcome of it all has been that to-day 
practically no one denies the more or less definite locali- 
zation in the motor area, but few would still adhere to 
the extreme views of invariable sharp localization of a 
given centre at a given spot, especially in the lower ani- 
mals. So with the heat centres. The chief bone of con- 
tention has been to determine just what was injured in a 
given operation, rather than to doubt the accuracy of 
the calorimetric method, although this has not escaped 
criticism. Then, again, different animals were used in 
different experiments, and discrepant results were ob- 
tained in this way, just asin the case of motor localiza- 
tion. At present we have every gradation, from Ott,* 
who locates six cerebral heat centres, two in the cortex 
and four in the basal ganglia, to Mosso,+ who, after a 
full review of all previous work, and numerous experi- 
ments of his own, is unable to admit “that there are, in 
the brain, centres which preside over animal heat.” 

The first observer to call attention to cerebral heat 
centres was Tscheschichin,} who, working with Du Bois 
Reymond, found that lesions of the medulla in the neigh- 
borhood of the pons Varolii were followed by a decided 
rise in temperature. His work was on rabbits, and he 
did not use the calorimeter. 

This was followed by Lewizky § in 1869, and by Bruck 
and Giinter| in 1870, disagreeing with Tscheschichin, 
and by Schreiber, {[ in 1874, agreeing, for the most part, 
with Tscheschichin, and disagreeing with Lewizky and 
with Bruck and Giinter. 

This was the status of the question in 1880, when 
Wood ** published his elaborate calorimetric researches 
on fever. Wood found that “section of the medulla at 
its junction with the pons is followed by increased heat 
dissipation and heat production, the increased heat dissi- 
pation usually keeping pace with the increased produc- 
tion, so that the bodily temperature rises.” Wood also 
found (p. 148) that “destruction of the first cerebral con- 
volution in the dog, posterior to, and in the vicinity of, 
the sulcus cruciatus is followed at once by a very decided 
increase of heat production, while after irritation of the 
same nervous tract there is a decided decrease of heat 
production.” Mild irritation of this region has no in- 
fluence on blood pressure—its destruction likewise is 
without vaso-motor effect (p. 153); therefore it is fair to 
presume that this centre influences body temperature 
through heat production—not heat dissipation. These 
earlier researches of Wood were confirmed later by a 
joint research of Wood, Reichert, and Hare,++ and by 
others, who find that there are thermogenic centres which 
affect the production of heat independently of blood 
pressure. 

Ott,t{ Richet,§$ and Aronsohn and Sachs, ||| working 
simultaneously and independently, all claim to have 
demonstrated the presence, in the brain, of centres which 
cause a rise of temperature by heat production. Richet 
and Ott used a calorimeter, Aronsohn and Sachs used the 
indirect method, determining both O and COs.. 

This work has in the main been supported by the later 
calorimetric experiments of Ott [4] and of Reichert,*** 
and of a number of others who have not employed the 
calorimeter. These observers, while differing as to the 
exact location of centres and as to the mode of their 
action, do agree, for the most part, that such centres 
exist. Reichert, in the work just quoted, has made an 
important contribution to our knowledge of heat centres 
in the spinal cord. He ascribes more importance to them 





-* Ott, N. Y. Med. Journ., 1889, vol. xlix., p. 247. 

+ Mosso, Arch. Ital. de Biol., 1890, vol. xiii., p. 459. 

+ Tscheschichin, Arch. f. Anat. u. Physiol., 1866, pp. 169-175. 

§ Lewizky, Arch. f. path. Anat., 1869, vol. xlvii., pp. 356-359. 

| Bruck and Ginter, Arch. f. d. ges. Physiol., 1870, vol. iii., pp. 578-584. 

4 Schreiber, Arch. f. d. ges. Physiol., 1874, vol. viii., pp. 576-596. 

** Wood, ‘‘ Smithsonian Contributions to Knowledge,” No. 357, p. 74. 

++ Wood, Reichert, and Hare, Ther. Gaz., 1886, p. 678. 

+t Journ. of Nerv. and Ment. Dis., 1884, vol. ix., p. 141. 

8§ Richet, Arch. de Physiol., 1885, vol. vi., p. 496. 

|| Arch. f. d. ges. Physiol., 1885, vol. xxxvii., p. 232. 

I Ott, Journ. of Nery. and Ment. Dis., 1887-88; Ther. Gaz., 1887, 
p. 399; N. Y. Med. Journ., 1889, vol. xlix., p. 247. 

peg wet Univ. Med. Mag., 1893, vol. v., p. 406, and 1894, vol. vi., 
p. 303. 


568 


than to those located in the medulla, basal ganglia, or 
cortex, 

The only later writer who takes an iconoclastic atti- 
tude with regard to cerebral heat centres, and bases this 
opposition on experimental data, is Mosso; and he* 
rather leans toward a position advocated by Girard,+ 
who says that we cannot speak of a thermogenic centre, 
but of many such centres scattered in the brain and spinal 
cord and working together. ¢It is quite probable that, 
when the confusion now existing is cleared up by later 
investigations, this view will be found very near to the 
truth. 

Those who wish to study this question more closely 
are advised to consult the papers of Wood, Ott, Reichert, 
and Mosso, here quoted; also papers by Hale White t 
and Riegel. White’s paper in Guy’s Hospital Re- 
ports gives interesting clinical data, which he says sup- 
port the calorimetrical findingsof Wood. The only clin- 
ical evidence quoted against cerebral heat centres is a 
case, reported by Dana,|| of a monster in which there was 
no cerebrum, basal ganglia, or cerebellum, and only part 
of the pons—yet the temperature was normal. This 
would support Reichert’s theory that the cord centres 
were the most important. 

To sum up briefly our knowledge of heat regulation 
and body temperature, we may say that the body tem- 
perature depends upon the balance between heat produc- 
tion and heat dissipation, each of which is directly con- 
trolled by the nervous system. Either of these factors 
may vary independently of the other, in either direction, 
so that body temperature may vary, as in fever, as the 
result of a change in either factor separately or of both 
acting together. Centres which control heat production 
are located in the cortex, basal ganglia, medulla, and 
cord. Some of these produce an increase in metabolism 
with a consequent increase of heat production, while 
some appear to diminish metabolism. These are usually 
regarded as inhibitory to the centres which cause meta- 
bolic activity. The spinal cord contains centres which 
influence heat production, and these are still active after 
being cut off from the medulla. 

There is a marked co-ordination, so to speak, between 
the centres which control heat production and those 
which control heat dissipation, the two striking a bal- 
ance, in warm-blooded animals, which keeps the body 
temperature practically constant at a certain point. It 
will be shown, in the following section, that in fever 
neither of these sets of centres is completely paralyzed, 
but that the balance is established at a higher point. 

The heat-regulating mechanism is more delicate in man 
than in apes, as shown by the experiments of Lefevre, { 


_ which are also of great interest in showing the reaction of 


the heat regulators of patients in a cold bath. 

The Separation of Motor and Trophic Nerves by Calo- 
rimetry.—Every muscular contraction is accompanied by 
the production of heat. It is well known that the mus- 
cles are the tissues in which is produced the greatest 
part of the heat which maintains the body temperature. 
That this heat may be produced independently of muscu- 
lar contraction is proved by the fact that the body tem- 
perature remains practically constant even when the 
muscles are at rest, as during’ repose or sleep. The ques- 
tion arises, Does the same set of nerves control muscular 
contraction and heat production, or do we have one set 
(motor) controlling muscular motion and another set 
(trophic ?) controlling the chemical changes (metab- 
olism) which give rise to heat? The first calorimetric 
experiments to solve this problem were undertaken by 
Kemp.** Making use of the fact that the drug curare 
paralyzes only the endings of the motor nerves, while 
leaving the nerve fibres and the muscle cells intact, 





* Mosso, op. cit., p. 463. 

+ Girard, Arch. de Physiol., 1888, pp. 326-328. 

~ Hale White, Journ. of Physiol., 1890-91; Guy’s Hospital Reports, 
1883-84, vol. xxvii., p. 48. 

§ Riegel, Arch. f. d. ges. Physiol., 1872, vol. v., p. 629. . 

|| N. Y. Med. Journ., 1889, vol. xlix., p. 248. 

‘| Lefevre, Compt. rend. Soc. de Biol., 1894-95. . 

** Kemp, Therap. Gaz., 1889, pp. 86 and 155. eh 


‘ 


, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Calorimetry, 
Calorimetry, 





Kemp studied the effect of different-sized doses of curare 
on dogs, and found that small doses, just sufficient to 
paralyze the motion of muscles, still allowed the heat- 
regulating mechanism to function, and the body temper- 
ature to be kept up to the normal oreven torise. Larger 
doses, he found, caused a fall of body temperature and 
a diminution of heat production as recorded by the calo- 
rimeter. His conclusion was that since the nervous sys- 
tem could still control heat production after paralysis of 
the motor nerve, either the motor-nerve endings para- 
lyzed by curare retained their grip on metabolism after 
losing it on motion, or, what was more probable, there 
were two kinds of nerves, the motor and the trophic; 
the former being paralyzed by a small dose of curare, 
while the latter required a larger dose to throw them out 
of function. Two years later Reichert,* as part of an 
extended research on the rise of temperature produced 
by cocaine and caffeine, made a number of experiments 
covering the same ground as Kemp. The two sets of 
experiments were not under exactly the same conditions, 
and the results were not absolutely in harmony. The 
main point of difference lay in the effect of large doses 
ofcurare. Reichert found that these sometimes produced 
a fall in heat production, thus agreeing with Kemp; but 
in other instances he found the heat production could be 
kept up to the normal or even increased. The observa- 
tions of both, however, are in thorough accord on the 
main point involved, viz.: that the heat-regulating mech- 
anism can work through nerves which still function 
after the motor-nerve endings are completely paralyzed. 
Reichert also added the interesting observation that co- 
caine fails to produce its characteristic effects in animals 
even lightly curarized, while caffeine can still produce 
an increase in heat production and temperature, though 
its effects are somewhat modified (p. 250). 

Mosso,+ in working with curarized dogs, found that a 
dose of strychnine caused a rise of temperature. He did 
not use a calorimeter in these experiments. Reichert t 
repeated these experiments and found that strychnine 
may produce an increase in heat production even when 
the animal is paralyzed by curare, which is an additional 
evidence for the theory that nerves, other than the motor, 
control metabolismin muscles. Reichert finds, however, 
that the rise of temperature is due more to lessened heat 
dissipation than to heat production. 

Relation of Heat Production and Heat Dissipation to 
Daily Variations in Temperature. — Every clinician is 
familiar with the daily fluctuations in body temperature, 
both in health and in fever. A number of observations 
have been made on animals and on man to see whether 
there is a diurnal variation in heat production. Most of 
these have been by the method of indirect calorimetry, 
and all unite in showing the profound influence of diges- 
tion on the heat produced. Fredericq, for example, 
found the maximum absorption of oxygen to be at 10 
A.M. and at 2to3p.m. Vierordt, Langlois, and Ott all 
agree that the period of maximum heat production is 
about this time. Fredericq noticed that in a starving 
man these maxima did not occur, and Langlois found 
that heat production may rise thirty-five to forty per 
cent. after a meal. Though we may feel warmer after a 
meal, it is well known that there is no actual rise of tem- 
perature, as shown by the thermometer, whereas the 
evening rise and morning fall occur, in a well-fed man, 
whether a meal be missed or not. 

Carter,$ in Ott’s laboratory, undertook an investiga- 
tion of the relation of heat production and heat dissipa- 
tion to this interesting phenomenon. His experiments 
were made on dogs, cats, and rabbits, both normal and 
with fever. He first established the fact that these ani- 
mals have practically the same daily fluctuations of tem- 
perature as man, the maximum temperature occurring 
from 7 to11A.M.,and the minimum from7tollp.m. As 
the result of his calorimetric observations, he found that 





* Reichert, Therap. Gaz., 1891, pp. 151, 242. 

+ Mosso, Virch. Arch., vol. cvi., p. 80. 

+ Reichert. Therap. Gaz., 1892, p. 386. : 

§ Carter, Journ. of Nerv. and Ment. Dis., 1890, vol. xvii., p. 785. 


“the maximum and minimum of heat production and 
heat dissipation do not occur synchronously with the 
maximum and minimum of animal temperature. The 
two are entirely independent of each other”; also, “the 
heat production and temperature are entirely independ- 
ent of each other.” This was true in fevered animals as 
well asin healthy ones. There is no paradox in these 
results, for we must recall, as shown in § 3, that the tem- 
perature depends upon two factors, heat production and 
heat dissipation, and that either or both of these may 
vary, at the same time, in either direction. What Car- 
ter’s researches show is the interesting fact that there is 
something in the body of mammals which causes the 
balance between heat production and heat dissipation to 
be established on a different level at different times of 
the day, and that this something does not reside in the 
centres which control heat production, nor does it reside 
in those which control heat dissipation. 

Lichatschew * found a closer relation between heat pro- 
duction and diurnal variations of temperature than was 
found by Carter. 

Relation of the Size of an Animal to the Amount of Heat 
Produced.—As this is a subject of interest less from a 
medical than from a biological standpoint, and as its dis- 
cussion would require considerable space, it will not be 
entered into here. 

Most investigators give as a general law, that, ceteris 
paribus, the heat produced by an animal is directly pro- 
portional to the cube root of the square of the weight, 
while Reichert thinks that “if any distinct relation exists 
between body weight and the quantity of heat produced 
it is in direct proportion.” 

Those interested in studying this question more closely 
are referred to papers by Rosenthal,+ Reichert,t and 
Richet,§ the latter of whom takes up a discussion of the 
effect of artificial conditions of the skin, such as shaving 
an animal, coating it with oil, clothing, etc. 

§ 6. CALORIMETRY IN PaTHoLoGy.—The chief use of 
calorimetry in pathology has been in connection with 
the study of fever. Some interesting results have also 
been obtained from investigating the effects on the sys- 
tem, of the products of the growth of specific micro- 
organisms; these latter will be taken up in § 7, on “ calo- 
rimetry in experimental pharmacology,” so that the 
present section will deal only with calorimetry in fever. 

Lavoisier’s theory, that animal heat resulted from 
combustions in the body, gained general acceptance about 
the beginning of the nineteenth century, and from that 
time until 1863 there was a strong feeling among pathol- 
ogists that pyrexia was the direct result of abnormally 
great oxidation in the body. The conflicting theory put 
forward in 1863 was that of Traube,| who attributed the 
pyrexia to retention of body heat, due to a constriction 
of blood-vessels in the skin, the result of which was to 
keep the heat of the blood from being lost by radiation 
at the surface. Traube’s chief opponent at this time 
was Liebermeister, who attributed the rise in tempera- 
ture to an increased heat production, denying that an 
increased heat retention ever took place. 

Numerous experiments have been made by indirect 
calorimetry, to determine whether there was an increased 
oxidation of food or of the tissues in fever, and the oxy- 
gen used, the CO, given off, and the nitrogenous waste 
excreted have all been taken into account. The results 
of these researches have not been in harmony, but from 
some of the most trustworthy we would gather that 
while the fever is on the rise, there is an increase in the 
oxygen used and the CO, given off, while the opposite 
is true for the decline of pyrexia. While the fever re- 
mains constant more oxygen is used and more CO, is given 
off than-in-health (nutritive conditions being the same), 
but there is not as high a percentage increase as when 





* See Richet’s ‘* Dictionnaire de Physiol.,”’ vol. iii., p. 135. 

+ Rosenthal, Arch. f. Physiol., 1889, p. 31. 

+ Reichert, Univ. Med. Mag., 1890, vol. ii., p. 225. : 

§ Richet, article ‘‘ Chaleur,” in Richet’s “* Dictionnaire de Physiol.,” 
Paris, 1898, vol. iii., pp. 127-138. 

| Traube, Allgem. med. Centralzeitung, 1863-64. 


569 


Calorimetry. 
Camden, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





the temperature is rising. Most observers found that 
the respiratory quotient (vol. CO. + vol. O) is the same 
in fever as in health, but Regnard,* one of the most 
competent, says that it is diminished, which would mean 
that the character, as well as the amount, of metabolism 
was affected in fever. 

Such experiments as these give valuable information 
about the chemical processes in the body during fever, 
and show that in fever there is increased oxidation, and 
hence increased heat production, as a rule; but they do 
not settle the question at issue between Liebermeister 
and Traube, viz.: “Does heat dissipation enter as an es- 
sential factor?” This can be answered only by direct 
calorimetry, as pointed out by Senator + when he under- 


took the first thorough series of investigations on the 


subject. 

Leyden had already made this question the subject of 
calorimetric research, but his method was the unsatisfac- 
tory one of partial calorimetry by baths.{ His results, 
however, were in harmony with those of Senator and of 
Wood, in 1880, the latter’s experiments being the most 
complete we have in calorimetry on fever. These ob- 
servers all find that both heat production and heat dissi- 
pation play an important part in fever, thus showing 
that each of the older theories of Liebermeister and of 
Traube was partly right, but neither entirely so. This 
position has been substantiated by practically all later in- 
vestigations. Our present views concerning the general 
pathology of fever cannot be better given than by the 
following quotations from some of the numerous gener- 
alizations of Wood: § 

(a) “The rise of temperature in fever is not dependent 
altogether upon increased heat production, as in fever 
there certainly is sometimes less production of heat in 
the organism than there is at other times when the bodily 
temperature remains normal; also excessive heat produc- 
tion may occur even at the expense of the accumulated 
materials of the organism without elevation of the body 
temperature.” 

(8) “In fever a daily temperature variation occurs 
which is parallel to that seen in health, and differs from 
the normal variation only in having a higher mean.” 

(y) “In fever vaso-motor paralysis, when produced, is 
followed by an immediate fall of temperature similar to, 
but greater than, that which is produced by a like dis- 
turbance in health.” 

(0) “The decrease of heat production which follows 
section of the cord is much greater in the fevered than 
in the normal animal.” 

(e) “The so-called inhibitory heat nervous system is 
not paralyzed in fever, but is less capable than in health 
of answering promptly and powerfully to suitable stim- 
uli; in other words, it is in a condition of paresis or par- 
tial palsy.” 

(¢) “The clinical succession and phenomena of a febrile 
paroxysm, such as that of an intermittent, seem plainly 
to depend upon the nervous system for their arrangement 
and relation.” 

(7) “Irritative fever, if it exists, is produced by an 
action of the nervous system.” 

(¢) “Fever occurring in cases of blood poisoning is 
often, and probably always, the result of a direct or in- 
direct action of the poison upon the nervous system, and 
hence is a neurosis.” 

According to Mosso,| there are two kinds of fevers: 
one produced by the nervous system, and one independ- 
ent of the nervous system, which has its origin in the 
tissues themselves. He claims that cocaine produces 
fever through the nervous system; while cultures of 
staphylococcus pyogenes aureus, injected into the blood, 


* Regnard, ‘‘ Recherches expérimentales sur les variations patholo- 
giques des combustions respiratoires,’’ Paris, 1878. 

+ Senator, ‘* Untersuchungen itiber den fleberhaften Process,” ete., 
Berlin, 18738, p. 2. 

+See § 4, ‘‘ Calorimetry by Baths.” 

§ Wood, ‘Fever: A Study in Morbid and Normal Physiology,” 
Philadelphia, 1880; also ‘* Smithsonian Contributions to Knowledge,” 
No. 357, pp. 254 et seq. 

|| Mosso, Arch. Ital. de Biol., 1890, vol. xiii., p. 483. 


570 


produce fever by direct action on the tissues. He has 
found that chloral will prevent the rise of cocaine fever, 
but is without effect on the fever produced by the staphy- 
lococcus. 

This question of the probable different origin of differ- 
ent fevers is an exceedingly interesting one, and would 
afford a fruitful field for further research. Certain drugs 
will influence one kind of fever but not another, anda 
careful study of this question would throw light not 
only on the action of drugs, but on the pathology of 
fever itself. 

Before leaving the subject of calorimetry in fever, 
two clinical papers should be mentioned, since each was 
written with direct reference to previous calorimetric 
work, and deal with the relation of the nervous system 
to fever. After reading them, one can scarcely doubt 
that “fever of purely nervous origin” exists. The papers 
are those of Drs. Hale White and Mary Putnam-Jacobi.* 
White,+ after a masterly review and synopsis of fourteen 
cases of lesions of the central nervous system, with clini- 
cal history and post-mortem findings, concludes that the 
results of Wood’s experiments on dogs are corroborated 
by clinical and pathological observations on man. 

§ 7. CALORIMETRY IN EXPERIMENTAL PHARMACOL- 
ogy.—In this section it is not proposed to discuss the 
physiological action of the drugsand poisons considered, 
but simply to show which of these substances have been 
investigated by direct calorimetry, and what direct calo- 
rimetry has done for medicine along this line. Unfortu- 
nately, many of the findings which will be mentioned 
are based upon too few experiments, so that the value of 
this section will be to call attention to work thus far 
completed, and needing, for the most part, corroboration, 
rather than to show positively established facts in connec- 
tion with the drugs or poisons. Only researches employ- 
ing direct calorimetry are mentioned. 


DRuvGs. 


Antifebrin.—Hare ! finds that antifebrin reduces normal 
temperature, and in so doing affects both heat production 
and heat dissipation. 

In fever it reduces pyrexia chiefly by decreasing heat 
production. It seems to have little effect on pepsin fever 
(see Pepsin, this section). 

Antipyrin.—W ood, Reichert, and Hare? find that anti- 
pyrin lessens heat production independently of any action. 
on the circulation. They think it influences the chemi- 
cal changes in the body through the nervous system, 
especially the heat-inhibitory centre. 

Girard * found that a lesion (pzqire) on the median side. 
of one of the corpora striata produced less effect after 
giving antipyrin than before. 

Martin‘? destroyed Ott’s inhibitory heat centre, and 
found that antipyrin produced an increase of heat dissi- 
pation, the same dose not always giving the same quan- 
titative results. Heat production was reduced in four 
out of six cases. He compared hydroquinone, antipyrin, 
thallin, and kairin, and all gave the above result. “As. 
a rule, heat production followed heat dissipation, in its: 
ups and downs, although the drugs sometimes reversed. 
matters,” especially antipyrin. 

Gottlieb ® attributes the fall of body temperature, after 
antipyrin, exclusively to increased heat dissipation. He- 
says there is no concomitant diminution in heat produc- 
tion. 

Atropine.—According to Ott,* atropine causes increased: 
heat production and increased heat dissipation, the effect 
on heat production being the greater—consequently tem- 
perature rises. 

Lewis’ finds that small doses of atropine produced: 
increased heat production and diminished heat dissipa- 
tion, while with large doses the temperature fell with in- 
creased heat dissipation in spite of increased heat pro- 
duction. 


* Jacobi, Journ. of Nerv. and Ment. Dis., 1890, vol. xvii., p. 373. 
+ White, Guy’s Hospital Reports, 1883-84, vol. xxvii., p. 48. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Calorimetry. 
Camden, 





Caffeine.—Reichert § finds that, under caffeine, heat pro- 
duction is always increased, while heat dissipation is not 
affected in any constant way. Curare modifies but does 
not check the action of caffeine. 

Carbolic Acid.—Hare! (p. 525) gives a summary of his 
work with carbolic acid as follows: ‘ Carbolic acid pos- 
sesses considerable power in lowering normal bodily tem- 
perature. It possesses more influence over pyretic tem- 
perature than does salicylic acid, generally preventing a 
rise or causing a fall of ternperature, but sometimes fail- 
ing todoso. Its mode of decreasing normal bodily tem- 
perature is as yet not fully understood, although it 
would seem probable that it acts on both heat functions. 
When reducing bodily temperature in fever, it acts chiefly 
by decreasing heat production, although it affects both 
functions.” 

Chloral.—Bevan Lewis’ says: “Hammarsten’s state- 
ment that the rapid fall of temperature is dependent 
upon diminished heat production . . . is, I consider, fal- 
lacious; in fact, all my observations tend to confirm the 
statement previously made, viz., that the heat production 
is greatly increased, and that the fall of temperature is 
really dependent upon the increased dispersion of heat 
from the body, ensuing from exposure during very gen- 
eral vascular dilatation.” i 

Cocaine.—As the result of a very complete research 
Reichert ® finds that cocaine increases both heat produc- 
tion and heat dissipation. Its action on heat production 
is much the greater, so that temperature rises. Curare 
seriously interferes with the action of cocaine. 

Curare.—See experiments of Kemp and of Reichert, 
§ 5, Calorimetry in Physiology. 

Ergotine.—Ergotine, according to Bevan Lewis,’ pro- 
duces a fall in heat production, with fall in temperature, 
followed by a rise in both. 

Hydroquinone.—See Martin’s* “ Researches on Antipy- 
rin,” above. 

Hyoscyamine.—Bevan Lewis’ found that hyoscyamine 
always produced great commotion in heat production and 
heat dissipation, but no constant effect could be ascribed 
to it. 

Kairin.—See Martin’s “Researches on Antipyrin,” 
above. 

Neurin.—Ott}° found that neurin produced fever by 
action on the nervous system independently of the circu- 
lation. 

Pepsin.—Many forms of commercial pepsin, when 
rubbed up with water or salt solution, and injected into 
the blood, produce a decided fever apart from their action 
on the circulation. This fever is the result of an effect 
on both heat production and heat dissipation, the former 
being the more affected. The active substance in these 
cases is not pepsin, but proteoses and peptones, which 
are found along with the pepsin (see Ott,'° and Wood, 
Reichert, and Hare’). 

Peptone.—See Pepsin, above. 

Proteoses.—See Pepsin, above. 

Phenol.—See Carbolic Acid, above. 

Picrotoxin was found by Bevan Lewis’ to increase, 
enormously, heat production. The effect lasted longer 
than that of strychnine. Heat production then fell to a 
minimum just before convulsions set in. 

Quinine.—Wood, Reichert, and Hare? investigated the 
action of quinine with the calorimeter, and found both 
heat production and heat dissipation to be affected. We 
quote them as follows: “ We do not think that our results 
are sufficient to positively determine whether heat pro- 
duction or heat dissipation is the function which is pri- 
marily influenced.” They think that quinine’s chief value 
is due to its “stimulating or restoring the normal tone of 
the centres which are connected with thermogenesis, so 
as to enable them to resist the morbific fever-producing 
influences. 

Another author* finds that doses of 0.1 to 0.2 of qui- 
nine lower the heat production inrabbits. In normal ani- 


* These observations were found among the writer’s notes without 
a reference to the original paper. 


mals the diminution is from eight to eighteen per cent., in 
animals with fever from pigire the diminution may be 
as high as forty per cent. 

Salicylic Acid.—Hare! finds that salicylic acid can re- 
duce normal temperature slightly; it has little power 
over the temperature in fever. In reducing normal tem- 
perature it probably acts on both heat production and 
heat dissipation; its action on fever is uncertain and ir- 
regular. 

Solanine.—This alkaloid was studied by Bevan Lewis,? 
who found that its vaso-motor effect produced diminished 
heat, dissipation of heat, with consequent rise of temper- 
ature. Thisrise took place in the face of an enormously 
reduced heat production. 

Strychnine.—Bevan Lewis’ found that strychnine in- 
creased heat production—the best effects were from small 
doses. Chloral counteracts the effect of strychnine. 

Thallin.—Martin? found that thallin regularly in- 
creased heat dissipation, but had no constant effect on 
heat production (see also Antipyrin, above). 


BACTERIAL Porsons. 


Tuberculin.—D’Arsonval and Charrin* found that 
tuberculin raised the rectal temperature and at the same 
time diminished heat production. 

Pyocyaneus (bacillus).—Certain poisons produced by 
this bacillus had the same effect as tuberculin mentioned 
above.* 

Pyogenes aureus (staphylococcus). — See account of 
Mosso’s work in § 6, Calorimetry in Pathology. 

George I. Kemp. 


1 Hare, Ther. Gaz., 1887, p. 389, 

2 Wood, Reichert, and Hare, Ther. Gaz., 1886, p. 811. 

3 Girard, Rev. méd. de la Suisse Romande, 1887. 

4 Martin, Ther. Gaz., 1887, p. 289. 

5 Gottlieb, Arch. f. exp. Path. u. Pharm., 1891, vol. xxviii., p. 184. 

§ Ott, Ther. Gaz., 1887, p. 514. 

ane on Lewis, West Riding Asylum Reports, 1876, vol. vi., pp. 


8 Reichert, Ther. Gaz., 1891, p. 249. 

® Reichert, Univ. Med. Mag., 1889, vol. i., p. 448; and Ther. Gaz, 
1891, p. 249. 

10 Ott, Journ. of Nerv. and Ment. Dis., 1884. 


CALYCANTHUS.—(Properly Butneria.)—A genus of 
three species of shrubs in the family Calycanthacee, grow- 
ing in the United States. The bark and leaves of B. 
fertilis (Walt.) Kearney, commonly known as the sweet- 
scented shrub or strawberry shrub, are used in domestic 
practice as an antiperiodic. The plant is chiefly of inter- 
est because of the poisonous nature of the seeds, sheep 
being killed by eating the fruit. An alkaloid, calycan- 
thine, has been extracted by Dr. R. G. Eccles from these 
seeds. H, H. Rusby. 


CAMDEN, S. C.—Situated in the pinewood, sandhill 
region of the State, about 30 miles from Columbia and 
twenty hours from. New York. It is a town of 3,500 
inhabitants, between 150 and 200 feet above sea level, 
and is a winter health resort particularly suitable for 
cases of pulmonary tuberculosis. The soil is very dry 
and porous, so that after a heavy shower the roads are 
not wet, the water quickly soaking into the sandy soil. 
The water supply and drainage are said to be good and 
the accommodations excellent, there being two hotels and 
a number of boarding-houses. The climatic data are as 
follows: 

Mean temperature (Fahrenheit): spring, 61.90°; sum- 
mer, 79.32°; autumn, 62.26°; winter, 45.16°. Average 
annual rainfall for twenty years, 42.22 inches. The cold- 
est noon temperature in February, 1890, was 50°; in 
March, 40°; in April, 50°. The warmest noon tempera- 
ture was: in February, 83°; in March, 81°; in April, 86° 
(Solly). The prevailing winds are south and southwest. 
In February and March there are some high winds, but 
generally the air is remarkably soft, dry, and balmy. 


*D’Arsonval, Arch. de Physiol., 1894, p. 362. 


571 


Camp Diseases. 
Camp Diseases. 





“Frosts occur at night only, and snow is exceptional.” 
The exaet number of sunny days is not known, but is 
said to be large. The relative humidity, though not 
known for this place, is probably not very different from 
that at Aiken, which is 59 per cent. for December, Janu- 
ary, and February. 

The oh ven advantages claimed for this region as a 
health resért are “its dry, balmy, bracing air, with con- 
ditions favorable for constant out-of-door life”; its dry, 
sandy soil; the pines, and its easy accessibility. 

Camden would appear to bea good resort for the open- 
air treatment of pulmonary tuberculosis, for cases not 
suitable for the colder regions or altitudes; also for con- 


valescents from influenza, pneumonia, or pleurisy, and . 


for those who merely desire to escape the dampness and 
cold of the Northern winter. Edward O. Otis. 


CAMP DISEASES.—There are no diseases peculiar to 
the soldier, but those by which he is chiefly affected are 
such as not infrequently occur among males of the mili- 
tary age in civil life. The conditions of military ser- 
vice, however, are often such that various factors predis- 
posing to deviation from the standards of health are 
greatly increased in potency; while the directly exciting 
causes often operate much more frequently, act over 
longer periods, and, in the case of infectious diseases, not 
rarely assume greater virulence. Since all these diseases 
have their counterparts in civil life, any extended dis- 
cussion of their etiology, pathology and symptomatol- 
ogy is unnecessary in this connection; and the treatment 
of such diseases also varies in no wise from that employed 
by the more advanced members of the medical profession 
throughout the civilized world. There remains, then, for 
discussion the relative importance of various diseases 
as affecting the health of troops; the predisposing causes, 
in so far as they are influenced by military service and 
conditions; the special methods of infection and the dis- 
semination of infectious material; and, finally, the means 
of preventing such diseases, as based chiefly upon the 
special military conditions by which the occurrence of 
the disease is favored or brought about. 

Excluding traumatism, the causes which chiefly im- 
pair the health and efficiency of troops, in garrison or 
during campaign, may be grouped according to their 
relative importance, as follows: 

1. Diseases of an infectious character, the spread of 
which, in the military service, is favored by the aggre- 
gation of young and susceptible individuals, ignorant or 
careless in regard to matters of personal hygiene, living 


under conditions implying intimate personai relation- - 


ship, constant contact and, frequently, overcrowding. 
In many instances the necessities of military service re- 
quire an existence in unhealthful localities, favorable to 
the development of pathogenic micro-organisms and un- 
der circumstances in which their opportunities for dis- 
semination and entrance into the system are much greater 
than in civil life. In addition, the occurrence of these dis- 
eases is also often markedly favored by depression of the 
powers of vital resistance, depending upon great fatigue, 
exposure to inclemencies of weather, insufficient or im- 
proper food, impure water and vitiated air. These dis- 
eases assume far greater importance during active service 
in the field than in garrison, being the chief cause of in- 
efficiency among troops during campaign. 

2. Diseases due to immoral or intemperate habits; as 
favored by an enforced celibacy, the absence of whole- 
some home restraint and the monotony often attaching 
to garrison life. These diseases are factors of the first 
importance in time of peace in raising the sick rates of 
an army, but during active warfare or field service they 
sink into comparative insignificance. 

3. Diseases the causative agents in which are un- 
known, but which appear to be largely excited by expo- 
sure to cold, wet and dampness, whether they be found 
in camp or garrison. These affections have but little 
tendency toward a fatal result, and their importance 
from the military standpoint lies in the considerable pro- 
portion of temporary unfitness for service which they 


572 


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produce. The number of soldiers who are temporarily in- 
capacitated for all or part of their duty, from these causes, 
is always large. 

4, Affections due to extremes of temperature. Such 
are obviously related to climate and season, and are 
largely influenced by nature of service; being naturally 
much more frequent among troops on campaign than 
among those in garrison. 

5. Disease due to an improper dietary; this being 
largely dependent upon facility of supply and transpor- 
tation, and hence being obviously more frequent among 
troops on active campaign or serving at remote, isolated, 
and newly established stations. 

6. Disease directly induced by military service. This 
may be of a functional or organic nature, and is largely 
dependent upon the muscular labor involved in the exe- 
cution of military movements, the method of disposing 
the equipment upon the person, and the mental condition 
often resulting from field service and conflict. Patho- 
logical conditions of this character are rarely observed in 
garrison, but are by no means infrequent during cam- 
paign. 

In the detailed consideration of the diseases of the 
soldier, it is obvious that only such as exert a certain 
positive influence upon military efficiency require dis- 
cussion. To consider a number of rare affections, from 
the liability to which the soldier is no more free than 
the young man of the military class in civil life, and 
upon the oceurrence of which military service appears to 
exert neither positive nor negative influence, is clearly 
both unnecessary and undesirable. 


I. InFEcTIOUS DISEASES. 


AsIaTIc CHOLERA.—Occurrence.—The military history 
of cholera begins with the year 1757, when the British 
troops in India suffered greatly from its attacks. It is 
said that one division of 5,000 men had 500 deaths from 
cholera in a single day. In 1817, according to Rosse, in 
a force under Hastings the onset of a cholera epidemic 
was so sudden that sentries fell as if struck by lightning, 
and it required three or four men to stand a tour of guard 
duty of two hours. In five days there were 5,000 deaths, 
and the command wasalmost destroyed. In 1821, cholera 
made such ravages in the armies of Turkey and Persia 
that it forced military operations in Mesopotamia to be 
brought to an end. In the years 1830-1831 cholera ex- 
tended all over Europe and was shortly afterward 
brought to this country. Troops were attacked at a 
number of stations. At Fort Dearborn, on the present 
site of Chicago, it is stated by Rosse that 200 men out of 
a garrison of 1,000 were admitted to hospital with cholera 
in the course of seven days. During the Crimean War 
there were 7,375 cases of cholera in the British army, 
with 4,518 deaths. In the French army, at the same 
time, there were 12,258 cases with 6,018 deaths. Among 
the French troops composing the ill-fated Dobrutscha 
expedition, it is said that at one time no less than 10,000 
men lay dead or struck down by cholera. Out of one 
battalion, besides those already dead, 500 sufferers were 
carried in the wagons. Coustan states that in one divi- 
sion of 10,590 men there were 2,036 deaths. In 1866, 
during the war between Austria and Prussia, more deaths 
occurred from cholera, in the armies of the latter country, 
than resulted from battle... At the close of the Civil War 
our troops suffered severely from cholera; there being, 
in 1866, 2,818 cases and 1,269 deaths. In 1867 there were 
504 cases and 230 deaths, and in 1868 there were 7 cases 
and 38 deaths. Cholera almost destroyed a body of re- 
cruits marching from Leavenworth to Fort Hays, in Kan- 
sas, and wasalso epidemic at Fort Riley and other stations. 
It was carried by: recruits from New York to California, 
Louisiana, Texas and Georgia. In 1866 it also broke out 
in Brazil and the Argentine, and was carried by the armies 
into Paraguay. In the outbreak of 1878, in this country, 
our army was little affected, there occurring but 12 cases 
with 8 deaths; and since that year there have been no 
further deaths from this cause in our service. The 


ra 





Algeria. Rosse states that in Paris, for the period 1832- 
49, and again in 1853, the mortality from this cause was 
14.76 per thousand among the civil population, and 42.59 
per thousand among the garrison troops. In many later 
instances, however, especially in the outbreaks of 1884 and 
1893, the greater care as to sanitary conditions in the mili- 
tary service preserved the soldiers, while deaths occurred 
in the surrounding civil population. In the British army, 
during the decade 1888-97, cholera occurred among 
troops in India, Egypt, China, and Ceylon. In India, 
for this decade, the admission rate per thousand was 
1.8; the death rate, 1.29. Cholera figures almost annu- 
ally in the returns for the Russian army, certain military 
garrisons of which are located in regions at which the 
disease endemically prevails. Recent figures for cholera 
in the Russian army are as follows: 

















, Admissions per Deaths per 
| 1,000 strength. | 1,000 strength. 
0.06 | 0.02 
4.3 1.83 
1.61 46 
1.00 35 
40 10 
OL 002 





Dissemination and Infection.—The specific. causative 
agency in cholera is given off chiefly by the bowels, and 
to a less degree in the vomitus. The length of time dur- 
ing which the stools of a cholera patient are infectious is 
unknown, but it probably is a considerable period. <As 
with typhoid fever, apparently healthy persons appear at 
times, during an epidemic, to act as hosts for the bacilli 
and play a part inthe propagation of the disease. While 
the disease at times follows contact with the sick, it may 
fairly be regarded as only slightly contagious and not 
likely to be contracted except by indirect infection. The 
latter undoubtedly occurs by way of the alimentary tract. 
There is no proof that air ever serves as the vehicle for 
the transmission of cholera bacilli; though in this disease, 
as in typhoid fever, its dissemination by this means should 
be regarded as possible. Water has long been recognized 
as the chief agent in the spread of cholera; and abundant 
circumstantial evidence to this effect is fortified by a 
number of instances in which the specific etiological 
factor has been discovered in suspected water by bacterio- 
logical investigation. Many instances have been reported 
in which the infection of a water supply was followed by 
outbreaks in communities further down the stream. In 
the epidemic of Hamburg, in 1892, the part played by an 
infected water supply was most marked; the proportion- 
ate number of cases being eight times greater in that 
part of the city in which unfiltered water was supplied, 
than in the part in which the drinking-water was par- 
tially purified by sand filtration. Recently, among the 
British troops at Umballa, in India, an epidemic of chol- 
era promptly ceased as soon as a supply of sterilized 
water was provided for drinking purposes. Cholera 
bacilli flourish best in sluggish streams, and especially 
in water containing a considerable proportion of organic 
matter. Under certain circumstances, not as yet fully 
understood, the bacillus is capable of rapid multiplica- 
tion in water, but many saprophytic micro-organisms are 
hostile to its development and appear to destroy its vital- 
ity in the course of a few hours or days. Any specific 
contamination, however small, is capable at times of im- 
parting to enormous quantities of water the power of 
originating the disease. Earth undoubtedly may serve as 
a medium for the development of the bacillus outside the 
human body. At Lucknow, 90 soldiers out of 600 died of 
cholera apparently as a result of placing fresh sand, taken 
from the bank of a river used as a general bathing place, 
in a filter from which water was drawn for the use of the 
command. Food contaminated by cholera discharges also 
serves as an agent for the spread of the disease. This is 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








Camp Diseases, 
Camp Diseases, 





rarely directly infected, but is contaminated by manipula- 
tion with unclean hands, by contact with infected objects, 
by dust containing the specific germs, or by the agency 
of flies which have recently fed on cholera discharges. 
In India, medical officers now regard the latter as one of 
the more common agencies by which the spread of chol- 
era is accomplished. In the Burdwan prison, where 
other means of infection were scarcely possible, it is said 
by Buchanan that an epidemic was directly traceable to 
flies which were carried over the prison wall by a high 
wind blowing from the direction of some native fouses, 
in which the disease had occurred. During the outbreak 
in the Gaya jail, Macrae found that milk to which flies in 
the jail were given access invariably became infected 
with comma bacilli; and he concluded that “flies should 
be looked on in the light of poisonous agencies of the 
worst kind during cholera epidemics.” The cholera ba- 
cilli may be carried in fomites, particularly in baggage, 
rags, or clothing, soiled with the feecal discharges of the 
sick. Under such conditions they retain their vitality for 
considerable periods, though they are readily destroyed 
by sunlight and desiccation. Asin typhoid fever, the dis- 
ease germs may be carried into camp or barracks on the 
shoes of individuals who have visited an infected latrine 
or locality. Marching troops, when infected, have done 
much to spread the disease to districts in which it was 
previously unknown. 

The period of incubation of cholera is usually about 
three days, but this, under rare circumstances, may ex- 
tend to as much as ten days. 

Predisposing Causes.—Cholera prevails endemically in 
India, from which it extends from time to time. It ap- 
pears to be a settled fact that where the disease prevails 
in an endemic form it does not occur in great epidemics. 
A severe outbreak appears to confer upon the locality 
attacked a more or less complete immunity ; the durabil- 
ity of which, so far as India is concerned, appears to last 
fora number of years. A high temperature is a predis- 
posing cause of great importance; but while many epi- 
demics have ceased with the advent of cold weather, this 
is by no means always the case. In the tropics, cholera 
prevails to the greatest extent at the close of the dry sea- 
son. A moderate rainfall tends to cause the further de- 
velopment of the disease, but where the rains are heavy 
and continued, a marked diminution in the occurrence 
of cholera is observed. There isa general consensus of 
opinion that the incidence and severity of the disease are 
greater among negroes than among whites. In the 
United States, during the epidemic at the end of 1866, 
the mortality among the white troops was 77 per thou- 
sand, while among the colored troops it was 185 per 
thousand. When the disease prevails endemically, the 
native population appears to enjoy a considerable but 
not absolute immunity to it. In the Hedjaz and in the 
sparsely populated parts of Arabia, it is said by Fauvel 
that the disease manifests only a feeble tendency to prop- 
agate itself among the native population. This immu- 
nity, however, is not shared by strangers visiting a locality 
endemically affected. As a race, the Chinese appear to 
be notably free from the ravages of cholera, probably 
chiefly from their general use of sterilized water in tea. 
In any outbreak of this disease, numbers escape attack 
through their hereditary or gradually acquired powers of 
resistance. For epidemics of cholera a stratum of moist 
soil pervious to air, in which organic material is decom- 
posing, affords the most favorable condition. General 
sanitary defects, by which the specific fouling of soil and 
water is possible, are essential to the development of an 
epidemic. 

It has long been observed that the poorer quarters of a 
community suffer by far the most during a cholera visi- 
tation. Epidemics also prevail more severely in low- 
lying regions than on high ground. Insufficient, poor, 
or coarse food, improper clothing, and inadequate shelter 
favor the occurrence of cholera; and physical and mental 
depression are both markedly predisposing causes. Over- 
crowding is also a factor of importance. Those affected 
with catarrh of the intestinal tract and diseases of the 


573 


Camp Diseases, 
Camp Diseases. 





digestive apparatus are particularly susceptible to chol- 
era infection. 

Prophylaxis.—In view of the fact that in practically 
every instance of an outbreak of cholera, in regions or 
communities in which it is not endemic, its origin has 
been traced to importation from abroad, it is manifest 
that where practicable a system of quarantine should be 
established as soon as the danger of an introduction of 
the infection is recognized. No person from the infected 
locality should be admitted within the military lines 
without undergoing examination, and after detention 
under observation for a period of tendays. All clothing 
and similar articles should be disinfected before being 
passed; supplies intended for food, unless carried through 


the affected district in unbroken packages, should not be’ 


admitted. Special cholera hospitals, in readiness for an 
outbreak, should be established and provided with a spe- 
cial staff of attendants. They should not be located at 
too great a distance from the troops, from the rapid na- 
ture of the disease. Such hospitals should possess sepa- 
rate facilities for the isolation and treatment of suspects 
as well as well-defined cases of cholera. 

When the disease prevails, all soldiers suffering from 
diarrhea, no matter how insignificant it may appear, 
should be regarded as suspicious and should be subjected 
to the same vigilant supervision as applies to recognized 
cholera patients, for many of these cases, though mild, are 
nevertheless true cholera and capable of disseminating this 
disease. Because of their apparently innocent nature 
these cases often escape the attention their importance 
demands; and unless it be borne in mind that they area 
grave menace to all with whom they are associated, and 
are treated as such, they can be regarded only as most 
dangerous sources for the dissemination of disease—far 
more so than the severe cases which attract attention 
from the outset. Frequent inspection of latrines should 
be made and the character of the discharges noted in this 
connection. Convalescents from cholera should be kept 
isolated, and the evacuations from the bowels should 
be disinfected, until bacteriological examination demon- 
strates that the specific micro-organism causing the 
disease has disappeared from the discharges. Such indi- 
viduals should be returned to their respective organiza- 
tions only after a disinfecting bath and after donning a 
complete outfit of clothing sterilized throughout. The 
antecedents of each case of cholera should be investigated, 
and all those who have been in immediate association 
with the patient should be placed under observation. 

As cholera germs can live and multiply for a time out- 
side the body in the presence of decomposing organic 
material, more particularly that of animal matter, there 
should be a thorough removal of every sort of filth and 
refuse from the camp or garrison. Thorough cleansing, 
airing, painting, or lime-washing should be carried out 
wherever indicated. It should not be forgotten that, al- 
though desirable at all times, measures of cleanliness taken 
beforehand are of far more value for protection against 
cholera than policing which is delayed until after the 
disease has actually made its appearance. All water 
used for drinking purposes should be sterilized, prefer- 
ably by heat. Under all circumstances, in time of chol- 
era, an immediate and searching examination of the 
sources and conduits of the water supply should be made, 
when it is in any way open to the suspicion of impurity. 
When pollution is found to have occurred, every care 
should be taken to prevent such pollution from continu- 
ing and the water from being utilized. When the water 
supply is believed to be at fault, bathing of the person, 
except with boiled water, should be discouraged. For 
marching troops, great care should be taken to prevent 
the use of water from the supplies of infected towns, 
Tea has been much used by British troops during out- 
breaks of cholera in India, as being more palatable than 
ordinary boiled water. Acidulated drinks containing 
sulphuric acid, acetic or citric acid, may sometimes be 
given with advantage. Red wine is also recognized as 
destructive to the cholera bacillus, and a ration of this, 
taken diluted in water, might well be issued during an 


574 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





epidemic. The food supplied should be abundant, simply 
prepared and readily digestible. Particular care should 
be taken toinsure the condemnation and rejection of any 
food of unsound character capable of exciting a diarrhea. 
With the exception of acid fruits protected by an outer 
rind, as oranges and lemons, no article of food should be 
eaten that has not been subjected to a boiling temperature 
in its preparation. Under nocircumstances should the 
use of uncooked vegetables in salads be permitted. All 
food and drink should be carefully protected against 
access by flies, since some of these may have previously 
come in contact with cholera discharges. Prior to use, 
all vessels used for the cooking, serving, or storing of 
food should be sterilized by immersion in boiling water. 
The purchase of food or drink by the men at points 
outside of military control should be prohibited. The 
hands of all should be washed before eating. Troops 
should be well clothed, sufficiently to protect against 
cold, chilling and moisture. Itis during outbreaks of 
intestinal disorders that the use of the abdominal band 
isof most advantage. The clothing should be frequently 
changed, washed, and sunned. 

There should be no unnecessary exposure to sun, rain, 
or night air; and no drills or fatigue other than to fur- 
nish occupation and needful exercise. The size of the 
guard and the length of the tours of duty should be re- 
duced as much as military conditions permit. In addi- 
tion to fatigue, nothing is more conducive to the spread 
of the disease than fear and unusual excitement, and a 
quiescent state of mind should be enjoined upon all. In 
general, the troops should be regarded as engaged in 
campaign against an insidious and implacable enemy, 
and the attention of every officer should be devoted to 
superintending the conduct of his subordinates with 
special reference to this view. 

In time of impending epidemic, troops should be scat- 
tered. A change of soil and locality often appears to be 
of advantage, and camps should be moved as often as 
a new case appears. Troops that have fallen back be- 
fore the advance of the disease have often escaped seiz- 
ure, or have avoided further sickness if withdrawn sub- 
sequently to their attack. 

A temporary abandonment of an infected locality is 
strongly toberecommended. When the disease has actu- 
ally occurred, efforts at disinfection should be primarily 
directed toward the vomitus and fecal matter. These 
should, as far as possible, be burned. If the cases occur 
on board transports, the excreta should be received in 
vessels and not discharged overboard, particularly if in 
harbor. The disinfection includes that of the barracks, 
tent, or place occupied by the sick, and the articles of 
clothing and bedding with which they may have come 
in contact; and upon its promptness and thoroughness, 
together with isolation of all those attacked by cholera 
and their attendants, depends the arrest of the epidemic. 
If due care in regard to cleanliness and disinfection be 
observed, there is comparatively small risk that the dis- 
ease will spread to those who nurse or otherwise attend 
upon the siek. 

As amethod of prophylaxis against cholera, inocula- 
tions with a specially prepared virus have been systema- 
tized and successfully practised in India by Haffkine. 

A large number of individuals—upward of 100,000— 
have been inoculated by him against cholera; among 
themanumber of white.and native soldiers in the British 
service. While the results have varied greatly, they are 
on the whole distinctly favorable. Among 1,526 non- 
inoculated soldiers at Dinapore and Cawnpore, there 
were 25 cases, while among the 268 inoculated there were 
no cases. In Calcutta, from the tenth to the four hun- 
dred and fifty-ninth day after inoculation, cholera visited 
26 houses. Among the 263 uninoculated inmates there 
were 14.45 per cent. attacked, while among the 137 
inoculated the proportion attacked was only .75 per cent. 
The East Lancashire regiment also received weak pro- 
tective inoculations. Some months later it was exposed 
to cholera, and the death rate showed the prophylactic 
value of the inoculation. According to Simpson, 654 in- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





dividuals who were not protected against cholera had, 
during the next two years, a mortality of 10.86 per cent. ; 
while of 402 members of the same households, inoculated 
by him, the mortality from cholera, during the same 
period, was but 2.99 per cent. 


Busonitc PLAGUE.—Occurrence.—With the recent oc- 
currence of plague in the Philippine and Hawaiian 
Islands, this disease at once assumes a practical im- 
portance to the army medical officer. Plague has not 
in recent years figured to any extent among the dis- 
eases affecting troops; but numerous epidemics have 
been reported in the past. The destruction of the 
Assyrian army, recorded in 2 Kings, was probably 
due to plague; and the disease described by Thucyd- 
ides as affecting the 200,000 men immured-in Athens, 
during the Peloponnesian War, presented the symptoms 
of the catarrhal form of this disease. Plague ray- 
aged the armies of the Crusaders, and it is said that in 
the first Crusade no less than 50,000 men died of this 
disease before Antioch. The soldiers of Cromwell died 
of plagueas well as typhus; and it prevailed among both 
French and English during the first occupation of Egypt. 
In 1816 plague was introduced into Arabia by the Egyp- 
tian army, and it has since prevailed there endemically. 
An epidemic of this disease is said to have occurred as 
late as 1828, in the Russian expedition against Turkey. 
Plague prevails endemically in China, Western Asia, 
Northern Africa, and perhaps India; from which points 
jt has from time to time extended. It has recently vis- 
ited Uruguay, Brazil, Mexico, and, in this country, Cali- 
fornia. It has also been lately transported to New Zea- 
Jand, Madagascar, South Africa, New Guinea, and a 
number of islands in the Pacific, among which are pos- 
sessions of our own. Recently it has occurred among 
the employees of the Quartermaster’s Department at 
Manila. 

Predisposing Causes. — The mortality from bubonic 
plague varies with different epidemics. Race exerts a 
marked influence both on the occurrence of the disease 
and the mortality. Of late years, whites in the Orient 
have rarely contracted the disease; and, when so affected, 
the mortality is low. In the epidemic at Hong-Kong, in 
1894, Lawson states that the percentage mortality of 
those attacked was as follows: Europeans, 18.2; Jap- 
anese, 60; Malays, 100; Chinese, 93.4. The disease is 
pre-eminently favored by want, privation and lack of 
proper sanitation. Meteorological conditions appear to 
have little influence on the occurrence of plague. 

Propagation and Dissemination.—Plague has arisen so 
uniformly in unclean places that filth is regarded as an 
essential factor in its propagation and spread. Almost 
without exception, plague centres have been character- 
ized by a soil polluted by decomposing animal material 
and by the overcrowding of a dirty and insufficiently 
nourished population. Plague bacilli have been isolated 
from the dust of infected houses, and the affection is gen- 
erally regarded rather as a ground than a water disease. 
When the microbe is removed from a soil saturated with 
organic filth, it appears to lose much of its virulence. In 
the epidemic in Hong-Kong, in 1894, Lawson was im- 
pressed with the part which dust and dirt played in the 
transmission of the disease. The bacillus has been shown 
to be capable of surviving for two weeks in water, and 
hence the supply used for drinking and purposes of 
cleanliness should be pure. While the disease appears 
undoubtedly to be transmitted by air, this is possible 
only within a small radius, and there is considerable evi- 
dence to show that it may be transmitted by means of 
food. The disease may be spread by means of clothing 
and other articles which have been used by plague pa- 
tients; but is most often disseminated by human inter- 
course. Aoyama believes that the plague bacillus gains 
entrance to the body largely through skin wounds, and 
much less frequently than has been supposed by way of 
the respiratory and alimentary tracts. The fact that 
there may be no local manifestations at the point of en- 
trance is important. 


A large number of animals, particularly rats, mice, 
and small rodents, are susceptible to the disease. Rats 
die in great numbers in pest-smitten districts, sometimes 
before the epidemic occurs in human beings. There can 
be little doubt that these animals play the most impor- 
tant part in distributing the disease over wide areas, 
when it has once brokenout. This has been abundantly 
proved in the case of Bombay, where observation has 
shown that the emigration of plague-infected rats to dis- 
tricts comparatively free from the disease has been at- 
tended by an extensive outbreak in those places. In 
addition to the pus of suppurating buboesand the blood, 
the bacilli have also been found in the sputum, urine, 
and feces of both menandanimals. Further, it has been 
shown that the flea is frequently an agent by which in- 
oculation is made from affected to sound animals. Pest 
bacilli have been found in the stomach contents of these 
insects, and fleas taken from plague-afflicted rats have 
been made the means of communicating the disease to 
healthy animals. Nuttall, Yersin, and Ogata have found 
pest bacilli in large numbers in the bodies of flies in an 
infected locality. Even after forty-eight hours’ reten- 
tion in a clean receptacle without infected food, infected 
flies were full of virulent plague bacilli. The experi- 
ments of Nuttall and Ogata also tend to show that ants 
and mosquitoes may be the carriers of this disease, the 
latter producing infection by direct inoculation. Bed- 
bugs appear to digest and destroy the bacilli. From the 
facts stated, with regard to the powers of comparatively 
rapid multiplication of the bacillus, its wide dissemination 
by the excreta and by animals and insects, it may be 
understood how extensively soil and habitation may be- 
come infected and how ditticult it may be to arrest the 
ravages of the disease. The important part played by 
infection of a locality is strikingly shown by the rapid fall 
in the number of cases where an infected site is aban- 
doned and the inhabitants placed in tents. 

General Principles of Prophylazvis.—The most important 
safeguards against the development of plague are clean- 
liness of person and surroundings, good drainage, free 
ventilation, and a war of extermination against rats and 
mice. In addition, the prophylactic use of Haffkine’s 
anti-plague serum appears to be of great importance. 
When the disease makes its appearance, the sick should 
be at once isolated in tent hospitals, and all who have come 
in close contact with them, or have been exposed to the 
same conditions, should be quarantined and kept under 
observation for ten days. The belongings and surround- 
ings of the patient should be carefully disinfected. The 
sputum, urine, feeces, and dressings from suppurating 
buboes should be burned. Only healthy persons, free 
from abrasions, sores or ulcers, should be allowed near 
the sick; and such should be required to maintain scrupu- 
lous personal cleanliness and take a disinfectant bath 
once daily. The troops should receive abundant food 
and pure water; and the necessity for personal cleanli- 
ness and the frequent change of clothing impressed upon 
them. The use of well-fitting shoes and great care of 
the feet is necessary, since there is considerable evidence 
to show that inoculation usually takes place in the lower 
extremities. Soldiers should avoid infected districts, 
except under competent authority. 

If proper care be taken, the liability of white troops 
to contract this disease appears slight. At Hong-Kong, 
in 1894, of 300 British soldiers who volunteered to assist 
in the sanitary policing of infected houses, but 10 con- 
tracted the disease; in Poona, in 1897, of over 900 white 
soldiers so engaged, not one became infected. In the 
latter instance the precautions taken included a hearty 
meat meal before beginning the work of the day; the 
retention in camp of all cases of slight ailment or those 
presenting cuts or abrasions; immediate disinfection by 
antiseptic solutions of cuts or bruises incurred during 
the work, and the thorough sunning of the clothing 
worn, for the rest of the day, after return to camp. 

In addition to the destruction of rats, preferably by 
traps and ferrets, precaution should be taken to prevent 
infection by means of insect life. Such individuals as 


575 


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Camp Diseases. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








recover from the disease should be kept in quarantine for 
at least a month. Kitasato has found the bacillus of 
plague in the blood as long as three weeks after the be- 
ginning of convalescence. ; 

The system of preventive inoculation against plague, 
as devised by Haffkine, has been carried out on an ex- 
tensive scale in India during the past six years. As with 
cholera, the method has been systematically tested by in- 
oculating a certain portion of the inhabitants of districts 
exposed to infection, leaving others uninoculated; and 
then observing the proportion of cases of the disease, 
and of fatal cases, among the two classes. The results 
have been distinctly successful. 

At Poona, inoculation was practised with anti-plague 
serum on the native followers of the artillery troops 
stationed at that point. While everything was done out- 
side of inoculation to prevent the spread of the disease, 
in 859 uninoculated there were nevertheless 143 cases 
with 98 deaths; in 671 inoculated there were 82 cases 
with 17 deaths. Had the inoculated, living under the 
same roof, belonging to the same families and sharing 
the same food and drink, been equally affected, the pro- 
portionate number of deaths would have been 77. The 
inoculation, therefore, reduced. the death rate 77.9 per 
cent. In 1898, at Hubli, 3,815 persons not inoculated 
with anti-plague serum had 446 attacks, while 26,428 
persons twice inoculated had only 31 attacks. If the 
latter had suffered proportionally as much as the non- 
inoculated they should have had 3,089 attacks. Such 
examples might be largely multiplied. In a statement 
published in June, 1899, Haffkine states that in the large 
number of inoculations made with anti-plague serum the 
difference in number of attacks occurring in inoculated 
and uninoculated was over 80 per cent., often approach- 
ing 90 per cent. The lowest in his experience was 77.9 
per cent. The case mortality also was only half as great 
among the inoculated. 

CEREBRO SPINAL MENINGITIS. —Occurrence.—No great 
epidemics of this disease appear to have occurred among 
troops, but the affection is one which prevails in all 
armies and is remarkable for the high mortality given 
by those affected. Sharp but distinctly localized out- 
breaks occur annually in all the larger armies; and in 
our own service cases of the disease were reported in all 
but six years of the period 1868-98. The affection may 
fairly be regarded asa camp disease; more deaths occur- 
ring in our army in the calendar year 1898, during the war 
with Spain, than had occurred altogether in the previous 
sixteen yearsof peace. For the period 1868-84 the death 
rate from this disease was .05 per thousand strength; for 
the decade 1885-94 it was .02 per thousand, while for the 
fourteen months, May, 1898, to July, 1899, the death rate 
was .70 perthousand. Inthe German army, during time 
of peace, the admission rates are much the same as our 
own under similar conditions, being given as follows: 


Admissions 
Period. per 1,000 
strength. 
1881-8240: T88D—86 op scclercrcisternie cree sieeve w speetememe e/a shactylleiers 0.03 
ASSC=87 POL SOO 01 We sek eie crates lomela orota revere ereleleteiete etelermetamieveters 07 
189192 al BOB-OG cece, atet cae a laeaik cuotetaletniavace ater Wieteracsteysters crete’ ereteiees -08 
1895-06 tO TBO 798. ccs: everwis.cre-e (tore cicisnie ns ayarare ie alaia ainve eratarese 07 


Among our troops the admission rate per thousand 
strength was .11 for the period 1895-98. In 1898, cere- 
bro-spinal meningitis was the greatest factor in the total 
mortality of the Belgian army, amounting to .85 per 
thousand. 

Predisposing Causes.—The disease is most common in 
individuals of the military age. Though want, priva- 
tion and poor ventilation usually seem to predispose to 
the disease, there is abundant evidence to demonstrate 
that these conditions are not essential to its causation. 
The disease usually occurs during winter and early 
spring, although it may make its appearance at any time. 
For the period from May, 1898, to July, 1899, the death 
rate in our army from this disease was .13 per thousand 
strength during the month of January; about twice as 


576 








high as in any other month of the period. For Decem- 
ber it was .07; for June and July, 1898, it was .06 and 
.05, respectively. Hirsch, Notter and Firth, and others 
state that the disease is unknown in the tropics. During 
the period of fourteen months just mentioned, however, 
the ‘death rate from this cause was .71 per thousand 
strength for troops serving in the United States; .34 for 
troops serving in Cuba; .16 for those in Porto Rico, and 
.26 for those in the Pacific islands. An epidemic of a 
most fatal type occurred on a transport at Casilda, in 
southern Cuba, during the occupation of that island by 
our forces. Of those attacked, all died within thirty- 
six hours. The epidemicabruptly terminated on sending 
the troops ashore. 

Infection and Dissemination.—lIt is difficult to offer any 
satisfactory explanation as to the manner in which infec- 
tion occurs or to the way in which the specific micro- 
organism is eliminated from the affected individual. 
Whether it enters the body through the alimentary or the 
respiratory tract, or through lesions of the integument, 
it is not possible to say. It is probably directly commu- 
nicable from the sick in a mild degree only; but there is 
considerable evidence to show that the infection may be 
introduced into a locality by infected persons and things. 
Abbott and others are inclined to the belief that cases 
occurring during an epidemic are infected from some 
common source, and that they are predisposed to such 
affection by some unusual local condition. This opinion 
is supported by the fact that the disease shows no spe- 
cial tendency to progress along continuous lines or 
through contiguous localities. It has been known to 
appear in two regiments in a camp, while a third, 
located between the infected regiments, escaped. Love 
states that at New Orleans, in 1847, the disease attacked 
one regiment which was quartered in poor barracks, built 
on a damp soil and which was supplied with poor cloth- 
ing, while an adjacent regiment, more favorably housed 
and clothed, escaped entirely. Depressing influences, 
whatever their nature, appear to be a predisposing cause. 

Prophylaxis.—With present defective knowledge con- 
cerning this disease, it is difficult to formulate any ra- 
tional scheme of prophylaxis against it. While rigid 
isolation of the sick has not been shown to be imperative, 
still this pecaution should invariably be taken in the 
military service. As with typhoid and measles, free 
ventilation should be assured, and no considerable ag- 
gregation under one roof of those sick with this disease 
should be allowed. As a not unreasonable precaution, 
all discharges and excreta should be promptly disinfected 
and accidental inoculation on the part of attendants 
guarded against. 

As far as the troops are concerned, free ventilation, an 
abundance of good food, and the avoidance of fatigue 
should be included in the scheme of general prophylaxis. 

DENGUE.—While dengue is not a disease which ap- 
pears to be especially affected by the conditions of mili- 
tary service, our troops have suffered equally with the 
surrounding civil class during the epidemics which have 
from time to time occurred. Since dengue is a disease 
confined to tropical and sub-tropical countries, the only 
posts in this country which have been visited are those 
located in the south and southwest. During 1893 the 
affection prevailed in several garrisons. In 1894 the 
disease occurred at Fort Ringgold, attacking 154 men 
out of the 178 stationed at this post. In 1897 dengue 
appeared at Fort Sam Houston; 144 cases developing 
among the garrison of 522, and over 100 cases being 
treated among the families of soldiers and civilians at 
the post. During the same year the garrison at Fort 
McIntosh suffered also. Recently a large number of 
cases of this disease have occurred among our troops in 
Cuba and in the Philippine Islands, causing much tem- 
porary inefficiency. 

The cause of dengue is unknown. Its outbreak is 
favored by high temperature and geographical location 
more than by any other factors; it occurring chiefly dur- 
ing summer and early autumn and being checked by 
frost. In its distribution, dengue closely resembles yel- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





low fever. Overcrowding and filth appear to favor its oc- 
currence. The mortality is small, and for soldiers other- 
wise in good health it may be regarded as nil. The dis- 
ease, therefore, is only of importance as it incapacitates 
for duty. The specific cause of the affection is supposed 
’ to be given off in the saliva and excretions, and perhaps 
fromtheskin. Its incubation period is only a few hours, 
a fact which may explain its almost simultaneous ap- 
pearance in large bodies of men. 

Prophylazis.—In the lack of knowledge as to the cause 
or means of spread of this disease, it is not possible to 
formulate definite plans for its prevention. Since the 
ubiquity of the virus is so great in this disease, the estab- 
lishment of quarantine would scarcely be effective even 
if it were justifiable. The isolation of the sick, with the 
disinfection of all excreta, clothing and surroundings, 
might be practised, but would probably not be of any 
great value in checking an epidemic. It is fortunate 
that the disease is mild in type, is of short duration and 
leaves no after-effects—thus being of comparatively little 
importance to the military sanitarian. 

DreuTHERIA.— Occurrence. — Diphtheria is a disease 
which is of somewhat rare occurrence among soldiers. 
It is less common during active field service than in gar- 
rison, where it not rarely retains a foothold in old, badly 
constructed barracks for long periods, yearly outbreaks 
occurring during each season of cold weather. The dis- 
ease is relatively frequent among troops living in case- 
mates—though at Fort Yates it occurred for a number of 
years, despite every effort to the contrary, among soldiers 
quartered in old decayed log barracks. At the same 
post, the troops living in barracks of recent and more 
sanitary construction were rarely affected. 

Figures for this disease show a somewhat lessened 
prevalence in our army as compared with those of Eng- 
land, France, and Russia. In the German army the ad- 
missions for diphtheria per thousand strength have been 
as follows: 


Period. Admissions. 
eae IEP ECO OUI cafe oTulglaterniiiy aiviats,e 6 sin ai coves Stalaie eters es nie ee 1.2 
apamON EDEL SATCU N 's aie Taras cis’ savve ete s-oinscieeletace'b ede, sare, sie, en nseeveca .92 
Ee sOISUO- OG mince ens. sis cele enol dé celebs sineceeescenee 93 
SUREEEE SSO Le TIS At Sic lhe jelalavdia «6 syacetaia/ciclnioss bc sins w/e 000 0:6 v:0.0/6 57 


In the Austrian army, for the year 1897, only one case 
occurred for each 10,000 men. In our own service sta- 
tistics would seem to show that the disease has of late 
years decreased in both frequency and virulence. 
Whether this is actually the case, or whether the reduc- 
tion merely depends upon more accurate modern meth- 
ods of diagnosis and treatment, is a question which can- 
not be definitely decided, but it is probable that both 
factors should be taken into consideration. During re- 
cent years, however, according to Coustan and Viry, the 
disease has steadily increased in the French army. In 
our own service the admissions for diphtheria, per thou- 
sand strength, since 1860, have been as follows: 


Admissions 
Period. per 1, 
strength. 
Peer e MMMICGSIN LAW EAT) cictalp iota’ cies elr'e) siuisle s)eiscnajerssle/pielaze’s ie  o'e)0.0 re 
ee ee ee ee oO: 
Seana SO PE ONT Ney ei ei a(o.0/a¥e sic,ex01el0ie 818 brag vpsisiele, giecale ei nsedvielors"e eeiomiase 43 
COMM aTT al enlaces vecseecieeresscaceneeseiesneeneses sti 
VE) LS6.n oa DEA cpp. OOD EINE Op TOC NOOO CORE CarS or eEnntpn 43 
MEAT ONS (SPANISH: WAT)! ss ve acias acess s 0 0.90.0 see eels sie nels +36 


Dissemination and Infection.—The causative agent is 
transmitted from the sick in the discharges and secretions 
of the affected surfaces. In diphtheria affecting the 
throat and fauces the disease is transmissible chiefly 
through infected particles of mucus or flecks of mem- 
brane, which may be ejected from the mouth or nose by 
the act of coughing or sneezing. When the disease oc- 
curs among those in attendance on the sick, its origina- 
tion is usually brought about by infection in this manner. 
It should be noted that the bacillus of diphtheria is very 
resistant to drying, and when dislodged from the throat 
in bits of false membrane it may retain its vitality for 
along time. When such particles of membrane are dried 


Wolmeliv=—o.7 











and reduced to dust, infection may occur from the in- 
halation of air in which such dust is suspended. All 
clothing and other articles which have been in contact 
with the sick and upon which saliva has been allowed to 
dry may serve in this way to spread the infection. Ab- 
bott states that diphtheria bacilli have been found in the 
hair and on the shoes of nurses in a diphtheria ward, also 
on a broom used in the same ward. The bacilli may be 
inadvertently conveyed to the mouth after handling in- 
fected articles, and, in fact, any direct or mediate contact 
with the sick offers opportunities for infection. There is 
no evidence that the disease is ever transmitted by water. 
Milk, specifically infected during handling, has been 
known to give rise todiphtheria. Among the lower ani- 
mals, cats may be affected with this disease. While 
diphtheria bacilli are capable of development on any 
mucous or abraded surface, for the military service in- 
fection may be considered to occur through the mouth 
and nose only. The period of incubation is difficult to 
determine; symptoms of invasion often appear within 
thirty-six hours after infection, but though they are 
rarely delayed more than four or five days, they may be 
absent longer and a quarantine of suspected cases for ten 
days isadvisable. Convalescents from diphtheria should 
be regarded as sources of infection so long as the specific 
bacilli can be detected in the throat or secretions. The 
duration of infectivity appears to be, on an average, 
about thirty days, though it may be as long as three or 
four months. 

Predisposing Causes.—Though widely diffused, diph- 
theria prevails chiefly in temperate and cold, damp cli- 
mates. Low-lying districts, possessing a soil favorable 
to the development of microbes and rich in decaying or- 
ganic matter, usually show a greater prevalence from 
diphtheria, especially if subject to the continued preva- 
lence of cold winds with a high rainfall. In our army. 
the disease is far less frequent in the southern garrisons. 
Its greatest incidence occurs in winter and early spring, 
probably largely through less free ventilation of barracks 
and the depressing influence of a vitiated atmosphere. 


‘The part long thought to be directly played by sewer gas 


in the production of diphtheria was undoubtedly due to 
accompanying influences of the above nature. Over- 
crowding is a factor of great importance in the spread of 
the disease, as is also inadequate sanitary police. Epi- 
demic diphtheria, according to Klebs and others, has a 
well-defined relation to manure and compost heaps, in 
which the germs find favorable conditions for develop- 
ment. From this it would seem that the disease should oc- 
cur more frequently among mounted troops, and such in 
fact appears to be the case. While figures for our own 
service are scarcely large enough for reliable comparison, 
it has been found by Longuet that in the French army, for 
the period 1872-85, the proportion of diphtheria cases 
among cavalry and infantry was in the ratio of ten to 
three. Inthe Germanarmy, 1874-82, diphtheria was more 
than three times as common among cavalry as among in- 
fantry. In general, persons who have been affected with 
diphtheria are especially liable to future attacks, as are 
those who suffer from acute or chronic inflammations of 
the pharynx or tonsils. 

Prophylazis.—In the prevention of diphtheria the pro- 
vision of dry, sunny, well-aired barracks, free from over- 
crowding, is important. No accumulation of filth or 
refuse, and particularly stable manure, should be per- 
mitted in the vicinity. Dampness arising from the use of 
too much water in cleansing barrack floors should be 
avoided, as often producing tonsillar inflammation upon 
which a diphtheritic infection may be engrafted. Laveran 
regards the general use of antiseptic mouth washes by sol- 
diers as of advantage during the prevalence of the disease. 
When the disease has actually occurred the sick should 
be at once isolated and clothing, bedding, and other 
articles which have been exposed to infection promptly 
removed and disinfected. The squad room of which the 
infected individual had been an inmate should be disin- 
fected. All discharges from the point of diphtheritic 
invasion should be received into a strong germicidal solu- 


5TT 


Camp Diseases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





tion, or on cloths, which are then burned. Soiled bed 
or body linen should be at once removed and disinfected 
before the secretions are permitted to dry upon them. 
When this is not practicable the soiled areas may be 
wet with strong disinfectant solution. The floor should 
be frequently mopped with a strong disinfectant solu- 
tion; and the hanging of a damp sheet over the door 
leading into the room is of advantage. Eating uten- 
sils should be scalded after use and all uneaten rem- 
nants of food at once burned. On the part of the 
attendants great care should be taken to disinfect the 
hands after each manipulation of the patient. While 
attending to the patient a cotton mask, suspended so as 
to shield the nose and mouth and moistened with some 
antiseptic solution, may be worn to prevent possible in- 


JUUNTOTUUENREAATLT 
cA 


Fic. 1080.—Distribution, by Months, of Cases of Diarrhoeal Disease, per Thousand Strength, 
Occurring in the United States Army during the Decade 1875-84. 


fection from ejected mucus or membrane. Careful dis- 
infection of the room and its contents is, of course, re- 
quired after removal of the patient. 

Protective Inoculation.—In preventing the occurrence 
of diphtheria in those exposed to infection the most im- 
portant prophylactic measure is that through which a 
condition of immunity is conferred by the subcutaneous 
injection of blood serum froman animal rendered highly 
immune tothis disease. As theimmunity thus produced 
is not permanent, lasting only from four to six weeks, 
the procedure should be employed only in the case of 
soldiers who have been presumably exposed to infection, 
or for the protection of such hospital corps men as are 
about to assume charge of diphtheria patients. 

For immunization of those exposed to the infection of 
diphtheria an injection of 400 to 500 antitoxic units is 
usually sufficient. 

DIARRHG@A AND DIARRHGAL DIsEASE.—Diarrheea is 
ordinarily to be regarded not as an essential disease, but 
as symptomatic of an effort on the part of a healthy 
bowel to relieve itself of irritating contents or of some 
morbid internal condition. In the military service, how- 
ever, the affection frequently prevails among a large 
number of persons at the same time and place, and by 
its severity, its tendency to become chronic, its refracta- 
bility to treatment, and its undoubtedly infectious char- 
acter, it may, under such conditions, be safely regarded 
as a distinct disease. Figures showing the prevalence 
of this specific affection are not available for our service, 
owing to the classification of all diarrhceas, whether 
symptomatic or essential, under the same heading. Fur- 
ther, in the medical reports of our army, conditions of 


578 








this character, together with dysentery, are classed to- 
gether as diarrhceal disease, and hence must be largely 
considered together. Under this heading they brought 
more men on sick report during the decade 1887-96 
than any other class of diseases, the rate per thousand 
strength being 107.09. Field service largely favors their 
occurrence, and in nearly all wars they have been the 
most common class of affections. For the year of peace, 
1897, in our army, the admission rate for ali diarrheal 
diseases was 73.77 and the death rate zero; while during 
the year of war, 1898, the admission rate was 303.76 and 
the death rate 2.14. These diseases are much more prev- 
alent in hot climates than in the temperate zone, the ad- 
missionsand deaths for troopsin the United States alone, 
during the year 1898, being respectively 247.39 and 1.39 
per thousand strength; while for 
those soldiers serving in the tropi- 
cal islands the admissions were 
551.54 per thousand, and the deaths. 
5.44. 

For diarrheea alone the average 
annual rate of admission, during 
the Civil War, was 608.84 per thou- 
sand strength; while the deaths 
from this cause averaged 13.70 per 
thousand. For the period 1868-84 
the admissions for diarrhcea had 
fallen to 230.45, and the deaths to 
.26, per thousand strength. For 
the decade 1885-94 the admission 
rate was 109.65, and the death rate. 
.02. For the year 1897 the admis- 
sions per thousand amounted to but. 
68.65, there being no deaths. For 
the year 1898, during the war with 
Spain, the admission rate rose to 
274.49, but the death rate amounted 
to only .27 per thousand strength. 

Diarrhceal diseases, in the tem- 
perate zone, are much more prey- 
alent during hot weather, as is well 
shown by the accompanying dia- 


gram. Race is a matter of no small 
importance. While our colored 


troops are particularly susceptible 

to infection by dysentery, this is not. 
the case with regard to simple diarrhcea, to which they 
appear to present considerable immunity. For the de- 
cade of peace, 1886-95, the admissions per thousand of 
white troops, for all diarrhceal diseases, amounted to 
115.68; while for the colored troops during the same. 
period the rate was 99.75. During the year 1897 the rates. 
of admission were 75.78 for white troops and 52.22 for col- 
ored soldiers. During the war with Spain a proportion- 
ally much greater number of negro soldiers saw hard. 
service than did those of the white troops, yet the ad- 
missions for the former were only 187.20 per thousand 
strength, while they amounted to 312.72 per thousand for 
the latter. Age exerts a marked influence on the occur- 
rence of diarrhceal diseases; the rates for our service, at 
various periods of life, for the seven years 1890-96, be- 
ing as follows: 


Admissions 
Age. per 1,000 
of each class.. 

19 years and Under aces. coca velista sive iohsleosaceysvelsl ola atopic 202.43 
20 TO 24s 6 diviaceniave pie a oe ¥iois'o che el oteretacs suas sre euslldlemit eee ne anaee 134.19 
2 TO'2D:, Se vie evste ara's aie sie ae cieiars tele s o7p e7h: glove oat ene 98.70 
BO GO:BE si ivinis sini o's o1oiele bie ob 0loe slvuwse plezen’ elssaperele ete isia Sanaa 82 

BD 10 BD: sisiereiriyas ceo clace'slarcie's 4aNeinls Hate erelereee tse eee 79 

AO CO. Fa occ. ocacasese) ave, 0 biaid avast eip's wpetole’e eroveLatalave’ «ve ele ietenan ena .96 
4D LO 4D vc cule’ ov'ec wlelcisatdaw eles bye ieteee foto soit Sere terete 75.68 


For the same seven-year period the admission rates for 
all diarrhceal diseases, per thousand strength, were thus. 
divided among various branches of the service: 


ATHIIOLY:: gies eie oe mal oietersrescae «ai siclte/a.a a aldvaleve ttl eee Feces ASOD 
CAVITY sis aaccie win, caterers ate iclerace pee alee bie ¥iptelsiacaiecx@ rerere eae 113.29 
Tmfan try’ ix’ve s,s: oveicle <.seierais atelwrava sieitigreisvels erete e/ele Cxaterarerae ane 96.84 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





Diarrheeal diseases are much less frequent among offi- 
cers than among soldiers. 

As stated above, in many instances diarrhoea is un- 
doubtedly infectious and capable of transmission to 
others by means of the excreta. No special micro-organ- 
ism has been shown to stand alone in a causative rela- 
tionship to the disease, and the latter may undoubtedly 
be produced by several forms of bacterial life. Diarrhea 
prevails most in damp soils, especially when contaminated 
with organic matter. The diarrhea prevalence and death 
rate are notoriously greatest among those whose resistive 
powers are impaired by malnutrition, exposure and 
fatigue. As with dysentery, chilling and sudden changes 
of temperature favor it. Foul air favors it, and want of 
ventilation and light are conducive to a high mortality. 
Density of population, as a factor in soil pollution, espe- 
cially in camps, markedly increases the prevalence of 
diarrhea. Food is closely concerned with the epidemic 
prevalence of diarrhea, not only by predisposing toward 
it by causing digestive disorders, but also through its 
contamination with infectious material capable of di- 
rectly provoking the disease. Bad water undoubtedly 
plays a prominent part in its causation, but probably 
not to the extent supposed by some. The cause of epi- 
demic diarrheea is undoubtedly transmissible by means of 
flies, and there is considerable evidence to show that 
air currents may be the means of its dissemination. 

A distinction should be made between the epidemic 
diarrheea indicated by the foregoing and those outbreaks 
of diarrhea which not rarely occur among troops who 
have partaken of food in which certain putrefactive 
changes have occurred. In these cases the causative 
agent is usually a chemical substance, and the diarrheal 
symptoms produced are merely those due to its proper- 
ties as an irritant poison. 

Prophylaxis.—The prevention of epidemic diarrhea in 
the field depends upon the proper location of the camp, 
the absence of organic pollution of the soil, a pure water 
supply, the careful selection, preparation and storage of 
food, and the prompt disinfection of all excretal dis- 
charges. 

While mild cases, in garrison, may probably be safely 
treated in quarters under most circumstances, in the field, 
where their infectious nature is suspected, such cases 
should preferably be removed to hospital for treatment; 
particularly since cases of diarrhcea may merely repre- 
sent the early stages of infection with dysentery, typhoid 
fever, or even cholera. From the many causes through 
which diarrhoea may be produced, it is evident that no 
general rule can be laid down to cover all contingencies, 
but each case must be acted on independently, according 
to its merits, by medical officers. 

DysENTERY.—Occurrence.—Of all the diseases to which 
troops are subject on active service, especially in hot 
climates, dysentery is one of the most formidable and im- 
portant; and this almost equally on account of its fre- 
quency, its severity, the difficulty of its treatment and 
its proportionately high mortality. The disease is one 
which is peculiarly favored by camp life. 

History gives many instances in which dysentery has 
become epidemic among troops. It made frightful rav- 
ages in the army of Xerxes, in4808.c.; and it is recorded 
that in the invasion of Italy by Theodebert, in the year 
5388, one-third of his force died of this disease, compelling 
retreat. The army of Henry IV. was reduced three- 
fourths of its effective strength before the battle of A gin- 
court, through an epidemic of this disease. In 1773, half 
the English army at Hanau had dysentery, which de- 
creased on the abandonment of the camp; and the same 
occurred in 1778 in the army of Prince William of Hesse. 
In 1757 the French army introduced an epidemic of this 
disease among the civil population of Mayence. In 1793 
it ravaged the French army in Italy, and in 1812 in Po- 
land. In Egypt, Napoleon lost more men from dysentery 
than from the plague. It prevailed largely during the 
Crimean War; and Laveran states that in three months 
there were treated, in the hospitals at Constantinople, 
9,919 cases of diarrhoeal disease—chietly dysentery—of 








which 15 per cent. proved fatal. At Metz, in 1870, it 
was one of the greatest causes of mortality in the besieged 
army. In the military operations in our own country, it 
prevailed in the French war of 1756, and during the 
Revolution it became epidemic in the trenches before 
Boston. It was most extensive and fatal during the 
Seminole Warin 1836; and the same was the case during 
the war with Mexico. During the Civil War period, 
July, 1861, to June 30th, 1866, the average rate of ad- 
mission for dysentery, per thousand strength. was 120.88; 
the death rate for the same cause and period was 3.67. 
While the admission rate varied but little during these: 
years, the mortality steadily increased; the death rate 
per thousand strength for this cause being 1.64 in 1861-62 
and 6.31 in 1865-66. Since the Civil War, its prevalence 
in our country is shown by the following figures: 











F Admissions per Deaths per 
Period 1,000 strength. | 1,000 strength. 

A BOS HBA Tete, arsveis’ ciaiesest.s.e silat ecechlacieiare 29.04 0.59 
LESH -O4 read sacle eal niin eae euapentue 6.52 10 
LBOD“OGr ais worcamravs isiedipeintnn esisiebieane 12.05 68 
ESOS LOS earcterdirtcwiaieaiis Se eranles ose tis.als 19.91 45 
LVOATHISOTRS c fornstyaiiiatcn semaine « 2.39 

PY CAI SO8 ee steis sient cusiareccrs birt utecesele's 28.39 1,86 








The rates for dysentery in foreign armies in the present 
times of peace, like those until recently obtaining in our 
own service, are low. Among the British troops sta- 
tioned in the United Kingdom during the decade 1888- 
97, the admissions per thousand strength amounted to 
.5, the deaths to .2. For the year 1898 the admissions 
amounted to .7, the deaths to .08. The occurrence of 
dysentery in the German army is shown by the follow- 
ing rates: 


Admissions 
Period. per 1,000 
strength. 
OSI=ABS: 10: LSSD=BG ria train aisversiaresel eels als eo haa ielalevalherslacese Sars Blayare 1.4 
TSSE-—B 7 FOMSOO-ODK sicrcrdtessiaietereteaaielels warcieetvaehs siniatics dmolele 24 
SOI OZNO MSO OG A, vel ereltielpiayercecaleenole’s ayeloteieislelaininieterecctsats tt pi'e lL 
BY CHT BOS Ob irate rcte-c stetets tae nlstste: cekeiave-b Guletet noe ditlese'e ot eianiente 25 
VOUT SOS—OG.e teted emda neve montae sitchin esi siomabeeaion new aceaen Aay 
WICATBLEIGO fica matviajeisiere’sio ecaiaejorne ererspie eis) ee astra si tretein g eiarel akioen 10 


The milder cases are not taken into hospital and do not 
figure in the above rates for the German army. 

In the Austrian and Russian armies the rates of admis- 
sion, per thousand strength, have been as follows: 





Austrian Army.| Russian Army. 





4,1 3.4 
1.3 2.1 
1.3 2.0 
1.2 2.3 
8 1.6 
6 ns 





The case mortality among the Russian and Austrian 
armies during the above period was twice as high as in 
our own military service or those of England and Ger- 
many. 

Nothing more clearly shows the value of modern mili- 
tary hygiene and sanitation than the great and progres- 
sive reduction of the rates for dysentery, which has oc- 
curred in all armies in the last two-score years. Notonly 
has the proportion of admissions been largely decreased, 
but the case mortality has been reduced to an even greater 
degree. Inour own army the vast improvement—as well 
as the favoring influence of field service on the occurrence 
of this disease—is shown in the chart (see Fig. 1081). 
For the French army in Algeria it is stated by Coustan 
that in 1847-48, out of every 1,000 deaths from all causes, 
403 were from diarrhea and dysentery, chiefly the latter, 
while for the period 1867-78 this disease occasioned but 
72 deaths out of each 1,000; and the rate has fallen pro- 
gressively since that time. 

Predisposing Causes.—Dysentery occurs both endemi-- 
cally and epidemically in all climates, but is especially 





5TD 


Camp Diseases, 
_ Camp Diseases, 





prevalent in the tropics. For the decade 1888-97 the 
admissions for this disease, among British soldiers in 
India, China, the Straits Settlements, Ceylon, West Indies, 
Egypt and Cyprus, and Mauritius, amounted to an aver- 
age of 15.17 per thousand for all; while for the United 
Kingdom they were but .5, and for Canada .1 per thou- 
sand. In our own ar my, for the fourteen months, May, 
1898, to June, 1899, inclusive, the death rate from diar- 
rhoea and dysentery is given as 1.3 per thousand of troops 
serving in the United States; 5.69 for those serving in 
Cuba; 2.08 for those in Porto Rico, and 2.48 for those 
stationed in the Pacific Islands. For the last six months 
of 1897 the admissions for dysentery in the Spanish army 
in Cuba amounted to 72 per thousand strength, and the 
death rate to 10 per thousand strength. 
climates, summer is the season when the disease, like all 
diarrhoeal diseases, prevails to the greatest extent; in the 
tropics it occurs most frequently at the close of the rainy 
season. Few facts in connection with the relation be- 








] 
ao 
Er coe Ses a nS et St Sk 


Baba 
Boece es 


E 
Soo oven anes ecodet 


So ean ov oad Sal cs a le 
ies es esto Ss 
Sec so os ton oe! a a A 


= 
mel 
ae 
= 
ries 
il 








L\ 


Fi ben owe fet te 
Sone 


























ies fs bop oo tet ed ak ed ed 


















































Fic. 1081.—Admissions for Dysentery in the United States Army, per Thousand Strength, for the 


Period 1861-98, Excluding the Year 187. 


tween dysentery and climate or season are more clear 
than those which indicate the influence of vicissitudes of 
temperature, and exposure to chilling, in determining 
attacks. The reduction of dysentery which has occurred 
in the French army has been thought to be largely due 
to the provision of conveniences which render unneces- 
sary the chilling of the soldiers at night while attending 
to the calls of nature. 

Dysentery, though sometimes occurring in dry locali- 
ties, manifests a decided preference for damp and water- 
logged soils. Of great importance in its epidemic oc- 
currence is the saturation of the camp site with organic, 
and particularly feecal, material. The destructive epi- 
demics of former times undoubtedly depended largely 
upon long occupancy of camp sites, resulting in fouling 
of both soil and water. All cachectic states of the 
constitution powerfully predispose to dysentery. Scurvy 
and malaria are no exceptions to this rule, and the latter 
gives rise to a form of the disease peculiarly resistant to 
treatment. Fatigue, exposure, hardship, and anxiety also 
appear to have no small influence in determining its 
occurrence. <A faulty dietary, especially as found in in- 
sufficient, coarse, or improperly cooked food, green or 
over-ripe fruits, an excess of salt meats, or the over-use 
of alcoholics, notoriously favors the disease. These points 
were particularly well shown in the happy change in the 
condition of the British army at the Crimea, in respect to 
dysentery, as soon as its wants as to diet, shelter and 


580 


In temperate 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


clothing were properly satisfied. A large number of out- 
breaks of dysentery have occurred during the prevalence 
of typhoid fever, the development of both diseases ap- 
parently being favored by the same general conditions. 
Dysentery is particularly liable to affect young soldiers 
through their disregard of matters of hygiene and prob- 
ably greater individual susceptibility. Tripler states that 
during the war with Mexico the death rate from dysen- 
tery was twice as high in the newly raised troops as in 
the old army. Negro troops appear particularly liable 
to contract dysentery. In our own service, for the decade 
1879-88, the rates per thousand strength were as follows: 


Admissions. Deaths. 
White troops. j. scacihensc scene Best eee 18.65 0.20 
Colored troops iis sinccirase os cevmeacnemeeiaite 29.65 32 


Among the British troops stationed in the West Indies, 
for the decade 1888-97, the rates for European troops, 
per thousand strength, were 6.9 for admissions, and .33 
for deaths. For the same period 
the rates for non-European (negro) 
troops were respectively 16.8 and 
.44. Coustan, on the other hand, 
notes an immunity to this disease 
among the natives of Northern 
Africa, citing an instance where 
“a French column in Algeria suf- 
fered severely, while the native 
Arab followers, who set every law 
of hygiene at defiance, escaped 
sickness.” From the greater care 
which they are able to give them- 
selves, and also owing to their 
greater attention to sanitary detail, 
officers are much less liable to dys- 
entery than are enlisted men. 

Method of Infection.—The com- 
monest recognized portal of infec- 
tion is the mouth; the specific 
exciting cause of the disease 
gaining entrance in contaminated 
water or on uncooked foods on 





























which the organism is located. 
Experiments show that infection 
can occur through the rectum, but 
this is undoubtedly a rare mode 
in human beings. The instances 
in which outbreaks of dysentery 
have been traced to the use of foul 
water, particularly that contami- 
nated with fzecal matter, are very numerous; and of all 
causes contributing to the occurrence of this disease, 
that of impure water is the most important. In most 
instances this fluid merely serves as a vehicle for the in- 
troduction of the specific cause into the system, but. it 
may at times, through suspended particles, have a pre- 
disposing influence through its irritative action on the 
bowel. 

Prieur has reported an epidemic of 315 cases of dysen- 
tery occurring in 1891 in a small garrison in the French 
army, which he regards as directly traceable to the use 
of the common latrine by the first patient, who, as the 
affection became more advanced, was unable to keep from 
voiding his discharges on the floor and seats. No case 
appeared until six days after the first case was well de- 
veloped. He believes that the affection was directly due 
to the dysenteric discharges being mixed with the dirt on 
the floor of the latrine and being carried into barracks 
on the shoes of the soldiers. The food of the latter was 
then contaminated with this infectious material; a result 
rendered very possible by the absence of mess rooms in 
French barracks and the fact that the soldier of that ser- 
vice usually sits on stairways or on the floors of halls or 
barrack rooms while eating his food. 

Prophylavis.—This is naturally dependent:on the eti- 
ology. All drinking-water should be protected from con- 
tamination, and, when open to the slightest suspicion, 
should be sterilized by heat. It is well to keep in mind 











2 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


that if pure water be not provided in a hot climate, the 
men will get it from any source, however impure. Food 
should be carefully watched in respect to its sufficiency, 
quality, and the thoroughness of its cooking. When an 
epidemic of the disease threatens, all raw fruits and vege- 
tables should be excluded from the diet; and, if possible, 
hard bread and beans also, since these are difficult of diges- 
tion and irritating to the intestinal canal. Chilling, es- 
pecially of the abdomen, should be avoided, and the use of 
the flannel band may be advisable. The camp site should 
be dry and well drained. If the disease appears with any 
severity the camp should be promptly moved without 
waiting for further developments. Instances have been 
known where regiments were affected with dysentery 
every time they encamped on a certain space, and old 
camping grounds notoriously favor the occurrence of this 
disease. The camp should be carefully policed to limit 
the fly plague, and the contents of latrines disinfected 
and covered twice daily. If possible, the excreta should 
be burned. Great care should be taken to prevent con- 
tamination of the water supply with feecal matter, either 
from the location of the latrines or from uncleanly habits 
on the part of troops. Dysentery patients should prefer- 
ably be removed from the locality in which the disease 
was contracted. Inasmuch as dysentery occasionally 
spreads in military hospitals where large numbers of such 
cases are under treatment, the necessity of free ventila- 
tion, abundant air space, and the prompt disinfection of 
the stools, bed pans, commodes and enema tubes are 
matters of the first importance. 

Epmwemic INFLUENZA.—Occurrence.—In the military 
service, influenza is chiefly of importance through the 
incapacity for duty which it produces. The military age 
does not include the extremes of life, at which the disease 
is most fatal, and hence the mortality directly resulting 
from this affection is small. That it exerts an unfa- 
vorable influence in the production of secondary pneu- 
monia and tuberculosis, however, there can be no doubt, 
though this is not shown by statistics. The disease in 
our army has occurred in well-defined epidemics of great 
intensity but short duration. During recent years these 
epidemics have occurred with much greater frequency. 
Following their subsidence there appears to have been a 
tendency on the part of medical officers to confound sim- 
ple respiratory catarrhs with this disease, even in the 
absence of any epidemic tendencies, thus probably un- 
duly raising the rates for this affection. During the 
Civil War the admission rates for influenza, per thousand 
strength, amounted to 60.84. For sixteen years, 1868- 
84, the cases fell to an average of 9.39 per thousand 
strength. During the decade 1885-94, epidemics in 
1892 and 1893 greatly raised the figures for this disease, 
making the admissions 49.88 per thousand strength. For 
the period 1895-98 the admission rate was 44.92. For the 
year 1897 the admissions were again increased to 74.35; 
while for 1898 they fell to 32.37. In foreign armies the 
disease has prevailed among troops during the widespread 
epidemics which have from time to time occurred. In 
1892 and 1893 high rates for this disease were given in all 
European armies. In the English army the disease has 
prevailed nearly every year since 1889. In the Russian 
army influenza appears annually as a potent factor in 
elevating the sick rates. 

Dissemination and Infection.—The powers of resistance 
of the specific organism appear to be of a very low 
order. Pfeiffer found that dried cultures of influenza 
bacilli kept at the ordinary temperature were usually 
dead in twenty hours, and that no growth could be ob- 
tained from influenza sputum at the end of two days. 
Their duration of life in ordinary water is also short, 
death usually occurring in two days. From these ex- 
periments, Pfeiffer concludes that outside the body the 
bacilli cannot multiply under ordinary conditions and 
can remain alive but a short timeonly. The mode of in- 
fection in the disease he accordingly considers to be 
chiefly by direct contact with infective mucus, with 
which the bacilli probably alone escape from the organ- 
ism. Its rapid spread over large areas was long thought 








Camp Diseases, 
Camp Diseases, 





to be explainable on the supposition that the infection 
was air-borne, but this is probably due to the combined 
effect of ashort incubation period, an early infectiveness, 
a widespread susceptibility, and the existence of early 
unrecognized cases. It iseimpossible to say what are the 
conditions that favor its development and spread, but 
atmospheric conditions which favor bronchial irritation 
certainly play a part. The incubation period is from two 
to six days, and perhaps at times the limits are wider. In- 
fectiousness commences early, in many instances before 
the disease has fairly declared itself. It persists for some 
time after acute symptoms have subsided, judging by the 
presence of Pfeiffer’s bacillus. While this bacillus ap- 
pears to be unable to cause influenza in the lower ani- 
mals, there is abundant evidence that certain animals 
suffer with symptoms much like those of influenza during 
epidemics of this disease. During the epidemics of 1892 
and 1893, in our army, the disease known as “ pink-eye,” 
regdrded by many as a form of influenza, was extremely 
prevalent among cavalry horses. 

Prophylavis.—Influenza is an infectious disease, the 
spread of which can be checked by isolation; but when 
the peculiar features of the disease and the conditions of 
military life are considered, it must be admitted that iso- 
lation has its limitations and can usually only mitigate 
rather than entirely prevent an epidemic. In general, 
however, it is important as far as possible to prevent the 
contact of the infected with the uninfected. Soldiers 
affected with the disease, even in a mild form, should be 
taken into hospital, not so much for their own benefit as 
in behalf of others. While the disease prevails, large 
assemblages should, as faras possible, beavoided. There 
should be an avoidance of all influences which lower the 
general tone, and good ventilation and cleanliness of per- 
sons and surroundings are of value. The sputum of af- 
fected individuals should be treated in the same manner 
as if it were tuberculous. All handkerchiefs, napkins, 
bedding, clothing, and other articles used by the sick 
should be disinfected; though when an epidemic is once 
fairly established, the infection is so widespread that 
efforts looking to the control of the disease are of but little 
avail. 

MALARIAL FEvERS.— Occurrence.—Malaria has ravaged 
armies in every age and climate, and has frequently 
modified military operations or brought about their fail- 
ure. Rome was saved from capture by malarial fevers, 
which so scourged the besieging Gauls under Brennus 
as to cause their retreat. In the year 208 the Roman 
army in Scotland lost 50,000 men, out of a total of 80,000, 
from this cause. No military disaster caused by malarial 
infection was ever more complete than that of the British 
expedition to the island of Walcheren, in 1809. On this 
occasion it has been said that the British were conquered 
before the battle. Out of an effective force of 39,219 
there succumbed to the fever, between August 28th and 
December, no less than 28,175 men. After the return to 
England there were 11,503 additional cases. But 217 
men, during this disastrous expedition, were killed by 
the enemy. In the Seminole War, in Florida, our troops 
suffered severely from malarial infection. In the French 
army before Sebastopol there were 20,623 cases with 
2,179 deaths. In the Union forces, during the Civil War, 
there were 1,314,744 cases of malaria with 10,062 deaths, 
giving a mortality of 3.92 per thousand strength. “But 
though the mortality from these fevers was compara- 
tively light, their influence in detracting from the effi- 
ciency of the army was. very great,” as well as largely 
influencing the rates of discharge for disability on ac- 
count of resulting anemia and chronic malarial poison- 
ing. The so-called “Chickahominy fever” was particu- 
larly severe in its effects. Malarial fevers prevailed in the 
French army during the Italian War in 1859, and during 
the occupation of the papal states. Ashmead states that 
from 5,995 Japanese soldiers sent to Formosa in 1873, 
there were 6,105 admissions to hospital for pernicious 
malarial fever during a single year. In the French ex- 
pedition in Madagascar, in 1895, out of a total force of 
22,850 men—soldiers and carriers—there were 7,498 


581 


Camp Diseases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





deaths; a mortality of about 33 per cent. Nearly all these 
deaths were from malarial fevers. During this expe- 
dition, with its enormous mortality, only 7 men were 
killed and 94 wounded by the enemy. In the same 
year a Spanish expedition in the Philippine Islands 
was scourged with malarial fever. During the last in- 
surrection in Cuba the Spanish forces were largely de- 
pleted by malarial fevers of asevere type; the admissions 
to hospital for this cause, during the year 1897, amount- 
ing to 420 peo thousand strength. In 1898, after the 
capture of Santiago, one-half of our forces in Cuba were 
at one time “incapacitated for duty by reason of malarial 
fever. This grave condition of affairs evoked an appeal 


to the War Department, signed by all the higher officers, 
urging an immediate removal of these troops to a more 
healthy locality and using the sentence: 
must be moved or perish.” 

Until within a comparatively recent period, malarial 
disease, in time of peace, constituted the prime factor in 


“This army 








Getta eter 
foe Sat all 


[7 


bo le tS 



















































































Fig. 1082.—Admissions for Malaria] Infections in the United States Army, per Thousand 
Strength, for the Period 1861-98, Excluding the Year 1867. 


the constitution of the sick reports of ourarmy. To-day 
it occupies a minor position for troops on the home sta- 
tion except for a few posts, the decrease not only having 
been great but steadily progressive. This reduction has 
been brought about by the withdrawal of troops from 
more unhealthful stations and by greater attention to 
sanitary detail at the few malarial posts at which military 
necessity requires garrisons to be maintained. During 
the last quarter of a century, also, the disease—espe- 
cially in the eastern portion of the United States—appears 
to have considerably decreased in frequency and vir- 
ulence. The possibility of retaining troops at stations on 
the Potomac river, as an example, was long a matter for 
serious consideration. At Fort Myer nearly all the gar- 
rison contracted malarial fevers during the season; of 
Washington Barracks it was at one time officially reported 
that during the malarial months there were scarcely 
enough well men to perform guard duty; and at Fort 
Washington the prevalence of malarial fevers resulted in 
the abandonment of the post as a station for troops for a 
number of years. These posts still lead all other stations 
in the army as regards malaria, but the number of cases 
of malarial infection are now very greatly reduced. Fol- 
lowing the regarrisoning of Fort Washington, the sick 

rates at that station have been by no means se jously high. 
Since the Civil War the admissions for malaria for the 
entire army, per thousand strength, fell from 793.75 in 
1868 to 78.88 in 1897. For the period 1868-84 the ad- 
mission rates per thousand strength amounted to 331.06; 
for the decade 1885-94 they were 92.27. The influence 
of war, and especially the exposure to malarial infection 
in the tropics, caused an increase to 694.60 in 1898. The 
death rate, too, was unusually high during the last-named 


582 

















year, showing the more grave nature of the tropical in- 
fections. Asfaras the United States itself was concerned, 
the board investigating the occurrence of typhoid. fever 
during the war with Spain came to the conclusion that 
malaria was a comparatively rare disease among those 
soldiers who remained in this country. As great as has 
been the reduction of malarial disease in our own army 
—to one-tenth of former rates—the improvement in this 


respect in the German army has been even greater. Of- 
ficial figures for the German army are as follows: 
Admissions 
Period. per 1,000 
strength. 
1881-82 [0.188086 i ca sreretaie tore oisisle'v seiarotnys o's o\a-o,e'e ous erejatentaeel 14.2 
1886-87 tO TS90-O0 is cicie s oic.o a e-orenjeisia cis sie oie pei eietete ee enna 4.1 
1891-92 £0°1895-06 20.5: civ cisvieis se cies tea acter eae beacon 1.1 
Wear 1805-96. <i isisiss sisterelntetore orcntn abc ere yasiehecele tote etevel erate aa 5d 
Wear 1896-07 2 ..2te,oseis:0\cs'v.cie aia s\eiais's,stcls oles e ats ee eee 45 


In the French army the admissions for malaria, per 
thousand strength, are thus given 
by Coustan for troops in France and 
Algeria: 


























Admissions 
Period per 1,000 
strength. 
18TB=719 os. aa.a0 sis sseienisinentee 30.0 
TS8Q: Foie: sats erase tse eterete eter eee 18 
LSB D ei.cii siceteteresv dthaie ls atekeee nies 25 
ASS2)., isis sieiate sinleisia's ohare see ea 30 
1888 ascieahns see dus eee eee 56 
DOSE. sie'ess. 0's clerun enieiealent ete eens 15 
1880 scien oisiev ares dies eee 20 
1888). jais.s/o:siaiele eis lalelelaitisteie ates 13 
ASSO 0's n:070:03e1sie ajereistoinletalciele ieee ents 16 
TOO ererertte cratslerenteletetete cncofslereretatale 17 
IR BEA BrSUGOnCOBCOUACobC AS 2 ooUS 36.1 
L8QR. s,<:s:ain't'sisj0'¢ ale aiseicleete ee eae 24.4 
1 BOS. << c:c,0.« asieceisielgiaten tel eee 14.2 
For the British troops on home 
stations the admissions per thousand 
strength, for the decade 1888-97, 
amounted to 6.38. For the year 
1898 they were increased to 9.5. In 


the Russian army the admission and 
mortality rates from malarial fevers, 
per thousand strength, have been 
as follows: 








Year Admissions. Deaths. 

SOONG. AGES» Site cine ee Weenie aaa 102.3 7.1 

SOD 1 a Farctensicis ctstate sits eiateralciare sieietefetariers 79.9 05 
1808S Sa, cicia cea teninlova. catemae eters ore 78.1 -08 
LSOS Se Sr attarc oe alstolele Bit Seletaho ermerners 79.1 07 
1SOh eRe SCE Aes dines teieiona wat 57.6 08 
LSOB ialhe eveis vas slaca.ainysin oe aiar@an sielcne ceaipes 44.5 -06 
1896 Geo kaercttts cree a cersevisus ie onleret cicetaeine 46.5 -08 
VEOT eae ae a8 steve cRidution Miwiaa le seminars 47.3 O07 





In the Austrian army the cases of malaria amounted to 
50.3 per thousand in 1885; to 30.6 in 1891; to 40.4 in 1892; 
to 34.7 in 1893; to 28 in 1894; to 26.1 in 1895; to 22.6 in 
1896; and to 31.9 in 1897. The-deaths from malaria per 
thousand strength have recently been as follows in the 
Italian army : 

Year. Death rate. 
1893 
1894 
1895 .. 





Manner of Infection.—Since the malarial parasite has 
not been observed outside the body, and nothing is known 
concerning its extra-corporeal existence, it is impossible 
to speak with certainty as to all the modes of its entry 
into the system. This very probably occurs in several 
ways. It has recently been advanced by some that the 
disease is directly transmitted from man to man only by 
inoculation, the mosquito serving as the intermediate host 
and transmitting agent by which infection is brought 
about. This claim, however, clearly lacks substantiation. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





It isa matter of common observation that the infecting or- 
ganism of malaria must multiply indefinitely outside the 
body independently of man. In fact, malaria is most prev- 
alent where man is not, and where human beings, through 
the prevalence of this disease, cannot maintain an exist- 
ence. Therefore this extra-corporeal multiplication must 
demand something more than a short cycle from man to 
mosquito and mosquito to man. Where this extra-cor- 
poreal life of the malarial parasite is spent has not yet 
been scientifically demonstrated, but both analogy and 
common experience point to water as necessary to its 
existence. The parasite in the blood is polymorphous, 
and in the flagellated variety it presents a type well fitted 
to pursue an independent existence. In water it may 
assume other and unknown forms quite capable of in- 
vading the organism through the walls of the alimentary 
tract. Certainly this is possible to other somewhat sim- 
ilar forms of life, as in dysentery, and there is much evi- 
dence of a practical nature to show that a malarial in- 
fection may actually be contracted in this way. Both 
Manson and Laveran believe that water in which infected 
mosquitoes have died may cause the disease. 

Military history is full of instances in which outbreaks of 
malarial fever have occurred apparently asa result of the 
use of impure marsh water, and under circumstances 
which leave little possibility for infection by other means. 
As a type of these examples may be mentioned the well- 
known outbreak of malaria among the French troops on 
the ship Avgo, and, like other similar instances, never yet 
disproved. Further, military history presents many cases 
in which the rates for malarial fevers were greatly dimin- 
ished on the substitution of a pure for an impure water 
supply. In our own service the following instances may 
be mentioned: Fort Brown, in 1889, had an admission 
rate for malarial fevers of 1,675.86 per thousand strength, 
with a rate of 88.58 for constant sickness. Distilled 
water from the ice-machine was then provided for the 
use of the troops, and the rates for 1891 became 825.91 
and 8.82, respectively. In 1892 the admission rates be- 
came 16.13 per thousand strength, and the constant sick- 
ness .85. The rates for this post have never returned 
to even a small fraction of what they were before the 
jntroduction of distilled water, and Fort Brown has ceased 
to be regarded as one of the malarious stations in the 
army. At Fort Ringgold the admissions for malarial 
fevers amounted to 2,804 per thousand strength in the 
year 1885. Distilled water was supplied for the use of 
troops—though its exclusive use was not compulsory— 
and in 1889 the rates had fallen to 562 per thousand 
strength. At this time there was considerable field ser- 
vice among the troops stationed at Fort Ringgold, and 
the post surgeon reported that he believed every case of 
malarial fever could be traced to an infection acquired 
outside the post. In 1897 the admissions for malarial 
fever at Fort Ringgold amounted to but 89.42 per thou- 
sand strength. In the experience of the writer, at Jef- 
ferson Barracks, the soldiers of that station were severely 
affected with malarial fevers. On the introduction of 
boiled water a marked reduction in malarial affections 
was apparent. Among the officers and their families at 
this station, who were careful to drink boiled or imported 
spring waters only, not a case occurred save in two chil- 
dren, who were shown habitually to use water from im- 
pure and unauthorized sources. Later, at Washington 
Barracks, it was observed that among the two batteries 
of artillery, who drank unfiltered water, the proportion 
of malarial cases was four times as great as among the 
men of the Hospital Corps Company of Instruction, hav- 
ing an average strength of about 150 men, who drank 
only water passed through Berkefeld filters. 

Such instances as the above may be largely multiplied, 
and serve to emphasize the fact that, however else the 
malarial organism may gain access to the system, its en- 
trance by means of the water supply should never be dis- 
regarded by the military sanitarian. Grawitz has shown, 
in connection with the infection of malaria by mosquitoes, 
that the disease is most common in the German army dur- 
ing spring when mosquitoes are not especially active, and 





he regards a water supply above reproach as a necessity 
in preventing malaria. It is true that a number of experi- 
ments have been made in the attempt to cause malarial 
infection by way of the alimentary tract. Healthy per- 
sons have been allowed to drink the water from sup- 
posedly malarious marshes; enemata of similar waters 
have been given to other individuals, and even the blood 
of malarial patients has been drunk by uninfected per- 
sons. These experiments were negative in their results. 
In the absence of positive knowledge that the water con- 
tained malarial organisms in the proper stage of develop- 
ment, the first experiments prove nothing; as for the 
experiment with the infected blood, it may well be that 
in this intra-corporeal stage the parasite has little powers 
of resistance against the digestive juices. In the light 
of the instances above quoted it may fairly be assumed 
that some important factor present in natural infection 
was inadvertently omitted from the experiments. On 
the other hand, besides abundant experimental evidence 
to the contrary, the theory that malaria is transmitted by 
water alone is refuted by the fact that men on board 
ships anchored off a malarial coast, who may not have 
been on shore and have used nothing but distilled water, - 
often contract malaria. There is a very general impres- 
sion that infection can occur through the respiratory 
tract, though in the absence of definite knowledge con- 
cerning the life of the malarial parasite outside of the 
body, it is evident that this point is not susceptible of 
absolute proof. Sleeping on the ground, where the 
emanations of a supposedly malarious soil are inhaled 
during repose, has long been thought to favor the preva- 
lence of the disease among soldiers. It should not be 
forgotten, in this connection, that a wind which serves 
to carry a so-called malarial miasm may also carry in- 
sects serving as hosts for malarial parasites. 

As a result of modern investigation, the occurrence of 
the disease through inoculation by infected mosquitoes 
has been scientifically demonstrated, and it appears prob- 
able that the organism frequently gains access to the 
blood in this manner. It has not, however, been shown 
that mosquitoes in a known malarial district harbor this 
parasite except after sucking the blood of an infected 
individual; and what part they play, if any, in the orig- 
ination of the first cases of the disease occurring in indi- 
viduals penetrating a previously uninhabited region has 
not as yet been worked out. That healthy persons may 
be directly inoculated by mosquitoes which have sucked 
the blood of a diseased individual there is no doubt. 

Predisposing Causes.—Excluded from the Arctic zone, 
malaria appears to increase in frequency and virulence 
as the equator is approached, but this progression lacks 
both constancy and uniformity and does not exactly 
correspond with the isothermal lines. Certain tropical 
countries, like Australia and New Caledonia, are free 
from these fevers. In the island of Réunion, where it 
was formerly unknown, it has recently appeared, pre- 
sumably imported by French troops from Madagascar, 
and now, according to Manson, it causes one-third of 
the deaths from all causes. In general, however, the 
disease bears a close relationship to warm climates, 
and of late years high mortality from malaria has oc- 
curred only in the tropics. In this country the rates for 
malarial disease are greatest among troops stationed in 
the southwest and in the Mississippi basin, although the 
few posts on the Potomac river are notoriously malarial. 
During the Civil War, statistics gathered by the sanitary 
commission showed the number sick from malaria per 
thousand to be proportioned as follows: 

In northern posts at a distance from the sea and great 
lakes, 151; in the lake region, 193; at seaboard stations, 
Delaware capes to Savannah, 370; on the lower Missis- 
sippi, 883; in Eastern Florida, 520; in the southwest, 
747, 

Among our troops now stationed in Cuba and Porto 
Rico the rates are high, but in the Philippine Islands the 
rates for malaria have been unexpectedly low. For the 
world at large the present distribution of malarial dis- 
ease, as affected by climate, is well shown by the fol- 


583 


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lowing figures, per thousand strength, for the British 
army. 























YEAR 1898, DECADE 1888-97. 

Stati oi a & st 

ation. 2 F =} ie A = 
BURS) a E BY os a 3 “4 
“14 | 8 | ful] 72 | 8 | au 

8 Q = g q = 
United Kingdom........ O:5 | see | User 6.3 | 0.01} 0.23 
Gibraltar. coherence ote 4 iris 220 1.2 02] 24 
Malta (eta ildse crete ctieas 152.1 | 0.11} 4.17 14.1 .08 .66 
Canadas ee ice. cease ce Ai ie RRL RS 55 UPS erion 05 
Egypt and Cyprus....... 58.4 2.19 21.9 .02 85 

Bermiad acon serivcntearct Mesor seal tencearsles terete LO. | eae .08 - 

West Indios. Hi v.enteseen 78.5 | 3.87] 4.13 62.2 .06 | 2.58 
South Africa’... ceesk ene 89.2 12} 1.65 30.2 .08 | 1.2¢ 
IMAUTITIMS rte niece secre 380.3 | 1.22 | 15.76 579.2 | 2.76 | 25.74 
Geylon- eee ifsc ies 71 Eee meee 93.0 87 | 2.27 
China saneonwieoceecone 379.2 | 6.37 | 16.95 489.6 | 2.36 | 14.39 
Straits Settlements ...... 829.9] .... | 1o.L% 95.4 .64| 3.18 
ENGIG erintak nes cater 434 -76 | 15.26 356.9 71 | 12.01 
West: ALrica:. .seenecaenies 2,027.8 | 18.89 | 67.36 || 1,815.8 | 52.63 | 50.26 























At certain military stations in India, malaria has at 
times been so prevalent that all drills and parades have 
had to be discontinued. In former times the death rate 
from this disease was often extraordinarily high. Davy 
mentions an instance in Ceylon where every white soldier 
sent toa certain station contracted malarial fever; out of 
a garrison of 254 men there were 205 deaths from this 
affection. 

Next to climate, the influence of season appears to be 
of the most importance upon the occurrence of malaria; 
the rates for troops throughout the United States pro- 
gressively attaining the maximum in September and the 
minimum in February, as is well shown in the accom- 
panying diagram (see Fig. 1088). 

The relationship between malarial disease and marshy 
and swampy localities has long been recognized; though 
these fevers have been known to occur in localities not 
especially marshy, and, on the other hand, to be absent 


] 
Aa 
! 
I 
| 
ll 
{ 


m1 
| AL eal A 
71-Wal_Y 

rer 


amen 

LA | 

V/A | WA - YW, WI 

WAL | UA BA | ee J A 


GR Year 1885. 


Occurring in the United States Army. 


from regions wet and swampy. It must be admitted, 
however, that malarial affections are much more fre- 
quent on marshy coasts and low humid plains than on 
higher ground where drainage of the soil is more com- 
plete, and a certain amount of moisture in the soil ap- 
pears to be essential to the development of the malarial 


584 





tH 
U7 | a 





G A Average of dec- 
Miliila * 46 1875-84, 


Fic. 1083.—Distribution of Cases of Malarial Fever by Months, per Thousand Strength, 


virus. Marshes that are alternately flooded and partially 
drained of water.offer conditions most favorable to the 
development of malaria. Under such conditions the pro- 
fusion of rank vegetation, together with decaying organic 
matter, does much to favor it; though it may occur on 
barren, sandy soils with high ground water, particularly 
if the soil be organically contaminated. The broad, allu- 
vial deltas of great rivers and the valleys of smaller 
streams, in warm climates, are usually malarious. The 
breaking or cleaning of new lands, in malarious regions, 
usually results in the appearance of malaria in the imme- 
diate vicinity, but by prolonged cultivation the disease 
becomes less frequent and severe, and may finally disap- 
pear altogether. The geological condition of a soil ap- 
pears to play a somewhat important part in the production 
of the virus. Animpervious surface soil, which does not 
readily become saturated but favors the rapid shedding 
of storm water, is not regarded as favorable to the devel- 
opment of the disease. A permeable, shallow surface 
soil with an underlying impervious stratum may favor 
the development of malaria under conditions of very mod- 
erate rainfall. In general, excessive or prolonged rain- 
fall favors the occurrence of the disease. At high alti- 
tudes the disease disappears or becomes infrequent. In 
the tropics it is said that a height of more than two 
thousand feet is usually necessary to secure immunity. 
In the Philippine islands, however, our troops stationed 
in the upland valleys of the mountain districts suffered 
more from malaria, and from a more fatal type, than 
those in garrisons on the low plains of the coast, even 
the rice-field districts. 

While troops may be attacked by malaria when on 
board ship, this is now rarely the case in practice. Dur- 
ing the disastrous expedition of the French in Madagas- | 
car, in 1895, it is stated by Lemure that not a single fatal 
case of malaria occurred on board the thirty vessels con- 
stantly maintained off the coast; many other striking in- 
stances to the same effect have been recorded. There is 
a general conviction that the malarial virus may be car- 
ried by winds. In malarious regions near the coast the 
land breezes, especially if they traverse neighboring 
marshes, appear to favor the disease, 
while sea breezes do not. Many lo- 
calities which might otherwise be 
highly suspicious, but which are con- 
tinually wind-swept, are often free 
from the disease. Under ordinary 
circumstances the virus of malaria 
does not usually ascend very high 
above the ground; troops in upper 
floors of barracks may largely escape 
the disease where those on the lower 
floors contract it. There is, however, 
evidence that the malarial infection 
may sometimes be carried to high al- 
titudes by strong winds blowing up 
narrow, unhealthful valleys. The 
Yh aa recognition of the mosquito as an 
Ht att || agent for the transmission of this dis- 
A ease has done much to explain the in- 

= = fluence of air currents in carrying the 
disease; and the same may also be 
said with regard to the supposedly 
baneful influence of night air, since 
the malarial mosquito is not active 
during daylight. Davy says of cer- 
tain British troops in Ceylon that 
they were largely exempt from mal- 
arial fever as long as they were em- 
ployed by day only; so soon as they 
were employed more by night than 
by day, particularly in guarding con- 
voysand the relieving of posts, fever became very preva- 
lent and destructive. Of one company 70 strong, which 
was forced to sleep out in the jungle for a single night, he 
states that every man contracted fever and many died. 
Lemure gives an instance of a garrison of 50 French sol- 
diers in Madagascar, of which at the end of two months 


BS 


SNS 
SNES 
inl 




















DAL ae 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases. 





6 were dead, 12 had been invalided home, and all the re- 
mainder presented malarial infections. At the same time, 
the condition as to health was good among a body of 
marines doing similar duty at the same place, but who 
returned to their ship at night to sleep. 

Experience shows that negroes native to and living 
in a malarious country possess an undoubted immunity 
to malarial fevers. This immunity, 
however, is lost to a considerable 
extent after long residence in a noh- 
malarious climate, and does not ex- 
ist to any very great extent among 
negroes native to regions where this 
disease does not prevail. The dif- 
ference in respect to susceptibility 
between white strangers.and native 
blacks is, however, great. In the 
British expedition up the Niger, of 
145 whites and 158 negroes, there 
were 180 cases of fever with 40 
deaths among the whites, while 
there occurred among the negroes 
but 11 mild cases, and these only in 
individuals who had passed several 
years in England. In West Africa, 
Great Britain has found it scarcely 
possible to retain white soldiers, and 
the garrisons are composed chiefly 
of native negroes. For the decade 1888-97 the ad- 
mission rates for malaria, in West Africa, were 1,815.8 
for the whites, in spite of special precautions taken to 
prevent their infection, and but 990.9 among the na- 
tive negro troops; the death rates for the whites and 
negroes were 52.63 among the former and but 5.75 among 
the latter. In our own service, the rates during time of 
peace have been invariably higher among the whites than 
in the colored troops, although the difference was but 
slight as compared with the figures given above. Dur- 
ing the war with Spain, however, the rates for colored 
troops were much higher than for the whites. This, how- 
ever, is readily to be explained by the fact that the negro 
troops were nearly all engaged in the tropics, while many 
of the white soldiers, especially artillery and cavalry, 
were not moved from the United States, or in some cases 
from their usual posts. In our army the native-born 
white American appears to be slightly more susceptible 
to malarial infection than are soldiers of foreign birth. 
For the seven years 1890-96, the admissions for malaria 
per thousand strength amounted to 84.24 for American- 
born whites, 81.94 for soldiers of Irish birth, and 74.76 
for those of German nativity. 

As is the case with nearly all other diseases, age isa 
factor of great importance in predisposing to malarial 
infection, as is shown by the accompanying diagram. 
The desirability of detailing old soldiers for duty in 
malarious stations is obvious. 

During time of peace, for the seven years 1890-96, the 
admission rates for malarial disease, according to the 
branch of service, were distributed as follows: 






Per 1,000 

strength. 
PA VUAGEY nen ietiercisereiclersin cle c'viesicin e cieisbielci'e we\Celeieiele sisalseve cle 163.24 
PUT ATOR IIe oc el oles elvcs sa 101a cle'o.@ elelele cleinisicls clase vle's'e's osielgiaie sie 130.66 
WELW INEY Be ircaelel 51a cig niajiein'aie) eleie/eiols(p vimcerais)e,0\e «10 w16 s\nisi0.s\aiole ea aie 110.79 
OTARIIATECE Oe retest c sin vir oi vie nie tiel> oie aiege sfoie.8. ravers (nie leis 60.91 
Medical Department ........cccccscccccccccvssscveccoes 55.31 
MTIEATIUC Viel os clelvie ris: alae nine wie erclesdloieio@ s\sluveislere eld nniole's « eivieies 46.28 


Malarial fevers are much more common among soldiers 
than among officers. For the seven years 1890-96, the 
admissions in our army per thousand strength were 81.74 
_ for enlisted men and 40.20 for officers. 

Common experience shows that a considerable number 
of individuals, exposed to the malarial poison, escape in- 
fection. While this may be due to a racial immunity, 
as already mentioned, the strongest predisposing element 
in the development of infectious disease, to which malaria 
is no exception, is a lowering of vital resistance through 
unsanitary surroundings, bad food, exhaustion, or expos- 








ure. Among these factors physical exhaustion is not of 
the least importance, and in this connection Coustan calls 
attention to the fact that in the late Madagascar ex pedi- 
tion the proportion of deaths among the French officers 
was 1:16.6, while among the soldiers, who were ex- 
hausted by the carrying of heavy burdens and long 
marching, the proportion was 3:5, Under-fed or fasting 


Fic. 1084.—Admissions for Malarial Fevers in the United States Army, Arranged According to 
Age, per Thousand of Each Class, During the Seven Years 1890-96, 


troops are very susceptible to malarial influences, and 
early morning drills before breakfast, or late guard duty, 
are especially favoring factors. Exposure to heat un- 
doubtedly exerts an influence favorable to malarial infec- 
tion, and the same is commonly believed to be the case 
with respect to alcoholic excesses. 

The acclimation of troops in a malarious country 
cannot be counted upon—military experience showing 
that the mortality increases with the length of the so- 
journ. Oneattack of malaria, unlike the eruptive fevers, 
predisposes to another; and it is an invariable rule in the 
French service to select for expeditions in the tropics only 
such as have not previously been affected with the dis- 
ease. 

After residence in a malarious country, with or with- 
out symptoms denoting malarial infection, the disease 
often appears in a persistent form after removal to a 
region in which there is no malaria, This has commonly 
been observed in recruits sent from malarious stations to 
healthful districts in the west, and was particularly evi- 
dent among our troops returned from Santiago. 

Prophylaxis.—This depends upon the application of 
both special and general measures of prevention, and of 
these the-former are probably of the most importance. 
Ya the avoidance of malarial infection by inoculation it 
is evident that troops should be shielded against the 
attacks of insects; further, that the insects should be 
destroyed. From the nature of military service it is ob- 
vious that soldiers cannot always avoid being bitten by 
mosquitoes, especially in the field. Much may, however, 
be accomplished to this end, and the less the number of 
bites the smaller are the chances of infection. In garri- 
son all doors and windows should be provided with 
screens, and mosquito bars should be attached to all beds. 
The nets should be square, should be hung inside a 
framework, tucked carefully under the mattress all 
around and stretched tightly better to allow the passage 
of air. The mesh may be fairly large, but should be free 
from rents. Care should be taken to destroy all mosqui- 
toes within the netting afterentering. Thisis best accom- 
plished by holding a light at one corner outside the net, 
toward which the insects fly and are readily despatched. 
In the field, in malarious districts, soldiers should be fur- 
nished with squares of mosquito net or head nets for use 
at night. The weight need not be more than a couple 
of ounces, and such a protection would conduce much to 
comfort and health and amply repay its carriage. In 
camps, smudges made of green boughs lighted to wind- 
ward, so that the smoke blows over the men, are often 
of great value. For this purpose the eucalyptus boughs, 


585 


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Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








where they can be obtained, are said to be particularly val- 
uable, the mosquito having an especial antipathy to this 
tree. Oil of pennyroyal, or oil of cloves, smeared in 
small quantity over the exposed surface or dropped on 
the pillow, may keep off these insects, but being volatile, 
these substances require to be frequently renewed. In 
Italy, pieces of onion are often used for the same pur- 
pose. Mosquitoes which have gained access to barracks 
may be destroyed mechanically, or by the fumes from 
burning pyrethrum powder, tobacco, or even from green 
wood. The vapor of kerosene oil or turpentine also kills 
them. Leggings are an excellent protection for the 
ankles against these insects, but gloves or head nets can 
rarely be worn on the march, Still, except during night 


marches, malarial infections are probably rarely acquired: 


under such conditions. Since patients suffering from mal- 
aria are capable of directly infecting others through the 
agency of mosquitoes, they should always be treated un- 
der mosquito netting; and this precaution should be con- 
tinued for weeks after the actual fever has disappeared. 

When mosquitoes are present in barracks, suitable 
conditions for their development are usually found close 
by. In the case of the malaria-carrying variety, these are 
small stagnant pools. Where these cannot be filled up 
or drained, recourse should habitually be had to culicides 
for the destruction of the larve and pupex. For this 
purpose the substance most available for military use is 
kerosene or mineral oil. This should be sprinkled over 
the surface of the water, as with a broom, until a fine 
film is produced, which destroys the larve by cutting 
off the supply of air and choking their air tubes. The 
adult insects, which alight on the surface to deposit their 
eggs, are alsodestroyed. This film mustspread over the 
entire surface of the water, and should last at least two 
days, to kill the larvee as they are hatched from the eggs 
already laid. The quantity of oil required naturally 
varies with the conditions met with. For small, still 
pools probably one ounce of kerosene to each fifteen 
square feet of water surface is quite sufficient. Surface 
vegetation, sometimes very abundant, may often obstruct 
the mechanical action of the oil, and in waters even very 
slightly running the supply of the oil must be frequently 
or continuously renewed. Petroleum, also, has the dis- 
advantage of evaporating somewhat rapidly in warm 
weather. Potassium permanganate will destroy the 
larve, but only in solutions having a strength of five 
parts to the thousand. Strong infusions of tobacco are 
fatal to the larvee; and they are destroyed by powdered 
chrysanthemum flowers, as now found in commercial in- 
sect powders, in the proportion of three parts to the mil- 
lion. Recently, Celli and Casagrandi have shown that 
gallol, in the proportion of seven parts to the million, is 
the most certain and effective agent in destroying the 
larvee and possesses the advantage of great permanency. 
Whatever be the method employed, the life history of 
the mosquito shows that it should be repeated at inter- 
vals of from seven to ten days. The introduction of small 
fish or minnows into fishless breeding-places of the mos- 
quito is of great importance, as these feed greedily upon 
the larvee and soon exterminate them. 

General measures of prophylaxis have been shown by 
experience to be of much value in the prevention of mal- 
aria. It isnot advisable to take an army into a malarious 
country during the fever season, and in localities where 
fevers prevail to great extent it is well to retire to high 
ground during the malarial period, as is done by the Eng- 
lish in India and Jamaica and by the French in Guade- 
loupe. In locating a camp or post in a malarious district, 
special care should be taken in the selection of the site. 
In general, the appearance of the natives will give some 
knowledge as to the prevalence of this disease among them. 

The abandonment of a highly malarious post, in time 
of peace, is much to be desired and can usually be ac- 
complished. The retention of unhealthful posts is at the 
expense of unnecessary suffering, and in the past many 
thousands of lives have been uselessly sacrified to tenac- 
ity of position. With marching troops, zones of malari- 
ous country should be avoided or passed over as quickly 


586 














as possible. The abolition of marshes by flooding or 
drainage, and the removal of adjacent shrubbery and rank 
vegetation are great prophylactic measures in reducing 
the amount of malaria in a garrison. Plants of rapid 
growth should be cultivated for the assistance which they 
give in removing moisture from the soil. For this purpose 
the eucalyptus, castor-oil plant and sunflower appear to 
be most satisfactory, not only drying the ground but being 
shunned by mosquitoes. Subsoil drainage is often of 
great value, but this can rarely be thoroughly carried out 
in the military service. Barracks should be raised on piers, 
be cemented underneath and be of two stories in height. 
All water used for drinking purposes should be sterilized 
by heat. Foodshould be abundant and nutritious. Dis- 
tributions of hot coffee for those on guard at night, or 
engaged in arduous labor, are often of value. The use 
of quinine as a prophylactic, where troops are temporar- 
ily exposed to marked malarial influences, is of great im- 
portance, as has been repeatedly demonstrated. Not only 
are the cases of malarial infection greatly decreased in 
number by its use, but the character of the cases which 
occur is favorably modified. In general, a dose of gr. v. 
once daily will be sufficient, preferably taken shortly be- 
fore any unusual exposure isanticipated. Ina malarious 
country the general issue of a small dose of quinine, after 
anything lowering the resistive power, asa forced march, 
wetting, or lack of food, has much to commend it. In 
the Italian army, arsenious acid has been tried in the pre- 
vention of malaria, but with little satisfaction. Expos- 
ure, particularly to heat and night air, and over-exertion 
should be avoided. Thesoil should be disturbed as little 
as possible. If this should be necessary, as little as pos- 
sible should be disturbed at one time and the work should 
not be begun too early in the day. The minimum num- 
ber of men should be employed in the work, and only 
such as have not had a previous malarial infection. 
MEASLES.— Occurrence.—Among troops, this disease is 
of frequent occurrence. Under certain conditions, when 
developed under conditions of want, hardship, exposure, 
and bad sanitation—and especially when associated with 
a scorbutic taint—the disease may assume an extremely 
severe and fatal character. Formerly the occurrence of 
the hemorrhagic form of measles was not infrequent 
among troops, and was much dreaded. The exposure, 
often unavoidable, in the treatment of the sick in tent 
hospitals does much to develop secondary bronchitis and 
pneumonia; and to these latter causes are to be attributed 
also much of the gravity which the disease.has assumed 
when prevailing among troops during the existence of 
hostilities. In garrison, the mortality from this disease 
is small; for the period of peace, 1885-94, in our army, 
the death rate was but one one-hundred-and-tenth of the 
rate given by the Registrar-General for the total popula- 
tion of England and Wales during the same period. From 
1832 to 1859, according to Rosse, measles was the cause 
of 2.7 per cent. of deaths from all causes occurring in the 
garrison of Paris. During the Civil War there were, in 
the Union forces, 75,177 cases with 5,174 deaths, the ad- 
missions per thousand strength during this period 
amounting to 31.72 and the deaths to 2.02. Among the 
Confederate troops, Eve states that measles prevailed to 
such an extent that whole companies, battalions and 
regiments, under organization, had to be disbanded and 
the men sent home. During the siege of Metz, measles 
was extremely prevalent and fatal in the garrison. In 
our army, for the period 1868-98, there occurred a total 
of 3,738 cases with 15 deaths, giving an admission rate 
per thousand strength of 4.50 and a death rate of .017. 
The disease appears to be more prevalent now than 
formerly among our troops, the rates being as follows: 








A Admissions Deaths 
Period per thousand. | per thousand. 
1868-84 1.88 ~ 0,004 
85-94 .. 4.85 004 
13.72 090 





, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


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Camp Diseases, 





The expansion of our army with a large number of 
susceptible recruits at the outbreak of the war with 
Spain, and their aggregation in large camps where the 
dissemination of the disease was favored, did much to 
raise the rates for both admissions and mortality during 
the last period given above, the admissions for the year 
1898 being 25.09 per thousand strength and the deaths 
from this cause amounting to 0.26 per thousand; while 
for the previous year of peace, 1897, the admission rate 
was only .82 per thousand, with no deaths. In the Ger- 
man army the rates of admission for measles, for varying 
periods, were uniformly low, as follows: 


Admissions 
Period. per 1,000 
strength. 
Sse CETL OSS =I Searle orsis cas ciaeie,a(a'ciate.s's.0isss/ spect esagowiecie vases 1.4 
rarer EM BOAT LB. aerate ctele alate, s eraieivie sie's:\psarere vig ah 'ein°s vislereiee 1.5 
RENEE ROOM ODIO ioe oviciai dogs sve Sew See de vet ewe oe ceees eee 83 
STIL ENS OS arcternic icy cielelr aeieis.civie'vis cee elec cialis sin vives celecle e's it 


For the French army the rates of admission per thousand 
strength, for the five years 1890-94, was 9.71. Coustan 
believes that the system prevailing in the French army, 
of turning intoa common magazine for storage certain 
articles worn by the men only during the period of the 
field manceuvres, greatly favors the dissemination of the 
infection of measles, and hence partially explains the 
high rates given by thatarmy. In the Austrian army, 
for the year 1897, the admission rate was only .8 per thou- 
sand, but the proportionate mortality was high, .02. 

Colored troops appear to be less susceptible to measles 
than are white, but certain mild cases are more liable to 
escape recognition in the former class; the rates of ad- 
mission in our army for measles, in 1898, were 25.91 per 
thousand whites and 14.42 for colored troops. During 
the Civil War the rates were 30.41 for white and 46.65 
for colored troops, this excess as regards the negroes being 
apparently due to lessened efforts for the control of the 
disease among them. The disease occurs far more fre- 
quently among recruits than among old soldiers; in the 
Civil War the number of cases depending upon the pro- 
portion of susceptible individuals and occurring particu- 
larly among country-bred recruits. For the French army 
Coustan gives the following figures, as illustrating the 
effects of age and length of service on the occurrence of 
this disease : 





Less than one year|More than one year 








Year service, admissions| service, admissions 
per 1,000 strength.| per 1,000 strength. 

23.63 12.69 

99.62 4.04 

11.98 6.08 

14.80 7.91 








In our own service, measles prevails to by far the 
greatest extent at the recruiting depots; in 1892, the re- 
cruits at Columbus Barracks furnishing more than half 
the cases occurring in the entire army. The disease or- 
dinarily occurs in time of peace most frequently during 
cold weather, when ventilation is comparatively re- 
stricted and the opportunity of infection is most favor- 
able. During the year of war 1898, when the number 


of recruits was great, the rate of admission was by far ~ 


the greatest during June and July, thus showing the 
greater importance of length of service as compared 
with season in influencing the occurrence of this dis- 
ease. During the same year the admission rate was 
19.82 per thousand among soldiers stationed in the Unit- 
ed States, while there was a total rate of 48.25 for the 
troops serving in the West Indies and the islands of 
the Pacific. The case mortality of measles, as already 
noted, is capable of varying within very wide limits, 
ranging from as little as 1 or 2 per cent. in some out- 
breaks to 40 or 50 per cent. in others. “In Paris, during 
the siege (January, 1871), out of 215 of the Garde Mobile 
who took measles, 86, or 40 per cent., died; and the mor- 
tality reached very nearly the same figures among the 
French troops who returned to Paris after the Italian 











war, 40 out of 129 cases dying in one hospital whose 
sanitary condition was bad.” As in typhus fever, the 
concentration of a large number of measles cases, with 
deficient ventilation, appears unfavorably to affect the 
course of the disease through an intensification of the 
virulence of the infection. 

From analogy, it may be assumed that the cause of 
measles is a specific micro-organism, but as yet its special 
nature has not been determined. The infection is pre- 
sumably given off by the breath and mucus from the 
catarrhal surfaces, also by exfoliated epidermis. The 
poison undoubtedly is capable of being air-borne and 
tends to cling to fomites and remain in illy ventilated 
spaces. The materies morbi is very tenacious of life; and 
where it once fairly establishes itself, as has been appar- 
ently the case at Columbus Barracks, annual epidemics 
are the rule. There is no evidence that the disease is 
transmissible by water or food; infection probably al- 
ways occurs through inhalation. In a garrison, the dis- 
ease is not infrequently introduced by children. The 
incubation period varies from eight to twenty days, the 
usual limit being about eleven days. The infective 
period begins with the earliest symptoms; it is greatest 
while the catarrh and rash are present, and probably 
extends well into convalescence. As a general rule, in- 
fection is over by the end of the fourth week, provided 
that cough and desquamation have ceased. One at- 
tack of measles usually confers an immunity to future 
attacks. 

Prophylazis.—In civil life, vigorous efforts are rarely 
made to prevent the spread of measles. In the military 
service the opposite should be the case, bearing in mind 
that this disease is never devoid of danger, and, particu- 
larly in the field, may assume a grave character. Further, 
it causes the loss of a considerable amount of service by 
troops to which the state is entitled. In view of the 
fact that measles was mild under favorable conditions 
and was often extremely fatal when the patients were ex- 
posed to inclemencies, it was seriously urged, during the 
Civil War, to infect all susceptible recruits with this dis- 
ease, and only after recovery to send them to join their 
regiments. The prevention includes the isolation of the 
sick and the disinfection of all clothing, bedding, and 
surroundings. The discharges should be disinfected, 
particularly those from the mouth and eyes. For the 
latter purpose soft rags should be employed, and these 
burned after use. As far as the patient is concerned, 
Cameron concludes that “so far as figures are of value, 
ample air space, free draught, freedom from overcrowd- 
ing and from effluvium nuisances, conduce most to re- 
covery.” 

In the spring of 1898 the writer carried out some inves- 
tigations with regard to the production of an artificial 
immunity against measles. The experiments were 
abruptly interrupted by field service, but appeared to 
be distinctly favorable so far as carried out. The method 
employed consisted in the subcutaneous injection of 
blood serum obtained from convalescents from measles 
by means of cantharidal blisters. The’ injections were 
made in children living in an infected garrison, 5 to 
10 c.c. being administered in three doses at intervals 
of about forty-eight hours. None of the cases so in- 
oculated contracted the disease, while a considerable 
proportion of the susceptible and uninoculated children 
became infected. 

Mumps.—Mumps occurs very frequently among troops, 
especially in young soldiers, but its mortality is prac- 
tically nil, and, like some other affections, it becomes of 
importance merely from the temporary disability for 
military service which it causes. In a total of 8,122 cases 
of mumps occurring in the United States army for the 
thirty-one years 1868-98 inclusive, there was not a 
single death which could be attributed to this affection. 
The admission rate for this disease for the period 1868- 
84 was 2.99 per thousand; for 1885-94, it was 5.08, and 
for 1895-98, it was 4.05. The rate of admissions for 
the entire period, 1868-98 inclusive, was 3.76 per thou- 
sand. 


587 


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Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





In the military service, mumps usually prevails in well- 
defined epidemics. Alarge proportion of the cases occur 
in recruits. The aggregation of such young men at cer- 
tain stations for purposes of instruction is very favorable 
to the occurrence of this disease; and in 1894, out of 337 
cases of mumps occurring in the army, there were 119 
cases at the two recruiting depots of Columbus Barracks 
and Jefferson Barracks. In the previous year, out of a 
total of 149 cases, 48 cases occurred at the first-named 
station. Orchitis and atrophy of the testicle are very 
common among soldiers affected with mumps, being pres- 
ent in about one-third of the cases. Coustan states that 
in an epidemic among French soldiers in 1891, every man 
attacked developed orchitis. Laveran found it 211 times 
in 699 cases. ; 

The infection is supposed to be given off by the breath 
and the secretions of the mouth, but as yet no specific 
organism has been isolated. It is not conspicuously dis- 
seminated by means of fomites; in garrison, it frequently 
appears to be introduced from outside by children. The 
period of incubation is reckoned as from fourteen to 
twenty-five days. The patient is regarded as infectious 
while there is any inflammation or tenderness of the sali- 
vary glands. Sanitary precautions consist in the isola- 
tion of the patient and the disinfection of his clothing 
and equipment. Beyond the cleansing and disinfection 
of the cuspidorsin the squad room, no further preventive 
measures, in view of the comparative triviality of the 
affection, will usually be necessary. Among soldiers 
mumps not infrequently occurs in close association with 
measles, but this apparent relationship is probably to be 
regarded as accidental. The disease is most common 
during the colder weather. 

AcuTE Croupous PNEUMONIA.— Occurrence.—Pneu- 
monia is a disease which, as might be expected, consid- 
ering the conditions of military life, though not one of 
the most common to which the soldier is exposed on ser- 
vice, is yet not of infrequent occurrence nor unproduc- 
tive of considerable mortality. Though ordinarily the 
disease occurs only sporadically, at times it appears to 
take on a distinctly contagious character; and well- 
defined epidemics of pneumonia among soldiers, either in 
garrison or in the field, are by no means infrequent. 
Under such conditions it is reasonable to assume the ex- 
istence of some common depressing influence, by which 
a number of individuals are predisposed to an infection, 
to which, under ordinary circumstances, they would be 
largely unsusceptible. In considering the prevalence of 
this disease in the military service, it should not be for- 
gotten that pneumonia may either occur primarily or be 
consequent to some other disease, particularly influenza 
and measles; and it is particularly during epidemics of 
the latter affections that the rates for pneumonia attain 
their maximum. While the disease occurs to some ex- 
tent among troops in garrison, it is considerably favored 
by the exposure incident to field service. : 

The rates in our army for pneumonia, since the Civil 
War, have steadily decreased as a result of the greater 
care given to the comfort and welfare of the soldier, as 
shown by the following figures: 











Dart Admissions per Deaths per 

Be ect 1,000 strength. | 1,000 strength. 
1861-66 (Civil War). ccc srcis's «aie sieiste 32.45 es 

868-84 te, ieee aoa Cecile eee eee 6.55 1.01 

D8S5-O4. aire rcinticaya ata cleteenetoie' ots toebaterad 4.28 76 
1895-08 ce... Sisrnushicanmeasaceme eae 3.66 1 
Year 1898 (war with Spain)......... 4.84 83 
Year [807 iiuvctee cue csatentos moeiacie oleree 2.96 al 





The case mortality of the disease has‘also greatly di- 
minished, but this is probably due to a more rational line 
of treatment than to any decrease in the virulence of the 
infection. As compared with the rates for foreign ser- 
vices, those for our army are extremely low. In the 
German army the admissions and deaths from pneumonia 
have been as follows: 


588 








; Admissions per| Deaths per 
ee 1,000 strength. | 1,000 strength. 
1881-82 to 1885-86 ......scceseccceces 11.0 0.19 
1886-87 to 1890-OL 20.5. ictene eves vos 10.5 43 
1891-92 to 1895-96 2... ecedevsscwees 9.3 .36 
Voor 1896-07 <5 5 <btirctrere averse eisnereiace 6.7 25 


It is seen that in the German army the death rate has 
latterly increased while the proportion of cases has di- 
minished, a fact which can be explained only on the sup- 
position of an increase in the gravity of the affection. 
In the Russian army the following are the recent rates: 








7 Admissions per| Deaths per 
pear 1,000 strength. | 1,000 strength. 
10.4 0.99 
10.2 -90 
8.7 81 
10.7 87 
7.7 -62 
8.3 66 
v iy 62 
6.4 49 


In the Austrian army, for the year 1897, the admissions 
for pneumonia, per thousand strength, amounted to 5.1, 
while the death rate was .49. 

Dissemination and Infection.—The specific micrococ- 
cus of pneumonia discovered by Surgeon-General Stern- 
berg, of the United States army, is found in the spu- 
tum of practically all persons suffering from this disease. 
It has also been found in acute peri- and endocarditis, 
acute pleuritis and empyema, acute meningitis, and otitis 
media. After death it may be found, in varying numbers, 
scattered throughout the body. It has been found to be 
constantly present in the mouth cavity of healthy indi- 
viduals, and by some has been thought to be present in 
the mouth of every one at some time or other. While the 
micro-organism usually loses much or all of its virulence 
by artificial cultivation, its original qualities are retained 
in sputum, blood, and other pathological exudates for 
considerable periods, according to Abbott for as long as 
fifty-five days, even in the dried condition. It is not un- 
likely, therefore, that dried pneumonic sputum, when 
ground into dust and inhaled, may induce the occurrence 
of the disease in susceptible individuals. This condition 
of susceptibility is, however, essential. “There must be 
some predisposing cause, for the micrococcus is widely 
disseminated, and is often present in the mouths of 
healthy persons without producing any ill effect. Under 
ordinary circumstances the protective mechanism of the 
body prevents invasion.” Since the micro-organism of 
pneumonia is so frequently present in the mouth, it is 
probable that the sporadic cases of the primitive disease 
so commonly seen are the result of auto-infection depend- 
ing upon a lowered vital resistance. As the lungs are 
the seat of attack, it is probabie that the infective organ- 
ism gains entrance by the air passages, though there is 
some evidence that it may be brought to the lungs from 
distant parts by the vascular or lymphatic circulation. 

Predisposing Causes.—Among the predisposing causes 
of pneumonia those of latitude and season are of impor- 
tance; the disease being most common in cold climates 
and, as shown in the accompanying diagram, during late 
winter and early spring. The negro race appears to be 
especially susceptible to the disease; the rates per thou- 
sand for our own service, for the decade 1879-88, being 
7.52 for admissions and 1.79 for deaths among the colored 
troops, and but 4.46 and .76 respectively, for the white 
troops. Among the whites, figures for the seven years 
1890-96 showed the American-born to be about 20 per 


_ cent. more liable to contract the disease than soldiers 


born in Ireland, Germany or England. Age appears to 
be a factor of no small importance; soldiers.under twenty- 
five years of age and over fifty years being more than 
twice as liable to contract the disease as those between 
twenty-five and thirty-five years ofage. Among the sev- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





eral arms of the service the admission rates per thousand 
strength, for the period 1890-96, were 4.12 for cavalry, 
3.46 for infantry and 2.95 for artillery. 

Pneumonia is especially apt to follow upon exposure 
to sudden and extreme variations in temperature. Troops 
returning from service in the tropics, and especially such 
as are insufficiently clothed for the colder climate, are 
particularly liable to this disease. Wetting appears not 
infrequently to precipitate an attack, as do exhaustion 


eaen [see [ree [5 [man [dome] mip [tm | [oe [ee [ow 


= Fe 


Fig. 1085.—Distribution, by Months, of Cases of Pneumonia Occurring in the United States 
Army, per Thousand Strength, During the Decade 1875-84. 


and alcoholism. The disease often occurs in soldiers who, 
after having been exhausted by fatiguing exercise, ex- 
pose themselves while sweaty to chilling draughts. In- 
sufficient heating of barracks has been thought to favor 
pneumonia. Repeated outbreaks sometimes occur in the 
same buildings, especially in casemates. It is a matter 
of common knowledge that epidemics of this disease 
among troops often occur at the same time as epidemics 
of pneumonia or influenza in cavalry horses with whom 
the soldiers come in frequent contact. 
Prophylazis.—From what has been said, it is evident 
‘that measures having reference to the prevention of 
pneumonia among troops are particularly those which 
look to the maintenance of a high physical tone. Good 
. and sufficient food, suitable clothing and shelter, rational 
exercise in the open air, cleanliness of person and tem- 
perate habits are all important. Chilling after drills and 
exercise should be avoided. 

When pneumonia assumes an epidemic or infectious 
type the patients should be isolated. All the precautions 
required in the case of tuberculosis should be taken in 
this disease also. Attendants on pneumonia cases should 
be well nourished and have sufficient rest; it being borne 
in mind that by being overworked and in constant asso- 
ciation with the patient they offer the conditions most 
favorable to their own infection. 

ScaRLET FevER.—This affection can scarcely be re- 
garded as a soldier’s disease; being rare in our own army, 
though less uncommon in those of other nations. Dur- 
ing the period 1868-98, there were reported in our service 
only 160 cases in a total numerical strength of 859,908 
men. Of these 160 cases there were but 6 deaths. The 
disease occurs in garrison rather than in camp, there being 
but 12 cases during the year of war with Spain. Of these 
12 cases, however, 3 were fatal, while of 148 cases occur- 
ring during the previous thirty years of peace but 3 suc- 
cumbed, thus showing the unfavorable influence of the 
exposure unavoidably incident to treatment in field hos- 
pitals. The admission rate per thousand strength was 
.19 for the period 1868-84; .18 for the period 1885-94, 
and .21 for the period 1895-98. In the Austrian army, 
for 1897, the admission rate is given as .30 per thousand 
strength and the death rate as .01. In the German army 
scarlet fever has occurred as follows: 


Admissions 
Period. per 1,000 
strength. 
AEE ORL GOO ieteete slecsiest viateda’ein's nia's eie/eiclsinve s.0.vleeteiGlete 1.2 
1886-87 to 1890-91... 95 
1891-92 to 1895-96... 92 
PYCAE LSOO-O (isialeaie ats .66 














Epidemics of scarlet fever have frequently occurred 
among children living at our army posts without the 
troops being affected. It usually occurs in late winter 
or early spring. The contagion of scarlet fever is proba- 
bly not developed until the eruption appears, and is es- 
pecially to be dreaded during desquamation, when the 
poison is spread by the fine particles of epidermis which 
are disseminated from the person. The morbific agent is 
very tenacious of life and may cling to rooms, clothing, 
and other articles for long periods, 
retaining its power to reproduce the 
disease under favorable conditions. 
The infection appears to be given 
off by the breath and the secretions 
from the nose, mouth, ears and kid- 
neys. The disease does not appear 
to be spread by water, although in- 
fected milk appears to have caused 
several outbreaks. Infection is al- 
most always contracted by inhala- 
tion. The incubation period is from 
one to six days; the quarantine re- 
quired is usually from seven to nine 
weeks, or until desquamation is 
at anend. Prevention includes iso- 
lation of the sick as a matter of 
the first importance. The apparel, 
equipment and former surround- 
ings of the patient should be carefully disinfected. All 
discharges should be disinfected before removal from the 
sick-room, and the arrest of contagious material from the 
skin secured by the application of some antiseptic oint- 
ment. The convalescent soldier should not associate 
with others until all desquamation has ceased, the pro- 
cess being aided by repeated bathing in warm soapsuds. 
Careful shampooing of the head is essential in securing 
disinfection of the person. 

SMALLPOX.—Occurrence.—Until well within the past 
fifty years this disease has prevailed generally among 
armies, being regarded as one of the most common and 
at the same time most fatal affections to which troops 
were ordinarily exposed. Its prevention among soldiers 
by means of vaccination was not attempted until 1831, 
when this operation was introduced in the army of 
Wiirtemberg. Some years later it was taken up in other 
armies and practised with more or less thoroughness. 
During the Revolutionary War the failure of our invading 
expedition into Canada was largely due to a scourge of 
smallpox among the Continental forces. It was present 
during the war with Mexico, and during the Civil War 
there were 18,962 cases with 7,058 deaths. In the Con- 
federate army of northern Virginia, from October, 1862, 
to January, 1864, there were 2,513 cases and 1,020 deaths. 
During the Franco-Prussian War the German troops, 
who had been carefully vaccinated, had only 278 fatal 
cases of smallpox in a total strength of 913,967 men; 
among the poorly protected French troops the deaths 
were said to have amounted to 23,400, and Coustan states 
that during the siege of Paris the mortality from small- 
pox among the besieged forces was no less than 6.76 per 
cent. In the military hospitals the German wounded 
escaped variola, where the French wounded prisoners 
were generally attacked. The lesson was not lost on the 
French authorities, and a vigorous system of vaccination 
was later instituted, so that 92 deaths from smallpox in 
1877 were progressively reduced to 4 in 1890 and 3 in 
1892. In the German army, excluding the Saxons and 
Bavarians, for the period 1873-74 to 1896-97, inclusive, 
there were but 17 cases of variola in a constant strength of 
over half a millionmen. Of these cases but 2 were fatal. 
In the Italian army of 204,312 men, for the year 1897, 
there were but 2 cases of variola; in tle Russian army, 
for the same year, the admission rate per thousand 
amounted to .4. In the British army, for the period 
1888-98 inclusive, there were no cases of smallpox 
among troops stationed in the temperate zone. In the 
tropics, however, the disease prevailed to no small ex- 
tent; the admissions per thousand strength being 1.1 for 


589 


Camp Diseases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





China, .8 for India, and 1.7 for Egypt and Cyprus. This 
difference was undoubtedly due to the general dissemina- 
tion of the disease among an unprotected native popu- 
lation. In our ownarmy, for the thirteen years 1885-97, 
there occurred but 6 cases of smallpox, and in these in- 
stances the fact of previous vaccination could not be de- 
termined. In the year 1898, however, our troops on 
foreign service were brought into contact with an unvac- 
cinated native class, and, furthermore, consisted largely 
of recruits hastily enrolled in an expanded army during 
the war with Spain. These men, examined largely by 
civilian physicians for enlistment, were less thoroughly 
protected against the disease by vaccination; and for that 
year the admission rate for the entire ar my was .40 per 
thousand. For 1898, from the troops in Porto Rico the 
admissions were 1.04 and the deaths .52 per thousand; in 
the Pacific islands the admissions were 5.51 and the deaths 
2.07. For the entire military force, regulars and volun- 
teers, May, 1898, to June, 1899 inclusive, the death rate 
from smallpox was .57 per thousand. 

Manner of Infection.—In the great majority of cases 
the disease appears to be directly transmitted from the 
sick to the well through the medium of the atmosphere, 
and this power of aérial convection is one of the most 
striking characteristics of smallpox. Persons unpro- 
tected by vaccination apparently contract the disease by 
simply breathing the air of the space in which a smallpox 
patient is confined. There is no evidence for or against 
the transmission of the disease by food or drink or 
through wounds. Persons or things which may have 
been in contact with the patient are, however, capable 
of conveying the contagion. Power showed that the in- 
fectious agent could be carried by the air, particularly 
when a large number of cases were aggregated and the 
atmosphere was moist, for as much asa mile. This isa 
matter for consideration in the establishment of isolation 
hospitals. The incubation period of the disease is prac- 
tically twelve days, and its period of infectiveness lasts 
at least six weeks in severe cases. The period of highest 
infectivity is believed to be during the stage of desquama- 
tion, when the morbific agent, whatever be its nature, is 
dispersed with the fine particles of epidermis that the 
patient sheds. The disease appears to be contagious at 
an early stage; after exposure to an infection the sus- 
ceptible individual should be quarantined for a fortnight. 
A certain proportion of individuals, according to Notter 
and Firth about five per cent., appear to be naturally 
immune to the disease. 

Soil and climate appear to have no influence on the oc- 
currence of smallpox. Season appears to affect its prev- 
alence, and in temperate climates the mortality curve is 
above the mean in the late winter and spring. In the 
tropics the disease is said to prevail chiefly during the 
hot season, the rains checking it to a great extent. “The 
negro and colored races are especially susceptible to the 
disease, and these also suffer a heavy case mortality when 

vaccination has been imperfectly performed. During 
the Civil War the admissions among the white troops for 
variola and varioloid amounted to 5.5 per thousand 
strength, while the admissions of colored troops for the 
same cause amounted to 36.6 and the deaths to 12.2. 

Prophylavis.—For the prevention and eradication of 
smallpox, systematic vaccination is the measure of by far 
the greatest importance. When arm-to-arm vaccination 
was practised in armies, great difficulty was found in 
obtaining the necessary amount of virus, and it was also 
impossible to eliminate entirely the possibility of trans- 
mitting certain constitutional diseases. Animal vaccine 
disposes of this danger and places at the disposal of the 
military sanitarian as large quantities as may be desired. 
With improved virus and better technical methods, the 
proportion of successful vaccinations has steadily in- 
creased. In the Italian army, of 3,095,571 vaccinations 
and re-vaccinations made during the period 1867-97 in- 
clusive, Livi states that the success increased from 260 
per thousand in we to 698 per thousand in 1897. In 
the last-named year, in the Belgian army, the number of 
successful A fees Vaccinations was 69:91 per cent.; of 


590 








those previously vaccinated, 48.21 percent.; of those said 
to have had smallpox, 20.50 per cent. In our service, 
Army Regulations require that as soon as a recruit joins: 
any rendezvous, regiment, or post he shall be examined 
by a medical officer to ascertain whether vaccination is. 


4 
; 
MM 


PZ 


| 





G8 = Mortality. 


Fig. 1086.—The Influence of Vaccination on Smallpox in the Italiam 
Army, Based on Figures for the Period 1867-97. A, Never had vari- 
ola or been vaccinated in childhood and not yet vaccinated in the 
army; 3B, either had variola or been vaccinated in childhood and not. 
yet vaccinated in the army; C, never had variola nor vaccinated in 
childhood and vaccinated in the army without success; D, never 
had variola nor vaccinated in childhood, and vaccinated in the army 
with success; EH, had variola or was vaccinated in childhood, and 
vaccinated in the army without success; F’, had variola or was vacci- 
nated in childhood, and vaccinated in the army successfully. (After 
Livi.) 


Sickness. 


required. In such cases as present no evidence of success- 
ful vaccination within a reasonable period the operation 
is to be performed immediately. The date and result of 
the last vaccination are to be noted in the company descrip- 
tive and deposit book, and also on the descriptive list in 
case of transfer. This system is not sufficiently compre- 
hensive and leaves too much to the discretion of the med- 
ical officer. It should be required that all young recruits. 
be vaccinated immediately on enlistment, and that they 
be examined after ten days and re-vaccinated if the first 
operation has not been successful. In suchas still prove 
refractory, the operation should be repeated at the end of 
three months. In time of epidemic the thorough vac- 
cination of the whole command should be practised. 
For old soldiers, after being vaccinated on re-enlistment, 
no repetition of the vaccination, if unsuccessful, will 
ordinarily be necessary.. The practice of simultaneously 
making several points of inoculation, as is done in Euro- 
pean armies, has much to commend it as reducing liabil- 
ity to failure. In general, the total area of the cicatrices. 
should not be less than half a square inch. The incuba- 
tion of vaccinia being shorter than that of smallpox, it is 
possible to modify or even entirely prevent an attack of 
the latter, by vaccination performed some days after in- 
fection. This is especially the case with re-vaccination, 
the incubation of which is often shorter than primary 
vaccination. The operation, if successfully performed 
within three days after exposure to smallpox, will pre- 
vent the appearance of the symptoms, and in all likeli- 
hood the attack will be arrested or modified if vaccination 
be performed as late as the fifth day. The few attacks 
that occur between six and nine days after successful 
vaccination are mild, and practically none commence 
later. With regard to what may be accomplished in con- 
trolling smallpox, the recent work of army medical offi- 
cers in the Philippines, Cuba and Porto Rico is a con- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





spicuous example. In the latter island nearly a million 
people were vaccinated, and the disease was practically 
eradicated. In the Cuban epidemic at Holguin, where 
12,000 cases of the disease were treated, not a single sol- 
dier of the well-vaccinated command contracted smallpox, 
though the men were constantly engaged in sanitary 
police and in guard duty at the lazarettos and infected 
points. 

In addition to the prompt vaccination of all persons 
who may have come in contact with a smallpox case, the 
patient should be carefully isolated. All clothing and 
other articles exposed to contagion, which cannot be 
readily disinfected, should be burned. During the stage 
of desquamation, fixation of the contagious matter should 
be accomplished by smearing the skin with olive oil, vase- 
line, or carbolized glycerin. All discharges from the nose, 
mouth, and elsewhere should be received into vessels 
containing a disinfectant solution. The scabs which 
have fallen off should, as far as possible, be collected and 
burned. Isolation should be maintained until the last 
scab has disappeared. The surroundings of a case of 
smallpox should be carefully disinfected. No special 
precautions on the part of the attendants, provided they 
are thoroughly protected by vaccination, appear to be 
necessary. 

In nearly all foreign armies, vaccine farms form part 
of the military establishment. In the French army there 
are five such farms, of which three are located in France 
and two in Tunis and Algeria. In our own service ad- 
mirably managed vaccine stations have been established 
in Porto Rico and in the Philippines, since it was found 
to be a matter of both great difficulty and great expense 
to import active vaccine virus from the United States, 
Japan, or other countries. In the stations in the Philip- 
pines the young water buffalo or carabao has successfully 
filled the place of the calf for the production of vaccine 
virus. 

TUBERCULOSIS. — Occurrence.—Tuberculosis isa disease 
which originates more frequently in garrison than among 
troops in active campaign; but, on the other hand, the 
arduous nature of the service required under the latter 
conditions is often responsible for the development of a 
previously latent infection. The disease is not uncom- 
mon among troops, a fact by no means strange when its 
great prevalence among the civil population is consid- 
ered. It is probably true that a proportionally greater 
number of cases of tuberculosis occur among soldiers 
than among males of the military age in civil life, in 
spite of the former being physically sound men; but, on 
the other hand, the disease is of a somewhat chronic 
nature, not usually amenable to such treatment as can 
be given in the military service, and hence the early dis- 
charge of well-recognized cases does much to depress the 
rates for the army and raise those for civil life. Military 
service appears not only to afford greater facilities for 
contracting the disease, but also to more certainly develop 
an existing but latent infection. 

The mortality from tuberculosis was extremely high 
among troops at the beginning of the present century, 
but has gradually decreased down to the present time as 
a result of more attention to their welfare. In our own 
servicé the admission rates for tuberculosis, during the 
Civil War, amounted to 6.22 per thousand strength; the 
death rate to 2.58. During the second year of the war 
the admission rate was 9.38 and the death rate 3.05. For 
the period of peace, 1868-84, the admissions amounted 
to 4.88 per thousand strength, and the deaths to 1.05. 
For the decade 1885-94 these rates fell to 3.89 and .59 
respectively ; and for the period 1895-98 they were still 
further reduced to 2.883 and .42. These rates are low 
as compared with those for other armies, and _ reflect 
credit upon the care given to our troops; but their exist- 
ence, even at present figures, implies a certain laxity of 
sanitary administration. The death rate from this cause 
should be made to approximate zero through a more 
prompt and thorough elimination of those affected with 
tuberculosis, while a higher physical standard in respect 
to recruits would do much to reduce the future admis- 








sions to sick report from this disease. At present our 
rates are considerably raised by the military sanitarium 
for the tuberculous maintained at Fort Bayard. In for- 
eign armies, figures with respect to the occurrence of 
tuberculosis, as given by Marvaud and contained in recent 
official reports, are as follows: 








Admissions per 
1,000 strength. 


Country. Period. 








1873-79 


= 








—_ 
oe 
: 
SSS Se eee a PA Ot 
WO 


RES A Cn 





In the Russian and French armies the death rates are 
particularly high, being 1.6 and 1.10, respectively. The 
lowest death rate is given by the Belgian army, in which, 
as a result of careful elimination of the tuberculous, the: 
rate was but .35 per thousand strength in 1898. For the 
year 1897 the death rate was .45 in the German army. 
Among the British troops on colonial service, during the 
decade 1888-97, the lowest rates of admission were 
given by Gibraltar, 1.9, and Bermuda, 2.4. The highest 
rates were given by the troops in India, 4.2, and in Cey- 
lon, 4.1. For the Spanish army in Cuba, in 1897, the 
admission rate for tuberculosis was reported to be in 
excess of that for yellow fever, dysentery, or typhoid 
fever. 

Dissemination and Infection.—Every tuberculous sol- 
dier is a source from which the disease may be propagated 
to his comrades. The particular manner in which the in- 
fectious material is thrown off depends upon the anatom- 
ical location of the tuberculous lesions. Undoubtedly the 
disease is most commonly disseminated by infected spu- 
tum, but this is merely because the specific bacilli more 
commonly find in the respiratory apparatus the conditions. 
which are favorable to their development. It should not. 
be overlooked that under certain conditions the urine, 
feces, or discharges from superficial lesions may be pro- 
portionally as infectious as the sputum. 

In the sputum of those affected with pulmonary tuber- 
culosis the specific bacilli are usually found in enormous. 
numbers. When such infected sputum is dried, pulver- 
ized, and disseminated as dust by air currents, the infec- 
tious material may be inhaled by those within its sphere 
of action, and, in susceptible individuals, may reproduce 
the disease. The same may also occur with tuberculous 
urine, feeces, and suppurative discharges. In the dried 
state the vitality of the bacillus is very great, and it has 
been shown to retain its virulence under these conditions 
for as long as from seven to ten months. In the wet state, 
its virulence is retained for about six weeks; but in this 
condition it is comparatively harmless, though not en- 
tirely so. Cornet found that the dust in rooms occupied 
by consumptives contained virulent tubercle bacilli in 
a large proportion of cases. Such dust, disturbed from 
cornices or out-of-the-way places, even after several 
months, is often capable of producing an infection, and 
to its agency the appearance of many cases of obscure 
origin may be attributed. In a study of consumption 
occurring in Philadelphia it was found that certain in- 
fected tenement houses were apparently responsible for 
a large proportion of cases; in some instances every fam- 
ily successively occupying these houses presenting one 
or more cases of the disease after an occupancy of any 
duration. These observations have a practical applica- 
tion to the military service in connection with the disin- 
fection of barracks in which a case of this disease has 
occurred. 

While the breath in consumptives dces not appear to 


591 


Camp Diseases, 
Camp Diseases. 





convey the infection, fresh tuberculous material, after 
infection, may be transmitted to food or drink by un- 
washed _ hands or other agency, and give rise to the dis- 
ease when taken into the alimentary tract. Vigoura, in 
ten examinations of the hands of hospital attendants in 
wards where consumption was being treated, found the 
tubercle bacilli present in two instances. In the same 
way, infected individuals who cough over food may also 
disseminate the affection. Flies feed greedily on tuber- 
culous material, and their importance as carriers of the 
specific bacilli has only recently been appreciated. Much 
evidence on this point has lately been collected. Spill- 
man and Haushalter examined the flies and fly excreta 
in a hospital ward and found tubercle bacilli in both. 
Hoffman examined the intestinal contents of flies taken 
from a room where a death from phthisis had recently 
occurred and found the bacilli in four out of six instances, 
as well as in the fly excreta on the walls and furniture. 
Guinea-pigs inoculated by him with fly intestine became 
tuberculous. Alessi fed flies with phthisical sputum 
and produced tuberculosis in rabbits inoculated with 
their dung. It is thus apparent that food may be read- 
ily contaminated by flies carrying infectious material. 
Tuberculous meat may also be’ a cause of the disease ; 
and in civil life milk from diseased animals is not infre- 
quently infected. Clothing or other articles, when in- 
fected, may convey the disease to those persons who 
handle them, and in such instances the disease appears 
to result from infection by way of the alimentary tract. 
Inoculation through a breach of the skin has often oc- 
curred, but such method of infection is not common in 
the military service. When it does occur, the process is 
usually localized at the site of infection. Direct infec- 
tion from the sick is rare, but there appears to be evi- 
. dence to the effect that the disease may be communicated 
by the sick to the well. In instances of this sort, how- 
ever, the affected individuals can scarcely be said to have 
been free from the possibility of infection by indirect 
means also. 

Predisposing Causes.—The disease occurs in all coun- 
tries and climates, but is especially prevalent where sud- 
den changes of temperature and damp atmosphere favor 
the occurrence of bronchial irritation, the tuberculous 
element being thus engrafted upon a simple benign affec- 
tion. A dry, equable, sunny climate does much to pre- 
vent the occurrence of this disease, and the same may be 
said with respect toaltitude. Of the greatest importance 
in determining the occurrence of this disease is the so- 
called tuberculous diathesis. There seems to be no doubt 
that certain individuals present a hereditary susceptibility 
to this disease, and this predisposition may generally be 
recognized by the well-known physical signs. Among 
these chest capacity is important, and it is of interest to 
know that, in the German army, where the chest of a 
soldier does not properly develop under physical train- 
ing, the man is regarded as predisposed to phthisis and 
returned to civil life. 

Race exerts a considerable influence on the occurrence 
of tuberculosis, though no race is exempt. The negro 
and Indian are especially predisposed to this disease. 
Among the Apache Indian prisoners removed from Ari- 
zona to Alabama a few years since, the annual death 
rates per thousand, for five years, were 55, 51, 110, 146, 
110—almost wholly from tuberculosis. For the white 
race, nativity seems to be not without influence in modi- 
fying susceptibility. In the United States army, for the 
seven years 1890-96, the admission rates for tuberculosis, 
per thousand strength, were 3.33 for American whites, 
2.97 for soldiers born in Ireland, and but 1.49 for those 
of German birth. Inthe examination of 501,068 recruits, 
during the Civil War, Baxter states that rejections for 
tuberculosis were more frequent in blonds than in men 
of dark complexion; and that the proportion of rejec- 
tions increased directly with the height. Age is a factor 
of great importance in the occurrence of the disease. 
For the period 1890-96 the admissions for tuberculosis in 
our army, per thousand of each class, were proportioned 
as follows: 


592 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








Period. Admissions. 
19: years and wnder shale sive ersten races oxen eee 5.03 
20 tO: 2b ss spersiach ou barssalngnewcnd epeirsle hy Gan ee aha eee eee 3.44 
25 1020 scan cc tives on cotaadaoeeleheos nebides | een anne ate 3.09 
BO to BA. ica Oia ae Bh dailies se tele nee Oeintae ann 2.69 
BB tO BD:csvisaiced Setndee sews Geet iek Selene aera 2.70 
£0. 44 oie abc ecicnduerdiere vierereipiis alninaiejerr a scale ie hee ee een 1.87 


The rates for infantry are slightly higher than for cay- 
alry and artillery, and nearly three times as high as those 
for the Medical Department; the latter showing the benef- 
icent effect of lessened exposure and overcrowding. For 
the period 1890-96 the admissions were about two-thirds 
as frequent among officers, 1.98, as among enlisted men, 
2.96. 

Nothing is better established with regard to tuberculo- 
sis than its relation to overcrowding and bad ventilation. 
As long ago as 1858 it was shown in the British army 
that the troops which suffered the most from overcrowd- 
ing presented the greatest amount of tuberculosis. The 
custom of living in common, as in barracks, greatly 
favors the occurrence of tuberculosis, since where an in- 
fection of the building has occurred all the occupants are 
equally exposed to the danger of contracting the disease. 
Casemates, from their dampness, defective ventilation, 
and want of sunshine, particularly favor the occurrence 
of tuberculosis among troops quartered in them. No 
more striking example of the influence of habitations on 
the frequency of tuberculosis has been given than that 
reported by Davy, in 1862, as witnessed by him at Fort 
Clarence, in England. At this post, converted into a 
military lunatic asylum, the deaths from tuberculosis 
among officers and among soldiers’ wives, these being 
lodged in ordinary houses, furnished 19 and 18 per cent. 
respectively of the mortality from all causes. Among 
the soldiers quartered in casemates, tuberculosis caused 
39 per cent. of all deaths. A susceptibility to tubercu- 
losis may be acquired by individuals, ordinarily resistant 
to the disease, through insufficient and improper food, 
want of exercise, poor ventilation, and uncleanliness of 
the person and surroundings. As in other diseases, any 
circumstance which tends to lower the powers of vital 
resistance favors infection. 

Prophylazis.—In the military service the prevention of 
tuberculosis depends largely upon the careful selection 
of recruits and the avoidance of enlisting such as appear 
to have a predisposition to this disease. If such have 
been enlisted, they should be discharged. All soldiers 
affected with the disease should be promptly discharged 
from the service, as their retention is a menace to others. 

Among other measures of prevention may be mentioned 
the location of barracks on dry, elevated, sunny sites; 
the provision of sufficient cubic space, and thorough 
ventilation; the avoidance of sharp corners or projecting 
ledges upon which dust can collect, and the rendering of 
floors impermeable with paraffin. Spitting on the floor 
and walls, aside from its being an offence against neat- 
ness and decency, should be prohibited for sanitary rea- 
sons. Metallic spittoons of a pattern readily cleansed 
should be provided, and should contain a small quantity 
of some odorless disinfectant solution so as to keep the 
sputum in a moist condition. These receptacles should 
be cleansed and scalded daily. Box spittoons containing 
sawdust, as too often found, should never be employed. 
They are not only a danger to health, but are often 
ignited by cigar and cigarette stubs. It should not be 
forgotten that a squad room which has contained a case 
of tuberculosis is not safe for occupancy until disinfected. 
In the routine cleaning of barrack rooms the use of dust- 
ers should be avoided, and all dust should be removed 
from shelves and projecting ledges by means of damp 
cloths. Meat from tuberculous animals should be re- 
jected for issue. An abundant diet containing a consid- 
erable amount of fat appears to be of value in the pre- 
vention as well as treatment of this disease. Chilling 
and exposure, which favor bronchitis and pleurisy, pre- 
dispose to tuberculosis and should beavoided. Exercise 
in the open air, especially such exercise as increases the 
mobility and capacity of the chest, is desirable. 


‘ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





With reference to the measures to be applied to the 
affected individual, the disinfection of the sputum and 
other discharges from persons suffering from various 
manifestations of the disease is of the most importance. 
The patient should be impressed with the fact that he is 
a possible source of infection, and that it is quite within 
his power to control the spread of the disease to others 
by attention to a few simple details that in no way inter- 
fere with his comfort. Special spit-cups should always 
be provided for the sick; since otherwise while endeav- 
oring to use those on the floor they will frequently cause 
its contamination. When the spit-cups cannot be used, 
clean rags or rice-paper napkins may be employed, and 
these subsequently destroyed by fire. Bed or body 
clothing, soiled with tuberculous material, should be at 
once removed and disinfected. The bedding of the 
tuberculous should never be used by the well. All 
blankets should be frequently sunned, and great care 
taken to prevent their being shaken under circumstances 
which would allow the dust to be inhaled, or become a 
means of infection to others. The tuberculous individual 
should be provided with separate eating utensils, and 
these disinfected after use. The 
uneaten portions of food should be 
burned. All personal contact be- 
tween the sick and the well is to 
be avoided. 

Typnoi FEVER. — Occurrence. 
—The history of typhoid fever, as 
a disease of soldiers, scarcely ex- 
tends over a period of fifty years, 
it being previously confused with 
several other affections. About 
half a century ago the disease was 
differentiated from typhus fever 
by Murchison, both previously 
being classed together by medical 
officers as “spotted fever”; and 
undoubtedly much of the fatality 
which prior to this time had been 
regarded as due to typhus was in 
reality due to typhoid infection. 
In addition, no distinction was 
long made between enteric fever 
and the continued malarial fevers. 
Shortly before and during the 
Civil War, however, medical offi- 
cers were forced to recognize the 
different characteristics of typical 
cases of these diseases, and about the same time the 
term “typho-malarial ” was adopted to cover that class 
of cases which, while they presented some of the clini- 
cal symptoms of both diseases, were apparently identi- 
cal with neither. Later, the fact that most of these 
cases of typho-malarial fever were in reality typhoid in- 
fections was strongly suspected; but it was not until 
Laveran, of the French army, discovered the malarial 
parasite that the differentiation between enteric and 
malarial fevers was definitely made. In the French 
army the official recognition of the existence of a disease 
intermediate between malaria and typhoid was with- 
drawn in 1888, and about the same time the term typho- 
malarial was discontinued in our own medical nomencla- 
ture. This example has since been followed in all the 
more important armies, and military statistics for this 
disease, for the past ten years, may be regarded as much 
more accurate. In the Russian army, however, even as 
late as 1897, no small proportion of the continued fevers 
were classed as “undetermined” innature. Itis obvious, 
therefore, from the difficulty which has until recently 
existed in the recognition of typhoid fever, that statistics 
for the periods prior to the past decade are of little value 
for purposes of comparison between different armies, and 
even for the same service they are not free from error. 
For our own army it may safely be assumed, from a 
better knowledge of the nature of the typhoid infection, 
that cases which have been ‘recorded as typho-malarial 
are in reality largely cases of enteric fever. 


Vou. -Il.—38 









































Typhoid fever at the present time is the most impor- 
tant disease affecting soldiers. While it prevails tosome 
extent among troops in garrison, it is among soldiers in 
the field, and especially those in camps of more or less 
permanency, that it makes its greatest ravages. In this 
country, as in all temperate or tropical regions, enteric 
fever is so prevalent and its specific cause so widely dis- 
seminated that no camp of any size or permanency can 
be expected to remain free from its infection. In the 
camps of our army during the war with Spain not a single 
regiment escaped its ravages. According to the board 
appointed to investigate the epidemics of typhoid fever 
during this war, nearly all the regular troops and ninety 
per cent. of the volunteer regiments developed typhoid 
fever within eight weeks after going into camp; in the 
northern equally as much as in the southern parts of the 
country. Thiscondition, far from being unusual, is what 
has commonly prevailed among all troops in active ser- 
vice; and Davies particularly notes a number of instances 
of epidemics occurring early in successive British mili- 
tary expeditions. The recent Anglo-Boer War in South 
Africa was no exception to this rule. It has been re- 


VISISIATRPS AIO Pe], 
VINISIS|SISIS [SINITS 
NSSNERRSES 
BRRRRRORRR AERO ROEEE 

PE 






























































INU 
PFT 





TT 
No 
ina 


Fig. 1087.—Admissions for Typhoid and ‘“Typho-Malarial”’? Fevers, per Thousand Strength, 
Occurring in the United States Army During the Period 1861-98, Excluding the Year 1867. 


peatedly observed, especially in the camps of 1898, that 
while troops in camp are heavily scourged, the surround- 
ing civil population may remain wholly unaffected. The 
conclusion is inevitable that conditions ordinarily found 
in military encampments or governing troops in the field 
are extremely favorable to the propagation of this dis- 
ease; and this fact isabundantly demonstrated by figures 
for our own service. During the Civil War period, 
1861-66, the admissions for typhoid and typho-malarial 
fever amounted to 57.71 per thousand strength, while for 
the sixteen years following the war, 1868-84, the admis- 
sions for the same cause were only 6.29 per thousand 
strength. Again, in 1898, during the war with Spain, 
the admissions for typhoid fever amounted to 88.55 per 
thousand strength; during the year 1897 they amounted 
to 6.25, and during the decade 1885-94 they were only 
5.51 per thousand strength. Throughout the period of 
peace, 1868-97, the rates for typhoid fever showed no 
very great variation except for the years 1882 and 1883, 
when sharp localized outbreaks of the disease occurred, 
and for the years 1874 and 1875, when the rates fell much 
below the normal. Of late years the disease has shown 
a tendency to become slightly more prevalent among our 
troops, in spite of the much improved sanitary condi- 
tions under which the soldier now lives. It is possible 
that the reduction in the period of enlistment from five 
to three years, through the greater proportion of more 
susceptible material in the army which is thus main- 
tained, has had an effect in neutralizing sanitary im- 


593 


Camp Diseases. 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





provements as far as their influence on enteric fever has 
been concerned. The relative prevalence of typhoid 
fever in our army, since the year 1860, together with the 
remarkable increase induced by camp life, is shown by 
the accompanying diagram (see Fig. 1087). 

During time of peace the mortality from typhoid is 
not high in our army as compared with the country at 
large. For the year 1896 the death rate was .48 per 
thousand; this being lower than the typhoid mortality 
rates in most of our large cities, such as Washington, 
Chicago, Pittsburg and Philadelphia, notwithstanding 
the great susceptibility of men of the military age to this 
disease. In the French army, however, Coustan states 
that the relative amount of sickness due to typhoid fever 
is constantly five or six times greater than among the 
civilian population. During time of peace there has 
been no great epidemic of this disease in our army, the 
highest rates of admission being given in the years 1882 
and 1888, when the admissions per thousand, for the en- 
tire army, amounted to 11.23 and 15.06, respectively. 
The rates are undoubtedly kept low through the fact 
that our troops have in the past been scattered in small 
commands over a large area, and that an infection of an 
individual water supply was therefore not able to affect 
a large number of troops at once, as is often the case in 
foreign armies. A considerable proportion of those ex- 
posed to the infection have at times contracted the dis- 
ease. Viry and Coustan cite epidemics in the French 
army, in 1875, in which 10 per cent. of those exposed 
contracted the disease at Nanly, 18 per cent. of those at 
Saratory, and 25 per cent. at Brest. In 1889, of the 
troops at Dinan, 60 per cent. of the command contracted 
typhoid during a single epidemic. The board which in- 
vestigated this disease during the war with Spain con- 
cluded that not less than one-fifth of all the troops located 
at the camps of mobilization were affected with typhoid 
fever, either in recognized or in unrecognized forms. 
It also stated that in all probability the deaths due to ty- 
phoid fever amounted to more than 80 per cent. of the 
mortality from all causes. 

With regard to the occurrence of typhoid fever in for- 
eign armies, Coustan gives the rate in the French army 
as follows: 














Ti Admissions per Deaths per 
peas 1,000 strength. | 1,000 strength. 

BELONG LOBSn, wareare cisatereiv ee 3's lates From 12 to 31 2.5 

Biss cerapioel evince se tasryce econ serie 13.2 Ly 
BSG) oocretsicvcvestyasvey cise cree nie sleieraceitvamnce Bye 11.6 1.6 
SSO) aio auetarotovas ere Gic,aterenceveseicinne eerie mnctotnte 10.5 ala 
SOUT, aetoretshcn tee Rlabsicaiesy eomete sictepiet 10.77 1.95 
BOS sates a biccauntoree ee nak seater 12.12 1.54 
ABIDE anes treescemeracerem mine 9.59 











Before 1888, typhoid fevers and continued fevers were 
classed together. Up to 1893, typhoid was the cause of 
about one-third of all the deaths occurring in the French 
army. Marvaud gives the case mortality for the period 
1878-90 as about sixteen per cent. 

In the German army reports the rates of admission and 
death for typhoid fever, per thousand strength, are given 
as follows: 








; Admissions per Deaths per 
Period. 1,000 strength. | 1,000 strength. 
1881-82 to 1885-86 ......cccceccccsces 5.6 0.46 
LS86-87 TO ESO0-9 1s. crete cic. olcierainyeicreare 3.6 28 
1891-02 to: 1805=-96)-% ser ciacic a eeaveecies 2 21 
Year 1805-96 ssncvoeeneicccesee sete eM, 19 
Year, [SOG O70, ccm ences tee ante reste 13 16 








The small proportion of cases of this disease, together 
with the reduction which has steadily gone on, shows 
most forcibly the admirable sanitary condition of the 
German army. 


594 








In the Russian and Austrian armies the admission rates 
have of late years been as follows: 








Year. Russian army Austrian army 
per 1,000 strength.|per 1,000 strength. 

TSOU fecsnie erctevnevertipteleites erviae eictelarsters 9.6 

1891 .. 7.9 

1892 .. 7.6 5.7 
1893... 7.2 14.0 
ASO4 isis elalss aiajouse. ots bs atolett ale eres 6.7 3.7 
SOD cess sisisicins viebie ewiessreptee eareetre ist 3.1 
1896 eweeracresiteetsies casiaonieeties 7.9 3.5 
WSOr ies aut yest neat eals o oiterecion 8.4 3.8 


In 1897 the death rate for the Russian army was 1.37. 
The admission rates for the British army, at home and 
on foreign service, are given elsewhere in this section. In 
the Spanish army, according to Coustan, the admission 
rate for the year 1886 was twelve per thousand. 
For the Italian army the mortality from typhoid has 
recently been as follows: 


r Deaths per 
Year. 1,000 strength. 

LEOG ey cre orriclele'o a seins scelele waist orale oie ole o.06 aie alscelele sister etre TE 1.12 

T8O4 |. sie os 5.018.016.5010 0 0's 5.6.0 Gls-e)0 s lero slow <isistaie aati lenient anaes 

TBO ce.cis's. cise ale-v b 10 elvielelelsisiesb eos ccee erniereisle tities otarelet etal a ta aannaaS 115 

TSG: 5.75 ois cisisciele.e o5v aid'e oivie 0168 ove ele «14 afeinss o en oatnie anon eee 1.10 

TBO occv:sreiese sieiers lois viciace9 o.0ie eee siale'sin pinele: old’ ele'eiets (tial ae eanannaan 


In the Belgian army, for 1898, the death rate from 
typhoid was .28 per thousand strength. 

Elimination of Infectious Material by the Sick.—It has 
long been recognized that the fecal discharges of typhoid 
patients contain the specific bacillus and are a potent 
factor in the dissemination of the disease. The enteric 
bacilli are not usually found in the stools earlier than the 
seventh day, although the latter are probably infective 
during the incubation period and certainly during the 
onset of the disease—and they ordinarily disappear soon 
after convalescence is established. In some cases, how- 
ever, the bacilli have been found as late as forty-one days 
after defervescence. The stools appear to gain in infec- 
tivity for several days after discharge from the sick per- 
son, but the reasons for the increase in virulence are not 
as yet understood. . 

The elimination of typhoid bacilli by the kidneys 
affords a ready means of spread which has not sufficiently 
engaged the attention of medical officers; and in inves- 
tigating the cause of typhoid fever in military camps 
this mode of dissemination is too often overlooked. 
Enormous numbers of the bacilli are frequently, though 
apparently not invariably, present in the urine. When 
they do occur, it is late in the disease and during conva- 
lescence. In 88 cases, Richardson found the bacilli pres- 
ent in9; always in large numbersand practically in pure 
cultures. They appeared only in the later stages of the 
disease and persisted far into convalescence. Smith found 
them present in 3 out of 7 cases examined by him, and 
observed that they may be present in sufficient numbers 
to render the urine turbid. Petruschky found typhoid 
bacilli in urine two months after the temperature had 
become normal, and calculated that in one instance the 
urine contained 470,000,000 typhoid germs in each cubic 
centimetre. In many cases the urine in convalescence 
has been found to be swarming with typhoid bacilli, 
while none could be detected in the feeces. In certain in- 
stances this condition has been found to persist for years. 
Richardson has reported an old case of cystitis in which 
the bacillus was found in pure culture in the urine five 
years after the attack; and similar results have been ob- 
tained by Houston and others. Horton-Smith finds that 
the specific bacilli are present in the urine in one-fourth 
of the cases of the disease, and, when present, occur in 
far greater quantity than in the feces. In comparing 
the two as to the most dangerous and frequent cause of 
the disease, he concludes that this is “the urine, and this 
partly on account of the enormous numbers of bacilli 
which may occur in it, and partly on account of the ex- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





cretion itself. Thus the stools by their color and odor at 
once attract attention, so that the slightest soiling of the 
linen is at once noticed and the damage rectified; but the 
same cannot be said of the urine.” It can readily be 
seen how a convalescent from typhoid fever, prematurely 
returned to duty, may infect the soil of his company 
camp by urine surreptitiously passed at night; where 
such contamination by fecal matter would be scarcely 
possible, and if it occurred would be readily detected 
and measures promptly taken to limit its evil effects. 





It has recently been questioned whether the sputum in 
typhoid fever may not be infectious. Investigation on 
this point by Williams and others has given positive re- 
sults in a number of instances. How early the bacilli 
may appear and how long they may persist are matters 
which have not as yet been determined. 

Methods of Dissemination among Troops.—The typhoid 
bacillus undoubtedly obtains entrance into the system by 
being swallowed either with the water or with the food, 
or by drawing into the mouth or pharynx the 
germs suspended in the air, or by placing in it 
some specifically contaminated object. 

In the epidemics of towns or large garrisons, 
water usually serves as the vehicle for the in- 
fective agent; but in military camps there are 
many modes of infection, and in the typhoid epi- 
demics of 1898 contaminated water was one of 
the least important factors. Vaughan says: 
“There probably were local water supplies that 
became specifically infected with the typhoid- 
fever bacillus, but infected water was not the 
great factor in the causation of this disease,” and 
this opinion will be shared by those who had 
experience in field service during the period 
named. At Jacksonville, Lexington, and Knox- 
ville, the troops used the same water supply as 
the adjacent civil population, yet one class had 
typhoid and the other had not. At Jacksonville 
there were only a few sporadic cases in the city, 
while in the adjoining camp, with about the 
same population, the admissions to hospital for 
typhoid fever were 60 or 70 per day. In Knox- 
ville not a case occurred among the citizens at a 
time when there were hundreds of cases among 
the soldiers. In time of peace, however, the 
part played by drinking-water in the occurrence of 
typhoid is very great. Instances might be multipled 
indefinitely to prove this point, and among these in- 
stances perhaps the best examples have occurred in the 
military service, and particularly in the French army. 
For the year 1886, among the French troops, the number 
of cases of typhoid fever amounted to somewhat over 
14 per thousand strength. In 1894 it had been reduced 
to slightly less than 6 per thousand strength; the result 
being obtained by an almost progressive yearly decrease. 
In 1895 the Minister of War reported that in 29 garrisons 
formerly extremely subject to typhoid fever, in each of 
which an uncontaminated supply of drinking-water had 
been provided, there had followed an almost total disap- 
pearance of this disease, and the few isolated cases which 
occurred were shown to have originated outside the bar- 
racks. In those cases in which a new water supply had 
been provided and the water was drunk unfiltered, epi- 
demics followed from time to time on the contamination 
of the source and disappeared after the introduction of 
Pasteur filters. At Avesnes, after the installation of these 
filters, 105 cases in 1891 became, for the next three years, 
only 1 annually. At Auxerre, 129 cases in 1892 were re- 
duced to 1 each in 1893 and 1894. At Melun, 122 cases 
in 1889 fell to 7.4 for the following five years. At this 
last post, in February, 1895, 28 dragoons were suddenly 
attacked, the infantry battalion in the same barracks hav- 
ing not a case. Investigation showed that the Pasteur 
filters had been allowed to freeze, and the soldiers had 
been ordered to drink only the weak infusion of tea, in 
which the water had been boiled, furnished them. While 
the infantry had obeyed, the dragoons had not, and had 


(_19 

18 

17 

i6 

15 
im 
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helped themselves to the Seine water from the hydrants. 


At Cherbourg, with a previous annual average of 114.5 
cases, the installation of Pasteur filters in 1890 reduced 
the cases to 28, 8, 11, 8, and 3 in the succeeding five 
years. At Dinan, with a previous annual average of 
278 cases, the installation of Pasteur filters in 1890 re- 
duced the number of cases to 1, 2, 3, and 1 respectively 
during the next four years. At Lorient, until 1889, 
there was a yearly average of 170 cases of typhoid 
fever among the garrison. In 1890 filters were set up, 
with the result of a decrease to 58 in that year, while 
the three following years numbered 2, 1, and 1 respec- 
tively. In 1894 water was brought into the barracks at 
this station from a spring supposed to be pure, and 11 
cases of typhoid shortly appeared. On examination the 
water was found to be contaminated, and the disease 
practically ceased to exist among the garrison upon its 
disuse. Viry states that of 194 epidemics of typhoid 
fever occurring in garrisons of the French army during 
the period January Ist, 1887, to January 1st, 1890, no less 


P 18s2 
JUNE 















































_| 

































































Fig. 1088.—Course of Typical Water-Borne Epidemic of Typhoid Fever, Occur- 
ring in the Garrison at Wittenberg, Germany. 


(After Gaffky.) 


than 187 of them could be directly associated with a “de- 
fective, doubtful, mediocre, or infected water supply.” 
Many instances of the relation of typhoid fever to drink- 
ing-water of bad quality have occurred in our ownarmy. 
At Jefferson Barracks the typhoid which prevailed en- 
demically at that station diminished greatly whena purer 
supply was substituted. 

Except in rare instances, examination of a water sup- 
ply during an epidemic of typhoid has failed to reveal 
the specific germ of this disease. It has, however, usu- 
ally determined the presence of the bacillus coli com- 
munis, Showing the probability of infection with typhoid 
discharges. In character, an epidemic of typhoid due to: 
an infected water supply will be marked by the sudden- 
ness of the outbreak and the simultaneous occurrence of a 
large number of cases. The accompanying diagram (Fig. 
1088) typically illustrates the course of a water-borne epi- 
demic. Asin most places the water supply soon regains its. 
purity, no increase subsequently may be anticipated un- 
less & second infection of the water supply occurs. In 
typhoid spread by other means than water, as in camp 
epidemics, the onset of the epidemic is gradual. With 
each case additional sources of infection are developed, 
and the prevalence of the disease steadily increases as 
long as efficient preventive measures are not taken and 
there is an abundance of susceptible material. 

Among articles of food, milk is not infrequently con- 
taminated with typhoid germs from infected water which 
may have been added to it or used to wash the dairy 
utensils. Many other articles of food which are eaten 
uncooked are liable to spread the disease, especially 
vegetables. Recently an epidemic of typhoid fever oc- 
curred in the Insane Asylum at Northampton, Mass., 


595 


Camp Diseases, 
Camp Diseases, 


- 


v 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





resulting from the use of celery watered with filtered 
sewage. Among many similar cases one was lately re- 
ported by Ferre in which an epidemic in a school fol- 
lowed the use of vegetables watered with the contents of 
a cesspool which received the evacuations of the pupils. 
Watercresses grown in ditches contaminated by sewage 
have been known to serve as the vehicle for the infectious 
agent. In 1895 Deshon reported several cases of typhoid, 
occurring at a western station, which he believed could 
be traced to the use of heavy, sour and indigestible 
bread. 

Among troops in camp during warm weather the use 
of food contaminated with the typhoid bacillus, brought 
from the latrines by means of flies, to whose feet the 
germs readily adhere, is a factor of the greatest impor- 
tance in spreading the disease. Numerous observers have 
detected. the specific bacillus in the excrement of flies 
made to feed on infected material, and colonies of typhoid 
bacilli have been shown to develop in the tracks of these 
insects which had been allowed to settle on typhoid dis- 
charges and then made to walk over a suitable solid cul- 
ture medium. Vaughan states that, during 1898, in some 
of the large military camps where lime had recently been 
sprinkled over the contents of the latrines, flies with their 
feet whitened with this substance were seen walking over 
the food. Healso noted that officers whose mess tents were 
protected by means of screens suffered proportionally 
less from typhoid fever than did those whose tents were 
not so protected. When flies are numerous in camp and 
are constantly settling upon and contaminating all arti- 
cles in common use, it is easy to see that even if the food 
and drink be protected from their invasion, an infection 
may readily be brought about by touching the lips with 
the fingers or other articles upon which the typhoid 
bacilli have been deposited. The typhoid epidemics of 
1898 gradually decreased with the approach of cold 
weather and the disabling of the fly as a carrier of the 
infection. It is well to remember that when a strong 
wind constantly blows from the same direction, a fly- 
borne epidemic will extend chiefly down wind, as this 
insect always rises, and generally moves, in the direc- 
tion of air currents. Flies lay their eggs in nearly all 
organic material, especially if this be in a putrid condi- 
tion. Howard regards horse manure as the most favor- 
able breeding material, but in the camps of 1898 the larvee 
were often seen by thousands in illy-policed latrines. 
Sprinkling the latrines with earth, as ordinarily practised, 
did not appear to destroy them. Care with respect to 
preventing organic contamination of the camp space and 
in carrying out proper measures of latrine disinfection 
will do much to prevent their development. The life of 
the fly is short, but the cycle of development is rapid. 
According to Howard, under favorable conditions the egg 
hatches in eight hours, the larvee pass to the pupal state 
in from sixty hours to three days, while from pupation 
to the issuing of the adult requires about five days. As 
the life cycle is complete in about ten days and the in- 
dividual insect lays about one hundred and twenty eggs 
at a time, the enormous numbers in which these insects 
may occur in standing camps are readily accounted for. 

Typhoid fever may also be transmitted by aerial infec- 
tion from drains, water-closets, latrines, dust heaps, urine 
or feecal discharges which have been allowed to dry on 
the linen or person or in receptacles. In this condition 
the bacilli are capable of being carried considerable dis- 
tances through the air to settle down on water, clothing, 
or food. It is not yet determined whether the disease 
can be contracted by breathing air containing suspended 
bacilli, but certainly in the case of mouth-breathers they 
should readily find their way to the pharynx and thence 
be washed into the alimentary canal by the act of deglu- 
tition. It is true that complete desiccation soon destroys 
the typhoid germ, but in practice it is not always com- 
pletely desiccated, and Fliigge and Fischer have shown 
that the enteric bacillus can successfully resist for a time 
a considerable amount of drying. Allchin, moreover, 
states that but a comparatively slight current of air, 4 
metres per second, is sufficient to raise germs into the 


596 


atmosphere from the surface of liquids or wet ground. 
The dissemination of typhoid by means of dust was 
undoubtedly a potent factor in its spread, in 1898, in 
the camps at Jacksonville and Tampa. In this connec- 
tion it is interesting to note that, in 1885, the British 
troops at certain stations in the Soudan used only dis- 
tilled water, yet typhoid was very prevalent. No reason 
for the spread of the infection could be shown except 
that the excreta were dried, converted into dust, and 
scattered over the camp by the desert winds. In the 
French army, Nollet was recently able to determine the 
presence of the typhoid bacillus in the dust of cracks in 
the barracks at Cherbourg, in which garrison typhoid had 
prevailed epidemically. 

Personal contact also does much to spread the infec- 
tion, especially among raw troops. Where lack of disci- 
pline permits the pollution of the ground in the vicinity 
of the camps by the indiscriminate deposition of human 
excreta, a certain proportion of such discharges will as- 
suredly be infected and portions may be carried into 
camp and tents on the shoes of incautious passers. Un- 
cleanly seats in latrines, or the ground therein, may spe- 
cifically contaminate the person, hands and clothing of 
those resorting to them. Where troops are detailed to 
do the heavier labor about hospitals, as is often the case 
during epidemics, the opportunity for an infection to be 
carried back into camp through their agency is often 
great. The board which investigated the occurrence of 
typhoid fever in 1898 was struck with the fact that men 
who were Closely associated in the same company or tent 
almost simultaneously developed typhoid fever, appar- 
ently through a localized infection imparted from the 
same sources. 

Heavy rains do much to disseminate typhoid among 
encamped troops, especially where there is bad sanitary 
police. Where sinks are dug in impervious soil and are 
so located as to receive surface drainage, they may be 
overflowed by storm waters and distribute their contents 
over the adjoining surface—to be later dried by the sun 
and scattered as dust by the feet of men and animals and 
the wheels of passing wagons. During the war with 
Spain, in camps where the tub system for the reception 
of excreta was in use, careless handling and transporta- 
tion by the scavengers resulted in the scattering of fecal 
matter, much of which was infected, almost broadcast 
over the camp area. 

A fruitful cause of the dissemination of typhoid 
throughout a camp lies in the fact that no small propor- 
tion of soldiers, with mild infections or with ambulant 
cases of typhoid, either do not go on sick report until 
the typhoid condition is well advanced, or not at, all. 
In many cases, also, the nature of the comparatively slight 
prodromal symptoms presented are not recognized by the 
medical officer, and the case for a considerable period is 
treated in quarters as one of diarrhea or similar trifling 
affection. This is particularly true in cases, noted by 
Allchin and others as being not infrequent, in which the 
individual has been exposed to great hardships, and in 
which the temperature is normal or sub-normal through- 
out the attack. As already stated, the stools in typhoid 
fever are probably infective even during the period of 
incubation, and there are probably a considerable propor- 
tion of cases in which an infection does not develop the 
typical disease, through either an attenuation in viru- 
lence of the specific germ or more or less marked insus- 
ceptibility on the. part of the subject. The experience 
of French medical officers in Algiers and Tunis would 
seem to show that apparently healthy persons may long 
carry the germs of typhoid, which, later scattered under 
favorable circumstances, develop the disease in others. 
British medical officers have noted the same in India and 
elsewhere—particularly during the Afghanistan expedi- 
tion. Many instances have been recorded also in our 
own service, especially in the days of Indian warfare, 
where outbreaks of the disease occurred among troops 
who had been for weeks in regions that were not 
known to have ever before been penetrated by man. 
From these facts army medical officers in all services 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





have, in the past, favored a theory of the de novo origi- 
nation of typhoid, or of the metamorphosis of the spe- 
cific germ from the colon bacillus under suitable con- 
ditions. It is easy to understand, however, in the light 
of recent investigations as to the infectiveness of ty- 
phoid urine, how the microbe of this disease can be 
carried with troops for long periods without its pres- 
ence being suspected, and then give rise to an epidemic 
when favorable conditions are encountered. Since the 
period of incubation is twelve or fourteen days—or even 
in some cases as long as twenty-three days—it is obvi- 
ous that infected individuals may be passed as healthy 
and sent to other stations, there to develop the charac- 
teristic symptoms of the disease and to serve as the 
starting-point for new epidemics. This was repeatedly 
shown to have occurred among recruits sent out from 
Jefferson Barracks—formerly endemically affected with 
typhoid fever—to western stations. Further, convales- 
cents from typhoid, returned to duty at too early a date, 
may be unrecognized but potent agents in the origination 
of the disease in others. All these classes of cases are 
particularly a menace to the health of a command under 
canvas, since by their agency every latrine in the camp 
may become infected, and the probability of contamina- 
tion of the camp space, and perhaps tentage, by infected 
urine and saliva is so great as to approach certainty. 
Direct contagion from the obviously diseased to the 
healthy plays astrong part in the spread of enteric fever. 
There is no reason for positive belief that the poison is 
given off in the breath or the emanations from the body, 
but it is probably contained only in the urine, the feces 
and, to some extent, the saliva. If these be properly dis- 
infected and disposed of, if strict cleanliness be observed, 
and if attention be paid to the disinfection of the soiled lin- 
en, the risk of contagion may be reduced to a minimum. 
Nevertheless, it has not been found possible with all pre- 
cautions entirely to prevent the spread of the disease to 
the attendants. During the typhoid epidemics of 1898 
the admissions for this disease from the Medical Depart- 
ment and Hospital Corps amounted to 193.41 per thou- 


a 
> 








1898 and the decade 1888-97, the rates per thousand of 
English troops at different stations were as follows: 
























YEAR 1898. DECADE 1888-97. 

nn = nN = 

Station. oa (are a Se foes 
Seu 84 | 32| 2 | gH 
42/3 | 2a ||~2| 8 | Ba 

ALA |S FLAS 
United Kingdom . 1.9 | 0.22) 0.31 1.2 | 0.2 0.20 
Gibraltar .... 4.2 | 1.82 74 5.4 .95 | 1.05 
Malian css setae 21.2 | 6.88] 2.44 6.6 | 2.48 | 1.15 
Egypt and Cyprus 81.0 | 23.40 | 11.12 || 21.3 | 4.87 | 3.90 
@anadar cco. 2ees aes Nee te 1.3 21 25 
Bermuda.... 15.0 |} 2.81 | 2.36 || 84.8 | 6.28 | 5.138 
West Indies . abit DD 23 9.0 | 2.15 | 1.386 
South Africa .. 82.9 | 55.77 | 4.88 |] 12.8 | 1.87 | 1.93 
Mauritius'......... 14.6 | 4.86 | 2.87 || 15.0 | 5.84 | 2.15 
GOVT ON. Gre ctersieretel asinlelelaie Seeernis 2.1 | 1.48 .09 6.9 | 2.138 84 
CTIA irs aisiate wisieicaneiel occa eieio se 1.9 64 39 1.5 50 21 
Straits Settlement ........... A a(iil Si ie 1.9 88 29 
INGIRMG Ie co hence seca 36.3 | 10.04] 4.90 || 21.8 | 5.75 | ‘8.12 


























On averaging together the figures for the two cold 
stations, the United Kingdom and Canada, for the decade 
1888-97, the admissions per thousand strength are seen 
to be 1.25, the deaths .22, and the constantly sick .22. 
For the same period the average rates for the remaining 
stations, located in hot climates or in the tropics, were: ad- 
missions, 12.4; deaths, 2.97; constantly sick, 1.92. From 
these figures it appears that British soldiers in hot cli- 
mates or in the tropics are almost exactly ten times as 
liable to contract the disease as those serving in cool cli- 
mates; while the liability to death from this disease is 
fourteen times greater. The apparently shorter course 
run by typhoid in the tropics, as expressed by the rates 
for constant sickness, is merely due to the higher rate of 
mortality, by which the elevation of the former figures, 
through tardy convalescence, is prevented. In our own 
service, for the year 1898, the admissions’ for this disease 
per thousand troops stationed in the tropical islands 
were 102.18 and the deaths 13.88; 
while of troops within the United 
States during the same period the 
admission rate was 85.46 and the 
death rate was 8.79. It should be 
remembered, however, that troops 
were exposed to tropical influ- 


. 
S 
S 
% 
0 











Mea 
peeks | 
real 
ra 
aes 
awa 
iam 
AES 
eee | 
ai 
pap 
iad 
soem 


=— 
SS 


SS 


Z. 


SS rnteric fever. WZ. 


Us 


the Decade 1875-84. 


sand strength, when the rate for the army as a whole 
was 88.56. This fact specifically demonstrates the im- 
mediately transmissible character of the affection. 

Causes Predisposing to Typhoid among Troops.—Typhoid 
fever occurs in all climates, outside the polar regions, 
but increases in prevalence as the equator is approached. 
In the British army, distributed asit is all over the world, 
the prevalence of typhoid varies greatly. For the year 





Typho-malarial fever, 


Fic. 1089.—Chart Showing the Distribution by Months, per Thousand Strength, of Cases 
Diagnosed as Enteric and Typho-Malarial Fever, Occurring in the United States Army During 


ences but a small part of that year, 
and that for full periods of ser- 
vice the difference in rates would 
undoubtedly have been much 
greater. Within the limits of the 
United States the influence of lo- 
cality is marked. The amount of 
typhoid fever in the Department 
of Texas is almost twice as high 
as in any other military depart- 
ment. In 1890 it was more than 
six times as high as in the depart- 
ments of the East, California, and 
Arizona. In 1897 it was fourteen 
times as high as in California, and 
much higher than in the other de- 
partments. Coustan states that 
typhoid fever is far more preva- 
lent in Algiers and Tunis than in 
France. 

As to season, the disease pre- 
vails especially in our army dur- 
ing the late summer and early 
autumn. For the decade 1875-84, as shown by the ac- 
companying diagram, the disease occurred least fre- 
quently during March and April and prevailed most ex- 
tensively in August and September. In the French and 
German armies it prevails to the greatest extent during 
and after the manwuvres in August and September; n 
the Austrian army its prevalence is greater during the 
July manceuvres. Certain notable outbreaks have oc- 


WN SESS 
3S Se RO ew Roe eat 
SSS [| 


NSN 
aa 


597 


Camp Diseases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





curred in the spring, but these are invariably to be 
traced to a localized water-borne infection and are excep- 
tions to the general rule. 

Military experience shows that an infection of enteric 
fever often fixes persistently upon asingle barracks, post, 
or district. As a rule, in those localities in which the 
disease is endemic, it will be found that unsanitary con- 
ditions abound; notably impure water supply, defective 
methods and arrangements for the disposal of excreta, 
and want of care in respect to preventive measures. In 
India, typhoid fever has been found to be a more diffi- 
cult Biase to eradicate from military posts than cholera, 
persisting with great tenacity and recurring year after 
year in spite of all efforts—and it has even been found 
necessary to abandon stations for this reason. Within 
these endemically infected areas newcomers are especially 
liable to attack, those long resident in such a zone ap- 
pearing to acquire a relativ e immunity through repeated 
mild infections. Great importance was attached by Pet- 
tenkofer to the height of the ground water in endemi- 
cally infected regions; a low eround water, in his opinion, 
always coinciding with outbreaks of the disease. This 
relation between the disease and ground water appar- 
ently holds true for certain localities only and need re- 
ceive no serious consideration. 

Negroes and other colored races undoubtedly possess 
an immunity, in their native countries, to typhoid fever. 
By some this is regarded as a_racial ‘characteristic ; by 
others as an acquired immunity resulting from an at- 


es 
=n 
fe | 
629 
= 
aa 
eee 
fe] 
=i 
=a 
=a 
ee | 
a 
aa 
zal 


Q~ eet Vannes 


Fig. 1090.—Admissions for Typhoid Fever, per Thousand of Each Class, aie According to 
Age, in the United States Army During the Seven Years 1890- 


tack of the disease during childhood. In India the blood 
of the natives has been recently shown to give, in most 
instances, a positive reaction with Widal’s test. In our 
own service the disease is undeniably less frequent 
among the negro troops than among the whites. For 
the period 1867-83 the admissions per thousand white 
soldiers, for typhoid, not counting typho-malarial fevers 
as then recognized, amounted to 3.58, while the admis- 
sions for colored troops were 2.59 per thousand strength. 
For the year 1887 the admission rate for white soldiers 
amounted to 4.25, and for colored soldiers .93. During 
the decade 1887-96 the admission rate for white soldiers 
amounted to 4.74, and for negroes 2.43. It is interesting 
to note that for our few Indian soldiers, during this 
period, the admission rate for typhoid was only .47. 
During the year of war (1898) the relative insusceptibil- 
ity of negro troops as regards typhoid fever was espe- 
cially noticeable, the admission rate being 93.24 per 
thousand white and 27.64 per thousand colored troops— 
this, too, in spite of the fact that as a class the negro 
regiments saw harder service. On the other hand, when 
the disease has actually occurred the case mortality bas 
been much higher among the negroes than among the 
whites. Typhoid fever occurs only exceptionally among 
the native troops in India, and their immunity as com- 
pared with the immunity of white soldiers serving in 
that country has long been noted. As illustrating how 
great this difference in susceptibility really is, it may be 
stated that, in 1893, of the forces in India, typhoid fever 


598 











was responsible for 1.41 per cent. of the sickness and 42 
per cent. of the mortality among the English soldiers, and 
for only .03 per cent. of the sickness and .4 per cent. of the 
mortality among the native forces. For the white race, 
nativity appears to bea factor of some slight importance. 
In the United States army, during the seven years 1890- 
96, the admission rate for typhoid fever from the native- 
born Americans, per thousand strength, was 5.69, for 
the soldiers of German nativity, 5.41, and for the soldiers 
born in Ireland, 5.02. 

Typhoid fever is especially a disease of young soldiers. 
How much greater their susceptibility actually is can 
best be appreciated by reference to the accompanying 
diagram (Fig. 1090), in which the number of admissions 
are seen to decrease arithmetically by almost exactly one- 
half during each five-year period up to the age of thirty- 
five. Not only are young men more liable to contract 
this disease, but the mortality, also, among those affected 
is higher. "Thus for the period 1890-96, in our army, the 
deaths per thousand of each class were as follows: 


Age. Death rate. 
19 Eabers ANA UNEP’. .isvs acls voc eve a 6 cceta oe Meant emer eae 3.32 
BS Oe 69 
BO £0 Bh 0's bcic ee ce dee o ase eeisldie ese seis ules ae Chmeleeettenaam 23 


The case mortality for this period was 16.02 per cent. for 
soldiers nineteen years of age or under; 9.21 per cent. for 
those twenty to twenty-four years of age, and 8.89 for 
those thirty to thirty-four years of 
age. 

Length of service, in which fac- 
tor age must of course be considered 
to enter, also markedly influences 
the occurrence of typhoid. The re- 
port of the surgeon-general for 1885 
shows the relative prevalence of 
this disease, excluding small frac- 
tions, among men of different peri- 
ods of service, to be as follows: 


Percentage 
Length of service. of cases. 

6 months and under............ 48.0 
Over 6 and under 12 months... 16 

Over 1 and under 2 years ...... 14 

Over 2 and under 3 years...... 5.5 
Over 3 and under 4 years...... 4.5 

All over 5 Years. wuciceclas seteentee 


Length of service not stated... 4.5 


In respect to English soldiers in India, Eyre and Spot- 
tiswoode state: 

“The susceptibility of young soldiers to this fever is 
clearly shown in the length of residence in India; for 
while the death rate from typhoid was 4.98 per thousand 
in the first and second years’ service, among those in 
their third to sixth years and seventh to tenth years it 
was 1.55 and .55 respectively.” The report of the Sani- 
tary Commissioner of India for 1896 states that out of 
the total number of deaths at all ages from enteric fever, 
78 per cent. were between twenty and twenty-four years 
of age and 86 per cent. were in the first year of resi- 
dence. In India, the prevalence of the disease appears 
to depend chiefly upon the amount of susceptible mate- 
rial presented. 

The influence of the branch of service upon the preva- 
lence of typhoid fever is by no means small. For the 
period 1867-83 inclusive, the admission rates per thou- 
sand strength were as follows: cavalry, 19; infantry, 
4.6; artillery, 2.5. For this period the cavalry thus suf- 
fered more than seven times as much from typhoid as 
did the artillery, and nearly five times as much as the 
infantry, while its death rate was more than three times 
greater than either of the others. This great difference 
was largely due to the active field service against Indians 
required at that time of mounted troops. For the seven- 
year period 1890-96, the admission rates per thousand 
strength were 8.03 for the cavalry, 5.74 for the infantry, 
and 4.74 for the artillery. In time of peace the personnel 


drinking purposes. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


e 


Camp Diseases, 
Camp Diseases, 





of the medical department is affected less than any of 
the above arms of the service; but during the war with 
Spain it suffered more than twice as much as any of 
them. 

Overcrowding among troops certainly predisposes to 
epidemic typhoid fever; Marvaud gives figures to show 
that in the French army the mortality from this disease 
bears a well-defined relationship to the number of men 
aggregated at a post. In camp, the effects of over- 
crowding are particularly noticeable. This is perhaps 
due in part toa lowered vital resistance in the individual, 
but is probably chiefly dependent on the greater intensity 
of the infection resulting from the rapid propagation of 
the typhoid bacillus on a soil more highly contaminated 
with organic material, on which it possibly acquires 
more virulent qualities. 

Uncleanliness of person and surroundings is a power- 
ful factor in the development of the disease among troops. 
Particularly is this the case with regard to the care and 
disposition of the excreta, the most important and diffi- 
cult problem presented to the military sanitarian in the 
field. The common method of disposal of excreta and 
refuse in camp—by pits—offers many facilities for the 
development and spread of the specific micro-organisms. 
All collections of filth are liable to contamination and 
hence to become foci of infection. In garrison the accu- 
mulation of organic matter under floors, together with 
the seepage of moisture as a result of the use of exces- 
sive amounts of water in cleansing, affords an exceilent 
medium for the development of the microbe. 

The influence of great fatigue as a factor in the occur- 
rence of typhoid has been particularly noted by medical 
officers in foreignservices. The arduousand exhausting 
manceuvres which take place yearly in all the larger 
European armies are invariably followed by outbreaks of 
typhoid. It is well known that by over-exertion the bac- 
tericidal power of the blood is diminished and suscepti- 
bility to disease greatly increased. Coustan mentions, 
as applying in this connection, the experiments of Charrin 
and Roger, in which rats made to turn a wheel until ex- 
hausted succumbed readily to inoculation with an atten- 
uated culture of anthrax, while similar animals not so 


exhausted resisted the same inoculation. 


Insufficient or improper food, through the malnutrition 


or digestive disturbance which results from its use, may 


facilitate the invasion of the organism by the typhoid 
bacillus. 

Prophylazis.—In the prevention of an epidemic of en- 
teric fever among troops in garrison, a pure water supply 
is of the firstimportance. Ifthe water supply be regarded 
as liable to pollution it should, in garrison, be filtered 
through the Berkefeld apparatus before being used for 
In the field, and sometimes in garri- 
son, water is best sterilized by boiling—preferably by the 
Forbes apparatus. If the water is originally pure, as 
water in springs, deep or artesian wells, or unpolluted 
surface waters, it will only be necessary to insure against 
its contamination before use. With troops in camp, 
while the water should be good, an early and correct di- 
agnosis of the cases of this disease which first appeared 
is quite as essential. Since in camps enteric fever is 
more directly propagated from the sick, and the latter 


can through their discharges soon disseminate the dis- 
ease through large bodies of troops, the prompt recogni- 


tion and isolation of these cases, with the disinfection of 
their excreta, equipments, tentage, and surroundings, is 
of the greatest importance. As already intimated, the 
diagnosis of this disease is frequently a matter of much 
difficulty and may be impossible in all instances, but 


constant watchfulness on the part of medical officers will 


reduce this error to the minimum. The beard investi- 
gating the typhoid epidemics prevailing during the war 
with Spain concluded that less than half of the cases of 
this disease which occurred were correctly diagnosed ; 
but stated its opinion that, in recognizing this proportion, 
the army surgeon probably did better than the average 
physician throughout the country does in his private 
practice. Any such error of diagnosis, however, implies 











too great reliance upon the mere clinical symptoms of 
enteric fever—which, it has been stated, are frequently 
modified or largely lacking—and a too infrequent use of 
modern and more precise means of diagnosis, as found in 
the Widal test with blood serum and the diazo reaction in 
the urine. It is obvious that under many conditions of 
military service, particularly with marching troops, the 
former test can scarcely be applied, but in a fixed camp 
or garrison it can always be carried out—and the tech- 
nique of the diazo reaction is possible under any circum- 
stances. These tests should be habitually applied to 
every case presenting fever the nature of which is not 
promptly and definitely recognized as being other than 
typhoid. Since the Widal and diazo reactions may not 
be given at certain stages of enteric fever, they should 
be repeated one or more times in possibly suspicious 
cases. 

When typhoid fever is recognized as existing, the af- 
fected individual should promptly be isolated. If in gar- 
rison, the clothing and bedding of the patient, together 
with the water-closet or latrine used by him, should be 
disinfected. If the case occurs under canvas these pre- 
cautions are required, and in addition the disinfection of 
the clothing and bedding of those sheltered with him 
should be sterilized. The tent itself should be disin- 
fected. If possible the camp, or at least that of the com- 
pany organization in which the case occurred, should be 
moved. If this be not possible, the site occupied by the 
infected tent should be vacated, policed and exposed to 
the sun. It should not again be occupied. In many in- 
stances it would, in addition, be desirable to freely scat- 
ter fresh lime over the former tent area. 

Since many cases of enteric fever in camp will not be 
recognized, it should be the rule to regard all human ex- 
creta as infected, and, where a camp has a permanency 
of more than three or four days, systematically to carry 
out measures for the destruction of its presumably nox- 
ious qualities. The cost of an epidemic of typhoid will 
be many times the additional expense of these justifiable 
precautions. In all camps of any permanency the use of 
excavated latrines should be prohibited, and either the 
trough system or crematories, as now used in our army, 
provided. Under the same conditions, urine tubs should 
be provided for night use and their utilization enforced. 
Careful police of the camp, with cremation of refuse, 
should be carried out, to limit soil contamination and 
prevent the development of the fly plague. A careful 
sanitary police is very effective in preventing the devel- 
opment of these insects in very great numbers; but where 
the plague actually exists the only recourse is toabandon 
the infected area for a new site, preferably to be located 
to the windward and at a distance of at least two miles. 

Other general methods of prophylaxis consist in the 
allotment of abundant space in the arrangement of the 


‘camp; the free exposure of the interior of tents—and of 


their contents—to sunlight and fresh air; cleanliness of 
person on the part of the troops; an abundance of good 
food and, in time of epidemic, the avoidance of exhaust- 
ing drills and exercises. It is important that a presum- 
ably infected camp site should promptly be abandoned; 
though if troops be allowed first to become generally in- 
fected the procedure is not as efficacious in controlling 
typhoid fever as in some other diseases, 

With respect to the measures to be applied to prevent 
further spread of the infection from the sick, the proper 
disinfection of the excreta is of the firstimportance. All 
discharges should be received in a solution of milk of 
lime. The nates of the patient should be cleaned with 
paper and afterward with a bit of compress cloth wet 
with a dilute disinfectant solution. The bed pan should 
be covered with rubber sheeting and removed at once. 
In garrison, the contents of the bed pan should be thor- 
oughly mixed and allowed to stand for half an hour 
before pouring into the slop hopper; in the field it should 
be burned at once. The practice of burying typhoid 
discharges, after measures of disinfection by chemical 
means, is strongly to be deprecated. In certain instances 
all the bacilli undoubtedly will not be destroyed, and it 


599 


Camp Diseases, 
Camp Diseases. 





has been shown that they not only develop in organically 
polluted ground but may grow upward through a con- 
siderable depth of earth. Even if buried deeply there is 
alwaysa possibility of their future disturbance. Whether 
in camp or garrison, the cloth compresses used to cleanse 
the patient should be destroyed by fire. The bed pan, 
rubber cover, and slop hopper should be cleansed with 
disinfectant solution, and the two former wiped dry. 
Both should be placed in a closed receptable to prevent 
access by flies. All sputum should be received in spit 
cups containing a disinfectant solution. Feeding uten- 
sils should be cleansed in boiling water immediately 
after use, and any uneaten remnants of food at once dis- 
infected by burning or scalding. All bed linen, body 
clothes, and towels soiled by discharges should be im- 


mediately rolled in a clean sheet wet in bichloride solu-. 


tion, and removed for appropriate disinfection. Bed 
spreads and blankets should be sunned and aired as often 
as possible. They should not be shaken any more than 
is absolutely necessary. Bed and body linen should be 
changed daily; rubber sheets should be used over the 
mattresses. Flies should be kept away from the patient, 
not only for his comfort, but to prevent the transmission 
of the disease to others by their agency. 

After attending to the wants of a typhoid patient, the 
hands of the attendant in each instance should be rinsed 
in a disinfectant solution and then washed in warm water, 
using soap and a nail brush. 

The urine of patients convalescent from this disease 
should be examined at frequent intervals for the typhoid 
bacillus. Return of convalescents to duty or quarters 
before this bacillus has been absent from the urine for at 
least one week should not be permitted. To effect the 
sterilization of the urine, where this bacillus is present, 
Richardson and others recommend the use of urotropin, 
in doses of gr. x. three times a day. Saloland other sub- 
stances appear to have little value for this purpose. 

Preventive Inoculation.—The problem of preventive in- 
oculation against typhoid fever, now receiving much at- 
tention, has a special importance for the military sani- 
tarian. Bokenham endeavored to producea prophylactic 
and curative serum by the immunization of horses 
through the repeated injection of living and dead cultures 
of the bacillus; but the serum thus obtained was not of 
sufficiently great potency to give it a practical value, 
and no means could .be found of precipitating or con- 
centrating what strength the serum contained. Pfeiffer, 
Wright and Semple, and others, then endeavored directly 
to produce in man the immunity which it was shown 
could be created in animals. At first these investigators 
cultivated virulent cultures onagar, making up an emul- 
sion of these cultures with bouillon so that each cubic 
centimetre contained about 2mgm. of fresh agar growth. 
The microbes were then killed by exposure to a temper- 
ature of 56° C. for several hours. 
was used as a dose, the liquid being well shaken. Re- 
cently Wright has attained more satisfactory results by 
cultivating the bacilli directly in bouillon. After incuba- 
tion at 37° C. for a period of from fourteen to twenty-one 
days, the culture is sterilized by exposure to a tempera- 
ture of 60° C. for five minutes. Thisis done by drawing 
the emulsion into small sterile tubes, which are sealed 
and placed in a beaker of cold water which is gradually 
raised to the desired temperature, and this is maintained 
for the period above noted. Agar tubes are then inocu- 
lated with the material to make sure of its sterility. 
Before injection, .5 per cent. of lysol is sometimes added 
to neutralize any accidental contamination. The amount 
used for human inoculation is two-fifths of the minimum 
amount which would be fatal to a guinea-pig weighing 
250 gm. The immunizing material appears to be valu- 
able rather on account of its antimicrobic than its anti- 
toxic properties. 

While the reaction following the inoculation is usually 
slight, it is at times somewhat severe. Rigors, nausea, 
and a tendency to syncope sometimes occur. There is 
a well-marked local reaction, which, however, never ad- 
vances tosuppuration. Where the inoculation is success- 


600 


Of this emulsion 1 c.c.° 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ful, the blood serum acquires the specific agglutinative 
property to a marked degree. Cameron found in his 
own case that at the end of twenty days the agglutinat- 
ing power of his blood serum was increased forty times; 
and an increase to this extent. has been shown by other 
observers to bea common result. In general, the aggluti- 
nating property is equal to that conferred by an attack 
of the disease itself. It is not known how long the in- 
fluence of the inoculation persists; and whena protection 
lasting more than two years is desired, it is recommended 
to insure a good reaction by repeating the inoculation 
after an interval of one week. 

At present, experience with these inoculations has not 
been sufficiently comprehensive to warrant the drawing 
of exact conclusions. The inoculations have been car- 
ried out on a considerable scale, however, with the sanc- 
tion of the British military authorities, on soldiers volun- 
tarily submitting to the operation before leaving for the 
recent scene of hostilities in South Africa. Foulerton 
states that reports so far received from South Africa show 
that typhoid fever has occurred at the rate of six to the 
thousand among the inoculated and nine to the thousand 
among the uninoculated. Figures given by Wright based 
upon 11,295 British soldiers in India show that .95 per 
cent. of the inoculated contracted the disease where 2.5 
per cent. of the uninoculated were attacked. These re- 
sults, while not brilliant, are certainly encouraging, and 
render the method well worthy of general use among 
young soldiers; particularly since the inoculation, when 
properly performed, is quite free from danger. 

Typuus FrEver.—Occeurrence.—A chapter might be de- 
voted to the historical pathology alone of typhus or 
spotted fever. The disease is as old as the disputes of 
nations, and has prevailed in formidable epidemics among 
troops in the field from 400 B.c. down nearly to the pres- 
ent time. During peace it has always been of compara- 
tively subordinate importance, although its occurrence 
in armies has given rise, from time to time, to disastrous 
outbreaks among the civil population. It is known to 
have prevailed during the Peloponnesian war; and in 
1489 it destroyed 17,000 of the troops of Ferdinand at the 
siege of Grenada. In 1528, at the siege of Naples, over 
5,000 of the French nobility lost their lives from typhus 
in a period of about three weeks, and the French army 
of 30,000 men was almost destroyed. In 1542, in the 
German army at Ofen, according to Hauser, typhus 
claimed 380,000 victims. Before Metz, in 1552, the be- 
sieging Spanish army lost 30,000 men in less than two 
months, compelling the abandonment of the siege. The 
roads taken by the retreating army were said to have 
been lined with the dead and dying. In 1556, it deci- 
mated thearmy of Maximilian II. In 1620, the Bavarian 
troops serving in Bohemia lost over 20,000 men from 
spotted fever. In 1628 and 1632 the disease ravaged the 
Swedish army. Both the Royal and Parliamentary ar- 
mies in England, in 16438, suffered severely ; in the wars of 
Louis XIV. it caused enormous losses in the French army. 
At the siege of Torgati in 1760, it is said that over 80,000 
men, out of a total of 85,000, died of this disease in a few 
months. Typhus is reported as having been one of the 
great factors in the mortality of our troops during the 
Revolution; and in 1790 the losses among the Russians. 
from this disease were so great that operations against. 
the Turks had to be suspended. In 1799 typhus deci- 
mated Genoa and the French force besieging it. The 
greatest recorded ravages of this disease, however, oe- 
curred during the wars of the first Napoleon. At Sara- 
gossa, out of 100,000 people, 54,000 died, chiefly from 
epidemic typhus. At Dantzic and Wilna, in 1803, and 
during the retreat from Moscow, vast numbers of French 
troops are recorded as having perished fromtyphus. In 
May, 1812, the Bavarian allies of the French mustered 
28,000 men; in February, 18138, it is said that this disease: 
had left but 2,500 to bear arms. In August, 1813, the 
first Prussian army of 60,000 men had lost one-sixth of 
its strength from an epidemic of typhus. Murchison . 
states that in Mayence alone, of the 60,000 French troops 
composing the garrison in 1813-14, no less than 25,000 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


¢ 


died of typhus in six months. According to Rawlinson, 
of the French armies around Paris, after the retreat from 
Russia, 40,000 men are recorded as having died of typhus 
in six weeks, one-fifth of the remaining force being sick. 
This disease raged in all the contending armies during 
the Crimean War, particularly among the French troops. 
Aitken says: “In the spring of 1856 it was computed 
that more than 17,000 men of the French force perished 
in less than three months, chiefly from typhus.” Bau- 
dens declared that of the typhus cases in hospital in Feb- 
ruary, 1856, two-thirds were devoted to certain death. 
The deaths during this outbreak among the French medi- 
cal officers amounted to 48, and there was scarcely one 
«that escaped attack. 

Typhus undoubtedly did not occur during the Civil 
War, although there were a small number of cases diag- 
nosed as this affection. These were undoubtedly ful- 
minant typhoid. It prevailed among the French troops 
in Mexico, especially on board the ships which conveyed 
the colored contingent from North Africa. Coustan says 
that the French troopsin Mexico “suffered a cruel loss.” 
In 1862-63, and again in 1867, typhus attacked the 
French garrisons, in Algeria; Marvaud stating that of 
one body of 3,500 troops, 1,200 died. Its existence dur- 
ing the Franco-German War in 1870-71 is disputed. 
During the Russo-Turkish War in 1878 it was said that 
at one time the cases of typhus were so numerous in the 
Turkish army as to threaten its disorganization, and the 
conditions in the Russian army were not much better. 
After the capture of Plevna, according to Coustan, 50,000 
men out of a total of 120,000 died during the period of 
inactivity, and in May and June of 1879 it is stated that 
half the Russian forces near Constantinople were pros- 
trated with this disease. 

Typhus, in the military service, is essentially a disease 
of campsand sieges. Of late years typhus has lost much 
of its dangerouscharacter. Its geographical distribution 
is not great, and at present, in time of peace, it occurs 
only among troops stationed in Southeastern Europe, 
where the disease is endemic. In the Russian army for 
the period 1890-97, the rates per thousand were as fol- 
lows: 











Year Admissions. Deaths. 
RUUD WEN ors otal ad alele sitive a vis-s.o%s we'd ve's 0.6 0.04 
AS) 07 
1.8 14 
yor "05 
3 03 
3 02 
Be .02 











In the Austrian army there were 9 cases in 1897, 4 in 
1896, and 8 in 1894. There has been no well-authenti- 
cated outbreak of this disease in our army within the 
past half-century. A number of epidemics of typhus 
have, however, occurred in the civil population of the 
country—the infective agent being in every case im- 
ported from abroad. 

Direct and Predisposing Causes.—The specific exciting 
cause of typhus fever has not as yet been isolated, though 
undoubtedly such a factor exists. Recently, in Russia, 
it is said that the disease has been experimentally pro- 
duced by inoculation with the blood of typhus patients. 
It is universally admitted that the most important influ- 
ences predisposing to its epidemic occurrence are want, 
misery, and hardship. Typhus appears to be largely 
favored by overcrowding and lack of proper ventilation. 
Cold weather, as shown in the Crimean War, indirectly 
promotes its occurrence among troops for these reasons. 
Viry notes that typhus was prevalent in public institu- 
tions in the city of Metz, in 1870, when it did not appear 
among the French troops living in shelter tents just out- 
side the walls. Poor food, dampness, fatigue, and other 
conditions lowering the resistive powers—together with 
psychical depression—have much to do with epidemics 
of this disease. 


Camp Diseases, 
Camp Diseases, 











Typhus fever is highly contagious, in the strict sense 
of the word: and there is probably no disease which has 
been proportionately more frequently contracted from the 
sick by their attendants. At Plevna, nearly all the medical 
officers were attacked: during the Crimean War 12.8 per 
cent. of medical officers and only .4 per cent. of line of- 
ficers, among the French troops, died from typhus. The 
specific virus appears to be distinctly transmissible from 
the sick to the well through the surrounding atmosphere. 
While nothing is known of the causative agent, infection 
appears to occur by way of the air passages. The poison 
may be harbored by and carried from place to place in 
fomites. Jacquot, in speaking of typhus in the Crimea, 
says that “wherever troops affected with typhus have 
camped, the dejections and excretions which have satu- 
rated the ground are fatal to troops which follow them.” 
The morbific agent appears to exist long in infected 
clothing and dwellings. The activity of the specific 
virus is favored by unsanitary conditions, and where the 
disease is introduced among troops which are poorly 
nourished and clothed and living under conditions im- 
plying overcrowding, there is every likelihood of an epi- 
demic cutbreak of the fever. The incubation period is 
variously stated at from six to fourteen days, though 
there appear to be some well-authenticated cases in which 
it was not more than from two to five days. The disease 
is most. common during the period of youth and early 
maturity, as found in young soldiers; but the mortality 
is lower than among those of greater age. 

Prevention.—It is manifest that: the prophylactic meas- 
ures against the disease are those that aim to prevent its 
introduction from without, and those that are designed 
to eliminate all local conditions favorable to its develop- 
ment. Quarantine against infected points should be rig- 
orously maintained. When the disease occurs among 
troops in garrison, the sick and well should promptly be 
placed under canvas; for the influence of fresh air upon 
the virulence and vitality of this disease is undoubtedly 
of the highest importance. The command, if large, 
should be broken up into smaller bodies. Especial at- 
tention should be given to the prevention of overcrowd- 
ing, to insuring the abundance and proper preparation 
of food, to the avoidance of fatiguing exercise, and to the 
maintenance of strict sanitary police. Careful watch 
should be kept for suspicious cases, and these should be 
at once isolated. It should not be forgotten that the ag- 
gregation of large numbers of the sick increases greatly 
their mortality, as well as the danger to the attendants. 
Tent hospitals should preferably be used, the supply 
of fresh air being unlimited and the floor space allowed 
to each patient being about two hundred square feet. 

As the contagion is especially virulent near and about 
a patient, attendants should avoid inhaling the emana- 
tions or exposing themselves unnecessarily to such in- 
halation, unless protected by a previous attack. They 
should not stay in the immediate vicinity of typhus 
patients longer than necessary and should never sleep in 
a ward. They should take plenty of sleep and good 
food, and should frequently employ disinfectant solu- 
tions on the face and hands. The attendants, like the 
sick, should of course be quarantined. Careful disin- 
fection of bed and body clothing and excreta is always 
called for. The barracks or wards, as well as all articles 
of furniture, clothing, or equipment contained in it, 
should be disinfected and thoroughly aired after removal 
of the patient. 

YELLOW FEVER.—Occurrence.—Yellow fever is essen- 
tially a disease of tropical and sub-tropical countries, and 
is ordinarily restricted to well-defined geographical limits. 
Bodies of troops serving within these limits for any 
length of time have uniformly been more or less affected 
by it. In 1648, “there occurred in Havana, and in the 
fleet of Don Juan Pujados, a great pest of putrid fevers 
which remained in the port almost all summer. A third 
part of the garrison and a larger part of the crews and 
passengers of the vessels died.” The disease was ex- 
tremely fatal among the British troops which subse- 
quently captured Havana; and it is interesting to note 


601 


Camp Diseases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





that the regiment of loyal Americans recruited for this 
expedition, largely from the south, was least affected. 
In 1740, in the expedition against Carthagena, its effects 
were most disastrous. In 1780 a force of 8,000 Spanish 
soldiers was landed at Havana, and in two months it 
lost 2,000 men from this disease. In Hayti, during the 
rebellion of the blacks, the French army of veterans 
was practically annihilated by yellow fever. Of this 
epidemic Lemure wrote: “In 1802 an army under the 
orders of General Leclerc embarked for San Domingo. 
The effective strength, on leaving Brest, was 58,545 men. 
In four months 50,270 men were dead; chiefly of yellow 
fever, which gave 82.5 per cent. of the mortality. Of 


JANUARY 
FEBRUARY 
AUGUST 
SEPTEMBER 
OCTOBER 
NOVEMBER 
OECEMBER 















































SNS 
































EHERE SERA REaeAe 
ASSESS 


cal 
S 
SSSSSNSSSASE EEE EE EEE 





ze 
DISS 





SIS 
ime +4 
NISISISISISIISS 


1876-77 1396 - 
LLL 


Fig. 1091.—Distribution by Months of Deaths from Yellow Fever in 
the Spanish Army in Cuba, per Thousand Strength, During the 
Epidemics of 1876 and 1896. 


the 8,275 men remaining, 3,000 were sick or wounded. 
In 1809, seven years later, this army was reduced to 300 
men, who returned to France.” The French also suffered 
severely during their occupation of Mexico. According 
to Coustan, there were 1,705 cases; the fever breaking 
out six days after the troops landed at Vera Cruz. Dur- 
ing the Civil War there were, in the Union forces, 1,371 
cases and 486 deaths; and in 1867 the disease attacked a 
number of Southern posts and caused 1,520 cases with 
453 deaths. For the period 1868-84 the disease recurred 
almost annually among such troops as were stationed in 
the South, the average for the whole army for this period, 
per thousand strength, giving a rate of .78 for admis- 
sions and .33 for deaths. For the period 1885-96 inclu- 
sive, there were no cases of yellow fever in our service. 


602 





In 1897 there were 7 cases with 3 deaths; and in 1898, at 
Santiago, there were 604 cases with 70 deaths. For the 
period 1868-98 the rate for admissions was 1.17, and for 
deaths .26 per thousand strength. The Spanish army in 
Cuba has always suffered severely from this disease, es- 
pecially during the epidemics of 1876, 1877, and 1896. 
The British and French troops stationed in the West 
Indies, have been repeatedly attacked. 

Vature and Mode of Dissemination.—With regard to 
the nature of the materies morbi of yellow fever nothing 
is as yet known, though investigations by many army 
medical officers have been, and are now being, vigor- 
ously prosecuted; hence it is impossible to say definitely 
whether it is disseminated by water, air, or insects. It is 
safe to regard the excreta of a yellow-fever patient as 
especially infectious. There is an abundance of evidence 
to show that yellow fever may be transmitted in clothing, 
merchandise, or similar articles. Such fomites as have 
been in the immediate vicinity of yellow-fever patients 
are to be regarded as especially dangerous. Infected habi- 
tations in the yellow-fever belt are probably the chief 
points from which the disease is spread. Apparently, the 
yellow-fever patient, removed to good surroundings, is 
not so greatly to be feared as is the place in which the 
sufferer contracted his infection. Experience has shown 
that, with proper precautions, those in attendance on the 
sick are not especially liable to contract the disease; and 
yellow-fever patients have often been treated in the same 
wards as susceptible patients without the disease having 
been disseminated. Such practice, however, is of course 
highly undesirable. While the patient, therefore, does 
not ordinarily affect others directly, he undoubtedly gives 
off, presumably in his discharges, the virus of the dis- 
ease, and this is capable of infecting a particular locality 
and thus of giving rise to the disease in others. Outside 
the body the micro-organism probably undergoes devel- 
opment in the soil. The incubation period of the disease 
is short, varying from one to five days. 

Predisposing Causes.—Absolute immunity to yellow 
fever is not possessed by any race as a peculiar charac- 
teristic; though relatively speaking, those individuals 
who are permanent residents in the endemic zones ex- 
hibit less liability to contract it than do strangers newly 
arrived from colder latitudes. In general terms it may 
be considered that the susceptibility to, and mortality 
from, yellow fever vary directly with the distance from 
the equator of the place of nativity and residence of the 
individual. According to Barton, of each 1,000 deaths 
from yellow fever which occurred in New Orleans in the 
epidemic of 18538, the distribution of mortality was as 
follows: 


Native Creoles.oescsjc:s9 09.0 dis ci as ale.c:e'ele eia'ets leans lela lslereietaneea 3.58 
Strangers from West Indies, Mexico, andSouth America 6.14 


Strangers from Southern United States.............06+ 138.22 
Strangers from Spain and Italy. .........eces «cesses 22.06 
Strangers from Middle United States ................0. 30.69 
Strangers from New York and New England;.......... 32.83 
Strangers from Western United States ............20e0. 44.23 
Strangers from Brante: = baci eis ere eis riers els alee eae 48.13 
Strangers from British AMEYIC@...........cececoesceses 50. 

Strangers from ‘Great Britaim 2. s/c sc cies siciemleteeieee 52.19 
Strangers from Germany: 2.2. ccc pes ce se cele eeteenirenel 182.01 
Strangers-from’ Scandinavia... <.0s6s. sce cesaeneenne 163.26 
Strangers from Austria and Switzerland ............... 220.08 
Strangers from: the; Netherlands’ <5 -.%. <1.0)2« 1 cemtatiomnna 328.94 


Long ago Blair wrote that among the West India island- 
ers in the Seamen’s Hospital at Demerara, Guiana, the 
percentage of deaths from yellow fever was 6.9; among 
French and Italians it was 17.1; among English, Ivish, 
and Scotch, it was 19.3; among Germans and Dutch it was 
20; among Swedes, Norwegians, and Russians it was 27.7. 
It has been thought that the Creole and the African, irre- 
spective of place of birth or of residence, possess a racial 
immunity to yellow fever. This, however, does not ap- 
pear to be the case. Such a relative immunity is prob- 
ably only the result of an attack of the disease itself, 
which in early life may be so mild as scarcely to be rec- 
ognized; or, to a much less degree, it may be due to the 
transmission of a relative unsusceptibility from ancestors 
immunized for generations through attacks of the disease. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





It should be noted that the immunity to this disease un- 
doubtedly possessed by many natives in the yellow-fever 
belt is more or less completely lost after they remove to 
cooler latitudes, and that such individuals on their return 
to the zone of endemic yellow fever often exhibit a suscep- 
tibility equal to-that of total strangers to the district. 
There is, therefore, no reason to believe that the negro pri- 
marily possesses any greater powers of resistance than 
does the white man under the same conditions, or that the 
negro born and resident in cold climates is as unsuscepti- 
ble as the negro from the yellow-fever belt. Anacquired 
oran inherited immunity is the essential factor. It should 
be noted that yellow fever prevailed among the negro 
troops at New Orleans during the Civil War and caused 
considerable mortality. Thus also for the year 1898, the 
rates in our army for this affection, per thousand strength, 
were as follows: 


Admissions. Deaths. 
We TEEPOUDS Mata tains cals neiaeiecieis ceisie tbe o.cie« 9.40 1.04 
IONE CULOODS's ovis sccjetlsie. 60's sels. cies ei oven a's 59.19 7.51 


The negroes recruited for our service are rarely drawn 
from districts in which the disease has prevailed. The 
great difference above noted in favor of white troops, 
however, is largely to be explained by the fact that the 
colored troops of our army were nearly all present at 
Santiago, while a much less proportion of the total white 
troops were so exposed. Further, one colored regiment, 
on account of its supposed relative unsusceptibility to this 
disease, was selected to do guard and police work at the 
yellow-fever hospital, thus largely increasing its oppor- 
tunities for infection. A fair comparison of the suscepti- 
bility of the unacclimated white with that of the negro 
native to the yellow-fever zone may, however, be drawn 
from the British troops in the West Indies. For the dec- 
ade 1888-97 the rates for yellow fever, per thousand 
strength of these troops, were as follows: 











Ad- Constant 

missions. Deaths. sickness. 
SHEE CI DEATIS calelcierstviete'c e's.s, s10.4:5.0 sve! 0.6 e's, ¥-* 3.0 1.66 0.16 
PROUSDUTOPCEDS stacic ces ccs cecscciscsss A 15 02 


Prophylazis.—As a preventive of the occurrence of yel- 
low fever among troops, expeditions into an endemically 
infected district should not be carried out during the rainy 
season. Troopsintended permanently to garrison infected 
points will be with advantage recruited from the native 
andimmune population. Whether in camp or in garrison, 
general prophylactic measures of great importance have 
reference to careful sanitary policing, free ventilation, an 
avoidance of overcrowding, and a pure water supply, 
with proper means of maintaining personal cleanliness. 
During the Civil War the comparative freedom from yel- 
low fever of Union troops garrisoning New Orleans was 
regarded aschiefly due to the vigorous sanitary measures 
introduced by General Butler. Recently, in the occupation 
of Cuba, the value of proper sanitation in controlling the 
disease has been strongly demonstrated. Troops should 
be prohibited from entering infected towns, and particu- 
larly from entering houses and shops. When an epi- 
demic occurs among the surrounding population, a care- 


ful quarantine should be maintained. With the outbreak _ 


of the disease among the troops all cases should be 
promptly isolated, preferably in tents. 
from the sick, especially the vomit and excreta, should 
be disinfected; if possible, by fire. The clothing and 
equipments of the soldier, and those with which he may 
have come in contact, should be disinfected; as should 
the tent or barrack in which the case occurred. If pos- 
sible, the troops should be moved to a locality in which 
the fever has not been known to occur. In this country 
troops have habitually been transferred from southern 
stations to Atlanta, when an outbreak of the disease was 
apprehended. If such a locality is not available, the 
troops should be moved to high ground—preferably to 


All discharges ~ 


an elevation of at least fifteen hundred feet. Moving 
camp even a mile or so may avert an epidemic, and this 
procedure should be repeated upon the appearance of 
every new case. Depopulation of an infected area is es- 
sential, a fact repeatedly demonstrated in our own ser- 
vice; as at Fort Brown in 1882 and at Santiago in 1899. 
If the disease appear on board a transport, the sick should 
be treated on deck and landed as soon as possible. A 
predisposition to the disease appears to be caused by 
fatigue, especially when combined with exposure to the 
sun; by the immoderate use of alcohol, and by insufticient 
or improper food. No prophylactic medication is known 
to be of value. Various methods of preventive inocula- 
tion have been devised, notably by Freire and Sanarelli, 
but experience has shown these to be without effect. 


DISEASES DUE TO INTEMPERATE OR IMMORAL HABITS. 


ALconHoLisM.—The attitude of the soldier toward the 
use of intoxicants is largely determined prior to his en- 
trance into the military service. That the majority of 
such soldiers as actually become drinking men after en- 
tering the army, do so as a result of social environment, 
cannot for a moment, however, be doubted. To drink 
and ask the companionship of others in consuming alco- 
holic beverages is the first step toward the development 
of the drunkard in the army, asin civil life. The idea 
that social superiority attaches to an ability to consume 
large quantities of alcoholics still exists to a certain ex- 
tent among a few soldiers of a lower class: and by such, 
a novice in the art of drinking may be assailed with ridi- 
cule and contempt. Such men are largely responsible 
for the idea which sometimes prevails among recruits 
that a physical tolerance of alcohol is an essential at- 
tribute of the seasoned soldier, and that only he who is 
able to imbibe his share of intoxicant without apparent 
effect has demonstrated his fitness to enter upon the pro- 
fession of arms. Besides the above class, a number of 
soldiers undoubtedly acquire the habit of alcoholism 
through favorable opportunity, particularly if they are 
men without aim or purpose in life beyond the per- 
functory accomplishment of routine duties; men who 
are possessed of no internal resources for their amuse- 
ment, and to whom the normal military existence is 
burdensome, dull, and monotonous. A certain class of 
susceptible individuals appear to be markedly influ- 
enced in their use of alcohol by atmospheric conditions, 
and excessive heat, cold, and moisture have been ob- 
served to develop a latent desire for drink on the part of 
soldiers which would probably otherwise have remained 
dormant. A small number of periodical drunkards are 
true degenerates. Without apparent cause, in the face 
of promises and protests to the contrary and in spite of 
inevitable court martial, disgrace, and punishment, alco- 
holic excesses are begun and continued until exhausted 
nature brings the debauch to a close. Then follow deep 
contrition and humiliation, renewed and earnest prom- 
ises of reform, and an apparently sincere attempt to 
repair the damage done to health and character; a period 
of steady habits, and again a sudden plunge into alco- 
holic excesses. A large proportion of inebriates, how- 
ever, as found in the military service, are men of unstable 
mental equilibrium, indecision, and weak character. 
Such, under any conditions out of the ordinary, find the 
mental strain beyond their power of endurance and 
promptly seek relief in the nerve-benumbing effects of 
alcohol. 

Frequency of Alcoholism.—In the army the abuse of al- 
cohol is one of the most potent factors by which military 
efficiency is impaired; and in the past drunkenness has 
been largely looked upon as a distinctively military fail- 
ing. Its influence, as well as its prevalence, however, is 
indifferently shown by statistics. All alcoholics do not 
enter hospital, and a certain proportion succumb to 
other affections, as gastritis, cirrhosis, and nephritis, in 
the occurrence and ultimate result of which the use of 
intoxicants may have played no minor part. Further, 
the term alcoholism includes many pathological condi- 


603 


Camp Discases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











tions and their symptoms, these varying according to the 
quantity of alcohol taken and the frequency with which 
it is consumed. Chronic drunkenness occurs chiefly 
among old soldiers; and this class is naturally not pro- 
portionately represented on the sick reports as compared 
with younger men, among whom the use of intoxicants 
more frequently occurs in the nature of periodical ex- 
cesses. Acute alcoholism not rarely terminates life, and 
even at as recent a period as the decade 1886-95 it stood 
sixth in order of importance in determining the annual 
mortality among white troops. The proportion of dis- 
charges and constant non-efficiency from this cause is, 
however, at all times low. 

The amount of alcoholism in our service has steadily 


decreased in the past fifteen years; this having been ac-. 


complished through greater care in the selection of re- 
cruits, a growing sentiment in favor of temperance in the 
social class from which the soldier is drawn, greater efforts 
on the part of the authorities for the elimination of in- 
ebriates from the service, and, finally, through the estab- 
lishment of canteens, the favorable influence of which is 
discussed subsequently. 

The following table shows the prevalence of alcoholism 
in the military forces of the United States during the 
thirty years of peace 1868-97, inclusive: 














Aoan Number of cases Number of cases 
Year. ae 5 th admitted to hospitaljof delirium tremens 
SLND ayaa per 1,000 strength. | per 1,000 strength. 

47,472 32.59 
35,221 37.70 
31,831 38.20 
29,430 45.80 
26,844 47.50 

7,909 49.40 
27,021 58.10 
23,575 68 
24,886 64.50 
23,707 59 
23,381 59.40 
23,964 65.10 
24,004 61 
23,222 57.60 
23,239 68.70 
23,489 66 
24,034 2.10 
24,188 53.50 1.57 
23,572 42.80 1.01 
23,841 46.70 
24,726 40.20 92 
25,008 41.40 51 
24,234 40.7 86 
23,269 40 90 
24,203 37.20 7 
25,287 33.80 55 
25,376 30.90 82 
25,204 30.10 83 
25,119 28.80 39 
25,417 27.80 58 











In 1898, during the war with Spain, the admission rate 
fell to 15.1; the more active operations and novelty sup- 
plying much of the desired excitement, while the unusual 
conditions undoubtedly attracted a superior and more 
temperate class of young men to the colors. 


ADMISSIONS FOR ALCOHOLISM AND ITs RESULTS, PER 
1,000 StRENGTH, 1885-97. 





Year White Colored Total for 
‘ troops. troops. the army. 
ASS: :. «ic taetaareamactesp tee eteteatese 59.00 4.00 54.00 
1886. '..c lemcneraceeateconee stele ete otaen 50.21 4.67 7.09 
TSB; sca cieciinbinna cnaeeinereG@aatite 50.88 2.23 46.31 
S88. isco catestetie titetemeete aeiecien 43.97 4.55 40.12 
1889; .)./ ccs einee’e since chine cieealee ce 45.64 2.07 41.43 
1890. icccnials seme sirente mole metuteoes 44.45 5.59 40.73 
ASOL; ciccasssaca bina eatontteters ttamoteteleaies 44.19 3.39 40.01 
1802: LFemeeionacewiom ee cieetiels ore 41.19 8.85 37.23 * 
L8OBS. Bice decison ecmttinces tees 37.23 7.47 33.97 
18Q4; cide seals etasasisichet sees 33.79 4.79 80.94 
1895.0 tetas pcaloid nowlenmuecicenseer 2.16 6.47 30.11 
Ifo! URE UMMan A hambadoendiauso0s 31.20 5.70 29.06 
DSO. 55 Sica ae oseleuetne we eietoores are 30.02 4.62 27.86 
Decade 1886-05. For ikissctiee sens 42.37 4.89 38.69 * 


* Including Indian soldiers. 


604 





The remarkable difference existing between the white 
and black troops of the United States service as regards 
the prevalence of inebriety is illustrated in the preceding 
table—statistics which cover extended periods and which 
show that there is approximately only one-tenth as much 
alcoholism among the negro regiments as among the 
white troops. Few colored soldiers are hard drinkers, 
and as far as beer and other malt liquors are concerned, 
there apparently exists a racial distaste for these bey- 
erages. It is well recognized that where negro troops 
replace white soldiers in a post, the canteen profits from 
beer and wine are greatly diminished while the sales of 
cigars and confectionery are proportionately increased. 

This racial difference as regards the use of alcoholics 
is further shown by statistics for the British army cov- 
ering the European and non-European troops in the West 
Indies. For the year 1897 the admission rate per thou- 
sand strength, for the former class, was 15.6, while the 
death rate was .74. For the native (negro) troops dur- 
ing the same year the admission rate from this cause 
was .6, while the death rate was nz. 

As to the amount of drunkenness existing in foreign ser- 
vices as contrasted with our own, no accurate comparisons 
can be drawn, from the fact that abroad none but the se- 
vere cases of alcoholism appear on sick report. Drunken- 
ness, however, is fairly prevalent in England and Ger- 
many—much less so among the Latin nations, who are 
comparatively free from alcoholic excess. In France, 
where absinthe is much employed, the rates are said by 
Laveran to be only about one-tenth as high as in the Eng- 
lish service, and Viry states that for the fifteen years 1875— 
90 the deaths from the use of alcohol in the French army 
amounted to only 11.5 annually, a considerable proportion 
of these occurring in Algeria. In Italy and Spain the 
rates are even lower than in France, and during the oc- 
cupation of territory by our troops as a result of the late 
war, it was a matter of frequent comment that an intoxi- 
cated Spanish soldier was rarely, if ever, seen. 

In both the British and French services the amount of 
alcoholism is much greater among troops serving in the 
colonies than among those at the home stations. 

Influence of Alcohol on Military Efficiency.—The effect 
of moderate drinking in the production of an increased 
amount of sickness is well illustrated by the data col- 
lected by Carpenter relative to British troops serving in 
India, based upon 17,334 moderate drinkers and 9,340 
abstainers. Of the former class he found that 1 out of 
every 7.28 soldiers was admitted to hospital, whereas of 
the latter group but 1 out of every 14.47 was so admitted. 
Still more favorable to the abstinence class are the figures 
for the average number of days spent in hospital; the 
moderate drinkers losing 102 days per thousand as com- 
pared with an average for the abstainers of 36.4 days. 
According toan editorial in The British Medical Journal, 
the admissions to military hospitals in India, during the 
year 1891, amounted to 5 per cent. for abstainers and to 
10.4 percent. for all others. Madden states that in three 
benefit associations in England, during the five years 
1884-88, there were lost by each laborer 26.20, 24.68, and 
27.66 weeks through illness—an average of 26.18 weeks: 
while during the same period, in the “Sons of Temper- 
ance,”. which admits only total abstainers to membership, 
the average number of weeks lost by each mem- 
ber were 7.48—less than one-third the rate given in the 
other organizations. 

As to the actual effect of alcohol upon the death rate, 
it is obvious, as already remarked, that military statistics 
furnish little information on this point, since only acute 
cases of intoxication are noted on the records. Chronic 
alcoholism, however, while it cuts no figure in military 
statistics, imparts a peculiarly grave character to all dis- 
eases occurring in drunkards, and does much, through 
the organic changes, local congestions, and nervous de- 
pression which result from the continued use of intoxi- 
cants, to bring about a fatal termination in any serious. 
affection. 

Alcohol is one of the most frequent causes of insanity 
and suicide in the military service. In civil life some: 


——— 


. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





writers attribute two-thirds of all mental diseases to alco- 
hol, and it is said to be the chief cause of self-destruction 
in England, Germany, and Russia. According to Mad- 
den, in the years 1878 and 1879 it was found that in 27 
per cent. of all male lunatics in the asylums of Germany 
the mental condition could be directly traced to the use 
of alcoholics. In Austria, according to Gauster, 40 per 
cent. of insanity occurring in males could be ascribed to 
alcoholic excesses. In our military service no figures as 
to the influence of inebriety upon insanity are available; 
but for the seven years 1887-93, out of 134 suicides oc- 
curring during that period, alcoholism was officially re- 
ported as being the cause in 31.3 per cent. 

With regard to the use of alcohol upon marching troops 
Rosse states: “The experience of the Ashantee War in 
1876 shows that alcoholic drinks are hurtful. The men 
who did not touch the supplementary ration of rum pre- 
sented a mortality and morbidity inferior to the other 
soldiers.” This statement will be supported by all who 
have served with troops on campaign. 

As to the effect of drunkenness upon military morals 
and the maintenance of discipline, no argument is re- 
quired to show that the infractions of discipline are 
largely the result of alcoholic stimulation. It was noted 
of the British troops in India, in 1891, that of all minor 
offences 1.5 were committed by abstainers to every 6.7 
committed by moderate drinkers. As expressed by 
Smart, “the medical.and court-martial records after pay 
day, in all camps where whiskey can be procured, fur- 
nish data sufficient for insistence on its exclusion as the 
cause of much disease and many injuries and accidental 
deaths.” 

As summed up by Parkes: “When debarred from 
spirits and fermented liquids, men are not only better be- 
haved but are far more cheerful, are less irritable, and 
endure better the hardshipsand perilsof war. The cour- 
age and endurance of a drunkard are always lessened; 
but in a degree far short of drunkenness, spirits lower, 
while temperance raises, the boldness and cheerfulness of 
spirit which a true soldier should possess. If spirits 
neither give strength nor sustain it against disease, are 
not protective against cold and wet, and aggravate 
rather than mitigate the effects of heat; if their use even 
in moderation increases crime, injures discipline, and im- 
pairs hope and cheerfulness; if the severest trials of war 
have not been merely borne, but most easily borne with- 
out them; if there is no evidence that they are protective 
against malaria and other diseases, then the medical offi- 
cer will not be justified in sanctioning their issue or their 
use under any circumstances.” 

Woodhull adds: “It is not necessary to insist, from 
theoretical or medical grounds alone, upon the mischief 
that alcohol causes soldiers. The observation of any offi- 
cer of experience is enough. Liquor, besides weakening 
men physically, tampers with their will power, disturbs 
their temper, makes them less trustworthy even when 
sober, is at the bottom of almost every violation of disci- 
pline, and is the one agent that can convert a regular 
force intoa mob. The absence of liquor usually means 
a clear guard-house. Abundant liquor means a heavy 
sick list, a large guard report, and a general feeling of 
doubt as to the command. It follows without saying 
that if the use of alcohol is hurtful in a personal and in a 
martial sense to the private soldier, who is the lowest 
unit in the military scale, it is very much more mischiev- 
ous in its ultimate consequences when an officer, who is 
so potent with those beneath him, is its victim.” 

For the United States service the discussion of alcohol- 
ism would be incomplete without reference to the can- 
teen, which, more than any other one factor, has brought 
about a reduction in drunkenness and its results. 

This institution, officially known as the post exchange, 
had its origin in our service at Vancouver Barracks in 
1880, but it was pot until February, 1889, that the insti- 
tution was recognized by the War Department, and rules 
and regulations for its establishment and government 
published to the army. 

The purpose of the army canteen, as officially an- 


nounced, is to supply troops with goods at a low rate of 
profit and to afford rational recreation and amusement to 
all enlisted men. The sale of ardent spirits is strictly pro- 
hibited therein; but commanding officers are authorized 
to permit light beer and wine to be sold by the drink, on 
week days, in a room set apart for the purpose, when 
in their opinion such action is promotive of temperance. 
Gambling of any character is forbidden. Each canteen 
is managed by an officer selected by the post commander 
for his fitness for the position, he being allowed one or 
more enlisted men as assistants; under recent orders 
civilians only being allowed to serve as barkeepers. As 
showing the favor with which the system was received, 
it is only necessary to say that in 1894, five years after its 
inauguration, there were 75 canteens in successful opera- 
tion, and that during that year the total receipts were 
$1,417,079.62; of which sum no less than $304,649.91 were 
returned to the men as dividend profits. 

The effect of the introduction of the canteen system 
upon the rates for alcoholism was prompt and marked. 
For the decade 1878-87 the average number of admissions 
for alcoholism and its direct results amounted to 64.28 
per thousand of white troops. This rate diminished dur- 
ing the next ten years in proportion as canteens were 
gradually established at various posts, omitting frac- 
tions, in the following ratio: 44, 46, 44, 44, 41, 87, 34, 32, 
31, 30. On observing the admissions for alcoholism 
for the seven years 1885-91 which immediately pre- 
ceded the general establishment of the canteen system 
upon a satisfactory basis, it is found that a yearly aver- 
age of 1,214.8 men found it necessary to apply for treat- 
ment from this cause; while for the six years 1892-97, 
after canteens had been generally instituted throughout 
the army, an average of only 928.4 men annually re- 
quired attention for this reason—a reduction amounting 
to 23.6 per cent. In 1890 there were 17 posts at which 
the admission rate for alcoholism exceeded 10 per cent. 
of the strength. In 1891 the number of such posts had 
decreased to 11, and in the six subsequent years dimin- 
ished at the following rate: 10, 7,4, 5, 2, 2. This favor- 
able showing for the army at large was duplicated in the 
case of each individual post, the introduction of the can- 
teen failing in no instance to be promptly followed by a 
diminution of alcoholism. For certain stations this im- 
provement was extraordinary. In 1889, Willet’s Point 
had an admission rate for alcoholism of 222.97 per thou- 
sand. In 1890, the year when the canteen was estab- 
lished at that post, it fell to 157.50, and in the next year 
amounted to only 70.46. At Fort Spokane the amount 
of sickness resulting from intoxicants was reported by 
the surgeon as having diminished 50 per cent. during the 
six months following the institution of the canteen. At 
Fort Douglas, in 1888 and 1889, the total number of ad- 
missions attributed to alcohol amounted to about 85 per 
thousand strength; while during 1892-94 this rate fell to 
52.95 per thousand strength; and such instances might 
be multiplied many fold. 

As to the’value of the canteen in the tropics as well as 
at home stations, in reducing alcoholism, all are agreed. 
A report by O’Reilly upon the condition of the British 
troops in Jamaica states that the canteen, from which the 
men can always procure beer, has been largely instru- 
mental in the disuse of stronger spirituous liquors and in 
a lessening of the evils which followed the free use of 
spirits in the tropics. In referring to the condition of the 
Fourteenth United States Infantry at Manila, Cardwell ex- 
presses his belief that a great improvement shown in the 
figures for venereal disease and alcoholism in this regi- 
ment was due to the establishment of a canteen, kept un- 
der admirable discipline; and he adds: “Cool American 
beer as a substitute for the ‘ beno’ of the native gin shops 
has a most beneficent effect.” 

The cases of delirium tremens will be accepted by all 
as furnishing reliable data by which the gravity of the 
admissions for alcoholism may be determined. It is, 
therefore, of interest to observe that, for the seven-year 
period above noted prior to the complete adoption of the 
canteen system, the average annual admissions for this 


605 


Camp Diseases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





cause, actual numbers, were 23.8; while for the six-year 
period of peace following the establishment of this sys- 
tem the average number of men admitted vearly for de- 
lirium tremens was 16.6, a reduction of 31.3 per cent. in 
this serious class of cases. It can scarcely be doubted 
that this remarkable decrease was chiefly influenced by 
the substitution of beer—a milder beverage, which rarely 
produces such effects—for distilled liquors, whose free 
use is well known to result in great mental excitement 
and nervous exhaustion. 

It isrecognized that alcoholism and insanity are closely 
related through the direct influence exerted by intoxi- 
cants in the production of mental aberration. Hence it 
is not surprising to find that theaverage number of cases 
of insanity annually coming under treatment was 35.1 
for the seven-year period 1885-91, prior to the complete 
establishment of the canteen system, and only 24 as an 
annual average for the six subsequent years, 1892-97. 
These figures show a reduction in insanity amounting to 
31.7 per cent. As to the number of days of service lost 
annually from insanity, the improvement since the insti- 
tution of the canteen is even more marked. Figures 
for the years 1885 and 1886 are not available; but for 
the five-year period 1887-91, the average number of 
days lost was 1,568, while for the six years 1892-97 
the service annually lost to the government from this 
cause amounted to only 924.5 days—a decrease of 40.9 
per cent. 

The canteen—for the maintenance of good order in 
which a commissioned officer is held responsible—is an aid 
to discipline as well as to the health and morals of troops. 
It provides a resort which, while under thorough military 
control, offers inducements to the men to remain at home 
and spend their idle time within the limits of the post; 
this condition obviously being far preferable to the one 
formerly existing, when the nearest and most generally 
patronized places of amusement and refreshment were the 
grog shops, usually with brothel annexes, which marked 
the limits of each military reservation. Except with the 
most dissolute class of men, the soldier is well satisfied to 
patronize the canteen to the exclusion of outside saloons; 
knowing, as he does, that he receives good value for his 
money in articles of excellent quality, and fully appreci- 
ating that the profits of the institution ultimately accrue 
entirely to his benefit, and are not, as is the case with 
outside establishments, diverted to the advantage of 
others. Besides the congenial resort which it furnishes, 
the influence of the profits of the canteen in promoting 
contentment among troopscan scarcely be overestimated, 
contributing as they do to improvement of the food, to the 
attainment of wholesome amusement, and to the provision 
of much by which the soldier’s life is made less irksome 
and he himself rendered more efficient in the performance 
of his military duties. The best index of the content- 
ment of ,troops is to be found in the rate of desertions, 
since it is obvious that the soldier who is well satisfied 
with his lot will not endeavor to escape from the per- 
formance of his military obligations. That the canteen 
system has, from this standpoint, operated to the general 
welfare of the men is undoubted, the desertions and 
percentage of desertions in the regular army, from 1885 
to 1897 inclusive, being as follows: 






































2s a} re or! s w 
ot tires) od (=| o055 =| 
Year. | £2 5 5 Year. | & 2 5 5 
Suet bine 3 5 B Paulas 5 
<¥ A a 4% a) a 
1885 24,816 | 2,626 10.6 1892 24,869 | 1,410 5. 
1886 24,365 | 2,012 8.3 1893 25,670 | 1,682 6.3 
1887 24,488 | 2,525 10. 1894 25,661 926 3.6 
1888 24,790 | 2,678 inh 1895 25,209 | 1,34 5.3 
1889 25,564 | 2,730 ine 1896 25,148 858 3.4 
1890 24,980 | 1,922 Ae 1897 25,300 726 2.9 
1891 24,525 | 1,398 5.7 | 
Average for seven years Average for six years 
before canteen system after canteen system 
was thoroughly estab- was thoroughly estab- 
lished i 4Atas senile 9.18 USHOG pc saps asses overs 4.53 





606 











From the above table it is observed that during the 
first year after the canteen system was authorized the 
rate of desertions fell 26 per cent., while during the next. 
year, as the system was more generally established, the 
rate was further reduced to 49 per cent. For the five 
years previous to the establishment of the first officially 
recognized canteen the number of men annually desert- 
ing from the service, per thousand strength, amounted 
to 101; while for the eight years immediately subsequent. 
to the institution of this system the annual number of 
desertions was reduced to 50 per thousand strength. 
The decrease noted has been practically progressive, and 
for the two years immediately prior to the war with 
Spain scarcely one-fourth the number of men, as com- 
pared with the three years immediately prior to the in- 
troduction of the canteen system, found the military ser- 
vice so uncongenial as to desire to escape from completing 
their terms of enlistment. These results are certainly 
most gratifying, and there is no reason for believing that. 
with the development of the canteen along its legitimate 
lines of growth a still further decrease in the present. 
small rate of desertions may not be confidently antici- 
pated. 

Drunkenness is certainly prevented by the constant 
military supervision to which the canteen is subjected. 
The men themselves are usually careful not to indulge 
in alcoholics to the point of inebriety; while such few 
individuals as are inclined to be forgetful of the dangers. 
of excess are usually restrained by companions, or by 
those connected with the canteen, from passing the 
bounds of actual intoxication. Should such a condi- 
tion actually result the drunken individual is rarely left. 
to his own devices or permitted to become offensive, 
but is usually prevailed upon by others to return to 
barracks without committing any breach of discipline. 
Hence, brawls and disturbances, with resulting court. 
martial, have, since the introduction of the canteen sys- 
tem, become relatively infrequent, and pay day, formerly 
synonymous with debauchery and riotous disturbances, 
is now scarcely to be distinguished by its effects from any 
other day. As illustrating the marked reduction of con- 
victions for drunkenness and for complications arising 
therefrom, since the establishment of the canteen, the fol- 
lowing figures, from the reports of the judge advocate 
general, are of interest: 














Total number of |Nusmhert rials and 
Trials ani 
Year. convictions in the ip rapeieepse 
Brily. arising therefrom. 
TSBO"eertasearnetaletiatn otele steals 1,640 842 
I tee) Gain cardamone sun dicoccae 1,730 289 
WSSR satetarctenrrela caro staceiecuts Reticnes 1,999 357 
BRO inreletesalsvoerisiaias vista as 1,752 423 
TSO0 Ree tericke ohametneneaeacs 1,907 407 
phot) Ron Renee met G Seire: 2,000 47 
TL BOR eprarahers (elec etmaisve er atecata eva 2,198 228 
SOS S fersssorsclous’s au saetactnasiee 2,189 163 
SOE 2 Be cathe eect ednasanes 1,728 120 
WBQD Sica veeterarecsielstereicronteiacretas 1,486 142 
WBOG i. B inte ciet ehets sesve reels oid etieisine 1,384 168 
DOO a oo rctens tye shayetate situa rains, oe 1,245 143 
Average for the six years 
N886=O1G eke ttinaeeita edhe core 1,838 372.5 
Average for the six years 
TSQZ=O7 cee roisa yates anwar 1,605 160.6 








From the above figures it is evident that coincident 
with the thorough establishment of the canteen system 
there has occurred a decrease, amounting to considerably 
more than one-half of the drunkenness which formerly 
tended to the impairment of discipline, to the demoraliza- 
tion of individuals, and to the occurrence of assaults, in- 
juries, and deaths. It is idle to deny that this excellent 
result has been largely due to the attraction furnished 
by the canteen, combined with the military discipline 
which prevails in that institution and which reduces to 
a minimum the possibility of dangerous alcoholic excesses. 

The opportunity given the men of purchasing light, 


: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


nutritious lunches in the canteen is also certainly of much 
benefit. Many articles of food not obtainable in the 
company mess are thus brought within reach, and the 
monotony which often pertains to company cookery may 
in this manner be agreeably interrupted. It is probable, 
too, that this feature does much to prevent the intem- 
perate use of alcoholics. The gastric cravings of hearty 
and idle men are thus satisfied, and a sandwich with the 
beer largely decreases the desire for an additional quan- 
tity of the latter. 

It is claimed by the advocates of total abstinence that 
through the sale of beer in the canteen the health and 
morals of the soldiers are impaired ; that such tacit encour- 
agement on the part of the government favors indulgence 
in alcoholics, and that drinking habits are thus formed 
by those who might otherwise have remained sober men. 
These objections are purely theoretical, and are at vari- 
ance with facts as observed since the establishment of the 
canteen. The sale of beer, under suitable restrictions, un- 


10 20 30 40 50 60 70 80 90 


10 20 80 40 50 60 70 80 90 


Camp Diseases, 
Camp Diseases, 


brings with him into the service the result of the moral 
moulding to which he has been subjected during child- 
hood and youth in civil life, and does not change his 
nature or moral standards concerning alcoholics with the 
mere donning of the uniform. The vice of drunkenness 
is certainly no longer either directly initiated or aggra- 
vated as a result of military service, and if the opinions 
held by some are correct as to the moral conditions ob- 
taining in the army, then its cause must be sought for 
within the social classes and the conditions of environ- 
ment from which the human material composing the 
army isdrawn. It is certain that there has been no more 
drunkenness to be found in the army—if indeed there 
has not been less—during the past few years than has 
occurred in the corresponding classes of civil life. 

VENEREAL DiIsEASE.—Of all causes, venereal disease is 
the one which, in time of peace, brings the soldier often- 
est to hospital and which most affects his efficiency—this 
being particularly the case in our own service. 


400 





10 20 30 40 50 60 70 80 90 10 20 30 40 50 60 70 80 90 10 20 30 40 50 
aa = oa | 





UNITED STATES. 


GERMANY. 





JAPAN. 











Biba 























SS 
TSS 






































HOLLAND. 


EAST INDIES. 
fener mes, Pp 



























































Fic. 1092.—Average Annual Admissions, per Thousand Strength, for all Venereal Diseases, in the More Important Armies of the World, 
for the Three Years 1890, 1891 and 1892. 


doubtedly results in good rather than in evil to the troops 
at large, and may properly be looked upon as a safety 
valve for those accustomed to regard the use of a certain 
amount of liquoras both harmlessand proper. Compar- 
atively few men to-day become inebriates through a taste 
for alcoholacquired in the military service ; and while there 
are a certain few individuals who may imbibe too much 
beer on pay day, they constitute a class which, in the ab- 
sence of a mild beverage of this character, would probably 
resort to stronger—and frequently sophisticated—liquors 
outside the limits of the command. That beer-drinking, 
viewed in the abstract, is unproductive of good, will be ad- 
mitted by all; that, when properly controlled, its sale in 
canteens, rather than its prohibition, redounds to the gen- 
eral health, morals, and military efficiency, few, ifany, who 
are conversant with the subject will attempt to deny. 
It is certainly unfortunate that the temperance element 
in civil life, which is so constantly endeavoring to enact 
legislation against the sale of alcoholics of any character 
in the military service, cannot be brought to regard the 
matter from tic practical rather than from the sentimental 
aspect, and thus assist in controlling and largely curtail- 
ing an evil which it is powerless to prevent, but which, 
if its efforts toward restrictive legislation should be suc- 
cessful, would undoubtedly be greatly increased. 

It may here be remarked that the view is commonly 
entertained by the civilian class just mentioned that the sol- 
dier is a sinner above sinners and requires special legisla- 
tive measures to safeguard him against his weakness—the 
fact being wholly ignored that the army is recruited from 
the general community, and merely reflects the qualities 
of the latter, whether they be good or bad. The recruit 





The following table shows the ratio of admissions per 
thousand strength for all forms of venereal disease in the 
principal armies of the world, compiled from the most 
available and reliable data: 












































S ae = = oo 

, ah = RITAIN. 
$|s|Es| g #5} 2 | £3 |———~ 

vera |B} 8a) 8] & jee) es) es) 2) a 

oO iF 3 3 =| Pm = 

Bees Neves ee aot oS So ge 
bby | ne apa eaeed Mer Bere lieaten! kets ea hoe 202.2 | 191.0 
ISTBS |lesse een Oo ale wee, Noieeed|| LOL 167.6 | 181.6 
1874*|.... | 38.4 | 53 easels We iia carestnoeeD 145.7 | 207.5 
ASTD Sines O10 1/59 ee elite ceuler cane LO: 139.4 | 213.5 
1876 | 57 28.8 | 65.8 ee cal chistes | seen 102.6 146.5 | 203.5 
187 57.8 | 30 |66.9 |. mates cree Wiese lao 153.2 | 224.4 
187 59.7 | 36 | 754+]. Bete ell Ue seul een | MeL) 175.5 | 291.6 
187 63.7 | 38.5 | 81.4 fe PE al | yeteae  esepc haa 179.5 | 253.3 

1880 | 65.8 | 84.9 | 75.7 tas. dete eaarcve | dost: 245.9 | 249 
1881 | 60.6 | 89.2 | 79 Caec a leien lieeret | oOLc8 le4.bsl' 259.6 
1882 | 62 41 73.7 Sree, lncealaullias cal: dock 246 265.5 
1883 | 58.9 ; 38.2 | 73.3 Hees Neral eon | obit: 260 | 271.3 
1884 | 52.1 | 34.5 | 73.5 eae Uineon waleete | eee 270.7 | 293.5 
1885 | 50.7 | 32.6 | 69 Soot eat etietes | ae 275.4 | 342.6 
1886 | 49.6 | 29.7 | 65.8 Bee Hive ties sO. Wi eOr bel ooo.s: 
1887 | 51.6 | 28.6 | 64.4 47.5 |.... | 389.8] 74.87 || 252.9 | 361.4 
1888 | 46.7 | 26.3 | 65.4 | 42.4 | 76.5¢)].... | 29.7 | 80.88 || 224.5 | 372.2 
1889 | 45.8 | 26.7 | 65.3 | 40.7 | 66.6 |.... | 24.7 | 84.66 || 212.1 | 481.5 
1890 | 43.8 | 26.7 | 65.4 | 43 73.4 | 96 27.38 | 75.22 || 212.4 | 503.6 
1891 | 43.7 | 27.2 | 68.7 | 41.5 | 71.5 | 60.4 | 37.5 | 72.46 || 197.4 | 400.7 
1892 | 44 27.9 | 61.6 | 44.6 | 69 53.1 | 36 76.73 || 201.2 | 409.9 

1893 | 42.8|....| 64.5 | 48.1] 93.38 |45.8]....| 73.8 || 194.6 | 466 
1894 | 40.9 64.8 2 54.3 80.40 || 182.4 | 511.4 
best tial | Ree te bs 84.8 | 48.1 73.70 || 178.8 | 522.8 




















*In the case of Germany, 1873-74, 1874-75, and so on. 
+ Bosnia and Herzegovina were occupied in this year. 
+ Compulsory examination of prostitutes abandoned. 


607 


Camp Diseases. 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Among European armies Germany has by far the low- 
est rate. Russia and France come next, then Austria- 
Hungary,sthen the home army .of Holland, then Italy. 
No continental army included in the above comparison 
has so high arate as that shown by the United States 
army—and with us, moreover, the actual prevalence of 
venereal disease, through its concealment to a consider- 
able extent by the men, is probably greater than the re- 
turns indicate. The small amount of these diseases in 
the army of Japan is noticeable. 

In all the above armies, with the exception of those of 
Great Britain and the United States, some special regula- 
tions are in force for preventing the spread of venereal 
disease. These generally consist of weekly or fortnightly 
examination of the men for the detection of venereal dis- 
ease, non-commissioned officersand married men being in 
some services exempted, together with registration and 
periodical examination of all women ascertained to be 
leading a life of prostitution. In the Italian army, reg- 
ulations of this latter kind were relaxed in 1888. 

In the case of most of the above armies the comparison 
may be carried into further details as follows: 


MEAN ANNUAL ADMISSION RATE PER 1,000 FOR THREE YEARS, 1890-92, 








DUTCH BRITISH 





Es TROOPS. || TROOPS. | 3 . 
Bie ae SHELIA ee 
a| 2|a a Hog 3 =i 
Fl s/#/S|e/8s\| 2) 4 | 58 
D H 2 Ss ols ) = 
mo) es) es) eS |e oi a] & 
Primary and secondary 1 
SYPHILIS) ccc cre cca. 5.5} 9.0]13.1]18.9)14.8) 47.0}|101.7/175.4/16.83 


All other venereal dis- 
CASES oc duroc eeu totes 21.8)34.9/29.9/57.4/55.0/408.6]|101.9]262.6)/57.96 


























In these three years, then, the German army had scarcely 
more than one-thirty-second, and no European army had 
as much as one-eleventh, of the amount of syphilis which 
devastated the British troopsin India. The Dutch troops 
in the East Indies, with an exceedingly high rate of vene- 
real disease generally, did not suffer from syphilis one- 
third as much as did the white soldiers of the British In- 
dian service; in which the rate has risen rapidly since the 
period included in the above comparison, while at the same 
time it has materially declined in the Dutch East Indies. 

Syphilis.—Figures with regard to syphilis are of par- 
ticular importance as directly bearing upon the military 
efficiency of an army. The disease, even at best, seri- 
ously undermines the constitution and renders the soldier 
at all times less resistant to invasion by acute disease and 
to its fatal termination. Even in many cases ultimately 
returned to duty, the men have frequently been in hospi- 
tal for considerable periods and are prone to later mani- 
festations from a temporarily latent infection. In such 
instances the state has not only paid the man for the 
time he was unfitted for duty, but receives back a doubt- 
fully efficient soldier, extremely liable to break down 
under the fatigue and privations of field service. 

The prevalence of constitutional syphilis in the United 
States army, during the past thirty years, has been as 
follows: 











Admissions 
to hospital per 
1,000 strength. 


Admissions 
Year. to hospital per Year. 
1,000 strength. 





HY NWWWHDDS 





BERR ESF SRERNESS 
ORR oo 

















During the year 1898 the admissions for this cause were 
only 10 per thousand. 

As is seen by the above figures, syphilis has apparently 
diminished, during the past thirty years, to one-tenth of 
the amount existing in 1868. While it is probable that a 
certain proportion of this reduction is due to a more ac- 
curate differentiation between the hard and soft venereal 
sores, the fact nevertheless remains that the reduction in 
syphilis has been not only great but steadily progress- 
ive. 

In the various armies on the European continent the 
tendency appears to be rather toward a reduction than 
an increase of syphilitic infection; butin the British army 
at home, and particularly among the British troops in In- 
dia, a serious feature of recent years has been the dispro- 
portionately great increase in the amount of primary and 
secondary forms of this disease. This growth was not 
great prior to 1884, when the Contagious Diseases Act 
was revoked, but since that time the advance has been so 
extensive and rapid as to be appalling. In the follow- 
ing tables the rapid development of syphilitic disease 
among the British troops in India is well shown; though 
figures for primary syphilis cannot be given for the 
period prior to 1887, as the hard chancre was not re- 
quired to be differentiated from the non-syphilitic sore 
until that year, and then only in part: 


SECONDARY SYPHILIS, RATIO OF ADMISSION PER 1,000 STRENGTH. 


























Bengal figures— 187 T apis .ecoidsareshasiusteeetioe 22.1 
TSGT cove aie chain pie staveletare o\epere'e 23.7 L878 34 sic steinastomtaetonen 22.1 
1868 wud release partesic we btes 25.4 18%9', o iaceazasanase stein 24,1 
VSCOM NR Sean carne te ete 23 1880) 3. oe seen ceemaees 23 
ASTON. il fea todas eeitdeee 25 1881 5.0.05..aRe Seto 23.1 
AST esate mmetometecetente 24.2 1882 «+ sis sislelelsolateresanreterae 23.2 
IBF. Getta tecneoloe oeatael 22.8 1888. oe lass sis:a eraurereieatefereete 23. 

All India— L884 Sots cite vrneelont een ete 
1BI2 Fo eas encase tdens 22.4 Mean for years 1872-84.. 23. 3 
Dy GRAB CHOIR Torniciact7 20.4 885.5 oviss vioiod Sere eee 28.7 
DSTA: costar tisteconcrstocmatereraranerete 25.2 1886. «:s\cierete. cereale ee 33.3 
ISTD oo sretupicieretomeenincienec 25.1 1887 ciieies some b eeeteeee 29.4 
AST Grca Meroe: ihcertaeaees 23.9 

Primary | Secondary Primary | Secondary 
Year. | syphilis. | syphilis. Year. syphilis syphilis. 
188i ene 75.5 29.4 1892..... 102.6 57.8 
1888.... 72.1 82.4 ite Sea ae 129.3 61.6 
1889.... 134.3 51.2 1804s ire 173 74.6 
1890.... 135.6 66.3 1895 ene 174.1 84.9 
1801 nee 104 60 























In 1898, of the British troops in India, venereal disease 
caused 466 admissions per thousand strength. No less 
than 2,619 men, or equivalent to more than two regi- 
ments, remained constantly in hospital throughout the 
year from this cause. Each case required treatment, on 
an average, for thirty days, and the average rate of non- 
efficiency for each British soldier in India was twelve 
days lost. The admissions for syphilis alone were 275 
per thousand. Of 70,642 British soldiers serving in In- 
dia on the 15th of July, 1894, 19,892, or 28 per cent., had 
been admitted to hospital for syphilis since their arrival 
in India; and only 26,247 men, or 87 per cent., had never 
suffered in or out of India from any venereal disease. Of 
the 13,000 soldiers who returned to England from India 
in 1894, over 60 per cent. are reported as having suffered 
from some form of venereal disease. In 1895, an average 
of 45 men per thousand, or 8,200 of a total force of 71,- 
031 British soldiers in India, were constantly in hospital 
for venereal disease. But these figures by no means rep- 
resent the total amount of inefficiency due to this cause. 
Many cases of secondary syphilis, in the British service, 
have in the last few years been treated by hypodermic 
injection of mercury without admission to hospital, and 
do not, therefore, figure in the returns; while a large 
number of men who have been discharged from hospital 
as nominally cured are fit for service only under peace 
conditions. Among 5,822 men detailed for field service 
with the Chitral relief force, 462, or nearly 8 per cent., 
had to be rejected, prior to m'litary operations, for exist- 


——— ee 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ing venereal infec- 
tion; 279 more, or an 
additional 4.5 per 
cent., had subsequent- 
ly to be transferred 
from the field hospi- 
tals to the base for 
the same cause. On 
a basis of 8 per cent. 
rejected before start- 
ing on field service, 
and 4.5 per cent. 
more subsequently 
invalided for disease 
contracted before 
crossing the frontier, 
8,880 men out of 
the total British In- 
dian force of 71,031 





ae AAS eA 
Guida we eis 


106 Uh 1 
i a a 














Camp Diseases, 
Camp Diseases, 






































would have to be put 
down as useless, from 





sestestant 
FEES 
esa ceaneet 

















this one cause, for 
field operations. The 




















report of the Depart- 








mental Committee 
says: “In 1895 vene- 
real disease attacked 


























the British troops in 
India to an unprece- 
dented extent. Out 
of the enormous total 


dy 


7 





























a 





PH 


] 
cr] 
ae - 
eit 
TS 
























































of 522 cases of vene- 
real per thousand 
troops, syphilis con- 
tributed nearly one- 
half, ¢.e., 259 cases 
per thousand, a figure many times greater than the high- 
est of which we can find any record in the statistics of 
continental armies for recent years either at home or 
abroad. Venereal disease caused more than one-third the 
total amount of sickness from all causes, the constant dis- 
ablement of 3,200 men out of a total force of 71,000 and a 
vast amount of partial disability and unfitness for any 
but routine duties.” In the mountain campaign of 1897, 
it is stated that out of an actual strength of 16,600 British 
troops on active service, 492, or 3 per cent., were incapac- 
itated during the campaign from venereal disease. The 
16,600 troops in the field were drawn from a force of 
21,489 men. Of these, 989 were rejected as unfit for ac- 
tive service on account of venereal disease. Hence 1,481, 
or nearly 7 per cent. of the total strength, were disquali- 
fied for service through this cause. 

As illustrating the constantly increasing proportion of 
venereal diseases, among British troops in India, as com- 
pared with all affections of a non-venereal character, the 
following figures are of interest: 


India, 1860-95. 
only); 4, secondary syphilis. 


MEAN ADMISSION RATE FOR NON-VENEREAL DISEASES. 




















Ratio of Ratio of 
; venereal to venereal to 
Year. Per 1,000. | non-vene- Year. Per 1,000.|  non-vene- 
real admis- real admis- 
sion rate. sion rate. 
Bengal : Per cent. India: Per cent. 
1860-64. 1,606 18. 1890.. 1,016 49.5 
India : 1891... 978 40.9 
1872-76 aly ie 1892. 1,107 37 
eg AGODe 3009 35.8 1893. 949 49.1 
aaah 1,010 36.8 1894, 997 51.3 
1880...../s,. 1,017 47.3 1895. 940 55.5 














In this service, also, the present greater virulence of 


venereal disease, as compared with former periods, is at- 
tested by a longer average duration of treatment and by 
an increase in the numbers of invalidings and deaths 
due to venereal disease, as shown in the following 
table: 


Vou. II.—39 














HH 





















































Fig. 1093.—Chart Illustrating the Admissions for Venereal Diseases, per 1,000 Strength, among British Troops in 
1, All venereal diseases ; 2, all venereal ulcers, primary; 3, primary syphilis. proper (1887-95 
(From report of Royal Sanitary Commission.) 














Average duration eee hela Ratio of deaths 
of each case of 4 5 due to syphilis to 
Year. - + real disease to total 
venereal disease. number discharred total deaths. 
Days. Pereite stl tw ren Canes 
25.95 3.0 0.1 
25.68 ad A 
28.39 7.2 Ai} 
29.07 6.3 6 
29.50 10.9 3 
29.01 9. 8 
29.82 3.7 5 
1804 ce siete 30.77 10.3 A 
OSs AAD 31.49 15.8 1.5 











As showing the extraordinary prevalence of syphilis in 
the British army as a whole it is of interest to note that, 
according to Longuet, this disease, in 1888, was fifteen 
times more prevalent anfong British than among French 
soldiers; while for the year 1896 the number of constantly 
sick from this cause, per thousand strength, was 14.22 
in the British service and only 1.29 in the United States 
army. 

It is probable that there is less syphilis among the sol- 
diers of the various European nations, excluding Eng- 
land, than exists among the unmarried male civilians of 
the same class, since those which appear to be severely 
infected with constitutional disease are promptly dis- 
charged from the military service. 

In the United States service, gonorrheea, in contradic- 
tion to syphilis, has been steadily on the increase for the 
past fifteen years; thus showing that there has been no 
improvement in the morals of the United States soldiers 
as regards chastity. In 1885, the admission rate for this 
cause was 37.76 per thousand, while in 1897 the rate was 
56.21 per thousand. For the year 1896 the number con- 
stantly sick from this cause in the British service was 
9.15, as compared with 3.22 in the United States army 
for the same period. In 1890 the admissions for gonor- 
rheea, per thousand strength, were 27.9 for the French 
army. 

oe the latter service, according to Marvaud, venereal 


609 


Camp Diseases. 
Camp Diseases, 


REFERENCE HANDBOOK 


OF THE MEDICAL SCIENCES. 








disease of all varieties has steadily diminished, as fol- 
lows: 


Admissions 
Period. per 1,000 
strength. 
TORO GO shies abet ee Naan tiawis vn seh ee tit eae eee meen 106 
TST oO eer cireicte cant cle tia ia cie’nictbis nieve aielertvelelesetare eeieielemte-atale 74 
TEC 2O8 ee ak ieee s cole cits tien olore nie ote sala le ceaetetersiatertiete e 5D 
TSSOSIO rie cities eelaaele daiwa cig cic seiucese scacele baleevelaiels Ste-ctes miners 45 
Causes Affecting the Prevalence of Venereal Disease 


among Soldiers.—The influence exerted by race upon the 
prevalence of venereal disease is undoubtedly not suffi- 
ciently appreciated by medical officers. A marked dif- 
ference in this respect exists even among the various 
armies of Europe, where similar measures of prophylaxis 
against venereal infections are in vogue; but it is when 
the rates for Asiatic forces are compared with those for 
white troops serving under the same conditions that the 
greatest difference is observed—this being particularly 
the case with reference to syphilis. It is undoubtedly 
true that this latter disease, introduced only compara- 
tively recently among the white and negro races, commits 
far greater ravages among those in which it has not long 
prevailed than among peoples who have acquired a com- 
parative immunity to the affection transmitted through 
a syphilized ancestry extending through scores of gener- 
ations. It appears to be true, also, that certain races 
possess in large degree peculiar powers of resistance to 
gonorrheeal infection; a quality long since demonstrated 
to exist in certain individuals of even the most suscept- 
ible peoples. The following table, taken from the report 
of the commission investigating the prevalence of vene- 
real diseases among the British troops in India, well 
shows the great difference in the admission rates for 
Europeans and Asiatics in respect to venereal disease: 


RATIO PER 1,000 STRENGTH. 












































DUTCH ARMY IN THE 7 ; 2 
East INDIES. ENGLISH ARMY IN INDIA. 
European Asiatic British Native 
Year. Troops. Troops. Troops. Troops. 
& |<23| 2 /<25|| & |<83) 2 [<28 
a O.2) b o.4 is Ol. B og 
n rt MN ro mM ae] RN ro 
L800 Se eGsade 58.9 | 483.9] 11.0 | 248.0 || 201.9 | 503.6 | 18.2 | 41.1 
ibe) eee 43 | 442 11.6 | 243.6 || 164 | 400.7 | 16.3 | 37.9 
1802 cr iscve sy eo 4f 440.9 9.7 | 223.5 || 160.4 | 409.9 | 17.1 | 39.6 
1808 ei eee 4.) 370 8 218 190.9 | 466. 17.9 | 36.4 
ABO4 i F acratsindle 37 | 416 7.8 | 191.8 |} 247.6 | 511.4) 17.7 | 32.3 
Mean for 5 years} 43.6 | 424.7] 9.6 | 225 195 | 458.3 | 17.4 | 37.5 




















From this it isseen that, in the Dutch East Indies, Asiatic 
troops suffer from all venereal diseases slightly more than 
one-half as much, and from syphilis but about one-fourth 
as much, as do Europeans. In the British forces in India 
the native troops do not suffer from venereal disease one- 
twelfth as much, nor from syphilis one-eleventh as much, 
as the white troops. It is probable that in India caste 
feeling helps to deter the native soldier from consorting 
with the lowest and most dangerous class of prostitutes, 
but his great freedom from venereal disease can be ex- 
plained only on the ground of racial insusceptibility. It 
is of interest to note that while the admission rate for Brit- 
ish troops in India has more than doubled since 1881, 
among the native troops there has been no appreciable 
increase. An inference which may be legitimately drawn 
from this fact is that venereal disease has not increased 
to any remarkable extent among the loose women of the 
country generally, but that among the class with whom 
the British soldier associates there has been an increase 
out of all proportion to their numbers directly as a result 
of such relations; both the native women and the British 
soldiers presenting rates far in excess of their racial 
normals. As between whites and negroes the greater 
resistance to venereal infection lies with the former, 
probably through a longer exposure to the processes of 
immunization through heredity, Comparative figures 


610 





for these two classes in the United States service, for all 
venereal diseases, are as follows: 











Admission rate | Admission rate Admissions 


Year. per 1,000 strength.|per 1,000 strength.| per 1,000 strength 
Whites. Colored. for entire army. 

ABB4, coals ctesei 75.00 101.00 78.00 
S855 tare pnecen 80.00 76.00 80.00 
LOSE. cesta steels chie hi WIlEREa asia 74.37 
ASST sates. 72.13 95.98 74.37 
ALSBS eee eet 78.08 98.51 80.07 
A BBO ere crteteh 84.86 82.75 84 66 
L890: Hrs ctor 72.02 105.39 5.21 
TBO T Setters 70.64 80.18 72.46 * 
180254 asen cas 75.71 86.94 76.72 * 
SOS reerolt ele tiie 74.94 49.00 73.08 * 
1808s vi Siesee a 82.21 47.46 80.43 * 
1890 ce. laslvcp 75.57 52.26 73.72 
TRG S tisiclaseiers , 80.04 56.53 78.08 
ac) eA re 81.80 114.60 84.59 
Decade 1886- 

eid lsietatwieliels 75.89 78.48 76.32 * 











* Including Indian troops. 


No satisfactory explanation of the sudden and marked 
reduction of the admission rates for the colored troops 
for the years 1893-96 can be offered. The experience of 
the British in the West Indies shows a higher percentage 
of venereal disease among colored troops than among 
white soldiers, syphilis being more than twice as com- 
mon among the former as among the latter. 

Another point well worthy of careful consideration is 
found in the fact that venereal infection, particularly of 
a syphilitic nature, appears to take place more certainly 
and to assume a much more severe character when rela- 
tions are entered into between individuals of different 
racial characteristics than when both are of the same na- 
tionality ; the aliens suffering in this respect to a greater 
degree than the resident population. It would almost 
seem as if there were localized varieties of venereal dis- 
ease the product of special environment, to one of which a 
race might be relatively insusceptible, although at the 
same time falling an easy prey to the allied diseases pre- 
vailing among peoples of other countries. Troops quar- 
tered among an alien but not entirely hostile population 
almost invariably suffer worse in respect to venereal dis- 
ease than those at home. In the Austrian army a large 
increase in such diseases followed the occupation of Bos- 
nia-Herzegovina in 1878; the French troopsin Algiers are 
more affected with venereal disease than thosein France, 
and the same is true toa marked degree in the case of the 
British troops in India and those of the Dutch in Java. 
In speaking of the native troops stationed in Bengal, it 
has been said with respect to venereal diseases that the 
“Gurkhas, being foreigners, have higher rates than other 
native troops.” These conditions, however, do not obtain 
when a command is moving or during campaign. The fol- 
lowing tables well illustrate the points just advanced: 


AMOUNT OF VENEREAL DISEASE AMONG FRENCH TROOPS IN FRANCE 
AND IN ALGERIA, COMPARED. (Admissions per 1,000 strength.) 





























3 F FRENCH TROOPS IN 
TROOPS IN FRANCE. ALGERIA. 
Year. | 2 | 8 3 B g £3 
5 G2) 2 ews 3 a | oe 9 
Py 3 168.) Ss); Bee eee 
B 5 os | e a is) hah oi= 
1802 ree tadels 8.3 5.6 | 27.4 | 41.3 || 15.0 | 11.9 | 28.6 | 55.5 
1808. eee Pre inek 5.8 | 25.38 | 39.5 || 15.0 | 12.1 | 32.5 | 60.6 
1804 series etic 74 | 5.2 | 23.5 | 36.1 || 13.2 | 11.4 | 26.6 | 51.2 




















ADMISSIONS PER 1,000 STRENGTH, FOR THE DECADE 1887-96, FOR 
BRITISH TROOPS IN INDIA AND AT HOME STATIONS. 








Disease. British army on | British army in 
the home stations. India. 
Primary Syphilis:.2. neces eee eee 59.2 127.5 
Secondary syphilis .............. 35.9 62.2 
Gonorrhoea .....6+6. BANG tacaore 86.2 176.3 


‘ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Camp Diseases, 
Camp Diseases, 





T 


AMOUNT OF VENEREAL DISEASE AMONG THE DUTCH TROOPS AT 









































HOME AND IN THE EAST INDIES COMPARED. (Admissions per 1,000 
strength.) ' 
ABROAD. 
TROOPS 
AT HOME. European Asiatic 
Troops. Troops 
4 |. 88 4 |.88 a |.ee 
Year| 3 |252| 3 = e348] a 2 (254) a 
p icsz| § | & \Ss2|/ 3 | & Sea! & 
a Sol & os Bol] ta) bol a 
1S a? | ae | pe BF so | aa 
‘ . 
1g7 }| No rieturn's for |! ¢1.8 | 447.7 | 509.5 '| 16.3 | 221 | 237.8 
1888 yejars. || 58 | 384 | 487 12.9 | 203 | 215.9 
1889 49.8 | 417.6 | 467.4 || 12.6 | 254 266.6 
1890 13 83 96 53.9 | 430 483.9 || 11 237 248 
1891 18 42.4 | 60.4 || 43 399 442 11.6 | 232 243.6 
1892 13.4 | 39.7 | 53.1 || 44 396.9 | 440.9 9.7 | 213.8 | 223.5 
1893 10.8 | 35 45.8 || 40 330 70 8 | 210 218 
1894 | 13.3 | 41 54.3 || 37 37 416 7.8 | 184 191.8 


























Climate also appears to influence the prevalence of 
venereal disease, as well as its intensity and character; a 
tropical climate appearing to lower the vital resistance as 
regards invasion by venereal infection, to induce disease 
of unusually severe type, and to cause, in syphilis, the de- 
termination of superficial rather than deep-seated lesions. 
The amount of venereal disease also bears a close relation 
to the age of the soldiers; young men, and particularly 
young recruits, being especially liable to such disease. 
The proportion of married men among the troops natu- 
rally exerts a marked influence on the occurrence of such 
affections; figures for the British army in India, for the 
years 1867-72, showing that the percentage of admissions 
for venereal disease among married men was one-fiftieth 
of the percentage for the unmarried. As might have been 
expected, recent investigations in the British service in 
India show that cases of venereal disease are much less 
numerous among abstainers than among those habituated 
to the use of alcoholics. In the French army, during the 
year 1887, it was found that the amount of venereal dis- 
ease for each garrison depended directly upon the amount 
of clandestine prostitution; the prevalence of these affec- 
tions varying directly with the rigor with which surveil- 
lance of prostitutes is maintained. According to von 
Tophy, the relative venereal morbidity in the armies of 
Austria, Germany, France and Italy bears a close rela- 
tionship to the prevalence of this class of diseases among 
the civilians in the district in which they are quartered, 
and hence all measures for the restriction of the disease 
should primarily be applied to the civil population. The 
amount of venereal disease also depends, according to 
Jeannel, upon the virulence of the type of the affection 
as found in foreign countries, and upon the facility of 
communication with the civil classes. 

Measures Looking to the Diminution of Venereal Disease 
among Troops.—Since no systematic attempt has been offi- 
cially made for this end, within the limits of the United 
States, through the control of prostitution in its relations 
to our military service—save at Memphis and Nashville, 
during the Civil War, —it is necessary to turn for data on 
this subject to the ample experience of other nations. In 
our small army, containing, as it has in the past, a large 
proportion of married soldiers and scattered in small de- 
tachments over a vast territory, the necessity for the re- 
striction of venereal disease among troops through the 
control of prostitution has not been markedly manifest; 
and the execution of such restrictive measures would in- 
deed have been impracticable at home stations. With the 
altered conditions and changed moral and social environ- 
ment which have, however, resulted from recent acquisi- 
tion of foreign territory and contact with alien races, the 
subject at once assumesa vast importance, believing, as we 
must, that the experience of the United States as regards 
the occurrence of venereal disease among troops will not 
be greatly different in this respect from that of England, 
France, Holland, and other countries holding tropical col- 


onies. That we may- profit in the future from their mis- 
takes of the past, and treat this matter forcefully, practi- 
cally and with an absence of sentiment, is much to be 
desired, but, in view of the varying political conditions 
controlling the policy of arepublican form of government, 
this is a result which is scarcely to be anticipated. 

On examining the figures given in the British Army 
Medical Department Report for 1883, as illustrating the 
influence of restrictive legislation in England upon the 
prevalence of venereal disease, the fact which chiefly at- 
tracts the attention is the enormous difference between 
the number of admissions for primary syphilis in the 
districts in which prostitution was regulated as compared 
with the admissions in the stations not under tie Conta- 
gious Diseases act. In the former the average annual 
rate for a period of thirteen years was 50 per thousand; 
in the latter the admission rate was 118 per thousand. 

The following table gives the total admissions for pri- 
mary syphilis and the average strength: 


AVERAGE STRENGTH AND TOTAL ADMISSIONS FOR PRIMARY 
SYPHILIS, 1870-82. 


Fourteen stations under the Fourteen stations not under 


act. the act. 
Average strength..... 47,394 Average strength..... 19,218 
Total admissions ..... 31,105 Total admissions ..... 29,582 


If these figures be compared, it is observed that if in the 
subjected stations the ratio of admissions had been the 
same as for those not under the act, the total admissions 
for primary syphilis would have been 72,952. It is thus 
obvious that 41,848 men were prevented from contracting 
the worst form of venereal disease, in this one group of 


' stations, owing to the enforcement of the provisions of 


the Contagious Diseases act. The number constantly in 
hospital for primary syphilis was only 3.97 per thousand 
in the group under the act, while in the group in which 
regulations were not in force it was 9.16 per thousand. 
The actual number constantly in hospital in the subjected 
group was 188, but if it were in the same proportion as 
in the group not under the act, the amount would have 
been 434; it is therefore evident that there was a daily 
saving of 246 men from being sick in hospital with pri- 
mary syphilis. In May, 1883, the act was practically 
done away with, the compulsory examination of prosti- 
tutes having then ceased; and the following tables are of 
interest as showing the disastrous results of interfering 
with such an essential regulation: 


CONSTANTLY IN HOSPITAL PER 1,000 STRENGTH, PRIMARY SYPHILIS. 











Group of stations 
under the act. 


Group of stations 


year ox Period: not under the act. 








ive i ; 8 
"| 12.41 | Act modified 14.01 


ADMISSIONS TO HOSPITAL PER 1,000 STRENGTH, PRIMARY SYPHILIS. 








Group of stations 
under the act. 


Group of stations 


Year or Porn. not under the act. 





1870-8 






101 188 
1883... é 
1S ee eee ee 138 s Act modified 160 


Browning has compared the admissions for primary 
syphilis, in the year 1875, at Chatham-Sheerness and Lon- 
don, one subjected to, and the other not under, the act; 
the average strength of each being about 4,000 men and. 
the places not farapart. For the former station’ the admis- 
sions for this cause were only 17 per thousand for the period! 
mentioned, while for London the admissions were 187 per 
thousand. Before the act came into force the admissions. 
at Chatham-Sheerness were 94 per thousand (average of 
1860-66). From 1867 to 1882 the rate was only 49 per 
thousand. On abolishing the compulsory examination of 


611 


Camp Diseases. 
Camp Diseases, 





prostitutes the ratio for primary syphilis rose, in 1884, 
to 141 per thousand. The average for London for 1867 
to 1882, not under the act, was 181 per thousand. 

The effect of the Contagious Diseases act in the 
United Kingdom in the number of admissions for gonor- 
rhoea was not so marked as in the case of primary syph- 
ilis; the ratio of admissions for this cause was 84 per 
thousand in the subjected group, while in the stations 
not under the act the ratio was 105 per thousand. It is 
computed, however, that the act prevented about 12,000 
cases of gonorrheea during the period 1870-82 at the four- 
teen stations where the regulations were in force. 

Previous to 1885, in the British service in India, lock 
hospitals had been established for the treatment of women 
suffering from venereal diseases. All prostitutes living 
in cantonments were registered and subject to medical 
examination. In many cases special quarters were al- 
jotted to them in regimental or cantonment bazaars, and 
women evading the rules were subject to ejectment from 
cantonments. In that year the Indian Government de- 
cided that a certain number of these lock hospitals should 
be closed, with a view to a comparison being made of 
the results at these stations and at protected stations. In 
1887 the results obtained showed that there had been a 
marked and progressive increase of venereal disease at 
stations in which the lock hospitals had been closed, and 
the percentage of disease compared most unfavorably 
with the percentages at the stations at which these insti- 
tutions had been maintained. The hospitals previously 
closed were directed to be re-opened, but in 1888 all control 
over prostitution in India was done away with by an act 
of Parliament. Since 1887, the last full year of the protec- 
tive system, there has been an advance of primary venereal 
disease of 187 per cent., and of secondary disease of 188 








HUNGER Tener 
ASS ANGEMEOA ConSBerr 








Hs 
PO Re 2 EY a a 
at SRE 
L A Ul epg a Sp eae 
olin eA 
SE 
Pitim, AMBER ol. Ci 


pf] toa 
Pang 


aol ¢ | | [\I Y | 
Siae anne 


PR 4 RS 
a ed pe pl hall ae 





S 
Pik HEDGE AMES Coe 


Fig. 1094.—Chart Showing the Influence of Laws Regulating Prostitution in the Rohilk- - 
hand District, India, and Cape Town, South Africa, upon the Admissions, per Thou- 
sand Strength, for Primary and Secondary Syphilis, from the British Troops Stationed at 

Black line, Cape Town; dotted line, Rohilkhand. Cape Town, without 

regulations, 1884-88, average admissions, 371; Rohilkhand, without regulations, 1889-97, 

average admissions, 370; Rohilkhand, with regulations, 1884-88, average admissions, 

132; Cape Town, with regulations, 1889-97, average admissions, 168. 


those Points. 


per cent.; a progressive severity of cases expressed by 
an average stay in hospital of 31.5 days in 1895 as com- 
pared with 26 in 1887, and a temporary inefficiency of the 
force exemplified by the fact that in 1895, out of 68,331 
men in cantonment 36,681 were in hospital for the above 
average period, of whom 22,702 were suffering from 


612 





SUESIRZEREERCOe 
COREE CCC EEE Ere pape 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





syphilis. The number constantly inefficient from venereal 
disease was 3,164. The invaliding from this cause ad- 
vanced from 1.13 per cent. under restrictive measures to 
5 per cent. in the statistics for 1895. In regard to the prev- 
alence of venereal disease in India in 1894-95, the army 
sanitary commission wrote: “The results of experience 
in India since 1885, when a number of lock hospitals were 
closed, and in subsequent years when all restrictive meas- 
ures were gradually removed, show that a progressive 
increase of venereal diseases has taken place among the 
British troops serving in India; and there is, unfortu- 
nately, no assurance that this increase has reached its 
limits.” 

In the year 1889 a Kontarions Diseases act was brought 
into force at Cape Town, South Africa, and in the same 
year all regulations for checking the spread of venereal 
disease were done away with in India; so, for a period 
of eight years it is possible to compare India, minus reg- 
ulations, with Cape Town and an act in force. For the 
five years previous to the act coming into force at Cape 
Town, the average admissions for primary and secondary 
syphilis were 371 per thousand of strength. The Rohilk- 
hand district of India, for the years 1889-96, had just the 
same proportion of admissions, viz., 8370 per thousand, 
both stations not being under a Contagious Diseases act. 

For the nine years (1889-97) during which the act was 
in force at Cape Town, the admissions gave an average 
of 178 per thousand; Rohilkhand, for a like number of 
years (1880-88), having nearly the same number of admis- 
sions, 184 per thousand, both stations being under a Con- 
tagious Diseases act. "The accompanying chart graphi- 
cally shows the influence of the acts upon the admissions 
for syphilis in these two stations; the heavy vertical lines 
marking the abolition of all restrictions’ in India, this 
being followed by an immediate and 
extraordinary rise; and also showing 
the point at which unrestricted prosti- 
tution in Cape Town came under official 
control, a remarkable and permanent 
decrease resulting. To such a con- 
vincing argument of the value of con- 
trolled prostitution it would be almost 
superfluous to add. 

Browning states that previous to the 
Contagious Diseases act coming into 
force at Cape Town, venereal diseases 
of all kinds were rampant, and the ad- 
missions to the military hospital from 
this cause appalling, they having 
reached 828 per thousand of strength. 
At no other region where British troops 
were stationed did the admissions reach 
such proportions. On comparing the 
admissions to hospital for venereal dis- 
eases for the quinquennial period be- 
fore the act, and the years following 
the act, a vast difference in the total 
sick with venereal disease was appar- 
ent. Theaverage forall forms of ven- 
ereal disease for the years 1884-88 was 
674 per thousand, while the average 
for the years 1889-97 was only 349. 
This was not a gradual fall which 
might be accounted for by an improve- 
ment in morals, but a sudden descent 
from 828 per thousand in 1888 to 347 
per thousand in 1889, and the rate is 
still decreasing. In 1896 it was only 
216 per thousand. 

In comparing the figures for all 
forms of venereal disease at Cape 
Town, it appears that not only has the 
number of venereal cases fallen since the act came into 
force, but of late years a large proportion of such affec- 
tions consisted of milder complaints. These, before the. 
act, constituted 34 per cent. of the total; for the eight. 
years subsequent to the act they averaged 49 percent. It 
is interesting to notice the great fallin the admissions for 


(SS Od EB 


74 Oe 


(After Browning.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


constitutional syphilis. 


for the period 1889-97. The disease 
was rapidly increasing when no regu- 
lations were in force, but twelve months 
after the act was promulgated the num- 
ber of attacks fell to what must be con- 
sidered a satisfactory ratio under the 
circumstances, and, with the exception 
of the years 1892, 1894, and 1895, the 
figures were under 50 per thousand. 
That the supervision and control of 
prostitution produce a beneficial effect 
on the general health of the troops at 
Cape Town is evident from comparing 
the total admissions per thousand of 
strength for all forms of disease, other 
than venereal disease, before the act, 
with the admissions after the act. For 
the five years previous to the act, the 


In 1888 the ratio for this disease 
was 209 per thousand, while in 1896 it was only 27 per 
thousand. The average rate for the quinquennial period 
1884-88 was 137 per thousand, falling to 51 per thousand 


Camp Diseases, 
Camp Diseases, 








tracted disease. There was a licensed brothel under su- 
pervision in the native town of Wady Halfa, and the 
women there were periodically examined. Very few 
cases of disease were contracted there. Stringent police 

















| Ly 
lees} | A [NT VT TTY 
SAR eo! 


pe ef 

jsco| Ve | | ATA TTT 
P TTT TATA TTT 
975 fenagern 





average annual rate for diseases other 
than venereal affections was 553 per 
thousand of strength, while for the 
years after the act (1889-97) the ad- 
missions were 502 per thousand, a fall 
of about 10 per cent. 

Browning concludes that the Con- 
tagious Diseases act of the Cape of 
Good Hope has “been the means of 
preventing thousands of soldiers in 
the garrison at Cape Town from being 
incapacitated by venereal diseases,” and 
that “the men who still contract such 
complaints suffer from a milder form 
than existed prior to the act coming 
into force.” He believes that “the act is a humane one, 
relieving the sufferings of hundreds of prostitutes and 
also alleviating the distress of women who, though not 
strumpets, contract venereal disease.” 

In the province of Pinar del Rio, Cuba, during its re- 
cent occupation by United States troops, the following 
order was published and enforced: “Clandestine prosti- 
tution will not be tolerated. Prostitutes shall be regis- 
tered. They shall live in such locations as are indicated. 
Each prostitute shall have a book. In this her name, 
age, nationality, and address shall be recorded. She shall 
be examined at least once a week by a physician, and 
the examining physician shall sign the book. This ex- 
amination shall be good only for one week. Any prosti- 
tute doing business when her book is not signed to date 
shall be punished. She shall not change her residence 
without the permission of the sanitary inspector. The 
proprietors of houses of prostitution will be held account- 
able for the condition of the houses and of the inmates, 
also for the orderly conduct of those living in or visiting 
such houses. No liquor shall be sold, given away, or 
drunk in houses of prostitution. Each prostitute will be 
required to provide the means necessary for securing her 
own and her visitors’ cleanliness. Cases of venereal dis- 
ease must be at once reported to the health inspector. 
When venereal disease is traced to any particular person, 
such person will be subjected to punishment.” As to 
the results which followed the enforcement of this order, 
Kneedler writes: “In connection with the matter of regu- 
lated prostitution, this command has been in Cuba three 
months and numbers three thousand men. These men 
have free access to the towns. I have not been able to 
find more than nine men who have contracted venereal 
disease in the Department of Pinar del Rio.” 

In the report concerning the sickness among the British 
troops composing the Dongola expeditionary force, in 
1896, the chief medical officer says: “On first arriving 
at Wady Halfa there was some trouble found in checking 
clandestine prostitution. There were a large number of 
native women who were living just outside the English 
lines, and it was from these women that the men con- 






Prostitution. 


Fig. 1095.—Admissions for All Venereal Diseases, per Thousand Strength, among the British 
Troops at Cape Town, Before and After the Regulation and Official «Control of 
(After Browning.) 








ad 


Z. 










Soar Voile nies pian 
(Co a WP GPP a 


4 
ba 
a 
ee | 
re 
| 

Ce 
as 
Fett 
fatibrs 
p | | 
LS 
ere 
Gl 
3a 
am 
am 


[aoa Op Ma 
Rar arias Sfeccecs 
Ea Rea BIN Steg Yo rE 


pe tet ly ae Se eer ale 
BOGE oe sole 


Lael ES 
MPa 
Ho 
yy 
Basin 


precautions were taken, and a military patrol was placed 
outside the camp to prevent women from coming near, 
and this answered. so effectively that after a few weeks 
the nuisance was almost stopped and there were hardly 
any admissions afterward for venereal.” 

For the period 1863-65 the Italian army had an admis- 
sion rate for venereal disease of 120 per thousand; this 
falling in 1874-76, as the result of sanitary inspection and 
careful control of prostitution, to 66 per thousand. 

Such facts as are given above may be greatly multi- 
plied, and there can be no doubt that the intelligent 
regulation of prostitution results in a great decrease in 
venereal disease ; this is to be accomplished by a system in- 
cluding careful registration and surveillance and frequent 
official medical inspection. The latter requirement is of 
the greatest importance, a fact of which the British Sani- 
tary Commission in India was fully convinced when it 
reported: “We are satisfied from the evidence that the 
frequent examination of women is the most efficacious 
method of controlling the disease.” These examinations 
should be made in private, and only in the presence of 
official examiners. The latter may be females who have 
been sufficiently trained for the intelligent discharge of 
this duty. Military garrisons attract to their vicinity 
lewd women of the lowest character, and largely subjects 
of venereal affections. Such being the case, great care 
should be taken to prevent loitering or importuning by 
this class or by their male associates within the limits of 
the command. Particularly in the tropics it is desirable 
that no females should be employed in, or in the imme- 
diate vicinity of, the barracks, since there is evidence that 
such women are frequently the source of aggravated 
forms of venereal disease. Clandestine prostitution 
should be prevented as furnishing a high rate of venereal 
disease. Colin noted that of,32 syphilitic French soldiers, 
14 were infected by public prostitutes and 18 by women 
employed in so-called wine-shops. AJl public prostitutes 
should be segregated within well-defined limits as re- 
gards residence and public solicitation severely punished. 
Brief printed instructions should be furnished these 
women as to the dangers and prevalence of venereal dis- 


613 


Camp Diseases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








ease and the importance of cleanliness as a measure of 
prophylaxis. Next to medical inspection, it is probable 
that care in maintaining cleanliness of the person is the 
most important factor in the prevention of venereal dis- 
ease; it having been experimentally determined that in- 
fection from the non-syphilitic venereal sore may usually 
be prevented by a thorough cleansing of the parts with 
soap and water if done within ten minutes from the time 
of exposure. When diseased, such women should be at 
once isolated in a proper institution. Apart from the 
great importance of such action upon the general wel- 
fare, it is merely a matter of humanity to these un- 
fortunates that they should have the benefits of medical 
treatment, with rest and care in hospital, until they are 
cured, Obedience to these regulations should be en- 
forced by police authority, and public exposure, as far as 
the occurrence of venereal disease is concerned, should, 
as far as possible, be prevented. It should not be for- 
gotten that when official control becomes too rigorous 
the number of avowed public women undergoes diminu- 
tion, while clandestine prostitution increases. 

The large amount of venereal disease occurring among 
troops—a condition entirely preventable and dependent 
upon vicious indulgences on the part of the soldier—has 
led many to suggest the institution of measures calcu- 
lated to prevent its occurrence through the imposition of 
penalties upon those offending in this respect. It has 
been suggested that those incapacitated for duty from 
this cause be deprived of their pay while rendering no 
service to the government; that their privileges be re- 
stricted, or that confinement be imposed. All these plans 
are, however, readily defeated by the concealment of the 
disease; and the proper imposition of punishment for 
this cause could be made only with the assistance of a 
careful system of inspection. In the French service a 
month’s imprisonment was at one time imposed upon 
every venereal case after discharge from hospital, but 
this led the men to conceal their diseased condition from 
the medical officers and p'ace themselves in the hands of 
empirics, and the order was revoked. _ It is certainly sub- 
versive of discipline and unjust to the more continent 
class of men that they are obliged to perform the extra 
duty which results from the entrance into hospital, as a 
result of their own misconduct, of those by whom such 
work should rightfully have been done. Such a condi- 
tion of affairs obviously puts a premium upon participa- 
tion in vice, and it is much to be regretted that no satis- 
factory method for its punishment has as yet been devised. 
Where measures for the control of prostitution can be 
carried out, the soldiers affected with venereal disease 
should be required to state where and from whom it was 
contracted, with a view to the proper segregation and 
treatment of the women indicated. In the British ser- 
vice, however, during the existence of the cantonment 
laws, Welch states that some difficulty was experienced, 
in the attempt to identify the source of venereal infection, 
through the unwillingness of the soldiers to expose their 
co-partners in vice. 

Many soldiers affected with venereal disease hesitate to 
declare its existence through the official publicity neces- 
sarily given to all cases, and through reluctance to have 
their names entered upon the records in connection with 
diseases of this character. Asaresult of such action the 
condition is, in many instances, aggravated either by be- 
ing left without treatment or by the employment of patent 
medicines or unskilled advisers. Where venereal dis- 
ease is concealed, the offender, if detected, should be 
severely punished; and where such practice is general the 
system of weekly inspection, as is customary in England 
and on the Continent, may have to be employed. This, 
in fact, has lately been carried oué among certain of our 
regiments in the tropics. It should be thoroughly under- 
stood by the men that it is greatly to their interest, in the 
way of cure, to declare the existence of such a disease as 
soon as its appearance is noted. To further assist in the 
accomplishment of this object, it should be required that 
all non-commissioned officers knowing of the existence 
of cases of venereal disease in their troop or company 


614 





should be held responsible for the prompt appearance of 
the sick men before a medical officer. 

It would certainly be of advantage to the military ser- 
vice if a short series of lectures by medical officers were 
required to be delivered annually for the purpose of ac- 
quainting soldiers with the grave and far-reaching con- 
sequences that are likely to result from immoral conduct, 
particularly from clandestine prostitution; the impor- 
tance of early treatment and the dangers of concealment; 
the intractable character of syphilis and the necessity 
for prolonged medication; the dangers resulting to the 
healthy from the presence of concealed venereal disease 
in barracks. Such lectures would be of special value at 
recruiting depots. Chastity should be inculcated. The 
common idea that celibacy increases sickness and mortal- 
ity should not be encouraged, since although many single 
men renounce marriage because of bad health or disease, 
this is a cause not met with in the army, where there is an 
enforced celibacy analogous to that of priests, who, al- 
though single, live as long as married men. 

INSANITY AND SuicrpE.—These are best discussed in 
this connection, since they are largely dependent upon 
the personal habits of the soldier, particularly in relation 
to alcoholism. 

Mental diseases have undergone a considerable diminu- 
tion in our service during the past few years, this un- 
doubtedly resulting from the greater provision officially 
made for the intellectual needs and recreation of the 
soldier, together with the withdrawal of troops from 
small isolated posts and their concentration near large 
centres of population. The following figures show the 
rates for this cause for a period of thirty years: 























Admissions Admissions Admissions 

Year per 1,000 Year per 1,000 Year. per 1,000 
strength. strength. strength. 

Ask TS7S Fert 15 1888..... Ly 

1.5 1879 ence 1.9 L880 ie ace 1.3 

2.1 SSUES rte: 2.1 1890.....3 1.3 

2.0 Aboot Beira 2.5 ASOT a, oe 1.5 

2.4 ISB2 icc as 2.8 1802 1.9 

2.2 1883..... 3.0 1893...... 1.3 

1.8 1884..... 2.1 SOLS es 9 

2.2 IS85 tence 1.4 1885 3ee. a 

1.4 1886..... 1.4 1806.5 8 

1.6 1SSU hee 1.9 SOGanece 8 


























In contrast with the conditions prevailing in our ser- 
vice, as shown above, insanity would seem to be steadily 
on the increase in the French army. The figures given 
below refer to troops on: home service and in Algeria, as 
sanitary statistics are not published regarding the garri- 
sons at various other colonial stations: 














Number of men Number of men 
Year invalided for Year. invalided for 
mental alienation. mental alienation. 
thc i Rocmnccncaae 62 f Cote AGGIE CIT 73 
BIS: cae celeste 94 \88atee Maen 120 
GUO Ri Stecama ert [7 1886 cAiec = sie ae 112 
ASSO eetiteeeess 63 L887 sac taser 130 
i hotel geen oie 82 1888 costo. 150 
TOSCEtertker's 81 TESS S Sarcc eestor 158 
ASS Saree cries 64 1800. setae 192 














In the British army the rates for mental disease for the 
ten years 1887-96 are given as follows: 


Admissions Admissions 
Station. per 1,000 Station. per 1,000 
strength. strength. 

WN OTANG 1 parels sister olecsters 1.2 Bermuda seamen deents 1.5 
Seotland i. Wiemcevecnt 1.8 West Indies.......... ie 
{relandc, tena cee. ooo 1.6 Geylon s..00% deste 1.3 
Gibraltar a iatcecs sear is China.0. 200s aee 1.2 
Malta Paice wae coe a hrs Straits Settlements.... 1.5 
Camadarg. 2 ccistects pus 38 India 5... occ seg ceca 


From the above figures it is seen that tropical service, 
contrary to what might be expected, does not apparently 
increase the liability to insanity. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The military spirit, which naturally cultivates indiffer- 
ence to life, is undoubtedly favorable to self-destruction, 
and does much to raise the rates for suicide in the mili- 
tary service above those prevailing in civil life. In ad- 
dition to this feeling the soldier, constantly under the 
control of others, separated from home and friends and 
often occupying isolated and lonely stations, is more 
prone to melancholia and mental depression and the ten- 
dency toward suicide occurring therefrom. In the United 
States service, after the Civil War, the rate for suicide 
had increased greatly until within the last three years, 
when there wasa suddenand great diminution. For vari- 
ous years the rates have been as follows: 


Suicides Suicides 
Year. per 1,000 Year per 1,000 

strength. strength. 
BOB rracicenileld vis iar vw se 0.44 ANG} Naoto Goernecie toe 0.83 
TVS asp eerene Sereieere 51 TB Od Fore crite sto eater one 79 
MSTOrcnnacicsc wees sae:s .63 gts Ounce Aare on SAGE 43 
ASaettene tdci s bee see +s 1.10 MOOT S certhe Fs Gotete tia vias 39 


In 1898, a year of war, the rate greatly diminished, being 
only .04 per thousand strength. The suicides for the 
seven years 1887-93 inclusive amounted to a total of 
134 cases: officers 7, and enlisted men 127. These were 
divided according to the branch of the service as follows: 





ATE SMISLD Vere tite it wrasels e's. s sissera (eles a o:elele civ wie vie inca ey are eee oamle 64 
MPR EAEL.VMatstaVatetetave¥e: clots) ste Par avolcre ative) esa levels) aTele svat ai axe ave dlevote, one rerate 28 
PMT NICHE Veet te teres Vet evocd ste)ote' oi slacevateusl svaiacacatatalatsye aise ten entactie oun esate ote 15 
RERISU NES Wate te eee ect faye ai esabs arelssie's eieyalecocs wiafe/syare ace, ololevuitieoltaid conip wPoione 5 
UIE ERAT SS PEPSI CET ebore atais eiore otece te oars e nis, @ Gina's eid venaiareaiars (stor wine 2 
PGA MAU GOSDIGAL. COLDS a raciec sie cctioscocsiovseecceceee re 
RN MIMCOT IAEA T MURALS ch crs l'ovel'cly eis Hhal'sh nual o date: sialsiptvle’aiaie ial Wis ecalfstaale lo alec 13 


Of these, 51 were under 30 years of age, 56 were between 
30 and 40, and 27 were over 40. The methods of self- 
destruction employed were: 


PRPEML SCO tetera ete plareis a shels. oinle: ata, ditvacato rein wiasaieae’ere:s vslousso aie ole avers ue 
EMEAOIREN ICC acc ccietas) oes etoncisicleie’ ists elsjoreipcalasaipraip (sia siele’s elses o's 26 
EACLE eve MTT tiiolnle ae sols reietels: olsttntnslele sient eva hia, sreressaneia’s @ ye 4 
MA ERCSARH CUS DEM Leta leiaeiais, viv siecle! aleve ielounle Gicla oleleis delet ews aisle ide 3 
PS ROMIOUTAAL AM ATDON Ye cies ateves's sre neralaielo,e.ers o'yiele" oes eH bole eles ele 1 
POEL OMe ECHIN acted aveiayaraiiaioe Wiavodetove's/s wisely Ai el elas anvne oteinaiereuaual e's e-enetoce 1 
BaD DteAIa OUT BLOM tense racsievaterstele tere t siveia'e ¢,0,0 slslaiadclaisieate Herre. «revere 1 
OMANI DY TAULTOAM TALI ssi01c ccveteie ove seis cielo aie wie eicise vives 1 


In 87 instances the causes of the suicide were undeter- 


mined. In the others the causes were reported to be as 

follows: 
PAURCOMAMUISEL aera aniAe oisialsisisie cela cinie\ o/sie\sievgis ie ¢ wyeinvs's aleieiwidl'.0 odie $38.0 42 
PA DSEICHAULEAVLES Vener stetawetsieysie a) c7eiseiene sveinis aveutie lieve tisieteiaversie sfelsra.e vin’ ave 12 
DIESEL ete tevtera enc aie ase o,oelecerel ec erecelelereie araee'neleieeis oraie a oe asaid sere 10 
RI MAIN CLT OM aera pie Sseoe ancliais isiais elvis: ofp lelsiaycierelele-siMervieisle y sacs, ¢.a's 6 
DP TMPOLATY. MEMUAL AVETLALION 5, 5,c.cis. x10 /0\s slareyelels sic cise a o:ms wi0(p si 5 
MeaIGM COULD MMATUUAL sc sraars cisco costes cloves cies eae Geis se ae © 5 
MFT RUC MEROUD LOS ae ialelole eid ciere:eleislaie slot ivta'e ioe eWieveeie oceld Bede 3 
Mea Om RESITSION SVPHIUIS is cc. o.c cievaiele are 'sisle v wwlaele seis eb,e\bres 0 2 
Meh asics ven ta Ie ARTI LATA IO" ia aVavale (s/s wisvajeraioSetnsels vipiale'e © siesaisasele ve-ecela,ele 2 
PP HC INO IMULIOL Geet bat te Wisco) raitiaaicle acres hisnsieTecacesisse et wise eevee 2 
PU RSENICI ELST SMEs cre ete the: oik oe ie che. a-oi\iel ofR OMe le & ovate ieteveosdietalara, vw 'elal eaves © 2 
POMC SUCHIMESS ty ipleloseiclc pac snician von ofelerelciarerayels @ slolaicineletee'a e o-alete i 
EEMCRIS LC EOSSIOTIY icteipis «/sie: 016) a,e(ole) e\e.eihleje Vainio. o's aie sushsisies.a oe ove 1 
WAL ILE WO, ODUAIM-PrOMObION <a occcc.c ce voces svmem sede ec ews 1 
MOTTON EVAR SS otee relents staieis-n6. wise a le'S ie: te el evsravaie ol Sin abet nike brave aia 'e il 
HO MSLRRDE LOTS OLVACOL , aisnote-c s/tiotels oo i hase o’ers'epalclSia tials daie apyaicterc t 1 


For the four years 1894-97, of the 58 suicides committed, 
only 3 occurred in the first year of enlistment; thus cor- 
roborating the general impression that self-destruction 
prevails chiefly among old soldiers. It will be observed 
that in our army, recruited by voluntary enlistment and 
with a short term of service, the suicides from dislike of 
the service or other reasons depending upon a military life 
are much less frequent than in foreign armies maintained 
by compulsory enrolment. 

According to Millard, the rate per thousand for suicide 
for the entire British army during the period 1852-56 was 
.155; for the period 1859-66 the rate was .26; in 1866- 
70 it was .448. In 1873 it had fallen to .25. For the 
British army on the home stations the rate was .23 in 
1897, .21 in 1896, and .20 as an average for the preced- 
ing ten years. For stations outside the United Kingdom 
these latter rates were practically doubled. In most 
cases the causes of suicide were stated to be unknown. 
In others, they were variously reported as hy pochondria- 
sis, disappointment in love, excessive drinking, dislike 











Camp Diseases, 
Camp Diseases, 





of the service, fear of punishment, insanity following 
diseases like malaria and typhoid fever, and “temporary 
insanity.” The chief methods selected for self-destruc- 
tion were, in order of preference, shooting, hanging, 
drowning and throat-cutting. 

In the French army serving at the home stations, the 
rate for suicide, as given by Viry, was .47 for the period 
1862-69, and .29 for the years 1872-90. In a study of 
69 cases, 9 of which occurred in sergeants, Arnould di- 
vided the causes as follows: 

Meal PUMISHMEN Gyr ten wert cole dersetelels ss. cecle Pifersiale se vie jes ve 


Mental alienation from disease 
UIE TO WIM Serevoie tates taletscreraove Mal odotete ied onaiete vaya clause SNR ee 


FLY POCDOMALIASIS storey) oyevoraie) oretalesoyeistors/orele/stols ame vio/oielay selene 
PATCOMOMUSTI ces seoteieratrisisierrissienie Gemieldiemiete nie 





Viry states that only one-sixteenth of the suicides among 
French soldiers are attributed to dislike of the service; 
the greater number being due to the fear of punishment, 
brought about by neglect of duty and not by the sever- 
ity of discipline. In Algeria and Tunis, for the period 
1872-90, the suicide rate was .68 per thousand. 

In the Prussian army, 1829-388, Baudin states that the 
suicides averaged .50 per thousand strength. From 
1846 to 18638 the rate was .46; from 1867 to 1872 it was 
.60. For the entire German army, 1873-78, the rate 
was .61, and from 1878 to 1888 it was .67 per thousand. 
The Saxon army corps is said to have had an unusually 
high rate, the suicides for a long time averaging .92. .The 
rate for suicides in the German army is nearly twice as 
great as that for the French service. In 1889-90 the pro- 
portional number of suicides, calculated for each thou- 
sand deaths from all causes, was as follows: 


MnGer One year OLSELVICE  asicce cect wa tiseiensineiiece ogee 87.7 
Fron) one t@two years’ SCLVICE 2.6 cnc siae elec cece ntece cle 80.9 
From two to three years’ SCrviCe........0.seccccscsccceccee 25.9 
Hromthree to four years’ Service shoes cece pense ve oncee 8.6 
Four years’ service and UPWard ...........0ccccccescceces 38.8 


The causes of suicide may be roughly divided into one- 
third due to fear of punishment, one-half to mental dis- 
eases, and the remainder divided into disappointment from 
various causes and dislike of the service. 

In the Austrian army the rate for self-destruction is ex- 
tremely high, having been .97 in 1870 and .81 in 1873. For 
the former year, suicide was relatively four times more fre- 
quent in non-commissioned officers than in privates. Of 
late the mortality from suicide represents 1.5 per cent. of 
the general mortality, and this rate appears to be increas- 
ing. Asin the German army, more than half the suicides 
occur during the first year of service; and mutilations of 
the index finger, middle finger and thumb of the right 
hand—to incapacitate for military service—are common. 
One-third of the suicides are ascribed to dislike for the 
service, one-third to fear of punishment and one-third to 
melancholia. About 70 per cent. are accomplished by 
shooting and 20 per cent. by hanging. 

In the Italian army, in 1887, the rate for suicide, per 
thousand strength, was .30. In 1888 it was .45, and 
in 1889 it was .388. Three-fourths of the cases are offi- 
cially attributed to causes foreign to the military service. 


DISEASES INDUCED By EXPOSURE. 


Broncuitis.—This affection, in our army, is one of the 
most frequent causes whereby soldiers are rendered tem- 
porarily incapacitated for duty. Its mortality in young 
men of the military age, when occurring idiopathically, 
is, however, small. In the United States service the ad- 
missions for bronchitis, since the year 1860, have under- 
gone a certain decrease during the period of peace, being 
as follows: 


Admissions 

Period. per 1,000 

strength. 
ASGLZGG I COUVALS WAT) itera cies e setaleleisrs sous vin sialeterssiattere ste 4 ssecete 92.94 
USOS-SE eater ares Nom ene eels vleeineteeeiee ne Rictoee dalawamle eltla 77.73 
MOO OL iaracct eiecehatate ty stators oe oliteayavalnciaiiale aierv-alalerelatecets wre glate'e oe 68.67 
SOROS. scree cistoletaberelars aval ereinie/e cial alsiaivin atesave gf sibassesei stasis ayeiats ec a\p 75.48 
LORIE LOM atrerteniecnveye eiatemctr neat tuts siticalctauele et ielne Atain at 59.72 
BY CAT LSOB MC war With Span revises oh « avsivis bie gete diathreie 100.65 


615 


Camp Diseases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Bronchitis may be brought about by a great variety of 
causes. There are those who regard it as largely due to 
the invasion of some specific micro-organism as yet un- 
determined; and any irritant gas or dust may produce it. 
In the military service, however, the evidence that an 
important part in its origination is played by exposure and 
cold, particularly the latter, is conclusive. Reports for 
our army have for many years shown its greatest preva- 
lence to occur in the more northern military departments 
and posts; and the remarkable influence of cold weather 
in inducing this disease, as determined by months, is well 
shown in the accompanying diagram. It would seem to 


Fic. 1096.—Distribution of Cases of Bronchitis in the United States Army, by Months, per 
Thousand Strength, for the Decade 1875-1884. 


be abundantly demonstrated that, for our army, idiopathic 
bronchitis chiefly results from exposure to cold; this in- 
terrupting the eliminative functions of the skin, whereby 
an increased duty is thrown on the pulmonary mucous 
membrane, thus inducing internal congestion. This hy- 
pothesis largely explains the commonly observed *fact 
that outbreaks of considerable magnitude not infrequently 
occur among troops who are naturally exposed to the 
same meteorological and environmental conditions. Age 
isa factor of great importance in the occurrence of the 
disease, very young and very old soldiers being particu- 
larly liable to it. For the period 1890-96, figures showing 
the distribution of bronchitis, according to age, are as 
follows: 


Admissions 

Age. per 1,000 of 

each class. 
19 Years ANd TINGEr Sct. cue chet iia teeaele cre eractart tetra tra 132.08 
PO TOE Gs a ro tithe eran Gildas cette weeoaluiehebacar ne etactte 83.70 
PD TOLD ae nocns gla eotcter ers eters oiarase tes lolots ois ole sit aie asinreln es aiectes 60.66 
BOTOBEL Se Nea s cies faa «al slaetete cnotnidlon ni auaitteteersiele eskevte 57.15 
BD LO BO cee diossiane eieeve eivielciontewn comes vetns ries centre 53.98 
BD 10 BAS, 5 roe acteds ite Fae Paola eG nae te eran See 60.52 
AS LOVED Mee Site cio ache nh aus tens oe aaa tree ice nears 61.39 
BO GOD Fes wossicsrgetiy be Sen aidicia cies warsivers acme petiaters area 70.75 
Hw TOS rca teeter ar sitar tiie ane cess onan tpt an ccre 88.60 


The greater exposure incident to mounted service ex- 
plains the higher rates, for the above period, given by 
cavalry, 76.08 per thousand strength, as compared with 
infantry, 68.18 per thousand strength. The same condi- 
tion explains the greater frequency of this affection 
among troops in the field as compared with those in gar- 
rison; the proportion of cases during the year of war 
(1898) being almost twice as great as during the previous 
year of peace (1897). In many instances wetting of the 
person, where an early cutaneous reaction is not secured, 
is followed by bronchitis. In barracks, many cases appear 
to be directly associated with the use of an excessive quan- 
tity of water for the cleansing of floors, with the damp 
atmosphere thus produced. 

In the prevention of idiopathic bronchitis the avoidance 
of surface chilling, whether from insufficient protection, 
draft or wetting, is extremely important. Wet clothing 
should be replaced by dry as soon as possible, the body 
being wiped and rubbed vigorously to restore capillary 
circulation. The barracks should be dry, warm, and 


616 








well ventilated without being drafty. The clothing 
issued should be of good quality and suited to the climate 
and season. More than that, its proper use should be 
enforced, and soldiers should not be allowed to go from 
warm barracks into a cold, damp atmosphere without 
donning additional protection or seeing that their outer 
garments are well buttoned up. On guard, especially in 
wet or foggy weather, it is important that the person be 
well protected. When men are wet and chilled frorn 
exposure the issue of hot soup or coffee is desirable. 
During a march in cold or wet weather, it would seem 
that mouth-breathers are more liable to be affected with 
bronchitis. As far as possible, duty 
which implies exposure to inclem- 
ent weather should be avoided. 
There is no doubt that troops long 
in the field and habituated to ex- 
posure are less liable to contract 
bronchitis as a result of such ex- 
posure. 

RHEUMATISM AND Myareta.— 
Under this heading are included, in 
our official nomenclature, all affec- 
tions of a rheumatic nature not spe- 
cifically diagnosed as rheumatic 
fever. Until 1884, rheumatic fever 
was also included in figures for 
rheumatism in general, and hence 
statistics for subacute and muscular 
rheumatism are not satisfactory 
prior to that year. These affections 
are responsible for a large amount 
of inefficiency and loss of service, 
notwithstanding the fact that many such cases, through 
their insignificance, receive treatment and are returned 
to duty without being taken up on sick report. On the 
other hand, it is probable that the rates for subacute 
rheumatism and myalgia are unduly raised by fraud, 
since these affections are the ones most frequently se- 
lected by malingerers for simulation. Since 1884 the 
admissions to sick report for these causes, per thousand 
strength, have been as follows: 


Period. Admissions. 
Decade 1884-98 aici: o:c:sie'sinieie's sie sivie vere siece ale otuleie oie eeelemenetee §3.84 
"VO ar 1804. 5.5.5 s:erreia rere etre elstehatre diate, at-ciels. c/a ale eee 63.33 
"V@ar W890. aiciwssecs 0's hivie oie. 0 grectiet ain nraiatese)evere aceite e fete ee eretevarene oneee 64.08 
VOar 189. sic) s.c5cjacwceweievore’e a die earelete ¥ ote a(euaeleice neler nent 79.33 
Year 1897 0s Aucc eG Geidiow se sacedis waves ecdieala cite eens 65.12 
Year 1898 05 Seacvda «sce sects cet sie|vxin et emis einersl eee een 72.88 


While the cause of these affections is unknown, they 
are markedly influenced in their frequency by moisture, 
and toa less degree by cold. They attain theirmaximum 
prevalence among troops in this country in early spring 
and late fall, coinciding with the periods of greatest rain- 
fall. In their geographical distribution they are highest 
in those military departments in which the humidity is 
greatest; and in posts, in those in which damp casemates 
and old, badly constructed barracks are in use. 

Among our troops the negro soldiers appear to be far 
more prone to affections of this character than the whites, 
the rates for these two classes being as follows: 








: Admissions per Admissions per 
Period. 1,000 white soldiers.|1,000 negro soldiers. 
1884-98 's Rec aeaies weet etre 79.68 121.60 
TBO4 is. dsortish s salamat nom estat 62.87 12.87 
W895 yeaen dengransins westie tone te 61.40 95.07 
VBOG: cickee araisie erect ciepis ates 75.79 117.74 
TSO ae Fri cseean oem ee ane 61.80 100.74 
TBOB Tire sre tre ccuet ace tiers rer ote 68.28 132.81 











The great difference shown by the above figures is 
even more noteworthy when it is considered that the 
negro troops have, during the above period, been largely 
stationed in military departments in which, for white 
soldiers, the affections under consideration are of relatively 
infrequent occurrence. The figures for 1898, when both 
classes came under practically the same climatic influ- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases. 
Camp Diseases, 





ences, probably show very closely the greater suscepti- 
bility of the negro race. These diseases occur more 
frequently among young soldiers than among those of 
somewhat longer service, probably through greater care- 
lessness with regard to exposure. In the class of very 
old soldiers the rate is, however, high. 

In the prevention of subacute rheumatism and myalgia 
dryness of person and surroundings appears to be by far 
of the most importance. Wetting of the person by rain 
should, as far as possible, be avoided, and damp clothing 
and bedding should be at once removed and dried. Water- 
proof clothing, rendered impervious by the use of wool 
fat, should be issued; and all clothing should be sufficient 
and adapted to climate, season, and weather. Barracks 
should be warm, dry, and well ventilated, should have a 
sunny exposure, and should be located on a dry site. The 
use of casemates as quarters for troops is to be vigorously 
opposed. Where these affections largely prevail in a 
post or barrack, a general inspection of cellars and 
foundation walls is indicated. 

Acute ARTICULAR RHEUMATISM.—Figures for the 
United States army with regard to the prevalence of 
rheumatism are not comparable for the period prior to 
1884 with the period subsequent to that year. From 1861 
to 1884 the official nomenclature included all forms of 
rheumatism under the same heading; but from 1884 to 
the present time the differentiation of rheumatic fever 
has beenrequired. Since the year just named, the admis- 
sion rates for acute articular rheumatism have been as 
follows: 

Admissions 


Period. per 1,000 
strength. 
BUCA Ceti mre er nictare trecsieal ere cessed wine eats wale euieieersielee sues 4.36 
rae WR SECM NM Paes Te Sater ee ie Treva stove od kcal ovelsiata ale el oud Afers fore! «62m eyed 7.03 


These rates for acute articular rheumatism are much 
lower than those of nearly all foreign armies. In the 
German army the occurrence of this disease has been as 
follows: 


Admissions 

Period. per 1,000 

strength. 
SEA Peete eS PEs alae tojavorsiose slaps" clslale,o¥e:eleyeiawelelp Gia acocti elo avase avo 9.2 
PERE RDOLLOOU-OL aie aciciorstoiee es devin ssiamameds damon «ate eee 9.8 
MN eANIRL OOD OU a hater ac ev ola cies el merelde wiesaianuve cisieisieoeiee «ere ies'e 8.9 
PPE ile Oty caetoehpcalste tals, ovG-alevelelsleis.\ sidisie atelave os Ge aipye-diete etesea we ala vere 
SUE OME NF N Lice cata cte: els saVarovn yi pa ola/vin\sheleie Gloleseirewvs sare sadina-va ve 6.8 


In the Austrian army the rates for acute articular rheu- 
matism appear to be higher than in any other service, 
during the past few years having attained the following 
high proportion: 


Admissions 
Year. per 1,000 
strength. 

ea SME eMt cre ee. archeievesvialalelays'ehsiore’s ote s/atela:e, ielals’ ele eiAvayaveveielet ofcrzvete’s 11.3 
Bio ami eee a Shaye ea Ge es oo cos w nln opera ls SVanohot'o,e asereieic ohare’a sveipieichaiece 12.2 
SF e ty MMP Tle cis) ste cue ct ith olelaroisravcielaisicie pawedaialstes nieiels waits 11.6 
SORA aes eis cloaked oe cists oa apc tis hve bieigrssisct )hulees 10.4 
1897 Ties are ola Sactalpe eit Ae t lesava alee che gace Sieaimueine wets 9.2 


The true nature and origin of acute articular rheuma; 
tism are still unknown. Taking into consideration the 
many forms in which the disease manifests itself, it is 
‘certain that no neurotic theory and no theory of per- 
verted metabolism can fully account for all the phenom. 
ena presented, many of which strongly suggest a microbic 
infection. No micro-organism has as yet been shown to be 
the cause of rheumatism; but the same is also true of such 
undoubtedly microbic diseases ‘as measles, scarlet fever, 
whooping-cough, and syphilis. The strongly marked 
hereditary predisposition to rheumatism causes no diffi- 
culty, for the same fact is observed in tuberculosis. 
That exposure to cold and wet is often a factor in the 
causation of a rheumatic attack is analogous to what is 
often observed in pneumonia. Exposure, however, is a 
factor of such importance in the occurrence of rheuma- 
tism in the military service that, in default of accurate 
information as to its specific cause, the disease is most 














conveniently classed with those induced by cold, wet, 
dampness, and exposure. 

Rheumatism, in its prevalence, has a certain relation to 
season. Coustan showed that for the French army the 
amount of rheumatism was much greater during the 
winter months than during spring or summer; in autumn, 
rheumatism was only about one-third as prevalent as 
in winter. Local conditions, as shown by statistics for 
our army, appear to have far more influence upon the 
occurrence of rheumatism than do geographical consid- 
erations. Race exertsa certain influence; the admissions 
for this disease being lower for white troops than for 
colored troops. Age is a factor of some importance, the 
rates for the seven years 1890-96, per thousand strength, 
being as follows: 


Admissions 

Age. per 1,000 of 

each class. 
1D Wears ANG UMS teacsieieh ale ete cb ed spore ele ner ait teres 8.61 
OTD Setatemrarete welttetey eva neraiecnte eaten oa oe es each ee eel dake Oe 5.71 
PAL Oars we aaa tie chataiaiolol tapi sie vicccld eat ies misioierh orotate wen 4.11 
OL Task ess Sera cs eae cTNctacetialeecbavousionslags.aic ore cieixe te/arsi terete 4.06 
ed LOGO ria cache statins lie Pls ieee ine nacle sanyo ecieeleate aeons 4.26 
MODAL rier, eiaeisisis ara ehiote tea carta ecstatic ae ean eee ae Henk OTOL 
AS CO/4D. ea cere ar aters wate asta hclela tela ale tere alos CO Rae 5.58 


There appears to be no great difference, with reference 
to the branch of service, as regards liability to rheumatism. 
Exhaustion and chilling—especially wetting—often ap- 
pear to markedly favor the disease; yet it undoubtedly 
happens at times that regiments may be long exposed to 
damp, wet, cold, sudden and violent changes of temper- 
ature, and be obliged to sleep on wet ground with but 
scanty protection, yet no cases of acute rheumatism fol- 
low. The disease appears to be less prevalent in garri- 
son than in the field; when it occurs in garrison it would 
seem that the causative agent finds its most favorable 
field for development in damp, illy drained barracks and 
casemates, and the same applies to damp bedding or 
clothing. Recurrences of rheumatism may be fresh infec- 
tions, or they may possibly be caused by renewed activity 
on the part of germs lying quiescent in some part of the 
organism, as with tuberculosis. As the individual who 
has been infected with syphilis is always syphilitic, so it 
may be that the soldier who has once suffered from rheu- 
matism may be permanently rheumatic, and temporary 
diminution of the powers of vital resistance by chilling 
may suffice to produce a second attack. 

It is evident that, in the absence of knowledge as to the 
etiology of acute rheumatic fever, it is difficult to formu- 
late any definite plan for its prevention. Asa matter of 
the first importance in reducing the rates for rheuma- 
tism, all those once affected with the disease should be 
eliminated from the service. Much may be done toward 
preventing the development of rheumatic attacks among 
soldiers by insuring dry, sunny barracks; by frequent ex- 
posure of bedding and clothing to the sun; by the prompt 
changing of wet garments; and, in the field, by the loca- 
tion of camps on well-drained sites and the adoption of 
measures calculated to keep the men above the surface 
of the ground while asleep. A sufticiency of clothing, 
especially of woollen material, is of importance 


AFFECTIONS DEPENDING ON EXTREMES OF 'TEMPERA- 
TURE. 


INsSOLATION.—Sunstroke is one of the most serious 
calamities that may overtake troops in the tropics: and 
prostration and the extinction of vitality by extreme heat 
are also common in temperate climates during the heated 
period. Military history is full of instances of the dis 
astrous effect of sunstroke. It is reported by Morehead 
that in India, in 1858, the Seventy-first Regiment lost 89 
men by death from insolation between the 5th of May and 
the 15thof August. The frequency of sunstroke among 
the British troops in India was very great when the soldier 
carried the same weight and wore the same clothing as 
in England, but became much rarer when special mod- 
ifications were adopted for tropical service. In the expedi. 
tion of General Bugeaud in Algeria more than 200 men 


617 


Camp Diseases, 
Camp Diseases, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





were reported as having been sunstruck ; but in the opera- 
tions of the French army in Mexico insolation was rare, 
probably through the altitude of the region in which the 
campaign was conducted. Viry states that, on July 8th, 
1858, two-thirds of a Belgian regiment were struck down 
by heat during a march; and that during the last war in 
Italy, on a hot t July day, no less than 2, 000 men of one di- 
vision of the French army fell in the ranks from sunstroke. 
In 1878 the Austrian troops occupying Bosnia lost many 
men from this cause; one regiment on the march having 
320 cases with 31 deaths, while the total number of cases 
of insolation during the campaign amounted to 2,181. 
Sunstroke is said to be particular ly common in Germany, 
and it is stated that on May 21st, 1827, the troops ma- 
neeuvring near Berlin were completely disorganized by 
heat—entire sections falling along the route and the cav- 
alry losing many horses. During the recent warin South 
Africa the British lost many men from sunstroke. In 
our own service but little marching has, in the past, been 
done during the heated season, but during the ten years 
1888-97 there were nevertheless 523 cases of heatstroke. 
During the campaigns in Cuba, Porto Rico, and the 
Philippines, the number of cases of sunstroke was very 
large. 

It is excess of internal heat rather than sunshine which 
results in the phenomena known asinsolation; and hence 
the condition may occur at night if the atmosphere, while 
hot, is saturated with moisture, and heat dissipation, as 
accomplished by evaporation of perspiration, is imper- 
fectly carried on. Insolation rarely occurs at a high 
altitude and in a dry climate, no matter what the tem- 
perature. Laveran and Regnard have found that as 
soon as the bodily temperature exceeds 40° C. (104° F.) it 
begins to exercise a marked influence upon the nervous 
sy stem, the effect being greatly increased if the head is ex- 
posed to the direct solar rays. Death results from primary 
stimulation and subsequent paralysis of the nervous sys- 
tem by heat. Exercise isa great factor in the produc- 
tion of heat-stroke. Animals made to undergo violent 
exertion succumb more readily than do those allowed 
to rest quietly—and in the army it is the infantry 
troops which are most affected, cavalrymen being less 
liable to sunstroke than are their horses. Exercise greatly 
raises internal temperature, and Hiller found that the 
rectal temperature in soldiers after a hard march was 

_that of a high fever. Anything which interferes with 
the loss of body heat increases liability to sunstroke; this 
including too heavy clothing , diminution of perspiration 
through ‘deficient water supply, or lowering of the proc- 
esses of evaporation through excessive humidity. If the 
atmosphere is both hot and moist, the loss of heat by the 
lungs is largely impaired; and in a marching column 
carrying with it a close atmosphere saturated with mois- 
ture, the men in the centre of the ranks are the ones 
most liable to sunstroke. The period of digestion is fa- 
vorable to insolation; and debilitated or intemperate sol- 
diers are the most in danger. Insolation is undoubtedly 
aided by the pressure of tight uniforms or of the belts 
and straps by which the soldier’s load is suspended from 
his person. McCartie, in India, records a striking instance 
in the Chitral campaign of 1897, when sufticient coolies 
could not be obtained and part of the baggage had to 
be carried by native soldiers. Before the end of the 
march nearly all the men in the ranks were completely 
exhausted, and some had heat apoplexy, while their 
companions, carrying a much heavier weight but having 
assumed the light and loose native dress, were not in the 
least disturbed, 

Some of the symptoms of heat-stroke are said by Notter 
to be caused by the reflected rays of the sun through the 
orbit. In the British service neutral-tinted glasses are 
frequently worn in the tropics, and were found of much 
value in the Egyptian campaign of 1882. 

The advance to the condition of insolation is gradual, 
and its occurrence can be largely prevented by proper 
observance of sanitary detail. The march should be so 
planned as toavoid exposure during the heat of the day; 
and, if possible, the direct rays of the sun should not 


618 


fall on the men’s backs while marching. The length of 
the distance ordinarily traversed in temperate climates 
or cool weather should be diminished, or rapidity of 
movement lessened. Usually, in hot weather, a march 
of ten miles must be considered a good day’s work. 
The weight to be carried should be reduced to the mini- 
mum. In the tropics troops should carry nothing but 
the arms, ammunition, and canteen; a sufficient number 
of coolies, pack animals, or wheeled vehicles being pro- 
vided to secure the transportation of the baggage and the 
remainder of the equipment. Troops should march in as 
open order as possible the better to allow access of fresh 
air to each soldier. Halts should be as frequent as pos- 
sible, and at points well shaded, elevated, and airy. For 
such stops ravines, especially if dry or sandy, should not 
be chosen. During such halts the men should not lie 
down, since in very hot weather, particularly if the ground 
be bare, the soil is heated to a greater degree than the 
atmosphere. Soldiers should have plenty of water, and 
canteens should be replenished as often as a suitable sup- 
ply is encountered en route. Where the supply of water 
is liable to be insufficient, special arrangements must be 
made for its carriage with the column. The use of alco- 
hol before or during a march should be interdicted. The 
clothing worn should be suited to the climate or season, . 
should be loose, and should well protect the head and 
back of the neck. Since sunstroke is by many believed 
to be due to the actinic solar rays, the lining of the hat 
and blouse with dark green cloth may be desirable. A 
heavy meal should not be taken immediately before 
marching. Company officers should watch their men 
carefully with respect to sunstroke. Ifa soldier looks pale, 
weak, and exhausted, he should be spoken to sharply, and 
if he does not respond clearly he should be told to fall 
out and rest or await transportation. By this precaution 
many cases of insolation may be avoided. When the con- 
dition of isolation has once occurred, the soldier is usu- 
ally unfitted for further military service, being particu- 
larly liable to future recurrences. For the military 
service it may be accepted that “once sunstruck is 
always sunstruck.” 

CONGELATION. — While sledging expeditions in the 
Arctic have been exposed without suffering to continu- 
ous cold of as great an intensity as —50° F., soldiers, on 
the other hand, have often been known to succumb to 
cold in comparatively mild climates and when the ther- 
mometer registered by no means a very low temperature. 
It may fairly be considered that accidents from this cause 
are relatively more frequent in the cold weather of tem- 
perate climates than in the far north, probably because 
of the more careful precautions taken for the conserva- 
tion of the body heat under the latter conditions of cli- 
mate. 

Since the famous retreat of the Ten Thousand, when the 
rigors of climate destroyed more Greek soldiers than did 
the Per sians, great cold has frequently exerted a strong in- 
fluence upon military operations. Voltaire states that in 
the winter of 1709 a large part of the army of Charles XII. 
was destroyed by cold, 2,000 men being frozen to death 
during one march. In 1719, 7,000 Swedes, on their way 
to the siege of Drontheim, perished in the mountains be- 
tween Sweden and Norway; while in 1742, in the retreat 
from Prague, 4,000 French soldiers died from cold and 
exposure. The sufferings of our own forces at Valley’ 
Forge, during the Revolution, are a matter of history; 
and in the destruction of Napoleon’s army in Russia cold 
was by far the greatest factor. During the Crimean 
War, according to Viry, there were 5,290 cases of frost- 
bite with 1,179 deaths among the French troops; while 
among the English forces the. numbers amounted to 2,852 
and 463 respectively. Laveran states that during the 
Franco-Prussian War, freezing of the feet caused much 
suffering in the French army and there were many 
deaths from cold. In 1879, according to the same au- 
thority, a column of 755 men in the field in Algeria, at 
the end of March, had 60 cases of frost-bite, of which 19 
died. In our own service, during the decade 1888-97, 
there were 648 cases of frost-bite reported, of which 141 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


occurred in 1888. It should be remembered, however, 
that but a small part of our forces were stationed in 
regions in which congelation was liable to occur to any 
extent, and hence the cases reported were necessarily fur- 
nished by a relatively small fraction of the whole army. 
The history of congelation in armies shows that a state 
of low vital resistance, brought about by unfavorable 
hygienic conditions, plays almost as great a role as cold 
itself; and it is a matter of common observation that 
freezing occurs by far the most frequently among such 
soldiers as are weakened by fatigue, sickness, and priva- 
tion. During the Crimean War the temperature encoun- 
tered was never very low, and a report made at the 
time suggests that the large number of congelations ob- 
served might justly be regarded as “ gangrene owing to 
scorbutic tendency exaggerated by cold.” On the other 
hand, troops which are well fed and warmly clad resist 
the most intense cold without injury, as has been re- 
peatedly shown in our winter campaigns against the 
Indians‘of the northwest. In the Powder River Expe- 
dition of 1876, conducted during the three winter months, 
with the mercury never above freezing and often down 
to —40° F., Rosse states that in a force of 2,000 men 
but 31 cases of frost-bite occurred, while in the 350 
Indians with the command no cases were reported. Dur- 
ing the winter of 1890-91, when about 6,000 troops were 
constantly in the field against hostile Indians, only 62 
cases of congelation occurred in the entire army. 

The phenomena which precede the death of the soldier 
from cold, while on the march, are well described by 
Larrey: “The dangerous condition isshown in the pallor 
of the face, by a kind of idiocy, by difficulty in speaking, 
by feebleness of vision or perhaps total ioss of that sense ; 
and in that state they march for a greater or less length 
of time, conducted by their friends; the muscular action 
is weak, and the individual totters on his legs like a 
drunken man. This weakness is progressive and is a cer- 
tain sign of the extinction of life. Separated from the 
column and abandoned to themselves, they soon lost 
their balance, fell into ditches covered with snow, a state 
of lethargy ensued, and a few moments terminated their 
miserable existence.” 

Muscular contraction is sometimés seen, particularly of 
the neck muscles, together with symptoms like those of 
catalepsy. According to Forestius, soldiers have been 
found frozen standing with their arms in their hands; 
and the same thing was observed by Larrey during the 
retreat from Moscow. 

In the prevention of freezing, an abundance of nutri- 
tious and fatty food is second only in importance to suffi- 
cient and proper clothing. The extremities are usually the 
chief points of attack, owing to their relatively poor pro- 
tection and distance from the main sources of systemic 
heat. The feet particularly are susceptible to frost-bite, a 
fact showing the necessity of warm protection and water- 
tight, loose, and comfortable footwear. To protect the 
hands, heavy gloves or mittens are essential. The latter 
are preferable, and the Japanese army uses a mitten with 
a single division into which the trigger finger can be 
slipped when desired. It is of advantage, in diminishing 
the effect of cold upon exposed surfaces, particularly 
when marching in driving snow storms, thoroughly to 
anoint the parts with some greasy substance, as beef, 
pork or mutton fat, or vaseline. Whenever possible, hot 
food or drink should be served out to troops on the 
march, unless the latter be short—stops being made and 
fires kindled for the purpose. In the Russian and Aus- 
trian armies, during cold weather, kettles filled with hot 
soup and enclosed in heavy felt are carried in wagons 
with the column. Even in the coldest weather the soup 
is said to remain warm for four or five hours. If a 
march must be made in extremely cold weather, it should 
be got through with as soon as possible without undue 
fatigue, the ranks being kept well closed up and strag- 
gling being prevented. In general, however, if an army 
is well fed, well clothed, and free from sickness, it can 
undertake a winter campaign with perfect safety, pro- 
vided the distances to be covered are not too long. 


Camp Diseases, 
Camp Diseases, 











Guard duty is particularly dangerous during cold 
weather, and sentinels should be kept on post not more 
than an hour at a time, or a running guard may be 
established. When relieved from sentry duty, soldiers 
should not be permitted at once to lie down, but should 
be required to pace briskly around the fires until numb- 
ness has worn off. Under stress of severe weather men 
should be told off to keep up the fires. 

Snow-BiinpNEss.—The glare of bright sunlight upon 
fields of snow produces the condition known as snow- 
blindness, particularly when troops are subjected to pro- 
longed marching toward the end of winter or in the early 
spring in cold climates. Since in our service soldiers are 
ordinarily housed in barracks during cold weather, the 
admission rate for this cause is usually low. Where field 
service is required in winter the rates are much increased ; 
and during the winter of 1890-91, when our troops were 
engaged against hostile Sioux, there were 133 admissions 
to sick report from this cause. Ina company fifty strong 
marching sixty miles in Montana during three days of 
March, 1894, nearly the entire command was rendered 
unfit for duty by reason of snow-blindness, 

The condition may usually be prevented among sol- 
diers by smearing the eyelids and upper part of the 
cheeks with a mixture of charcoal and grease; but when 
exposure is constant some further protection is necessary. 
For this purpose dark goggles, fitted in frames covered 
with chamois skin, have been recommended. The 
“snow-eyes” of the Esquimaux are made of light wood 
with the bridge resting on the nose, like spectacles, and 
presenting narrow transverse slits for the passage of 
light. These are said to be superior to goggles as a pro- 
tection, can be readily made by the men, and are not liable 
to the accident of fracture. Under any circumstances 
where snow-blindness is to be apprehended, the men 
should be marched in close column and each soldier 
directed to keep his eyes on the dark clothing of the man 
in front of him, the leading rank being changed fre- 
quently to the rear. 


DISEASE DUE TO IMPROPER DIETARY. 


Scurvy.—Occurrence.—Scurvy, from time immemorial 
down to a comparatively recent period, has been the 
scourge of armies, especially during campaign. In the 
thirteenth century scurvy ravaged the hosts of the Cru- 
saders; and it appears to have been almost continually 
present during active military operations until within 
the last score of years. . The history of its epidemics 
could be multiplied almost indefinitely. At Thom, in 
1708, during the Spanish siege, 6,000 men died of scurvy. 
During the Napoleonic wars it crippled the efficiency of 
the French troops in Egypt; in1801, and in 1807 and aie 
it ravaged the garrisons in Prussia. In the war of 1812 
was noted as lar gely occurring among our troops; aad 
Rosse states that among 1,016 United States soldiers 


“marching to and garrisoning Council Bluffs in 1820, the 


number of cases of scurvy was 516, and the number of 
deaths from this cause 168. The disease occurred among 
our troops, to some extent, during the invasion of 
Mexico; and for the eighteen years prior to the out- 
break’ of the Civil War the average annual admission 
rate was 26.3 per thousand strength. During the Cri- 
mean War 23,865 cases of scurvy occurred in the 
French army; the Turkish force was almost destroyed 
by it, and the cases in the British army amounted to 17,- 
597. In the various base hospitals at Constantinople, ac- 
cording to Marvaud, there were treated in 1855 no less 
than 14,879 cases, of which 1,407 died; in 1856 there were 
10,295 cases with 1,509 deaths. It was present during 
our Civil War, and its recognition was a surprise and 
shock to professional ideas preconceived from practice in 
civil life. In spite of all effort to the contrary, there were 
46,913 cases of this disease during the period 1861-66, 
giving an admission rate of 19.80 per thousand. There 
were during the same time 771 deaths directly ascribed 
to scurvy; but, obviously, no record of its well-known in- 
fluence in bringing other diseases to a fatal termination 


619 


Camp Diseases, 
Camp Diseases, 





was to be made. After the conclusion of the Civil War 
the disease prevailed to a great extent among troops 
serving at frontier stations, there having been 887 cases 
in 1868 and 211 cases in 1869. There were 115 cases in 
1871, after which the rates for this disease fell rapidly 
on account of the greater facilities afforded troops for 
procuring vegetables—both by better means of commu- 
nication and from the gardens which were gradually es- 
tablished at military posts. In the first few years after 
the Civil War there were several minor outbreaks of great 
severity. 

During the Franco-Prussian War, while the number 
of cases of scurvy was not great, a general scorbutic 
tendency was thought to have done much to increase the 
mortality of the troops. Rosse states that inthe Russian 
army, in 1873, the number of cases amounted to 5.3 per 
cent. In the Russo-Turkish War of 1878 it was present 
in both armies. In our own service, for the decade 
1885-94, there were 27 cases, of which 18 occurred in 1888 
and 5 in 1889. From 1892 to 1898 inclusive, only a single 
case was reported. The addition of fresh vegetables to the 
ration, in 1890, was undoubtedly most potent in remov- 
ing the scorbutic predisposition previously existing 
among our troops. In the British service a few cases, 
in spite of all precautions, are constantly present; par- 
ticularly among troops in India, in which for the decade 
1887-96 the rate of admission was 7.4 per thousand. 
The admissions for the decade 1888-97, for the entire 
British army, were .4 per thousand. In the German 
army in 1897 there were reported 74 cases of scurvy and 
purpura. Coustan states that, in the French service, a 
number of minor outbreaks have recently occurred among 
troops stationed in Algeria. For the Russian and Aus- 
trian armies, the rates of admission per thousand strength 
have lately been as follows: 











Year. Russia. | Austria. Russia. | Austria. 
Bet eek aera Wed: IBY; 1.5 1.4 
BOS eerie 1.9 2.3 1.3 1.0 
18045.38 tae 1.7 1.2 1.2 1.0 








Through a better knowledge of its etiology, scurvy is 
now quite rare among troops. Its insidious character, 
however, favors a possibly unnoted invasion, its infre- 
quency renders it unfamiliar, and the very knowledge 
of the means possessed for its prevention gives a false 
idea of security. It is a mistake to regard scurvy as 
being attendant solely on the unhygienic conditions of 
past centuries, long voyages, famine diets or special 
cases of privation. The dyscrasia, for troops in the field, 
is rather to be regarded as merely latent and requiring 
but a temporary interference with the distribution of 
supplies, and a brief subjection to depressing influences, 
to render its existence apparent; though not necessarily 
in the aggravated form with which the continued action 
of its cause characterized it in former times. The immi- 
nence of scurvy, where a proper nutritive, standard is 
departed from, should be fully appreciated by the sani- 
tary officer. 

Cause.—Scurvy is due to an illy balanced dietary in 
which fresh vegetables and their saltsare deficient. Salt 
meat, and fresh meat which has undergone putrefactive 
changes but is still eatable, are considered to favor the 
occurrence of scurvy. As predisposing causes may be 
mentioned excessive fatigue or overcrowding of quar- 
ters. Cold and humidity are also powerful factors, al- 
though scurvy is by no means uncommon in warm cli- 
mates. Besides these, depression of spirits, nostalgia 
and lack of exercise play no unimportant parts. As 
illustrating the latter point, an instance is given in which 
a number of prisoners of war were removed on board 
ship and fed on exactly the same diet as those on shore. 
The prisoners on ship contracted scurvy—those on shore 
did not. 

Scurvy, occurring in the military service, usually at 
once assumes an epidemic character, through the reason 


620 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


that large numbers of men are at the same time exposed 
to the conditions to which the disease owes its origin. 


From this fact, scurvy was long thought to be conta- - 


gious. The disease is a great respecter of military rank 
and rarely occurs in officers, a fact due to their better 
nutrition and lessened exposure to depressing conditions. 
It has a marked tendency to attack convalescents—and 
may frequently be associated with other diseases, to 
whose attacks it imparts additional severity. In the 
Crimean War, typhus occurring in a scorbutic patient 
was said to have been uniformly fatal. Winter is par- 
ticularly the season when scorbutic manifestations ap- 
pear, this being the season when fresh vegetable material 
is scarce and troops are largely confined, through the 
inclemency of the weather, in the vitiated air of their 
quarters. Sometimes, however, scurvy occurs in the 
autumn. ‘This was the case at the Crimea, when, in a 
period of three months, 500 cases occurred among the 
French troops. 

While the symptomatic diagnosis of scurvy is not a 
subject for discussion, it may be here remarked that 
scurvy, in the military service, is usually seen in the 
early stages, at which time it not infrequently simulates 
muscular rheumatism and is liable to be mistaken for the 
results of simple exposure to wet and cold. The char- 
acteristic symptoms of the disease are later manifesta- 
tions. Among the conditions not infrequently present 
as a result of scorbutus are acrodynia and hemeralopia, 
or. night-blindness. Both have prevailed epidemically in 
armies. Hammond noted the presence of hemeralopia 
among our troops in Kansas and New Mexico, and even 
as late as 1884 it figured in the returns for the army. 
During the Crimean War both French and English were 
attacked, and after the capture of Sebastopol the number 
of hemeralopics was so great in the French army that 
certain regiments could not furnish the necessary num- 
ber of men to mount guard. The condition has repeat- 
edly been caused to disappear by improvement in the 
character of the food supplied. In this connection, men- 
tion may be made of ulcerative stomatitis, which, for- 
merly common in armies, is now rare. 
undoubtedly depended upon a scorbutic tendency and 
lowered powers of resiStance resulting from malnutrition. 
Coustan mentions 19 epidemics of it as having occurred 
in the French army between the years 1793 and 1877. 

Prevention.—Scurvy is entirely avoidable, and its ex- 
istence is a reproach to the sanitary officer. The disease 
would rarely occur if the character of the food supplied 
corresponded with the natural cravings of the individ- 
ual, and it is only where the use of a restricted and im- 
proper diet is required that its occurrence is possible. 
At the present day its existence is evidence of lack of 
sanitary administration or short-sighted economy—either 
being inexcusable. The prevention of scurvy is accom- 
plished by the administration of citric, tartaric, malic, 
acetic and lactic acids or their salts. These are best 
given in the juices of fresh, succulent vegetable mate- 
rial; fresh fruits, tubers, roots and leaves being better 
than seeds, while the leguminose have no antiscorbutic 
virtues. The raw potato, onion and tomato are espe- 
cially valuable. Fresh cabbage is excellent, being bet- 
ter than sauerkraut. Radishes are also valuable.- Where 
such vegetables can be obtained in abundance scurvy 
will not appear. For troopsin the field the dandelion and 
lamb’s quarter are frequently available, and may be boiled 
and eaten as greens. The yellow mustard and cresses can 
be used as salad, while the young shoots of the poke- 
weed serve an excellent purpose as a vegetable. In 
some regions the so-called scurvy grass, or cochlearia, 
will be found. Woodhull especially recommends the 
agave as an antiscorbutic. To prepare it the leaves are 
cut off close to the roots and cooked well in hot ashes. 
The juice is expressed and taken, either raw or sweet- 
ened, in the proportion of one to four wineglassfuls sev- 
eral times daily. The white interior of the leaves may 
be eaten. All the varieties of the cactus are useful, in 
the absence of other vegetable material, in the preven- 
tion of scurvy. In general, fresh vegetable matter of any 


This affection ~- 


: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases, 
Camp Diseases, 





variety can be used with advantage, provided only that 
it has no harmful qualities. Made into soups, nearly all 
are tolerably palatable. 

Wherever the authorized issue of vegetables is scanty, 
the supply should be increased, from outside sources, 
by every means possible. Dried vegetables are anti- 
scorbutic, but much less so than the fresh; the vegetable 
acids being probably decomposed by heat and keeping. 
When the vegetables are desiccated and compressed, a 
considerable proportion of these acids and their salts are 
removed, and what remains is too often largely cellulose. 
It is said, however, that our forces in the expedition to 
Utah, against the Mormons, owed their preservation from 
' scurvy largely to the use of desiccated vegetables, at a 
time when nothing else of an antiscorbutic nature could 
be obtained. The use of fresh vegetables should never 
be superseded by the preserved article when the former 
can be obtained. Fresh fruits, especially lemons, limes, 
grapes, oranges and acid fruits generally, are excellent 
antiscorbutics. Even unripe fruits are better than none, 
and diarrhoea may at times be hazarded for the sake of their 
valuable properties. Dried and canned fruits are also of 
advantage. Preserved lime juice has been much used 
on shipboard in the prevention of scurvy. It has long 
been employed in the British army and navy, and forms 
part of the British field ration, in the proportion of half 
an ounce daily, in the absence of fresh vegetables. Ex- 
cellent results have long followed its use, and it could be 
adopted with advantage in our own service for similar 
conditions. Good beer and wine appear to have decided 
antiscorbutic value. Spruce beer has been made and 
used with advantage. Vinegar, one-half to one’ ounce 
daily, should be used in the cooking or taken with pick- 
les; it was much used as an antiscorbutic in the armies 
of antiquity. It has long been known that those who 
eat large quantities of under-done fresh meat, even 
though a limited amount of vegetable material is used, 
escape scurvy. This antiscorbutic quality of meat is 
largely destroyed by cooking, probably through the split- 
ting up, under heat, of the lactic acid which it contains. 
It isa matter of common observation that Indians and 
Esquimaux, who may eat no vegetable material for con- 
siderable periods but who habitually use meat either raw 
or in a partially cooked condition, are not affected with 
scurvy—and the same is true of whites who follow their 
example. At times when scurvy was very prevalent in 
our western garrisons, the hunting parties sent out to pro- 
cure fresh supplies, living largely on under-done flesh, 
were notably exempt from this affection. The value of 
raw meat as an antiscorbutic has been repeatedly noted 
by Hayes, Kane and other Arctic explorers. Kane 
wrote: “Had we plenty of frozen walrus I would laugh 
at scurvy.” Pemmican, prepared with fat, sugar, raisins 
and currants, is an excellent antiscorbutic for cold cli- 
mates and is much in vogue with travellers in the far 
north. 

Where fresh vegetables cannot be obtained, the admin- 
istration of the vegetable acids, especially tartaric and 
citric acids, combined with an alkali, is highly desirable 
to prevent the occurrence of scurvy. Since the disease 
is favored in its occurrence by confinement, impure at- 
mosphere, cold, dampness and mental depression, any 
unfavorable conditions of this character should be reme- 
died and every effort made to elevate the physical and 
mental tone of the soldier. 


DISEASES DEPENDENT ON MILITARY SERVICE. 


IRRITABLE HEART IN SoupreRs.—A_ well-defined 
group of symptoms, for want of a more scientific desig- 
nation known as “irritable heart of the soldier,” has re- 
ceived considerable attention from military and medical 
writers in this country, notably from Taylor and Da 
Costa. The condition is one which was long practically 
found only in soldiers, but is now not infrequent in ath- 
letes and is common in bicyclists. At the outset the 
trouble is purely functional in character, but when the 
exciting influence is long continued it is capable of ulti- 





mately producing organic lesions. Many different de- 
grees of the affection are therefore observed. 

The condition usually occurs in young and untrained 
soldiers, especially when weakened by disease or priva- 
tion, during the occurrence of forced marches and _ par- 
ticularly in warm weather. The general symptoms may 
be indefinite, but the soldier usually complains of pain 
in the chest and inability to carry his equipment on the 
march without losing his breath. The pulse is weak, 
intermittent and dicrotic, and there is the general ap- 
pearance of exhaustion. Often there is dizziness, which 
may be more pronounced atnight. In more pronounced 
cases there are gastric disorders, the mind, memory and 
voice are temporarily enfeebled and the walk is weak and 
uncertain. Slight murmurs may be noted, and there is 
usually dilatation of the cardiac chambers, often exces- 
sive. The right ventricle is the one usually dilated be- 
cause of its thinner walls and the greater proportionate 
strain to which it is subjected. The action of the heart 
may be seriously impaired or even paralyzed through 
the stretching and separation of the muscular fibrille. 
Permanent and serious impairment of the cardiac func- 
tion at times results, though the symptoms of heart strain 
may disappear as long as active exertion is not required. 
A number of cases immediately fatal through cardiac pa- 
ralysis have been noted, although the condition must be 
regarded rather as chronic than acute. 

As a result of an examination of a body of soldiers who 
had marched a distance of fifty miles, Teissier noted that 
the apex of the heart was displaced outward, that its 
breadth was increased, and that the venous circulation 
was impaired. The action of the heart was short and 
irregular, and a well-defined cardiac murmur was pres- 
ent. The arterial pressure was considerably lowered. 
Similar results were observed by Coustan. According 
to Taylor, at the battle of Corinth, during the Civil War, 
of two companies which had engaged in a lively recon- 
naissance one-fourth of the men returned in a state of com- 
plete exhaustion, while three men had dropped from the 
ranks from cardiac syncope and were supposed to be dead. 

The condition is brought on by great physical exertion, 
particularly in the absence of preliminary training, and 
especially in such men as may be affected with latent 
cardiac weakness, not discoverable on ordinary physical 
examination. The habitual use of alcohol and tobacco 
appears to favor it, but syphilis has not been shown to 
play a part in its occurrence. Restricted respiratory 
function should be regarded as an important exciting 
cause of heart strain, and its occurrence is largely favored 
by the mechanical compression of the chest wall by tight 
clothing, belts, and the weight and mode of carriage of 
the equipment. With modern improvements in these 
respects the affection has become less frequent. 

Coustan states that cardiac irritability not rarely oc- 
curs in cavalry soldiers, especially inexperienced riders 
mounted on hard-trotting horses. 

Irritable heart generally has a good prognosis so far as 
the individual is concerned—but even under the most 
favorable conditions the soldier is usually disqualified for 
future hard service; for the same influences which origi- 
nated the affection will operate even more powerfully 
in a weakened organ. 

Should a soldier on the march present symptoms of 
heart strain, any tight clothing should be loosened, his 
equipment removed and he be furnished with wheel 
transportation. Continuance of exertion in such a case 
can result only in serious permanent injury to the indi- 
vidual. The treatment is symptomatic, with rest as an 
essential feature. Prophylaxis depends upon the elimi- 
nation from the military service of soldiers who at any 
time show symptoms of cardiac weakness. The length 
and rapidity of marches should be kept within reason- 
able limits, and soldiers,especially raw troops, should not 
be forced to perform tasks beyond their powers except 
under pressing military necessity. The weights carried 
should be as light as military conditions permit, and 
should be properly disposed upon the person. Any con- 
striction of the chest should be avoided. 


621 


Camp Diseases, 
Camphor, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











FresriLeE Exnaustion.—A so-called “fever of exhaus- 
tion” has been described by Coustan and others. The 
affection often occurs in troops during campaign or hard 
marches, especially in warm weather. It occurs chiefly 
in infantry after rapid marching, but mounted soldiers 
are not infrequently affected. Recruits are particularly 
liable to its occurrence. The symptoms are somewhat 
variable, but include a remittent temperature, a tendency 
to adynamia and marked nervous depression. Usually 
there are headache, insomnia, restlessness and severe lum- 
bar pains. The urine is scanty, red, and turbid, but be- 
comes clear in about twenty-four hours. The muscles 
which have been excessively fatigued are sometimes sore 
to the touch for several days. Diarrhcea is a prominent 
symptom, and during a severe march the alvine discharges 
of the men become noticeably frequent and watery. Vom- 
iting not rarely occurs. The condition is generally re- 
garded as being due to an excess of acid produced in the 
muscles under the influence of muscular work, and in its 
action on the muscular fibres it diminishes their contrac- 
tility. The local pains are thought by some to be due to 
minute lesions occurring in the muscles as a result of 
excessive use, and resembling those which occur from 
prolonged massage. Thesubstances given off as a result 
of muscular work may affect the nervous centres in the 
production of nervous depression and fever; while the 
diarrheea probably depends upon relaxation of the mucous 
membrane and upon the large amounts of fluid drunk to 
replace the losses by perspiration. 

The prevention of this affection obviously depends 
upon proper conduction of the march. The treatment 
includes rest, with sometimes warm baths. 

FrigNepD DrtsEAses.—No reference to the diseases of 
the soldier would be complete without mention of the 
intentional simulation of disease—not uncommonly ob- 
served in the military service, and for the detection of 
which medical officers are constantly on the alert. The 
feigning of diseased conditions of mind or body has al- 
ways been a favorite method with all classes of people 
for securing betterment of condition, relief from distaste- 
ful duty or the evasion of punishment, and this is par- 
ticularly the case among soldiers, whose medical assist- 
ance is gratuitous and whose pay and subsistence are 
assured without the necessity of securing them by con- 
stant personal effort. 

By far the most elaborate and persistent efforts at de- 
ception are those which occur in time of war, when 
recruits endeavor to escape draft or to avoid duty on the 
firing line. In time of peace the conditions simulated 
are usually simple, and the claims as to their existence 
are not long continued. Sometimes, however, as where 
an effort is made to secure discharge from the service, 
the symptoms feigned are extremely complex and are 
maintained with great pertinacity. The disease selected 
for simulation, and the persistency with which its symp- 
toms are exhibited, are for the most part determined by 
the familiarity possessed, or thought to be possessed, by 
the malingerer with reference to it. In general, some 
morbid condition the symptoms of which are largely 
subjective, as muscular rheumatism or neuraigia, is se- 
lected. Another condition not infrequently simulated is 
that of involuntary nocturnal enuresis, and this fraud, with 
the above, is especially difficult of demonstration. Among 
the affections feigned may also be mentioned various 
fevers, diarrhoea, dysentery, chorea, epilepsy, hysteria, 
hemorrhages, apoplexy, imbecility, insanity, coma and 
even death—in fact, the diseases simulated belong to 
every department of medicine. Not infrequently such a 
varied array of symptoms is presented to the medical offi- 
cer as would scarcely suggest any known affection. The 
degree of success of the attempt at simulation naturally de- 
pends upon the skill with which it is executed, and this is 
influenced by a more or less comprehensive knowledge of 
the symptoms of the affection selected and the degree of 
natural cunning possessed by the malingerer. Usually 
the imitation is imperfect and readily to be detected; 
but occasionally an instance is found in which every 
effort to prove the case to be fraudulent, even where it 


622 








is a moral certainty that such is the fact, meets with only 
negative results. In most instances, careful questioning 
and observation suffice to expose the fraud. In other 
cases it often becomes necessary, while apparently agree- 
ing as to the reality of the affection, to confine the pa- 
tient to bed, place him on low diet and administer dis- 
agreeable potions. Under such treatment recovery is. 
usually rapid. Where rheumatism or neuralgia is simu- 
lated the use of the actual cautery may be advisable, but. 
in general every case must be treated according to cir- 
cumstances. At times the inconvenience and suffering 
unhesitatingly endured by the malingerer are truly re- 
markable. 

The prevention of malingering can be largely accom- 
plished by careful investigation of each case on the part 
of the medical officer, whose knowledge of the personal 
character of the individual, gained by contact or by in- 
quiry of his company officers, will largely aid him in 
arriving at a correct conclusion. Men of unstable or 
undesirable character, who present no objective symp- 
toms of disease, should in general be promptly returned 
to duty. Where conditions are such that the fraud can 
be definitely proven—which, unfortunately, is rarely the 
case—the offender should be tried by court-martial and 
severely disciplined. In general, the personality of the 
medical officer is a factor of no small importance in de- 
termining the amount of malingering in a command. 

Edward L. Munson. 


CAMPANULACEA. —(The Harebell or Lobelia. 
Family.) This family, of some two score genera and 
more than a thousand species, is of greater interest. 
through its poisonous species than through its medicinal 
value. Its plants represent every habit, though the most. 
of them are herbs and there are no large trees among 
them. The juice is milky and the flowers are mostly 
showy. They inhabit all except very cold countries. Of 
the three sub-families, the first, Campanuloide, is much 
more closely related, in composition and properties, to the 
distinct family Cichoriacew than to the remainder of its. 
own family, and it appears, from various considerations, 
to be a mistake to class these and the third sub-family, 
Lobelioide, in the same family. The Campanuloide are 
not poisonous, but, on the contrary, produce numerous. 
wholesome and nutritious roots, containing inulin, and 
some of their fruits also are edible. Of the Lobelioide, 
on the other hand, one or more species will be found 
recognized in almost every country as deadly poisons. 
The poisonous constituents are chiefly alkaloids. As 
poisons, they are classed as acrid narcotics, and act gen- 
erally like Lobelia infiata, which see. 

Henry H. Rusby. 


CAMPHOID is a substitute for collodion made by dis- 
solving 1 part of soluble gun cotton (pyroxylon) in 
alcohol containing 20 parts of camphor. It is a thick, 
colorless liquid which dries very rapidly, and when 
painted on the skin leaves a thin impervious film. It 
may be applied as a protective, or as a vehicle for iodo- 
form, chrysarobin, tannic acid, etc. 

W. A. Bastedo. 


CAMPHOR.—Camphora, U. 8. P., Br. P., CioHi60. 
A stearoptene imported in a crude state and purified in 
this country, by sublimation. The tree from which 
camphor is obtained is a member of the order Lauracee, 
and was named by Linneus Laurus camphora. Nees and 
Ebermair classed it with cinnamon as Cinnamomum cam- 
phora, and later Nees separated it into a special genus as 
Camphora officinarum. It isa large tree, of slender habit, 
with long, horizontal, smooth, green branches, and a hard, 
light-colored, very fragrant and valuable wood. The 
alternate evergreen leaves are dark and shining above, 
lighter, glaucous-green beneath, ovate acuminate entire, 
three-nerved. Flowers minute, greenish-yellow, in small 
axillary panicles. Perianth thick, six-lobed stamens, nine 
with four-celled anthers opening by valves. Staminoides 
six. Ovary free, one-celled, one-seeded. Fruit about as 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camp Diseases. 
Camphor, 








large as a pea, surrounded by the persistent perianth 
tube. This tree grows extensively and abundantly in For- 
mosa and the Japanese islands, from which places all the 
camphor of European and American commerce is ob- 
tained; and in Central China. It has also been trans- 
planted and flourishes in most tropical or sub-tropical 
countries of both hemispheres. 

Camphor isalso obtained from other sources. The best 
known are the Borneo and Ngaicamphors. The former is 
collected on the islands of Borneo and Sumatra from Dry- 
obalanops camphora, the latter from Blumea balsamifera, 
which grows abundantly throughout China and India. 
The increasing de- 
mand for camphor 
in the arts, partic- 
ularly in the man- 
ufacture of cellu- 
loid and smokeless 
powder, is direct- 
ing attention to 
its production, as 
the demand is ex- 
ceeding the natu- 
ral supply. To 
replace this defi- 
ciency the manu- 
facture of artificial 
camphor is being 
improved, and the 
market will prob- 
ably be supplied 
with camphor pre- 
pared from some 
of the turpentines, 
quite indepen- 
dently of the pres- 
ent source. 

Camphor is a 
constituent, or more properly, an oxidation product of 
the essential oil of camphor, which is abundantly present 
in all parts of the plant. Very frequently the camphor is 
found in a more or less pure state beneath the bark, hav- 
ing separated from the oil. It is separated from the 
leaves, smaller branches, and chopped wood by a crude 
method of sublimation, in which impure condition it is 
exported. In this country it is resublimed. 

Camphor occurs “in white, translucent masses, of a 
tough consistence and « crystalline structure, readily 
pulverizable in the presence of a little alcohol, ether, or 
chloroform; having a penetrating, characteristic odor, 
and a pungently aromatic taste. Specific gravity, 0.995 
at 15° C. Very sparingly soluble in water, but readily 
soluble in alcohol, ether, chloroform, carbon disulphide, 
benzih, and in fixed and volatile oils. It melts at 175° 
C., boils at 204° C., and is inflammable, burning with 
luminous, smoky flame. On exposure to the air it evap- 
orates more or less rapidly at ordinary temperature, and, 
when moderately heated, it sublimes without leaving a 
residue” (U. 8. P.). The solubility of camphor in water 
is about 1 part in 1,800; this is increased by the presence 
of sugar, magnesia, carbonic acid, and spirits of nitrous 
ether. When camphor is mixed with menthol and simi- 
lar products, in definite proportions, the two substances 
become a liquid. The following are some of the com- 
binations: camphor1 part—with menthol 38, with thymol 
1, with chloral hydrate 1, with salol 1.5; camphor 2 
parts—with naphthol 1; camphor 4 parts—with phenol 
12 to which water, 1 part, has been added. Withcertain 
resins and gums, camphor forms a soft mass of pilular 
consistence, which lasts for a variable length of time ac- 
cording to the gum selected. Guaiac, asafcetida, gal- 
banum, benzoin, and tolu are some that are of pharma- 
ceutical importance. 

The oil of camphor of commerce is separated during 
the first sublimation and is obtained as a thin fluid, vary- 
ing in color from a light yellow to a reddish-brown ac- 
cording toage. It hasa strong odor and taste resembling 
those of camphor. It is very variable in character, the 





Fig. 1097.—Camphor Tree, Flowering Branch. 
(Baillon.) 


camphor with nitric acid. 


percentage of camphor that may be present is uncertain, 
some samples being entirely free from it. The oil is not 
of much therapeutic value in this country, although 
thought much of in China and other Eastern countries, 
where it is employed not only for its remedial properties 
but also as a turpentine in the preparation of india ink and 
varnishes. It is also used as an illuminant. Its action is 
similar to that of camphor, and it is recommended in the 
same conditions in doses of from gtt. i..to gtt. iij. 

Camphoric acid, C,oH:004, is a product of camphor 
that is of much therapeutic interest. It is an oxidation 
product of camphor, and may be prepared by heating 
The acid forms in small col- 
orless needles or plates, odor faintly aromatic, taste acid 
and bitter, very sparingly soluble in cold water, more 
soluble in hot, soluble in alcohol and ether. Ten per 
cent. of alcohol added to hot aqueous solution p.events 
the acid from being deposited on cooling. This acid has 
long been known, but it is only during the last few years 
that its therapeutic properties have been utilized. Its 
chief use is in the treatment of diseases of the respiratory 
tract and as a preventive of night sweats. For the latter 
purpose it promises to be one of the most valuable addi- 
tions to our materia medica. 

Compared with atropine, its effect is more certain and 
more prolonged, while it does not produce the difficulty 
in swallowing, dryness of the pharynx, disturbed sleep, 
and vertigo, which often accompany the use of the latter 
drug. Its mode of action differs from that of atropine, 
as its beneficial effect is thought to be due to its power 
of destroying the ptomains in the blood which cause 
this distressing symptom. 

The dose as an anhydrotic is gr. xxx. at bedtime, or 
gr. xv. during the afternoon and the same dose repeated 
at bedtime. The action is not rapid, and in some in- 
stances no effect has been noticed until the following 
day. The effect of a single dose often continues for sev- 
eral days. The reports of cases treated show beneficial 
results in a great majority of them; it does not in any 
way interfere with the appetite or digestion, and in most 
instances a quiet sleep follows its use. As the taste is 
somewhat disagreeable, it is best administered in wafers 
or capsules. 

In diseases of the mucous membrane of the respiratory 
tract, camphoric acid is used by applying locally and as 
aspray. In acute coryza, pharyngitis, and laryngitis, a 
half- to one-per-cent. solution may be used every three 
hours, or tampons saturated in the solution may be in- 
troduced into the nasal cavities; in ulcerated throat, a 
solution of two to six per cent. may be applied. This 
drug has no corrosive action; it possesses antiseptic prop- 
erties and produces contraction of the blood-vessels of 
the mucous membrane. 

Internally, it is also used for intestinal diarrhoea of a 
catarrhal character, and where intestinal antisepsis is 
desired, the dose is from gr. v. to gr. x.-xv. Itisexcreted 
by the kidneys and renders the urine clear and acid in twu 
or three hours. 

In cystitis, when the urine is alkaline, it has proved of 
benefit. In this condition it is also used as a wash in a 
half of one-per-cent. solution. The bladder is to be irri- 
gated twice a day, about an ounce of the solution being 
left behind. 

Camphor is absorbed from the skin and mucous mem- 
brane, and is found unchanged in the blood and the vari- 
ous organs and tissues. ‘The kidneys do not excrete it. 
unchanged, but it -is thought to be excreted by the lungs 
and skin. In its action camphor is antiseptic and stimu- 
lant, with a sedative effect following the primary stimula- 
tion. This action is exercised upon the surface when 
applied externally, and when administered internally, 
the same effect is directed to the mucous surfaces with 
which it comes in contact. In the stomach it stimulates. 
the muscular coats, adds a sense of warmth, and reflexly 
stimulates the heart and abdominal circulation. After 
absorption its action is directed to the cerebral and spinal 
centres through which it influences the heart and vascular 
system. 


623 


Camphor Salicylate. 
Canary Islands, 





Camphor is not now employed to the extent that it 
was formerly. The difficulty of giving it in suitable 
doses, without deranging the stomach, has proved a seri- 
ous obstacle, and other remedies have supplanted its use. 
When given in pill form, or in its pure state, it proves 
irritating to the stomach and has been charged with pro- 
ducing gastritis and ulcerations. When given as an 
emulsion, with sugar, gum arabic, and water, it forms a 
nauseous mixture, At present it is given in small doses, 
combined with other remedies, and the former doses of 
gr. x. and xv. are rarely heard of. It is of value in car- 
diac and circulatory depression, and in all conditions 
in which rapid stimulation is required; as in typhoid con-, 
ditions, pneumonia, cedema of the lungs, and dilatation of 
the heart. In chronic depression of the nervous system 
when there is a loss of control it is a useful stimulant in 
repeated small doses. Hysteria, chorea, epilepsy, sper- 
matorrheea, and melancholia are some of the conditions 
in which it has been much employed. Its excretion by 
the skin and bronchial mucous membrane has made it a 
very useful diaphoretic and expectorant, and in febrile 
states, particularly when combined with opium and other 
diaphoretics, it has always been recognized as of much 
service. Its action upon the genito-urinary organs has 
been a disputed point. It is supposed to havea sedative 
action and also to possess anaphrodisiac properties. After 
its continued use it certainly acts as an anaphrodisiac. 
As a sedative it is combined with bromides, opium, and 
hyoscyamus. After its continued use and in large doses 
it excites the brain and produces a form of intoxication. 
Its continued use produces a craving for the drug, and 
it has been shown that a camphor habit may be acquired. 
In toxic doses there is over-stimulation, which is of very 
short duration and is rapidly succeeded by depression, 
with stupor or coma, paralysis, cold surface, clammy 
perspiration, and other symptoms of collapse, which may 
terminate in death. 

Formerly camphor was given in doses of gr. x. and 
xv. It is now given in one-, two-, and three-grain doses, 
rarely exceeding five grains. It may be administered 
hypodermically, particularly in conditions of collapse. It 
may be given in pills or capsules, or in powder with sugar, 
or the spirits of camphor may be given in wine. The 
camphor may also be dissolved in ether and added to 
wine. The following forms a good emulsion: camphor, 
gr. xv.; ol. olive, 3ij.; mucil. acacie, 3v.; syr. sim- 
plicis, i. For hypodermic use, the spirits, ethereal solu- 
tion, or camphorated oil may be selected. 

Monobromated Camphor, CioH;sBrO, is a_ substitu- 
tion compound of camphor in which one atom of hy- 
drogen is replaced by one of bromine. It is official in 
the United States Pharmacopeia. It occurs in color- 
less prisms, with a taste and odor of camphor. It is 
almost insoluble in water, but soluble in alcohol and 
fixed oils. It is permanent in the air and unaffected by 
light. 

This camphor compound was introduced as a nervous 
sedative and antispasmodic. It has been employed in 
delirium tremens, hysteria, epilepsy, whooping-cough, 
cbhordee, spermatorrhcea, and numerous other conditions 
arising from disturbance of the nervous system. It has 
also been used as an hypnotic in insomnia of the same 
character. In all these conditions it has proved of ser- 
vice, but appears to be of most value in the milder forms 
of epilepsy. The dose is from gr. v. to gr. x., once or 
twice in twenty-four hours and gradually increased until 
the dose is repeated four or five times.a day. When its 
administration is being pushed its effect requires to be 
watched, as when given in excessive doses to animals it 
produces muscular weakness, paralyses, and depression 
of the vital centres. 

On account of its disagreeable taste it is administered 
in pill form, or in capsules, or perles. Elixirs are pre- 
pared by dissolving it in spirits and adding aromatics and 
syrup. An emulsion may also be formed by dissolving 
in sweet almond oil and forming an emulsion with gum 
and water. 

Beaumont Small. 


624 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


CAMPHOR SALICYLATE.—This is a compound of 84 
parts of camphor with 65 parts of salicylic acid. It oc- 
curs as a crystalline, camphor-like mass, or it may be 
made to crystallize out from its solution in benzol. It is 
insoluble in water and glycerin, soluble in alcohol, in 
mineral oils, and in 20 parts of olive oil. Used internally 
as an intestinal antiseptic and carminative, it acts in the 
alimentary tract much like salol. Its systemic effect, how- 
ever, is not marked, and its internal use has up to the 
present been confined mostly to the summer diarrheeas. 
The dose is gr. i. to v. In lupus and other skin diseases 
it is applied locally in the form of an ointment or liniment 
of from five- to twenty-per-cent. strength. 

W. A. Bastedo. 


CAMPHORONIC ACID. — Iso-propyl-carballylic acid 
—C,H;,(COOH);. Obtained, by the oxidation of cam- 
pholic acid, it forms white, acicular crystals, soluble in 
water, and very hygroscopic. It is recommended as an 
antiseptic in aqueous solution. W. A. Bastedo. 


CANADA BALSAM.—Balsam of Fir. Spurious Balm 
of Gilead. The liquid oleoresin obtained from lacunze 
in the bark of Abies balsamea (L.) Miller. This fine, tall 
tree is abundant in the Northeastern United States, 
northward and northwestward. Its leaves are much in 
demand for making “balsam pillows,” which are deli- 
ciously fragrant. Its buds are often sold as balm of 
Gilead buds, but this name properly applies to those of 
Populus candicans. 'The oleoresin is collected by break- 
ing the blisters upon the bark and catching the exuda- 
tion. It is of a pale-yellow color, absolutely clear and 
transparent, somewhat viscid, aromatic, and bitter. It is 
insoluble in alcohol and water, but dissolves in ether and 
chloroform. It possesses the ordinary stimulant anti- 
septic and expectorant properties of the family (see Con#f- 
ere), and is given in doses of .3 to 2 gm. (gr. v. to Xxx.). 
It is more largely used in microscopical mounting than 
otherwise, for which its perfect transparency peculiarly 
fits it. Henry H. Rusby. 


CANADIAN HEMP. See Apocynum. 


CANARY ISLANDS.—These islands, justly celebrated 
for their admirable climate and beautiful scenery, lie be- 
tween the 27th and 28th north parallels of latitude, five 
degrees north of the tropics, and in longitude 13° to 18° W. 
They are in about the same latitude as Florida, Southern 
California, Southern Texas, Northern Egypt, and the Des- 
ertof Sahara. They are from 120 to 170 miles distant from 
Africa, and may be reached by steamer from Plymouth 
or Southampton, England, in from five to eight days; 
and from Cadiz, Lisbon, Gibraltar, Marseilles, or Genoa, 
in three or more days. The islands (of volcanic 6rigin) 
are seven in number; but the two generally visited by 
invalids and always meant when the Canary Islands are 
referred to, are Tenerife and Gran Canaria, about 30 
miles from each other. In these islands Las Palmas in 
Gran Canaria, and Orotava in Tenerife are the towns usu- 
ally resorted to. The climate is.characterized by medium 
dryness, a large amount of sunshine, equableness, and a 
stimulating quality; in brief, it is a moderately dry 
marine climate. “The Canaries lie in the region of the 
dry, northerly trade winds, which are the prevailing 
winds throughout the year, usually blowing about 240 
days out of the 865, but more strongly and almost with- 
out break during the summer months; hence the mean 
maximum temperature of the summer months, which is 
about 77°, is lower than might be expected for the lati- 
tude” (Melland, “Climatic Treatment in Grand Canary,” 
Medical Chronicle, Manchester, 1897, vol. viii., p. 821). 

As both Tenerife and Gran Canaria are mountainous, 
the mountains rising to the height of 6,000 feet or more, 
there is both a shore and a mountain climate. For the 
summer, Melland considers the mountain climate superior 
to that of the shore in the treatment of lung diseases, 
and already hotels adapted for invalids have been erected 
in these higher regions. During the winter months Las 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Camphor Salicylate. 
Canary Islands, 





Palmas, of which Melland especially writes, is to be pre- 
ferred, he says, for cases of early phthisis and rheuma- 
tism, to some of the other health resorts of the island, on 
account of the clear sky, free radiation, and abundance 
of sunlight. These advantages of Las Palmas are due 
to its geographical position away from mountains and 
northern slopes. The vegetation of these islands is rich 
and varied; the date, palm, pepper, and eucalyptus are 
some of the trees found there; and of fruits there are 
oranges, apples, pears, peaches, plums, figs, grapes, 
guavas, bananas, pomegranates, and prickly pears. The 
flora is very extensive and the variety of plants great. 
“Anything put into the ground will grow,” says Mrs. 
Stone (“Tenerife and Its Six Satellites,” by Olivia M. 
Stone; 2 vols., 1887). 

The meteorological observations, taken at Las Palmas, 
are given by Melland as follows: 



































ae Bs 
SHADE TEMPERATURES. F-| q Fs 
a: wR lopss| OO 
1ss0-03. | _£| 4 ee | é [ge3| 2s 
Pacts | ; a 8 i4g.| 34 
Sssjsgqg o Sn en Sco oes 
Oo. O g 0 Se Ad me a 'g cel 
aulae| ¢|/3 i B2 | 4 EE 
| g| 4 f ma fa Zi 
Hrs. Min. 
October.....| 73.4 | 65.8 | 69.6 7.6 5 § 380 | 3.22 | 73 i 
November .| 71.3 | 62.3 | 66.8 9 5 38 | 1.87 | 68.5 | 10 
December..| 67.6 | 57.2 | 62.7 9.7 4 50 | 1.86 | 68 12 
January . 66.5 | 57.38 | 61.7 8.8 5 3 | 1.41 | 66.6 | 8.5 
February 66.5 | 55.7 | 61.2 | 10.7 6 9 DL | 65.8 | 3.5 
Maren: )':0' 67.4 | 56.5 | 62.1 | 11.2 5 57 84 | 67.6] 5 
ADT. Sea.0e 69.3 | 59.1 | 64.2 | 10.2 6 2 4 | 67.3 | 4.5 
Byicescvee + | 6o.2 | GL.S | 65.4 8.4 6 43 38 | 67 4 
Average for 
winter...) 68.5 | 58.8 | 63.6 9.7 5 41 | 8.15*| 67.1 | 49* 
* Total. 


The small diurnal range of temperature is to be espe- 
cially noted, as well as the slight variations from one 
month to another. The rainfall is very inconsiderable, 
and there is the small number of forty-nine days upon 
which any rain fell. Each day gave an average of over 
five hours and a half of sunshine. The relative humidity 
greatly decreases as one ascends into the mountain regions. 

The following observations for Orotava are condensed 
from various observers: 








Average : Daily F 
Months of winter. tem- | Meandaily| sunshine, | Relative 
perature renee hours | humidity, 
degrees. degrees. per diem. per cent. 
Hrs. Min 
November......... 66.97 11.8 ae ke 67.3 
December . 65.05 11.2 5 48 63.2 
January... 62.88 11.2 5 42 61.5 
February .. 61.1 12.1 5 47 68.6 
March..... 62.7 11.9 7 32 66.9 
Average for winter 63.74 11.6 6 12 65.5 











The temperature of Orotava, says Gihon (Transactions 
of the American Climatological Association, 1889), never 
falls below 50° F. or rises above 82° F., and attains these 
extremes only on rare occasions. 

“The February of Orotava,” continues the same writer, 
“is the June of London, the May of Paris, and the April 
of Rome, Nice, and Cannes.” In Orotava storms are 
unknown, and linen garments may be worn the entire 
year. “Here, if anywhere,” to again quote Gihon, 
“reigns perpetual spring, without fogs and frosts, where 
the sap never dies, where rain seldom falls, winds and 
storm are scarcely known, and burning heat is never 
felt.” 

From observations taken at Las Palmas, it is seen that 
the six warmest months are from June to November, 
with a mean temperature of 71.7° F.; and that the six 
coldest months are from December to May, with a mean 
temperature of 63.5° F. September and October are the 
hottest months, with a mean temperature of 73.5° F.; but 


Vou. II.—40 


ny os from the coldest month, February, by only 

The mountain climate of the Canaries, at an altitude of 
from 1,300 to 5,000 feet, differs from that on the coast by 
increased dryness—the relative humidity at the village of 
Villa Flor (4,300 feet) for the month of August being 35 
per cent.; by the absence of the northerly trade winds; 
by the absence of rain during the summer; by a greater 
range of temperature; by a more invigorating atmos- 
phere; and by almost continuous blue skies. The sum- 
mer is the proper season for visiting the highlands, as the 
climate is then at its best. “Here,” says Brown (“Ma- 
deira and the Canary Islands,” by A. Lander Brown, 
London, 1896), “the invalid may live for months under a 
rainless blue sky and in a genial climate, wandering 
among gorgeous forests and magnificent precipices; be- 
low him a vast sea of billowy cloud out of which the 
summits of the other islands rise, beckoning him to new 
explorations.” Melland considers the mountain climate 
much more rapidly curative in cases of early phthisis 
than that of the coast. In some of the mountain sta- 
tions, as at Laguna (1,800 feet) in Tenerife, there are good 
accommodations, and camping is also not an infrequent 
method of living in the higher altitudes. Orotava con- 
sists of the town, or villa de la Orotava, at an altitude of 
1,100 feet, and three miles distant from this is the Puerto 
de la Orotava on the coast; it is the latter locality to 
which invalids resort. Round about these two Orotavas 
and including them is the famous Orotava valley, which 
Humboldt considers “the loveliest scene in the world,” 
and of which M. J. Leclercq, in the Annuaire du Club 
Alpin Frangaise, 1879, writes: “I have seen sights more 
varied, more striking, and a more brilliant sky; vegeta- 
tion is more thoroughly green in the celebrated Cintra 
Valley in Portugal, which Bryon considered the most 
delicious locality in Europe; but where can be found 
those mountains and classic beauty, those velvety tints, 
that soft and balmy atmosphere, that moderate tempera- 
ture, notwithstanding the vicinity of the torrid zone, that 
charm impossible to define?” 

And of its climate W. Vignal writes (British Medical 
Journal, 1893): “Ido not think it possible to find any- 
where a more perfect climate, and as far as I know there 
is none comparable to it.” 

From May to August there is no rainfall at Orotava, 
and the annual precipitation is 18 inches. The average 
number of rainy days is 51 ; and the rain falls most fre- 
quently at night. The temperature of the sea water 
is lowest in March, 64°; and highest in July, 68° (Solly, 
“Medical Climatology”). 

In comparing the Canaries with Madeira, the former 
have in common with the latter the equability of climate, 
but they have a slightly higher temperature and are con- 
siderably drier, the relative humidity from November to 
April at Orotava being 64.9 per cent., and at Funchal, 
Madeira, during the same time, 72 per cent. The Cana- 
ries, say Weber and Foster, “have a greater claim as 
health resorts than Madeira and offer good accommoda- 
tions, but are much wanting in means of amusement.” 
The accommodations at Las Palmas and Orotava, and 
at some of the other towns in the islands, are good and 
abundant. The water-supply at Las Palmas and Oro- 
tava is brought from the mountain, and is of good qual- 
ity. There is no general drainage system, but each hotel 
has its own private water drainage system; in general, 
cesspools prevail. The soil is porous and dries rapidly 
after rain. Zymotic diseases are not common. At Las 
Palmas quite recently a cold-storage and freezing estab- 
lishment has been opened, and a building estate devel- 
oped, with villas suitable for residents and visitors. At 
present most of the invalids and visitors come from Eng- 
land. 

The diseases for which the climate of the ‘Canaries is 
favorable are incipient phthisis—Las Palmas or the port 
of Orotava in the winter, and the mountains in the sum- 
mer,—scrofula, chronic bronchitis, heart diseases and 
Bright’s disease, and rheumatism. 

While we have a climate in many respects similar to 


625 


Cancer, 
Cancer. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











that of the Canaries, in Southern California, more espe- 
cially inland, and in some portions of the Southwest, the 
novelty of the change, the ocean voyage, and the variety 
and beauty of the scenery of the “fortunate isles” may 
tempt some invalids to try its mild, sunny climate and 
pure atmosphere, and enjoy the “ equadility of an island 
climate combined with the dryness of a continental one.” 
For a more extended account of the Canaries the 
reader is referred to: “Tenerife and Its Six Satellites,” 
by Olivia M. Stone, 1887; “Madeira and the Canary 
Islands,” by A. Lander Brown, 1896; “The Canaries for 
Consumptives,” by E. Paget Thurstan, 1889; “Climatic 
Treatment in Grand Canary,” by Brian Melland; The 
Medical Chronicle, Manchester, England, 1897; “The 
Canary Islands as a Health Resort,” by John Whitford, 
1890; “The Therapy of Ocean Climate,” by Albert H. 
Gihon, M.D.; Transactions of the American Climatologi- 
cal Association, 1889. Edward O. Otis. 


CANCER. (CLINICAL.)—In the first place it is well 
to have a clear understanding as to what we mean by the 
term “cancer.” JI believe that the time has come when 
we should give up trying to limit the term “cancer” to 
tumors of epithelial origin, excluding those arising from 
connective tissues, though the latter may, and frequently 
do, equal or even surpass the former in malignancy. 
There is really no good reason for this distinction, and it 
is far better to go back to the older use of the word in 
which cancer included all varieties of malignant tumors, 
whether carcinoma or sarcoma; the feature of malig- 
nancy should really be the determining factor, and not 
some microscopic distinction in histological structure that 
is often so finely drawn that the trained pathologist is un- 
able to decide upon the proper classification. At pres- 
ent, though we often are able to give some temporary 
comfort to a patient with sarcoma by assuring him that 
his trouble is not cancer, yet, if he happens to be suffer- 
ing from a subperiosteal sarcoma of the femur and knew 
that of sixty-eight cases treated by the most extensive 
operation, viz., hip-joint, or very high amputation, but 
one was known to have been cured, he might readily 
wish to exchange places with his neighbor who has a 
well-marked cancer of the lip with one chance in two of 
being cured by a small operation. 

GENERAL CONSIDERATION.—While the problem of the 
etiology of malignant disease comes hardly within the 
province of this article, it is so intimately connected with 
the clinical history and rational treatment that a few 
lines may not be out of place. 

As having a more or less direct and very important 
bearing upon the etiology of cancer, should be mentioned 
(1) its local distribution; (2) its rapid increase during re- 
cent years; and (3) the influence of injury as a direct or 
predisposing factor in its development. 

Local Distribution.—Much has been written in proof of 
the fact that cancer is far more prevalent in some coun- 
tries than in others, and in some localities in the same 
countries than in others, but we are more deeply indebted 
to Mr. Alfred Haviland than to any other writer for ac- 
curate and detailed data concerning this varied distribu- 
tion. 

In 1868, in his, first paper, read before the Medical So- 
ciety of London, on the “Geographical Distribution of 
Cancer among Females throughout England and Wales 
during 1851-60,” he found that 4.83 cases of cancer oc- 
curred in every 10,000 females and only 1.94 in every 
10,000 males. 

In a recent paper (1899) he has found in the period 
1881-90, 7.80 cases in every 10,000 females and 4.30 cases 
in every 10,000 males. That is, the number of cases in 
females has nearly doubled and the number in males has 
more than doubled during a period of thirty years. 

Roswell Park, of Buffalo, is a firm believer in the in- 
crease of cancer, and inarecent paper he makes the state- 
ment that in England and Wales from 1840 to 1890 the 
death rate has increased four or five times, and he further 
adds: “A careful study of all these tables permits one to 
make the following startling prophecy: If for the next 


626 


ten years the relative death rates are maintained, we shall 
find that in ten years from now, viz., in 1909, there will 
be more deaths in New York State from cancer than from 
consumption, smallpox, and typhoid fever combined.” 

It is true certain writers, among the ablest of whom 
may be mentioned Newsholme,* attempt to show that 
this increase is more apparent than real, and may be 
largely explained by greater accuracy in diagnosis at pres- 
ent than in preceding years, and in the increasing num- 
ber of autopsies. I prefer to believe with Mitchell Banks, 
in his recent and most valuable lectures on “Cancer of 
the Breast” + that these explanations account for but a 
very small part of the increase, and that it is as real as it 
is alarming. 

Haviland’s latest conclusions upon the local distribu- 
tion of cancer, based upon the most careful study of more 
than a third of a century, are as follows: 

“1. That districts having the highest death rates from ~ 
cancer among females were ,invariably associated with 
seasonably flooded areas traversed by, or in close pro- 
pinquity to, seasonably flooded rivers. 

“2. That geologically these high mortality districts 
were characterized by alluviums and subsoils of clays of 
every variety of formation. 

“3. That districts having the lowest mortality were 
situated on an elevated land where drainage was good. 

“4. That geologically these low-mortality districts 
were characterized by the oldest paleozoic rocks, espe- 
cially those of the carboniferous limestone period.” 

This question that Haviland first brought before the 
medical public in 1868, “ How is it that limestones are 
always associated in England and Wales with the lowest 
mortality from cancer and flooded clays with the high- 
est?” he is still unable to answer, but when it is an- 
swered, he believes much light will fall upon the cause 
of cancer. 

The most complete of recent statistics on cancer are 
found in the elaborate paper of G. Heiman, of Berlin 
(Archiv f. klin. Chir., Bd. 57 and 58). These statistics 
confirm the view that cancer is rapidly increasing. 

In the year 1877 there were 6,971 deaths from cancer in 
Prussia, and in the year 1896 17,643, an increase of 153 
per cent. Of 10,000 living in 1877 the mortality from 
cancer was 2.66, while in 1896 it was 5.53. 

Heiman has also made separate statistics for the mor- 
tality in cities and the country districts: In 1876 in the 
cities it was 3.62, in the country, 1.82; in 1881 in the cities it 
was 4.70, in the country, 2.25; in 1886 in the cities it was 
5.71, in the country, 6.48; in 1891 in the cities it was 6.48, 


‘in the country, 3.24; in 1896 in the cities it was 7.9, in 


the country, 3.8. 

In still further confirmation of the opinion that cancer 
is increasing may be cited the mortality records of the 
Mutual Life Insurance Company of New York, as re- 
cently quoted by Oliver, London Lancet, November 
10th, 1900, p. 13841. The statistics show that in 1879 the 
percentage of deaths from cancer in patients between 
fifty and seventy years of age was 4.23; in 1889 it was 
6.22, and in 1898, 7.59. In further support of this view. 
Oliver refers to the statistics of the Scottish Widows’ 
Fund, collected by Claude Muirhead. Between 1815 and 
1845 the deaths from cancer were .98 per cent. of the 
whole number; from 1845 to 1852, .72 per cent.; from 
1852 to 1859, 2.87 per cent.; from 1859 to 1867, 3 per 
cent.; from 1867 to 1878, 4.56 per cent.; from 1878 to 
1880, 4.384 per cent.; from 1880 to 1887, 5.23 per cent. 
Muirhead states that, “allowing for greater accuracy 
in returns, the nuinber of deaths from this cause has in- 
creased enormously.” 

As to the question of heredity, the statistics of the 
Scottish Widows’ Fund show that 9.5 per cent. gave a 
history of malignant disease in parents. 

The difference between the prevalence of cancer in the 
city and the country is very striking. This steady in- 
crease cannot, I think, be explained by increasing skill in 
diagnosis. 


* Practitioner, London, April, 1899. + Loc. cit., March 10th, 1900. 


. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancer, 
Cancer. 





As Mitchell Banks has pointed out, in 1861 such men 
as Miller, Syme, Spencer, and Wilson, the leading surgi- 
cal teachers of Edinburgh, were the equal of any of the 
present day in diagnostic skill as regards both external 
and internal cancer. , 

The Parasitic or Infectious Theory of the Origin of Can- 
cer.—The embryonic theory of Cohnheim which has long 
been accepted by most pathologists falls far short of ex- 
plaining many important points in the etiology of cancer, 
and must, I believe, soon be abandoned. While the re- 
sult of the long and patient investigations of Russell, 
Plimmer, and San Felice and Leopold in Europe, and of 
Park and Gaylord in this country, have not yet absolutely 
demonstrated that cancer is of a parasitic origin, we are, 
according to Park, justified “at least in maintaining that 
some cancers are of such origin.” And if it can be de- 
monstrated that some are, there is strong probability that 
all are. The almost constant presence of these peculiar 
bodies in all cancers including sarcoma, and especially in 
the advancing and growing borders, as proven by Plim- 
mer, whether they prove to be blastomyces or protozoa, 
furnishes strong presumptive evidence that they may 
have some bearing upon the causation of the tumor. Now 
that pure cultures of these organisms have at last been 
made, and that actual carcinoma has been experimentally 

produced in animals by these cultures, it would seem 
that the parasitic or infectious theory of cancer has passed 
beyond the stage of ridicule and is worthy of serious con- 
sideration. It explains far better than any other theory 
the geographical differences in the prevalence of cancer, 
as well as the increasing mortality. Furthermore, can- 
cer closely resembles other diseases, ¢.g., tuberculosis and 
_ syphilis, which are known to be of infectious origin. If 
’ weadmit the origin it is easy to explain the various types 
of the disease, from the slow-growing epithelioma of the 
face to the rapidly fatal sarcoma of the testis or orbit, by 
supposing that the infectious agent, like the malarial or- 
ganism, varies as to its morphology within wide limits, dif- 
ferent types of the germ (or different conditions) causing 
very different clinical manifestations. The whole clini- 
cal course of cancer is strikingly suggestive of an infec- 
tious disease. The question of the infectious or parasitic 
nature of cancer has very recently and ably been discussed 
by Mitchell Banks in the last of his three lectures on 
“Cancer of the Breast” (doc. cit.). He calls attention to 
the fact that the first notable step in advance was made 
by W. Russell, of Edinburgh, in 1890, whose paper on 
“Characteristic Organisms of Cancer” excited profound 
interest. These so-called “fuchsin bodies” of Russell, 
which he described as both intracellular and extracellu- 
lar, were even then regarded by Russell himself as blas- 
tomycetes, a variety of saccharomycetes or yeasts. While 
the great majority of pathologists in different countries 
have been of the opinion that these bodies described by 
Russell are not “characteristic organisms of cancer” but 
rather certain forms of cell degeneration, there have al- 
ways been notable exceptions on the other side, and the 
question has remained an open one until at present the 
weight of evidence is strongly in favor of regarding them 
‘as separate organisms. 

In 1892, Soudakewitch, of Kieff, and Armand and 
Ruffer, of London, published papers describing bodies 
similar to those described by Russell. Specimens of 
these bodies were carefully examined by the distinguished 
Metchnikoff, who believed them to be “parasitic proto- 
zoa.” The original opinion of Russell that they are blas- 
tomycetes has recently been revived and strongly advo- 
cated by the well-known Italian investigators, San Felice 
and Roncali. These bodies are of various size, estimated 
by Plimmer at from .004 to .04 mm., and they may be 
stained in several different ways. The Ehrlich B triple 
stain or the Ehrlich acid hematoxylin, in distilled water 
rendered faintly alkaline with lithium carbonate, may be 
mentioned as most satisfactory. 

The latest researches of Leopold* along the same lines 


* Leopold, “ Researches as to the Etiology of Carcinoma and Patho- 
genic Blastomycetes.” Archiv f. Gynakologie, vol. 1xi., No. 1. 





are strongly confirmatory of the work of Plimmer and 
San Felice. Leopold’s paper is the result of diligent 
labor extending over many years. He has examined 
several hundred carcinomata of numerous localities, ex- 
cluding as far as possible ulcerating tumors. Leopold 
found the organisms variously described by others, and 
believes them to be blastomycetes. In twenty cases he 
tried to cultivate blastomycetes from the carcinomatous 
tissue and met with greater success than any of his pre- 
decessors. In four cases he obtained pure cultures from 
malignant tumors. In attempting to inoculate animals 
he had three positive successes. A curious fact was ob- 
served that, while the culture of blastomycetes had been 
obtained from carcinomatous tissue, the tumors in two 
instances resulting from inoculation were sarcomatous. 
This fact. if further confirmed, together with the fact 
that hereditary malignant disease not infrequently takes 
the form of carcinoma in some member of a family and 
of sarcoma in others, would go to show that the etiological 
relationship is exceedingly close. 


SYMPTOMATOLOGY AND TREATMENT OF CANCER. 


Draq@nosis.—There is no department in surgery in 
which there is greater need of large clinical experience 
and well-trained powers of observation than in the diag- 
nosis of malignant tumors. In every suspicious case a 
careful history of the patient should be obtained before 
a diagnosis is attempted. Among the most important 
points to be elicited may be mentioned: hereditary in- 
fluence, the anatomical situation of the tumor, its dura- 
tion, and the rapidity of its growth. .Too much stress 
should not be laid upon the apparent duration of the 
tumor, inasmuch as in not a few instances it may have 
existed for a considerable time before it was observed by 
the patient. The situation of the tumor is often of great 
aid in diagnosis. If itis first observed in the glands—for 
example, the cervical, axillary, or inguinal—there is a 
strong probability that it may be a secondary growth, 
and careful search should be made for a primary growth 
in the mouth or throat, the breast, rectum, or pelvic 
organs, or even the extremities. I have myself observed 
a large fungating sarcoma of the groin, supposed to 
originate in the inguinal glands, and although the patient 
stated that he had never had any swelling in the leg or 
foot, careful inquiry showed that two years previously 
he had had a small ulcerated area upon the ball of the 
foot, produced by the irritation of a projecting nail in the 
shoe. This apparently healed, but from time to time 
there was a recurrent ulceration and a slight discharge. 
A small indurated area remained, but gave such slight 
symptoms that the patient never thought of connecting 
it with the trouble in the groin. The patient soon died 
of general metastases. At autopsy the area in the ball 
of the foot was excised and found to be the primary pig- 
mented sarcoma. 

On examining the tumor itself, the surrounding tissue 
should be carefully palpated in order to determine its 
relation to the skin, the muscles, or the underlying bony 
structures. The size of the tumor, and the rapid- 
ity of growth, are very important points to be noted. 
Pain and tenderness, while far less important than many 
writers have led us to believe, should nevertheless be 
always noted. While in most cases of malignant 
disease, especially in carcinoma of the breast, pain is 
rarely present in the early stages, it is seldom absent after 
the tumor has become well developed. Pain ismuch more 
important in the diagnosis of recurrent than in that of 
primary tumors. In many cases of recurrent cancer the 
patient based her suspicion solely upon the peculiar 
stinging pain resembling that which she had experienced 
during the existence of the primary tumor, and in almost 
every case I have found these suspicions well founded. 
Therefore, in suspected recurrent cancer, one cannot be 
too careful in considering the symptom of pain. In some 
localities the primary tumor naturally is attended with 
marked pain. This is especially the case in malignant 
tumors originating in the spine or in the pelvic bones. 


627 


Cancer. 
Cancer, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





In most cases of sarcoma of the ilium, sacrum, orischium, 
the first symptom isa severe neuralgia of the crural or 
sciatic nerves, and cancer is seldom suspected for a con- 
siderable time. 

Tenderness.—Tenderness is a very important diagnos- 
tic sign, especially from its negative value. It often 
enables us to distinguish between a malignant and an 
inflammatory tumor. Tenderness may be said to be 
practically absent in most malignant tumors. 

Palpation.—By this means may be determined the 
consistence of the tumor, its mobility, the presence or ab- 
sence of pulsation, tenderness, or crepitation. Mobil- 
ity is a valuable guide in differentiating sarcoma from 
carcinoma, or carcinoma from a benign tumor. Inas- 
much as carcinoma has a tendency to infiltrate the sur- 
rounding tissues, sarcoma will be found to be much more 
freely movable than carcinoma. 

General Symptoms.—Careful inquiry should be made 
as to the patient’s general health, his mode of living and 
his habits, and a thorough physical examination should 
be the rule in all cases. Also the age of the patient 
should invariably be ascertained, for not infrequently 
this alone will enable one to diagnosticate a malignant 
from a benign growth. While carcinoma occasionally 
occurs under the age of thirty years, such cases are ex- 
tremely rare. Loss of weight, if of considerable amount 
and progressive, is of much significance. A general 
physical examination often enables one to avoid a useless 
operation, by disclosing the fact that the patient is al- 
ready suffering from metastatic deposits in the lung, 
liver, or other localities, although the primary growth 
may be readily removable. The local examination of the 
tumor itself should be thorough and systematic; one 
should note its color, its size, the condition of the over- 
lying skin, whether thickened, adherent, or dimpled as 
in carcinoma of the breast, or greatly thinned out as in 
a rapidly growing sarcoma, the presence or absence of 
ulceration, and the amount and character of the discharge, 
if present. The consistence of the tumor throws much 
light upon the diagnosis. If it is hard and indurated, 
with other signs of malignancy, the diagnosis points 
strongly toward carcinoma, while if soft and semifluc- 
tuating, the probabilities are much in favor of sarcoma. 

Exploratory incisions, or the removal of specimens for 
microscopical examination by means of the Mixter punch, 
under cocaine, have been frequently resorted to, and are 
still much used by many surgeons. While there is much 
to be said in favor of this method of confirming a doubt- 
ful diagnosis, there are strong reasons for restricting its 
use within the narrowest limits. I believe that the cut- 
ting into a highly vascular and soft malignant tumor, or 
even the removal of a portion with the Mixter punch, is 
attended with considerable risk of disseminating tumor 
cells throughout the body and producing generalization 
of the disease. I have personally observed a number of 
cases in which this method was used, develop metastases 
within a few months after exploration, so that I have 
given up exploratory incisions, except in cases in which 
it seems absolutely necessary. In the case of a small, 
doubtful tumor of the breast it is far better to remove 
the entire growth than to cut into it and remove a small 
portion for the purpose of microscopical examination. 
In a case of suspected sarcoma of the femur, instead of 
removing a portion prior to operation, I have adopted 
the plan of preparing the patients for a hip-joint ampu- 
tation, then—after the tourniquet has been applied—cut- 
ting into the tumor to confirm the diagnosis prior to 
amputation. 

Proenosts.—The prognosis in cancer depends very 
largely upon the locality of the primary growth. It also 
depends greatly upon the rapidity of growth prior to 
operation. This point is very well brought out by the 
statistics of cancer of the breast by Dr. J. Collins War- 
ren, of Boston, which show that in the successful cases 
the tumor had existed prior to operation for a longer 
time than in the unsuccessful. In other words, the more 
rapid the growth of the tumor the less the probabilities 
of curing it by operation. The prognosis has improved 


628 


remarkably within recent years by reason of earlier diag- 
nosis and earlier operation, as well as from improved 
technique. Yet this great improvement has been in- 
sufficient to offset the increase of the mortality, on ac- 
count of the rapid and progressive increase in the number 
of patients afflicted with cancer. In certain regions the 
prognosis is still absolutely bad; for example, periosteal 
sarcoma of the femur which, according to the latest sta- 
tistics of Butlin, show but one cure in sixty-eight cases 
treated by amputation at or near the hip-joint, and cancer 
of the stomach or larynx, in which the percentage of cures 
is extremely small. Onthe other hand, if weare dealing 
with cancer of the breast or lip, the extensive operations 
and improved technique of the present day offer the 
patient about one chance in three for being cured. The 
age of the patient also has an important bearing upon the 
prognosis. It may be laid down as a general rule, par- 
ticularly true in carcinoma, that the younger the patient 
the more rapid the course, and the worse the prognosis. 
In the very aged, while perhaps the probability of a cure 
may not be greatly increased, the progress of the disease 
will be very much slower. I have observed a cancer of 
the breast ina woman aged ninety-four years, of eight 
years’ duration. During the two years of my observation 
there was little change in the size or appearance of the 
growth, and the general health of the patient was but 
little affected. Early and repeated recurrences, while 
making the prognosis much worse, should not cause the 
surgeon to give up all hope of a cure, and if the tumors 
are anatomically removable, he should continue to 
operate. 

TREATMENT.—General Treatment.—While the major- 
ity of the profession believe that drugs have little or no 
influence upon the progress of cancer, there have been 
many remedies that, from time to time, have enjoyed 
much favor in the treatment of the disease. There is no 
inherent or @ prtord reason why certain drugs should not 
have an inhibitory influence upon the growth of malig- 
nant tumors, especially if these tumors prove to be due, 
as many of us believe, to an infectious agent. There- 
fore, we should not deny the possibility of the existence 
of such a drug, or refuse to give all a fair trial. The 
statement of Senn that “no kind of internal medication has 
any influence whatever in limiting tumor growth, much 
less in causing the disappearance of the tumor,” is not, 
I believe, in harmony with the facts. There are certainly 
well-authenticated cases of sarcoma, especially of the 
skin, in which the disease has been clearly retarded by 
the use of large doses of arsenic; there are likewise well- 
authenticated cases of sarcoma and even of carcinoma, 
that have shown decided improvement under mercurials 
and iodides. I have personally observed more than one 
such case in which the diagnosis was confirmed by micro- 
scopical examination. In one case, a carcinoma of the 
breast, the improvement was so marked under large 
doses of iodine that the diagnosis of syphilis seemed 
clearly correct; after a time the improvement ceased and 
exploratory operation showed the growth to be a typical 
carcinoma. ; 

Local Treatment.—This includes operative treatment 
as well as removal by caustics, electrolysis, parenchyma- 
tous injections, and the injections of the toxins of erysipe- 
las, which produce both local and systemic action, though 
the local predominates. 

Operative Treatment.—Free and thorough excision of 
cancerous tumors with the knife is the only method of 
treatment that should be considered in cases in which it is 
possible completely to remove the disease. By removal 
we mean not only removal of the tumor itself, but of all 
the neighboring lymph glands, together with the con- 
necting lymphatics. A careful study of recurrent cancer 
shows that in by far the largest proportion of cases the 
return takes place in the region of the skin or cicatrix. 
Therefore, if we expect to improve the results, we must 
remove wider areas of skin in the future than has been 
our custom in the past. 

Limitations of Operative Treatment of Cancer. Cancer 
is unquestionably a local disease at its origin and during 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


é 








Cancer, 
Cancer, 





the period of its early development, and if treated by 
thorough removal at this period can, in the majority of 
cases, be cured. The difficulty, however, in operating at 
this time lies in the fact that the tumor itself is not al- 
ways discovered until the disease has already infected the 
neighboring glands, and in other cases when discovered, 
the patient refuses an early operation. The curability 
of cancer depends largely upon our ability, anatomically 
and surgically, to remove the invaded area, together 
with a sufficient amount of healthy tissue on all sides. 
From a clinical standpoint we must admit that it is im- 
possible to cure all cases, but even with the limitations 
which I have mentioned as regards early diagnosis and 
the difficulties in persuading patients to submit to early 
operation, we are still able to cure a very large number 
of patients and materially to prolong and render more 
bearable life in many others. I believe with Banks and 
Shield, that the pendulum has swung too far in the 
direction of operative treatment for cancer, especially 
in the later stages of the disease. We are not likely 
to err in the direction of too extensive operations in the 
early stages, and, indeed, there is reason to believe that 
our operations are generally not extensive enough in such 
cases; but I have seen many cases of advanced recur- 
rent cancer subjected to operation, in which there was 
little or no prospect either of curing the patient or of 
rendering the disease less distressing. It is natural that 
surgeons should not always agree as to the exact classifi- 
cation of operable and inoperable cases, yet it is possible 
for us to lay down certain general rules which may be of 
help in deciding this difficult question. There will al- 
ways be surgeons who will operate only upon cases in 
which there is a high probability of final success, and 
there will be others who will continue to operate when 
there is practically no hope of effecting a cure, or of com- 
pletely removing the disease, even though the operation 
itself may be attended with the gravest risk to the life of 
the patient. Partial operations in which there are large 
infected areas left behind, instead of decreasing, fre- 
quently increase the rapidity of growth. Watson Cheyne 
does not believe that we should refuse operation unless 
early recurrence is very highly probable, or unless opera- 
tion means almost certain death. 

My own feeling is that often in persuading ourselves 
that there is a bare possibility of curing the disease in 
these advanced cases, we are apt to forget that the high 
mortality and the very small proportion of cures cannot 
but have a great influence upon the laity in destroying 
their confidence in all operations for cancer, and thus 
prevent many patients suffering from cancer in the early 
and operable stage from consulting a surgeon or con- 
senting to operation at a time when the prospect of cure 
is good. Operations, therefore, I think, should not be 
advised unless there is strong probability of being able to 
remove the entire disease. This does not mean that we 
should not in certain special cases remove foul, fungating 
masses, when thereby we may be able to add greatly to 
the comfort of the patient, although there is no prospect 
of prolonging life. 


GENERAL CONSIDERATIONS. 


Sex.—Of 7,878 cases of primary neoplasm collected by 
Williams the proportion of males and females was 1 to 1.7. 
According to statistics covering years between 1872 and 
1898, cancers of all kinds show a proportion of 1 male to 
2.29 females. Comparing the mortality of cancer with 
that of all other diseases, we find that among males we 
have 1 death from cancer to 100 deaths from all other 
diseases; while among females we have 1 death from can- 
cer to 49 deaths from ‘other causes. The statistics of the 
year 1889 show that of every 21 males who reach the age 
of 35 years, 1 dies from cancer; while in females who 
reach the age of 35 years, 1 in 12 dies of cancer. Wil- 
liams’ statistics show, however, that the relative differ- 
ence in the mortality of the (two) sexes is gradually de- 
creasing, the records for 1851 showing the ratio to be 1 
male to every 2.2 females, whereas, in 1896, it had dimin- 


ished to 1 male toevery 1.4females. Curiously, in certain 
localities this ratio is reversed. For example, in New 
South Wales and New Zealand the mortality is greater 
in males than in females. 

Age.—Of 941 consecutive cases of malignant tumors 
observed by Williams, there were only 25 cases under the 
age of 25 years. 

Williams believes that a considerable number of malig- 
nant neoplasms are of congenital origin, and that in some 
instances these are multiple from the start. I have per- 
sonally observed 1 case of a very large multiple round- 
celled sarcoma in an infant 6 months of age, in which the 
multiple growths were noted soon after birth. The dis- 
ease ran a very rapid course. 

Under the age of puberty carcinoma is so rare as to be 
practically unknown. ‘The rectum is the most favorable 
site for malignant epithelial disease occurring before the 
age of 80. The type of disease is either carcinoma or 
malignant adenoma. About 20 such cases have been re- 
ported under the age of 30. R. de Bovis (Revue de 
Chirurgie, Jain, 1900) found 35 cases of cancer of the 
large intestine (exclusive of the rectum) under the age 
of 80, out of a total of 400 cases. Of 500 cases of mam- 
mary cancer observed by Williams, the youngest patient 
was 24 years of age. Of 1,622 cases collected by Gross, 
the youngest patient was 22 years. 

In the uterus the disease may occur somewhat earlier 
in life than in the breast, although the difference is not 
great. Of 500 cases collected by Williams, it occurred 
once in an individual 22} years old; while out of 3,885 
cases collected by Boussereau, it occurred in 2 under the 
age of 20 years; and 1 authentic case has been reported 
at the age of 17 years. 

It is a well-known and somewhat striking fact that 
cancer is seldom seen in the very aged. Williams states 
that of 1,087 centenarians only 5 died of cancer, giving a 
proportion of 1 in 217; while of 202 individuals between 90 
and 100 years of age, not a single one died of cancer. Of 
500 cases of cancer of the uterus, the oldest was aged 838 
years. The oldest individual with cancer of the breast 
observed by Williams was 84 years. I have personally 
observed cancer of the breast in a woman aged 94 years. 
The disease had existed for six years and the progress was 
extremely slow. It may be stated that the average age 
of women with mammary cancer is 48, and with uterine 
cancer 44, with cancer of the tongue and mouth 50, of 
the lip 51.6, of the rectum 50.7, of the stomach 40.5. 
The maximum period of frequency in the female is 
45.55, in the male 55.65 years. 

Geographical Distribution.—The mortality from cancer 
differs very greatly according to locality, also according 
to the period covered by the statistics, the mortality 
showing a general increase, as has already been stated, 
all over the world during the past half-century. The 
mortality for 1890 was 7.9 per cent. for Boston; 6.2 per 
cent. for New York; 4.8 per cent. for Brooklyn. Fifty 
large American cities, in 1888, showed a cancer mortal- 
ity of 7.9 per cent., of which 5.1 per cent. were females, 
2.8 per cent. males. Comparing these statistics with 
European cities, we have for London, 6.8 per cent. in 
1881 to 1890; for Paris, 10.4 per cent. in 1886 to 1891; 
for Lyons, 16.3 per cent. in 1892. 

Heredity.—The influence of heredity upon the etiology 
of malignant disease is a question about which there is 
still little uniformity of opinion. However much author- 
ities may differ as to the amount of influence attributable 
to heredity, it is impossible to deny that there is some 
influence. Numerous cases have been cited to show that 
in certain families this influence has been very striking. 
Williams observed a patient, aged 53, suffering from 
uterine cancer, and whose maternal grandmother, mother, 
mother’s two sisters, and patient’s two sisters all died of 
cancer of the uterus. The Bonaparte family is another 
striking illustration of the influence of heredity. Napo- 
leon’s father, brother Lucien, and two sisters, died of 
cancer of the stomach. Manichow reports 23 families in 
which intermarriage had been frequent, showing 69 cases 
of cancer, of which 57 occurred in the stomach. The 


629 


Cancer, 
Cancer, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











tendency of hereditary cancer to attack the same organ in 
different members of the family is another remarkable 
peculiarity of this mysterious influence. A case was 
cited by Williams, in which the mother and five daugh- 
ters all died of cancer of the left breast. I have myself 
reported two cases of sarcoma of the left breast occurring 
in two sisters, appearing at the same age and both imme- 































































































Fig. 1098.—* Squirrhe Disseminée,” Acute Traumatic 


diately following trauma. Williams believes that these 
peculiarities associated with heredity point to intrinsic 
rather than extrinsic causes of the disease. It seems to 
me that such a conclusion is hardly warranted by the 
facts. We certainly can get very little light upon the 
vexed question of etiology from what we know of hered- 
itary influence. 

As to the frequency with which hereditary influence 
has been observed, statistics differ. Williams found a 
family history of cancer in 24.2 per cent. of 186 cases of 
cancer of the breast; while of 209 men suffering from 
cancer of various organs, a history of heredity was found 
in but 11 percent. Selecting only those cases in which 
there was a history of cancer in parents, the percentage 
is 8. A very curious fact has been noted, namely, that 
a patient is capable of transmitting this hereditary in- 
fluence to offspring while latent, or long before any evi- 
dence has been visible in the patient herself. For ex- 
ample, Broca’s famous case of Mme. Z., who had four 
daughters, all of whom died of cancer, and yet they were 
born from fifteen to thirty years before the mother herself 
contracted the disease. It has further been noted that 
hereditary influence is more often transmitted to the fe- 
male than tothe male line. For example, of 19 daughters 
and granddaughters of Mme. Z. that lived to be 30 years 
of age, 14 died of cancer, whereas of 17 males only 1 died 
of cancer. 

Cancer is far more frequently seen in persons of robust 
health than in thin, weakly individuals. Williams is 
inclined to attribute considerable weight to the opinion 
that the increase in cancer may possibly be due to the 
fact that during the last fifty years the standard of liv- 
ing has become so much higher, much larger quantities 
of animal food being consumed now than formerly. 


CANCER OF SPECIAL REGIONS. 


CANCER OF THE BREAST.—Carcinoma of the breast 
rarely occurs in women under the age of 30, and one sel- 
dom sees it until after the age of 35. The average age at 
which it appears, as given by Gross, is 48 years. The first 
thing the patient usually notices is a lump in the breast, 


630 





without any history of antecedent pain. The growth does 
not change materially in size for a number of months, 
and it being nearly or quite painless, the patient does not 
regard it of serious importance. Later on, occasional 
sharp twinges of pain may appear. The pain is always 
at first intermittent, and does not become dulland steady 
until the later stages of the disease. The family history 
of the patient, as well as the 
previous personal history, is 
of great importance. 

Heredity is found in about 
21 per cent. of all cases. A 
considerable number of pa- 
tients give a history of local 
injury, and the more one 
studies the malignant tumors 
from a clinical standpoint, the 
more importance does one 
attach to the influence of an- 
tecedent injury in the etiol- 
ogy of cancer. MacWilliams* | 
states that in 100 consecutive 
cases operated upon at the 
Presbyterian Hospital of New 
York, 44 gave a history of 
antecedent injury. 

Inflammatory trouble often 
precedes the development of 
cancer of the breast, and, no 
doubt, likewise has some in- 
fluence on its causation. Al- 
though many—perhaps the 
majority—of surgeons refuse 
to believe that there is any 
direct etiological relationship 
between trauma or chronic 
inflammation and cancer, the clinical fact remains that 
these conditions are very frequently associated with the 
development of cancer, and although we are at present 
unable entirely to explain this relationship, the facts must 
have due weight in making our diagnosis. Antecedent 
injury in carcinoma of the breast is variously estimated 
at from 12 to 40 per cent. In sarcoma the percentage is 
much higher. Nearly all the cases of sarcoma of the 
breast that I have personally observed have given a dis- 
tinct history of local injury. It has been the custom of 
most writers to minimize the patients’ statements with 
reference to having received blows or knocks upon the 
breast, the reasons given being, first, that only a certain 
percentage of patients give this history, and second, that 
every woman probably receives similar blows without the 
development of cancer, and that, therefore, they cannot 
have an important bearing on the disease. If we could 
know the exact facts, I believe that the percentage of cases 
in which injury has been noted is far smaller than the 
actual percentage in which it has occurred, the reason be- 
ing that many patients have forgotten the antecedent in- 
jury. The fact that many women who receive blows 
upon the breast do not develop cancer is no more argu- 
ment against the etiological relationship of trauma, than 
it would be to cite the fact that many patients are ex- 
posed to the diphtheria bacillus and do not contract the 
disease, as an argument against the relationship between 
the bacillus and the disease in persons who did contract 
it. 

Malignant disease of the breast may be either acute or 
chronic. Acute miliary carcinosis or squirrhe disseminée 
is exceedingly rare, and but few cases have been re- 
ported. I have personally observed one case occurring 
in a woman of 38 years, immediately following a blow. 
The disease ran a very rapid course, spreading quickly 
to the other breast, involving the entire skin and the 
anterior portion of the thorax, causing death in about 
nine months. Only 2cases of this variety were observed 
by Williams in 170. Carcinoma en cuirasse is also com- 
paratively rare, only 3 cases having been observed by 


Carcinoma. 





* Medical News, April 28th, 1898. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancer, 
Cancer, 





Williams in 170. Carcinoma en cuirasse is not a special 
type of cancer, but derives its name from the fact that 
the superficial or skin lymphatics are early and exten- 
sively involved. The opinion held by some writers, that 
the disease is limited to the skin, is probably erroneous. 
The primary focus is in the breast, and the contiguous 
lymphatics are involved at an early period. 

The chronic form of carcinoma of the breast includes 
those cases in which the disease has a duration of five 
years or more. In Williams’ list of 170 cases 31 were of 
the chronic form. Of these, 14 cases had a duration of 
from 5 to 10 years; 6a duration of from 10 to 15 years; 
2a duration of from 15 to 20 years; and 1 a duration of 
from 20 to 25 years. 

One case of undoubted breast cancer has been reported 
in which the disease lasted for over thirty years. 

Melanotic growths are exceedingly rare in the breast, 
especially in the female. Williams’ table of 2,397 cases 
of primary carcinoma of the breast does not contain a 
single example of melanotic carcinoma; while in 100 cases 
of cancer of the male breast there were 3 of the melanotic 


type. I have personally observed 1 case of melanotic 
cancer of the female breast. The history of the case is 
as follows: 


Melanotice Sarcoma of the Breast.—Mrs. F., aged 44, 
married, with four children, good family history, had in- 
flammation of the right breast ten years ago. Shortly 
after this she noticed a small lump in the region of the 
nipple, but not attached to the skin. This remained 
comparatively stationary for nine years. At the end of 
this time the nipple became slightly retracted, and a 
small lump appeared in the opposite breast, which was 
of bluish color and attached to the skin. The first oper- 
ation was performed by Dr. Abbe, of St. Luke’s Hospi- 
tal, on the 19th of July, 1897. Both tumors were re- 
moved, together with two other smaller ones on the outer 
aspect of the left arm. Whenseen by myself, on August 
29th, 1898, there was an area four by five inches in ex- 
tent, of local recurrence, together with numerous small, 
dark-colored nodules scattered through the skin of the 
abdomen. ? 

Paget’s Disease of the Nipple.—Shield, who has made 
a careful study of this disease, believes “superficial car- 
cinoma of the skin” a better term. The disease is rare 
and the diagnosis not infrequently difficult. It is almost 
invariably, although not certainly, followed by carcinoma 
of the breast itself. As regards the treatment of this 
disease, I am thoroughly convinced that nothing short 
of a very radical operation (namely, complete removal of 
the breast and axillary glands) should be performed. 
Shield states that he has never known a genuine case of 
Paget’s disease cured by local remedies. I have person- 
ally observed two cases of Paget’s disease; in the first of 
these I operated upon September 13th, 1897, and the entire 
breast, together with the axillary glands, was removed. 
The patient has remained well up to the present time, 
three and a half years after the operation. The. second 
case refused operation, and one year later the disease had 
involved the breast so extensively that operation was 
impossible. 

Cancer of the breast occasionally may co-exist with 
sarcoma of other organs. Roger Williams has collected 
11 such cases. I have personally seen one. The patient 
was a woman, 53 yearsof age. In July, 1896, I operated 
for a recurrent carcinoma of the breast; in September, 
1896, I removed from the same patient a round-celled 
sarcoma the size of anegg, from the submaxillary region, 
on the same side. The disease quickly recurred, and in 
a few months proved fatal. 

»  Diagnosis.—Age. Cancer of the breast is extremely 
rare under the age of 30, and few cases have been ob- 
served under the age of 35. The average is estimated 
by Gross as 48 years. 

The clinical history of the ordinary case would be 
something as follows: The patient will be in middle life, 
probably married. Eighty-eight per cent. of the cases 
collected by Gross occurred in women who were or had 
been married, There will be a history of slight pain, or 


occasional stinging sensations hardly severe enough to 
be characterized as pain. There is seldom dull or con- 
stant aching in the early stages of the disease. In many 
instances the patient discovers the lump while bathing, 
before the advent of pain. Too much stress should not 
be laid upon pain, inasmuch as many cases of cancer of 
the breast become comparatively far advanced before 
they produce appreciable pain. Gross states that “car- 
cinoma of the breast begins as a small, painless nodule.” 
In about one-third to one-half of the cases the patients 
give a history of having received some injury to the 
breast at varying intervals of time prior to the discov- 
ery of the tumor. Previous inflammatory trouble or 
antecedent injury is of great importance and should be 
carefully inquired into. For notwithstanding the cir- 
cumstance that many refuse to admit that there is an 
etiological relationship between trauma and cancer, the 
clinical fact remains that these conditions are very fre- 
quently associated with the development of malignant 
disease; and, although we may not at present be pre- 
pared to offer a satisfactory explanation, the facts must 
have due weight in our efforts to establish the diagnosis. 

The frequency of histories of previous trauma in cancer 
of the breast varies from 12 to 46 per cent. in the statis- 
tics of different writers. A careful physical examination 
will enable us in most cases to make a diagnosis; and in 
making this examination the fingers should be applied 
flat against the parts and should not be used as in pinch- 
ing. In carcinoma of the breast the tumor is generally 
very hard, no matter how smallit may be. It is usually 


found somewhere in the periphery of the breast, and is, 





Fig. 1099.—Carcinoma of the Breast. 


even in the early stages, much more fixed to the surround- 
ing breast tissue than are benign growths. In about half 
of the cases there will be found a retraction of the nipple, 
although I believe that the diagnosis should be made in 
most cases before this sign has appeared. The condition 
of the skin is of very great importance and is of great help 


631 


prin ils REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancer. 











































Fig. 1100. 


in determining the diagnosis. The peculiar con- 
dition, known as “ dimpling of the skin” is caused 
by the contracting of the fibrous tissue lying 
between the skin and the gland tissue. In the 
great majority of cases the skin is obviously dim- 
pled. Shield states that there is no sign of more 
vital importance than this. Even when the skin 
did not appear dimpled, I have seen cases in 
which the dimpling could be easily brought out 
by slightly pinching a considerable area of skin 
overlying the tumor. Examination of the axilla 
should always be made, although the absence 
of enlarged glands would not justify us in ex- 
cluding carcinoma. The axillary glands are pal- 
pably enlarged in about 50 per cent. of the cases. 
The tumors most likely to be mistaken for carci- 
noma are fibro-adenoma, cyst-adenoma, fibroma, 
sarcoma, chronic inflammatory and tuberculous 
disease. Fibro-adenoma occurs, as a rule, in 


younger individuals. Of 63 collected by Shield, © 


45 occurred before the age of 40. This variety 
of tumor more frequently occurs in single than 
in married subjects, a fact just the reverse of 
that found in cancer. The age of the patient 
and the absence of the characteristic symptoms 
and signs already noted with reference to can- 
cer enable us to make a diagnosis in most cases. 
In certain cases, however, it is impossible abso- 
lutely to be sure whether the tumor is malig- 
nant. However, the plan advocated by some 
surgeons in such an event, to cut out a portion 
of the growth under cocaine or with a tumor 
punch for examination, is hardly to be recom- 
mended. The better way is to prepare the pa- 
tient for a complete operation, first remove the 
tumor, and if the surgeon is not able to deter- 
mine whether or not it is malignant on exami- 
nation of a gross section, a frozen section might 


632 





be made and examined. In very few cases will this be 
necessary. 

Results of Operative Treatment.—The improvement in 
results of the operative treatment of cancer is nowhere 
more manifest than in cancer of the breast. The gradual 
and, as it were, painful evolution of modern methods 
from the incomplete operations of a few years ago has 
been very clearly shown by Sir W. Mitchell Banks in his 
recent Lettsomian Lectures on “ Practical Observations on 
Cancer of the Breast.” * He states that in 1862 opera- 
tions for cancer of the breast consisted in local removal 
of the tumor of the most imperfect description. If any 
glands were affected, this was a sufficient bar to any 
operation. In 1867 Mr. C. H. Moore wrote what is now 
an almost historic paper on “Inadequate Operation in 
Cancer,” which set a great many minds thinking, inas- 
much as it-was “a revolt against constituted authority.” 
Banks’ paper, “A Plea for the More Extensive Removal 
of Cancerous Growths,” was published in 1877, and the 
classic work of Gross on “Tumors of the Mammary 
Gland” in 1880, or three years later. The works of 
Moore and Banks and Gross were slow in being accepted. 
Banks again, in 1882, in a paper read before the British 
Medical Association, said: “Surgeons, as a rule, do not 
remove cancers of the breast; they persuade their pa- 
tients that they do and they almost persuade themselves, 
but there is always that little bit that they leave behind, 
and which they fondly hope will not grow because it is 
such a little bit. Alas, that such little leaven should 
leaven the whole lump!” Banks made a most urgent 
appeal in favor of removing the entire breast with a very 
wide area of skin, but he advocated the removal of all 
the axillary glands and fat in atl cases, whether the 
glands could be felt ornot. As late as 1888 this complete 





* Lancet, April 7th, 1900. 


Fic. 1101.—Double Carcinoma of Breast. 





e REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





omas Smith even went so far as to say that 


while 
patients lived longest who had never been operated upon 


atall. It is true that the high mortality that followed 
the operation at this period (16 per cent.) gave some jus- 
tification for those who were content with the simpler 
procedure. In spite of all criticism and obstacles Banks 
and Gross continued to 
practise as well as to 
preach the complete 
operation, until to-day 
we find that even But- 
lin himself has not only 
come over to the com- 
plete operation of 
Banks, but has gone a 
step further and is now 
a most enthusiastic ad- 
vocate of Halsted’s op- 
eration. - While many 
who advocate the ex- 
tensive operation of to- 
day prefer to credit 
their conversion to the 
histological researches 
of Heidenhaim, we 
must in fairness ac- 
knowledge that this 
great change has been 
largely due to the ear- 
lier clinical works and 
the superior results of 
Moore, Banks, and 
Gross. Banks’ statis- 
tics are the largest and 
most complete yet pub- 
lished. He has operat- 
ed upon 213 cases of 
cancer of the breast. 
Of these, 175 have full 
histories; 67 died of 
local recurrence, and 
it is a most remarkable 
fact that of these 67 
cases 17, or 25 per 
cent., lived from 8 to 
13 years; 38 patients 
were alive and well 
from 3 to 21 years af- 
ter operation. Of 108 
cases that remained 
free from local recur- 
rence, 73 lived from 3 
to 21 years after operation; 40 from 3 to 6 years; 28 
from 7 to 14 years; 28 from 16 to 21 years; 80 died of 
metastases without local recurrence. Of these it is im- 
portant to note that 20, or 66 per cent., died from 3 to 14 
years after operation. 

Adding the cases that died after 3 years from local re- 
currence to those that died after'3 years from general re- 
currence, we have 37 patients who, according to the usual 
reckoning, would have been regarded as cured, yet who 
really died of recurrence. 

Let us then compare the percentage of cases estimated 
by the usual 3-year basis with the percentage of actual 
cures of Banks’ series of 213 cases (we must exclude 60 
operated upon during the last three years and 7 in which 
only partial operation was performed); we have left 146 
cases; 90, or 62.3 per cent., lived beyond 3 years. The 
careful tracing of the after-history of these 90 cases 
showed that 38, or 42 per cent., recurred after having 
passed the 3-year limit. Thus 26 per cent. of the total 
of 146 cases operated upon more than three years ago 
recurred after 3 years. This shows the great importance 
of following up the patients for long periods of time, 


and makes the statistics of Banks by far the most impor- 


Cancer, 
Cancer, 








Fig, 1102.—Cancer ‘* En Cuirasse.”’ 


tant data we now possess upon which to base a true esti- 
mate of the curative value of surgical treatment of cancer 
of the breast. 

These statistics certainly justify the conclusion of 
Banks, that “the plan of taking percentages in small 
numbers of cases ought to be abolished,” and, further- 
more, that “the 3-year cure system, too, must be abol- 
ished if people are to be instructed fairly.” The recent 
statistics of Barker bear out the conclusions of Banks.* 
Barker’s tables contain 
100 consecutive cases 
of breast tumors treat- 
ed by operation, most 
carefully traced to final 
results. Of these, 90 
were malignant; 6 died 
of operation; 383.7 per 
cent. lived over 3 years 
and 16 per cent. over 
5 years. 

In regard to the 8- 
year limit Barker says: 
“Tt is clear that 33 per 
cent. live more than 3 
years after operation, 
which has been sug- 
gested to some sur- 
geons that they should 
be regarded as perma- 
nent cures; but some 
of the cases (26.9 per 
cent.) have died most 
likely of recurrence in 
all but 1 after an im- 
munity of over 8 years, 
so that such a presump- 
tion is unwarranted.” 

In one of Barker's 
cases there was exten- 
sive glandular infec- 
tion and a bad prog- 
nosis was given, and 
yet the patient was 
well 14 years later. 

Cheyne’s latest sta- 
tistics + are among the 
best that we have. He 
gives the details of 61 
cases operated upon 
more than three years 
ago. Excluding the 
cases not traced and 
those which died of 
operation, which I did 
not do in estimating 
Banks’ percentage, Cheyne has 87 cases remaining, of 
which 19, or 51 per cent., were alive and well. 

Butlin’s most recent statistics { give 116 cases operated 
upon between 1880 and 1894. Of these 6 died of opera- 
tion; 3 were not traced; 51 had local recurrence; 22 had 
general recurrence; 2 died of other causes within 3 years; 
3 died of other causes after 3 years; 29 are alive and well 
more than 3 years after the operation. 

In 1895 Butlin adopted Halsted’s method, and of 33 
cases up to the end of 1897 had but 1 death. Of these 
11 were operated upon more than 3 years ago. Of these 
1 died of operation; 3 of recurrence (2 local), and 9, or 70 
per cent., were well more than 3 years. These results are 
brilliant, yet it would be clearly unfair to form an esti- 
mate of the value of any operation for cancer on such a 
small number of cases. 

Supraclavicular Glands.—I have not yet been convinced 
of the wisdom or value of removal of the supraclavicular 


*“The Expectancy of Life in Cases of Cancer of the Breast.” 
Lancet, September 3d, 1900. 

+ ‘* Further Statistics as to Results Obtained by Operations for Cancer 
of the Breast.’”’ Lancet, March 13th, 1899. 

+ St. Bartholomew’s Hospital Reports, vol. xxiv., 1898. 


633 


Cancer. 
Caneer, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





glands asa routine method in operations for cancer of 
the breast, and it should be noted that Butlin, who in 
other respects followed Halsted’s method closely, did not 
remove the supraclavicular glands in any of his cases, 
and believes with Cheyne that when these glands are 
removed, the case is hopeless. The statistics of Banks, 
Cheyne, and Butlin, which equal those of Halsted, would 
go to show that as good results can be obtained without 
this step. Until further evidence is forthcoming, I be- 
lieve we are justified in not removing the supraclavicular 
glands, unless glands are discovered very high up. In- 
asmuch as removal of the pectoral muscles does not 
greatly interfere with the usefulness of the arm and does 
facilitate the dissection of the axillary contents, it is per- 
haps better to remove at least a portion of the greater 
pectoral muscle along with the breast. ; 

In order to obtain better results, I think it is far more 
important to remove wider areas of skin and more of the 
adjacent fat, for we find that recurrences take place in the 
skin or fat a dozen times to one in the pectoral muscles. 

The recent statistics of 100 cases of the Presbyterian 
Hospital of New York published in 7he Medical News, 
April 28th, 1900, by MacWilliams, still further support 
this view. His cases were operated on during the years 
1889-99. In 48.9 per cent. of them the lymphatic glands 
were palpably enlarged. Yet of 75 cases which were 
examined microscopically after removal, 78.6 showed can- 
cerous infection. The mortality of operation was 4 per 
cent. ; and of 66 cases traced, 34 per cent. were well for 
a period of from 3 to 10 years. MacWilliams states that 
all the recurrences except 2 died within 2 years. 

Here again we see the danger of generalizing from a 
single series of a small number of cases, especially as in 
26 cases the after-histories were not traced. It is a sig- 
nificant fact that more than twice as many recurrences 
took place in the skin and scar than in any other locality. 
Of 34recurrences 15 took place in scars and 6in the lung; 
3 in the opposite breast, and only 2 in the supraclavicu- 
lar glands. 

Halsted’s brilliant “Results of Operation for Breast 
Cancer at the Johns Hopkins Hospital from June, 1889, 
to April, 1898,”* are of great interest and value. In 
all 133 cases were operated upon, 76 of these more than 
3 years ago. There have been 13 (9 per cent.) local 
and 22 (16 per cent.) regionary recurrences. Of the 76 
cases operated upon 3 or more years ago, 31 (41 per cent.) 
are living without local recurrence or signs of metastases ; 
10 died more than 3 years after operation, and 1 as late as 
5.5 years after. Of these 10, 1 had a local recurrence. 
Forty cases, therefore (52 per cent.), lived more than 3 
years without signs of local or regionary recurrences. 
Some of the 10 cases which died may have had, at 3 
years, signs of metastases. Thirty-five (46 per cent.) 
died within 3 years of the operation, and 7 of these were 
local recurrences. 

Dr. J. Collins Warren, in his valuable paper on “ Cura- 
bility of Cancer of the Breast,” gives results of 72 cases 
operated upon during the past 15 years. Of these 38 
died of recurrence of the disease, 26 are alive and well, 
2 died of other diseases, and the remainder were not 
traced. Out of 50 cases in which recurrence was noted, in 
34 the disease returned locally, either in the skin or subcu- 
taneous fat, showing, as I have pointed out in most of 
the other statistics, that the present methods of operation 
fail to remove a sufficiently wide area of skin. In only 1 
case did the recurrence take place in the supraclavicular 
region. Seventeen cases have remained well beyond 3 
years, giving a percentage of 30.9 per cent. During the 
period of 1883-95, 22 cases were operated upon by more 
elaborate methods than the preceding cases; of these 36.3 
per cent. passed the 3-year limit without recurrence; in 
all of the cases, however, the axillary glands were care- 
fully removed. Warren states, with truth I believe, that 
the present experience with the new operations hardly 
justifies one as yet in deciding upon the limits of the 
curable cases. Until these limits are more strictly de- 


* Transactions Am. Surg. Assn., 1898. 


634 


fined, it is probable that many incurable cases will be 
subjected to operation. He adds that it is his hope that 
wider experience will spare many a patient the ordeal of 
a useless operation. 

With regard to glandular involvement, the glands were 
felt in the axilla in 54 cases; in 5 cases supraclavicular 
glands were noted; 3 of these died: 1 was alive, at time 
of writing, and 1 was not traced. 

Warren’s statistics emphasize some very important 
facts as to the duration of the tumor prior to the opera- 
tive interference; the average period in 68 cases was 10.1 
months. In 16cures the average was 11.6 months, while 
in 38 failures it was9,4months. At first it seemed some- 
what strange that the successful cases were operated 
upon later than the failures. Warren’s explanation is prob- 
ably correct, that the longer time during which the tumor 
had existed in the successful cases prior to operation 
simply shows the milder type of the disease. A person 
with a rapidly growing and consequently more malig- 
nant type of tumor is far more likely to be disturbed and 
to seek early surgical or medical advice than one with a 
more slowly and hence less malignant disease. 

CANCER OF THE Lip.—Sarcoma of the lip is exceed- 
ingly rare, so rare that it is seldom mentioned by writers 
on cancer. I have personally observed one case of small, 
round-celled sarcoma of the lower lip in a little girl aged 
five years. The disease was twice removed, but recurred 
rapidly after each operation. It disappeared under the 
injections of the mixed toxins of erysipelas and bacillus 
prodigiosus, and is now well more than three years after 
operation. Cancer of the lower lip is almost always of 
the type of squamous-celled carcinoma, and rarely occurs 
in subjects under the age of forty years. The usual 
history is that of a slight irritation near the junction of 
the mucous membrane and the skin, resembling a small 
wart, which is irritated by the patient’s picking and rub- 
bing it. It frequently heals over, but in a short time the 
scab comes off and a small ulcer or fissure remains. It 
may continue for years with very slight increase in size. 
The duration of the disease is very variable, ranging be- 
tween a few months and fifteen to twenty years. Death 
almost always occurs by exhaustion and seldom from 
metastases. The submental, submaxillary, and, finally, 
the cervical glands are likely to become involved in the 
order mentioned. The glandular involvement may occur 
early in the disease or it may be delayed fora long period. 
Simple enlargement of the glands does not always mean 
that infection has occurred. Butlin cites a case of a pa- 
tient who died within a few months from the first ap- 
pearance of the cancer, with extensive ulceration of the 
lip and secondary infection of a large number of glands. 
I have personally observed a similar case in a negro, in 
whom the disease ran sucha rapid course that it strikingly 
resembled anacute infectious process. Within six weeks 
from the time the tumor was first noticed, the entire 
lower lip, floor of the mouth, and portion of the jaw, to- 
gether with nearly all the glands in the neck, were in- 
fected, the latter being enormously enlarged. The pa- 
tient died within three months from the inception of the 
disease, without metastases. In those cases in which the 
progress of the disease is very rapid, there is another 
point of similarity between cancer and acute infection, 
namely, a marked rise in pulse and temperature. 

Method of Operation.—The only method that needs to 
be seriously considered is free removal with the knife or 
scissors, of a V-shaped portion of the lip containing the 
tumor and a wide margin of healthy tissue, from one- 
half to three-fourths of an inch beyond the border of the 
disease. In cases requiring removal of a large portion of 
the lip, the method of Malgaigne, or some one of the 
numerous modifications of the method, should be em- 
ployed.. The glands should always be removed when 
enlarged, and I believe that it is better to remove the 
submental and submaxillary glands as a routine measure 
in all cases, except in those in which the disease is of 
very short duration. The deformity caused by the re- 
moval of cancer of the lip is very slight when the tumor 
is small, and when it is large, almost the whole lower lip 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancer, 
Cancer. 





may be removed without causing great deformity, so 
ane as the plastic operation is carefully and skilfuily 
done. 

Results of Operation.—The mortality of operation at the 
present time is very slight. In 896 cases collected by 
Worner* there were 62 deaths, or a mortality of 7 per 
cent. Fricke’s more recent statistics of the Gottingen 
Clinic, covering the years between 1874 and 1896, show 
8 deaths in 114 cases, or the same mortality as that re- 

orted by Worner. Five out of the 8 cases collected by 
Fricke, however, were complicated by removal of a por- 
tion of the lower jaw. The question of the necessity of 
removal of the glands in all cases 
Fricke’s paper leaves still in 
doubt. In 8 of the successful 
cases they were not removed, al- 
though they were decidedly en- 
larged; yet the patients lived 
from 8 to 18 years after opera- 
tion. Butlin states that at pres- 
ent he does not believe that rou- 
tine operation for removal of the 
glands in every case of cancer of 
the lower lip is indicated. In 
Fricke’s list they were removed in 
24 out of 33 unsuccessful cases. 
This, however, does not prove 
that the patients would have done 
any better, had they not been re- 
moved. It seems wise to remove 
them in all cases, inasmuch as this 
procedure is not likely materially 
to increase the mortality, if at all. 
In Fricke’s series the lower jaw 
was resected in 10 cases with 5 
deaths; and only 1 of these cases 
was cured by the operation. Curi- 
ously enough, this case of cure 
was one in which the prognosis 
was exceedingly bad from the 
start. A second operation was 
done for extensive recurrence 4.5 
months after the first, and yet the 
patient was well 11 years after. 

Loos (Bettrdge 2. klin. Ohir., Bd. 
XXVII., May, 1900) gives an an- 
alysis of 565 cases of cancer of the 
lip treated at Bruns’ Clinic, at Tii- 
bingen, 534 of which were of the 
lower lip and 31 of the upper lip. 
In three-fourths of the cases the 
glands were enlarged. The mor- 
tality of the operation during the 
period from 1843 to 1885, was 6.24; 
from 1885 to 1898 it was 0.4%. The final results showed 
51.6% successful in the earlier period and 66% in the later 
period. Of the cases operated upon between 1843 and 
1884, 1 was well at the end of 45 years, 10 were well at 
the end of from 22 to 26 years, and 14 were well at the 
end of from 15 to 19 years. 

The final results of operation for cancer of the lip are 
perhaps equal, or superior, to those in any other locality. 
The statistics of the cases at the Gottingen Clinic, 114 in 
number, mostly operated upon by Konig, show that 53 
per cent. remained well more than 8 years after operation. 
Four hundred and twenty-four cases of cancer of the 
lower lip, collected by Butlin prior to the statistics of 
Fricke, show 88 per cent. of cures. After the disease has 
once recurred, there is very little hope of saving the pa- 
tient by further operation. In only 3 out of 52 cases re- 
ported by Fricke as having passed the 3-year limit had 
there been a second operation performed. If the jaw is 
already involved, the prognosisis exceedingly bad. But- 
lin states that such operations are followed by a high 
rate of mortality, and are very rarely permanently suc- 
cessful. 





* Beitr. z. klin. Chir., II., 129, 1886. 


Fig. 1103.—Epithelioma of Cervical Lymph Gland. Secondary to epithelioma of tonsil. 





CANCER OF THE ToNnGuE.—Cancer of the tongue, 
though less frequent than cancer in many other locali- 
ties, is perhaps the most distressing of all to the patient. 
The disease usually begins along the free border, either 
at the extremity of the tongue or on one side. Not in- 
frequently there is a history of irritation from a carious 
tooth. In the early stages the diagnosis may be difficult. 
The conditions most likely to simulate cancer of the 
tongue are: tuberculous, syphilitic, or chronic inflamma- 
tory affections. Tuberculosis may so closely resemble 
cancer that a careful microscopical examination may be 
necessary to differentiate it. Tuberculosis of the tongue, 





(Buxton.) 


however, is so rare that it will seldom cause difficulty in 
diagnosis. I have, however, operated upon one case in 
which the clinical appearances pointed very strongly to 
epithelioma, and, in addition, a portion of the tumor re- 
moved for examination was pronounced epithelioma by 
the pathologist of a large hospital. When the anterior 
portion of the tongue was removed, further and more 
careful examination showed that the disease was not epi- 
thelioma, but tuberculosis. Syphilitic lesions may closely 
simulate cancer, but in most cases we are able to find 
other evidence of specific disease, even if the history is 
denied. 

The treatment consists in removal of the whole or part 
of the tongue as soon as the diagnosis is made. The 
choice of operation depends somewhat upon the extent 
of the involvement. If the muscular portion of the 
tongue is involved, especially of the posterior region, 
better results may be obtained by the method known as 
Kocher’s operation. Whitehead’s operation; or a slight 
modification of the same, including preliminary ligature 
of the lingual arteries and removal of the’sublingual and 
submaxillary glands, will, I believe, prove the best method 
in the great majority of cases. Its advantages over 
Kocher’s method are very great. The mortality is much 


635 


Cancer, 
Cancer. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





lower, and the wounds are more likely to heal primarily. 
Kocher’s method is open to the serious objection that, in 
dragging the tongue out through the floor of the mouth, 
it is impossible to prevent the tumor, usually in an ulcer- 
ated condition, from coming in contact with the freshly 
cut healthy tissues, thereby running the risk of new in- 
fection. Curtis’ suggestion of removing that part of the 
tongue containing the tumor through the mouth and 
completing the operation by Kocher’s method, is objec- 
tionable in that it unnecessarily complicates the opera- 
tion. The results of Whitehead’s method are equal, or 
superior, to those obtained by Kocher’s method. The 
question of how much of the tongue it is necessary to re- 
move is a very important one. Some surgeons advocate 
removal of the entire tongue, even if the disease is com- 
paratively limited in extent. Butlin does not believe 
that the entire tongue should be removed in every case. 
He states that the aim of the operator should be to re- 
move the disease and about three-fourths of an inch of 
healthy tissue. If the disease is on the border of the 
tongue, the best practice is to remove that half of the 
tongue to an inch behind the disease. When it is near the 
tip or fore part of the dorsum, the fore part of the tongue 
should be removed. Butlin does not advocate the pre- 
liminary ligature of the lingual arteries as a routine meas- 
ure. In my own cases I have usually tied the linguals 
prior to removal of the tongue, and this does not really 
complicate the operation, inasmuch as the glands of the 
neck may be removed through the same incisions which 
expose the arteries. Butlin’s latest method of dividing 
the operation into two stages has much to recommend it. 
Thorough dissection of the anterior triangle of the neck 
and removal of all the glands is in itself a considerable 
operation, and if to this is added the removal of the 
tongue, the mortality is likely to be higher than if the 
operation were divided into two stages. Butlin now re- 
moves the disease of the tongue first, and about three 
weeks later the anterior triangle is opened and the glands 
are removed. 

Results of Operation.—The latest statistics, comprising 
83 cases of Kroénlein, 59 of Kocher, 1389 of Whitehead, 
and 102 of Butlin, giving a total of 333 cases, show 42 
deaths from operation. Whitehead’s personal cases (139 
in number) show 20 deaths, or a ratio of 14.3 per cent. 
In 23 deaths in which the cause was stated, pneumonia 
and sepsis account for 12. As regards final results, 199 
of the 333 mentioned were traced. Of these, 40, or 20 per 
cent., were well and free from disease or had died from 
other causes than cancer, upward of 8 years after opera- 
tion. Butlin’s personal statistics show 10 deaths in 102 
cases. The remaining 92, with 7 exceptions, were traced 
to final results. Of these, 20 were well from 8 to 12 years 
after operation. In 18 cases there was local recurrence, 
in 28 glandular alone. 

Operative treatment is contraindicated if the disease 
extends far back, or if the glands of the neck are mark- 
edly enlarged and fixed, or if the jaw is involved. 

CANCER OF THE F'ace.—The face is one of the most 
common sites for cancer, the probable reason being that 
it is more exposed to various sources of irritation. The 
most common type of cancer found in the face is rodent 
ulcer. There is very little difference in the two sexes as 
regards the frequency of cancer in this locality. Of 200 
cases collected by Butlin, 110 occurred in the male, 90 in 
the female. The mortality of operation is comparatively 
high. Butlin’s statistics of 206 cases of cancer of the 
face, mostly rodent ulcer, show 21 deaths, of which 9 
were due to erysipelas. The more recent statistics show 
a lower mortality. In 100 cases treated at the St. Bar- 
tholomew’s Hospital, in 1889-1898, there was only one 
death. 

As regards permanent cure, the prognosis is good if 
the disease is attacked early. Kroénlein’s cases show 36 
per cent. well beyond 3 years. But in this particulas 
locality we must bear in mind the fact that late recur- 
rences (namely, at periods considerably beyond 3 years) 
are by no means infrequent. Glandular involvement is 
very rare in rodent ulcer of the face, and the disease de- 


636 


stroys life by local extension and gradual exhaustion. 
This form of cancer is perhaps the most distressing and 
painful of any with which we have to deal; and while 
it, in most instances, could be cured if attacked very 
early, when once it has gained a firm foothold it is ex- 
ceedingly difficult to eradicate. This is the form of can- 
cer in which caustics of various kinds have been most 
frequently employed. While it is unquestionable that 
rodent ulcer in the early stages may be cured by caustics, 
we believe that in the great majority of cases better re- 
sults will be obtained by the knife. Besides, they are 
obtained in a shorter time and with less pain and discom- 
fort to the patient. One of the best caustics to be em- 
ployed for cancer in this locality is the liquid butter, or 
terchloride, of antimony, applied by means of a glass rod. 
As regards the value of caustics, Butlin states “there is 
not the slightest reason why even extensive rodent ulcer 
of the face should not be treated by caustics with as 
thorough success as if the knife had been employed.” 
He admits, however, that, as usually employed, they de- 
stroy only the surface of the disease, leaving the base be- 
hind and, hence, doing more harm than good. To be of 
any value, they must be used freely and vigorously. 
Butlin believes that Vienna paste is the best form of 
caustic. It is applied ina thick layer over the area to be 
destroyed, including half an inch of apparently healthy 
integument all around the ulcer. 

CANCER OF THE SToMAcCH.—Malignant disease of the 
stomach is practically always carcinoma. Sarcoma, 
though occasionally found, is extremely rare. It may 
be either the columnar-celled or the squamous-celled va- 
riety, the former being by far the most common. 

Diagnosis.—The diagnosis in the early stage is difficult, 
and inasmuch as it is important that it should be made 
at a very early moment if treatment is to be of much 
avail, the tendency at present is more and more in the 
direction of an early exploratory operation. With careful 
aseptic precautions this exploration is not likely to be at- 
tended with appreciable risks. 

Hemmeter advises operation: (1) in the presence of 
dilatation; (2) in the presence of cachexia; (8) in the ab- 
sence of hydrochloric acid; (4) in cases of excess of lactic 
acid; (5) in the presence of the Oppler bacillus. 

Operative treatment consists in gastrectomy, complete 
or partial; pylorectomy or gastro-enterostomy. Space 
will not permit a description of the various operative 
methods. (See Stomach, Surgery of the.) 

Results of Treatment.—Up to the present time 7 cases 
of complete gastrectomy have been reported, with 3 
deaths. Seven other cases of nearly complete gastrec- 
tomy have been operated upon, with 2 deaths. The 
mortality of pylorectomy, as estimated by Haberkant * 
from a study of 257 cases, operated upon between the years 
1881 and 1887, is 64.4 per cent. Between 1887 and 1894 
it is 42.8 per cent. Goffe + found the mortality to be 76.5 
per cent. in English and American cases during 1882 and 
1890; 28.6 per cent. between 1890 and 1898. Individual 
statistics show much better results. For example, Kron- 
lein operated upon 24 cases with 5 deaths, and only 2 
deaths occurred in his last 20 cases. As to the duration 
of life after pylorectomy, Haberkant found that in 51 
cases traced, 21 were alive from 1 to 8 years after opera- 
tion. Nine of these were well for over 8 years. The im- 
provement of later results is attributable to earlier ex- 
ploratory operations and more extensive excision of the 
stomach. The high mortality of earlier days was largely 
due to postponing the operation until the strength of the 
patient was insufficient to stand the shock. 

CANCER OF THE INTESTINE.—Cancer may occur in any 
portion of the intestines from the stomach to the rectum. 
The relative frequency of its occurrence in the different. 
portions of the intestines is well shown by the statistics 
of de Bovis: 

Cancer of the rectum, 49.24%; colon, 20.4; sigmoid, 
11.9%; small intestine, 6.3%. Sarcoma may occur, but is 


* Arch. f. klin. Chir., 1896, Bd. 51, p. 484. 
+ ‘* Lectures on the Surgery of Diseases of the Stomach,” by Barker. 


‘ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancer, 
Cancer, 





extremely rare. Madelung has collected 14 cases of sar- 
coma of the small intestine. Carcinoma occurs most fre- 
quently between theages of 40and 65 years. R. de Bovis 
(Revue de Chirurgie, 1900, Nos. 6 to 12) has given us the 
most extensive and valuable contribution to our know]- 

edge of cancer of the large intestine yet published. He 
collected 426 cases of cancer of the large intestine (exclu- 
sive of the rectum). Of these, 53.9 per cent. were among 
males, and 46 per cent. among females. The diagnosis is 
seldom made until the growth has advanced sufficiently 
to cause stenosis in the bowel. Furnevall states that 
crises of paroxysms of colic, or periods of prolonged con- 
stipation and diarrhea, with ear ly weakness and progres- 
sive wasting in spite of medical treatment, are important 
symptoms. In several instances I have noticed that lo- 
calized distention, due to the accumulation of gas in 
front of the stricture, isanimportant sign. This is some- 
times observed by the patient himself, and regarded as a 
lump or tumor. Sometimes by manipulation it disap- 

pears with a slight gurgling sound. 

Operative Treatment consists in resection of the bowel, 
making anastomosis, short-circuiting the constriction, or, 
if the disease is situated lower down toward the rectum, 
making colostomy. If the disease is in the small intestine, 
the Murphy button can be employed with advantage. 
Czerny states that he has given up its use in the colon 
for the reason that the lumen will become blocked 
with semi-hardened feces, and the patient will die 
of obstruction. R. de Bovis (loc. cit.) states that in 
his series of 426 cases of cancer of large intestine, Mur- 
phy’s button was employed 14 times with 4 deaths. Of 
these deaths 3 were attributed to the button. In 1 
patient upon whom I personally operated, and in whom 
I did a double resection of the sigmoid and seven inches 
of an adherent loop of small intestine which had be- 
come involved by contiguity, I employed two Murphy 
buttons, one for uniting the ends of the small intestine, 
and the other, a large, oblong button, for making a lateral 
anastomosis between the closed portion of the ascending 
colon and the cecal end of the small intestine. The pa- 
tient made an uneventful recovery; both buttons passed 
on the ninth day. The patient remained well for 1 year 
and then had a slight recurrence in the parietal perito- 
neum. He is alive and in good general health at present, 
twenty-one months after the operation. The mortality 
of resection of the large intestine in 241 cases collected 
by Lardinnois was 34.8 per cent. Czerny’s mortality for 
resection of the large intestine is 50 per cent. ; Woelfler’s, 
54 per cent. in 114 cases. Wallace reports 12 cases of re- 
section at the St. Thomas Hospital, London, between 1888 
and 1897, with 7 deaths, or 58.3 percent. Of 51 cases col- 
lected by Frank between the years-1884 and 1888, only 1 
was known to have lived more than 3 years without re- 
eurrence. Woelfler, however, has collected 17 cases that 
were well from 4 to 16 years after operation. 

R. de Bovis found the mortality in 101 cases of entero- 
anastomosis for cancer of the large intestine to be 38.6 
percent. Theaverage duration of life after the operation 
of entero-anastomosis was 6.4 months, and the total aver- 
age duration of life from the inception of the disease 21.2 
months. Of 171 cases treated by resection the mortality 
was 31.5 per cent.—de Bovis believes that 38 per cent. is 
the actual present mortality. Up to 1889 it was 58 per 
cent. Fifty-one cases operated upon by 22 of the most 
distinguished continental surgeons since 1889 show 387.2 
per cent. mortality. Of de Bovis’ series of 171 enter- 
ectomies there were only 8 cures. 

CANCER OF THE Rectum.—Cancer of the rectum rarely 
occurs before the age of 35, and it is seen more -fre- 
quently in men than in women, the proportion being 
about 6 to 5. It forms 4 per cent. of all cases of cancer. 
The symptoms during the early stages of the disease are 
ill defined, and usually consist more in a feeling of heavi- 
ness and discomfort than in one of actual pain. Stools 
are apt to be scanty and more frequent than usual. Con- 
stipation often alternates with diarrhea. Later on, there 
is actual pain and occasionally some blood passes with the 
stools. The rectum should always be examined in sus- 











picious cases. Carcinomatous ulceration shows the char- 
acteristic induration with hard, irregular margins, and if 
the disease is within reach of the fins ger, which is usually 
the case, the diagnosis is not often very difficult, except 
in the very early stage. In addition to digital examina- 
tion, the speculum “should be used in cases in which 
there is still doubt, and a portion of the suspicious area 
should be removed and examined microscopically. 

Treatment.—The only treatment to be recommended is 
excision of the rectum in all cases in which it is possible 
to remove the disease. The choice of methods lies be- 
tween the sacral or Kraske’s operation, and the older 
perineal method. During recent years Kraske’s opera- 
tion has been adopted by most American as well as con- 
tinental surgeons for all cases of cancer of the rectum, 
on the belief thatits results were so much more promising 
as to outweigh the higher mortality. Even Watson 
Cheyne, one of the best representatives of sound and 
conservative English surgery, states that while the peri- 
neal operation is suitable in some cases, in the majority it 
is best to employ one or the other of the methods which 
give good access to the part from behind, such as 
Kraske’s operation or some of its modifications. Com- 
paring the results of the perineal with Kraske’s method 
up to 1896, Cheyne states that the mortality of the peri- 
neal method seems to be about 8 per cent.; that of the 
sacral, 18 or 20 per cent. The results of operative treat- 
ment of cancer of the rectum at Kiister’s Clinic, Marburg, 
since 1885,* reported by Wendel, throw valuable light 
upon the comparative value of these different methods. 
The total number of cases observed was126. Of 46 cases 
operated upon by the perineal method, 8 died directly or 
indirectly from the operation. Of the 38 remaining, 35 
were traced. Six of them were well from 8 to 5 
years; 3 from 7 to 11 years after operation. Of 46 cases 
operated upon by Kraske’s method, 14, or 30.4 per 
cent., died of the operation; 26 of the remainder were 
traced to final results, and 5 were alive from 6 to 11 
years after operation. Thus, the mortality of the sacral 
method was nearly double that of the perineal; and the 
final results as regards cures were inferior. As Wendel 
points out, these figures should not be taken as a true 
indication of the relative value of the methods, as in 
many of the cases operated upon by the Kraske method 
the disease was more advanced. The duration of wound 
healing is much longer in the sacral than in the perineal 
operation, the average duration being 64 days in the 
sacral. Wendel concludes that 9.4 per cent. of the cases 
in which radical operation was performed survived from 
6 to 12 years without recurrence. Adding to these the 
cases that died of other diseases without recurrence, he 
estimates the number of final cures at 16.8 per cent. 
Kraske’s personal results in 80 cases show a mortality 
of 18.7 per cent. and 6.2 per cent. of cures. Hochenegg 
operated upon 89 cases by the sacral method with a 
mortality of 9 per cent. and 12.49 per cent. of cures. 
Mikulicz’s 57 cases operated upon by Kraske’s method 
show a mortality of 24.56 per cent. and 6.69 per cent. 
of cures. 

These statistics, combined with those of Kraske, show 
a mortality of 18.7 per cent. and 10 per cent. of cures. 
They certainly justify the conclusion of Wendel that 
there is no reason for ignoring the perineal method to the 
extent thatit has generally been done. The planadopted 
at Kiister’s Clinic might well be followed by others. It 
is, never to decide beforehand what method of operation 
is to be performed, but always to employ that method 
which best meets the conditions of the individual case. 
Whenever the cancer is within easy reach and well de- 
fined, the perineal method should be chosen. In cases 
in which the disease is located high up, or complicated by 
inflammatory infiltrations of the neighboring tissues, ex- 
tension of the tumor to the adjacent parts, the sacral 
method should receive the preference. Wendel believes 
that in one-half of the cases reported it is possible, or 
even preferable, to operate after the perineal method. 





* Deutsche Zeitschr. f. Chir., January, 1899, Bd. 1., Hefte 3, 4. 


637 


Cancer. 
Cancer, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Heinrich Wolff, in his article on the “ Radical Opera- 
tion for Cancer of the Rectum,” * refers to the apparently 
contradictory statements as regards results in the statis- 
tics of various authors, and says that the same are due to 
the different views taken by different writers with regard 
to the indication for operation before and during the in- 
terference. 

Of 155: cases of cancer of the rectum (101 men, 57 
women) admitted to the Clinic between 1888 and 1900 
(excluding those of 1900), 125, or 80.6 per cent., were sub- 
jected to radical operation. On the other 80 cases no 
operation at all, or palliative operation, was performed. 
In 60, or 48 per cent., of the 125 cases of radical oper- 
ation, amputation of the rectum, and in 65, or 52 per 
cent., resection of the rectum, was done. The ages of 
the patients ranged between 20 and 80: 7 between 20 and 
380; 14 between 80 and 40; 126 between 40 and 70; 8 be- 
tween 70 and 80. Of the 60 cases of amputation of the 
rectum, 9, or 14.7 per cent., died in consequence of the 
operation. Of the 51 patients on whom the operation was 
successfully performed, 39 were traced, and of these 12 are 
still living, 1 with a recurrence more than 3 years after 
operation. The remaining 11, or 28.2 per cent., of the 
number traced, are alive and free from recurrence from 3 
to 11 years after operation. Of the other 27 who sur- 
vived the operation, 17 died within the first 2 years; 7 
within the third year after operation; 2 lived 3 years 9 
months each, and one 5 years. The majority died of re- 
currence. In most of the cases of amputation of the 
rectum it was necessary to operate by the sacral method. 
In 17 instances no bone operation was done (Lisfranc, 
Kocher); in 21 instances the coccyx was extirpated, and 
in 8 instances the coccyx and part of the sacrum were re- 
sected. The peritoneum was opened in about one-half 
of the cases. 

In the 65 cases of resection of the rectum the perito- 
neal cavity was opened as arule, but immediately after 
the gut had been drawn down the peritoneal cavity was 
closed by suture. In 2 cases laparotomy was performed 
(1 death and 1 permanent result). In all of the remain- 
ing 63 cases the sacral method was used; 46 times an 
osteoplastic preliminary operation was done—.e., 8 times 
temporary resection of the coccyx; 88 times temporary 
resection of the sacro-coccyx. Of the 65 cases of resec- 
tion, 31, or 47.7 per cent., died; of these, 20 in direct con- 
sequence of the operation, 11 of complications, such as 
pneumonia, general cachexia, embolism of lung, ete. Of 
the 34 who survived the operation, 28 were traced. Of 
these, 8 are still living, 1 with a recurrence 1 year and 6 
months after operation. Of the remaining 7, 1 is well and 
free from recurrence 1 year and 5 months after operation ; 
1, 2 years after operation; 2, 3 years; 1, 8 years and 3 
months; 1, 7 years and 9 months; and 1, 11 years after 
operation. Of the other 20, 10 died during the first year; 
8 during the second and third years; and 2, 3 years and 
9 months and 4 years and 6 months, respectively, after 
operation. All succumbed to recurrence except the last 
2, who died of intercurrent disease. If we include the 
latter among the permanent curesand exclude the 2 cases 
that are free from recurrence less than 3 years after oper- 
ation, we have 7 out of 26, or 26.9 per cent., of perma- 
nent cures. The total mortality of all the cases of radical 
operation (resection and amputation) is 40 out of 125, or 
32 per cent. Counting only the deaths directly due to 
operation (27), we have a mortality of 21.6 per cent. 
Twenty of the deaths were due to collapse. Not 1 of 
the 60 cases of amputation, and only a very small num- 
ber of the 65 cases of resection, died of infection, a circum- 
stance which Wolff ascribes to the “fully open” treat- 
ment of the wound and extensive use of iodoform gauze. 
The total number of permanent cures obtained in the 
entire series of 125 is 27.5 per cent. 

As regards continence, there were 9 cases of absolute 
continence. In 7 instances the continence was relative. 
In 1 case it was moderate, and in 1 there was absolute 
incontinence. On the whole, the patients were able to 


* Arch. f. klin. Chir., lxii., i. 


638 


_as endothelioma. 


insure an almost complete continence by exercising a lit- 
tle care in regulating their stool. 

CANCER OF THE PAROTID GLAND.—Cancer of the paro- 
tid gland may be of different types; mixed-celled sarcoma 
is, however, the most common. ‘The malignancy of these 
tumors varies within wide limits. Formerly nearly all 
the growths were regarded by pathologists as carcinoma. 
Later observers were inclined to class them as sarcoma, 
while at present the tendency is to group many of them 
The classification is extremely com- 
plex and difficult. Butlin believes that the only course 
left open in dealing with the subject from a clinical and 
operative standpoint, is to consider all malignant growths 
of the parotid under the common name of “cancer.” 
This certainly seems the most rational course. Some of 
these tumors of the parotid run an extremely rapid 
course. Ihave personally observed one, a round- and 
spindle-celled sarcoma of the parotid of high vascularity, 
which developed in a man, aged forty, immediately after 
a blow from a horse’s head. It grew very rapidly and 
was removed a few weeks later. Recurrence quickly 
following, a second and a third operation were performed 
without checking the progress of the disease, which 
proved fatal in about four months from the date of its ori- 
gin. Ihave had under personal observation 12 cases of 
malignant disease of the parotid; all of these were classed 
by pathologists as sarcoma, mostly mixed-celled, although 
some were pure round- and some spindle-celled. Two 
of these cases that were recurrent and inoperable at the 
time of first’ observation, and hopeless, have been appar- 
ently cured by the mixed toxins of erysipelas and bacillus 
prodigiosus, 1 having remained well more than 4 years, 
and the other upward of 3 years after treatment. 

According to Butlin, the prognosis after operative 
treatment is extremely bad. Three out of 17 patients in 
his statistics died of operation, and it is not stated that. 
any remained well long enough to be considered cured. 
Butlin states, with regard to cures, that up to the present. 
time there are very few instances of cures by operation 
of undoubted malignant disease of the parotid. One 
probable reason for this is, that up to the present time 
surgeons have been too anxious to save the facial nerve 
and, hence, the operations have not been sufficiently 
extensive to eradicate the disease. If there is to be a 
reasonable prospect of curing the patient by operation 
in the future, the facial nerve will undoubtedly have to 
be sacrificed. 

CANCER OF THE PENIS.—Cancer of the penis almost 
always takes the form of carcinoma, sarcoma being ex- 
ceedingly rare, only 10 cases having been collected from 
the literature. Epithelioma is the type of carcinoma 
most frequently found, and it usually begins at the junc- 
tion of the prepuce with the gland. The disease seldom 
occurs before the age of 50 years, and is most frequently 
seen between 50 and 70. 

In making a differential diagnosis, the condition most 
likely to simulate cancer of the penis is a specific ulcer. 
The absence of a history of infection or other signs of 
syphilis will enable us to make the diagnosis. If the 
lesion is very small and there is doubt as to its character, 
a small portion may be safely removed under cocaine and 
submitted to microscopical examination. Secondary in- 
fection of the glands in the groin usually occurs, though 
not, as a rule, until the disease has existed for a consider- 
able time. The average duration of a cancer of the penis 
without operative treatment is about 3 years. 

As to methods of operation, partial or complete ampu- 
tation of the penis is usually indicated. Although the 
cautery. has been advised by some, the knife is to be pre- 
ferred. The inguinal glands should in all cases be re- 
moved, whether they can be felt or not. If the operation is 
performed under the best aseptic conditions, the mortal- 
ity is comparatively low. The risks of death from hem- 
orrhage are very slight. The vessels should be tied as 
they are cut, and the oozing from the corpus cavernosum 
may be checked by pressure from iodoform gauze. The 
mortality as estimated by Butlin is 6 per cent. in the 
simple operation, but considerably greater in the cases 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancer, 
Cancer, 





in which complete extirpation of the penis, together with 
the inguinal glands, has been performed. 

As regards the final cures, Butlin reports 65 cases that 
were traced for 3 years, in addition to 16 others that were 
alive and free from recurrence for periods ranging from 
a few months to from 2to 8years. Of the 65 patients 23 
were well beyond 3 years, giving a proportion of suc- 
cessful cases of upward of 35 per cent. Butlin states 
that in almost all the successful cases the operation con- 
sisted in simple amputation of the penis and not extirpa- 
tion, the disease having been at or near the extremity. 
The number of cases in which the inguinal glands were 
removed is not known. 

H. Kittner, in his article entitled “ Carcinoma of the 
Penis and Its Dissemination through the Lymph Pas- 
sages,” * furnishes some very valuable data based on a 
series of 60 cases observed at the Tiibingen (Bruns’) 
Clinic. He states that while for the local extension of 
the disease the vascular system is of greatest importance, 
it is of little or no account as regards metastatic spread, 
internal metastases being of rare occurrence; in addition 
to 1 of his own cases reported, he has been able to find 
but 9 such cases in the literature. He has made some 
extensive anatomical studies, and gives his conclusions, 
which are very important. 

As regards the prognosis of carcinoma of the penis, 
Kiittner states that there is hardly a carcinoma which 
offers such favorable conditions for a permanent cure as 
this. This is partially due to the fact that in a large 
percentage of the cases the disease remains local for a 
long time and shows little tendency to invade the region- 
ary lymphatic glands, or to form metastases even in cases 
in which the tumor has become very extensive locally. 
It may be mentioned here that in 73 per cent. of the per- 
manent cures obtained at the Tiibingen Clinic the glands 
were not removed, although the disease had existed from 
1 to 4 years prior to operation. Of the 60 cases reported 
by Kiittner 53 were operated upon, with 8 deaths, a mor- 
tality of 5.6 per cent. Excluding these, as also those 
that could not be traced, there remain 37 cases, 15, or 
40.5 per cent., of which died of recurrence; while 22, or 
59.4 per cent., were permanently cured, 7.e., they re- 
mained well and free from recurrence wpward of 3 years. 
Of these, 9 died of other causes within 3 to 29 years after 
operation. Thus thereare 18 still living free from recur- 
rence, the youngest of them 3 years and 6 months after 
operation, all others having lived Jonger: 3 upward of 
20 years after operation; 2, 10 years, and these were 
operated upon at the age of 70 and 71 years, respectively, 
showing that age need not deter us from operating. 

As to the 15 cases that died of recurrence, details are 
missing regarding 8. Of the remaining 12, 11, or 91.7 
per cent., had a recurrence in the glands. The rapidity 
with which recurrence followed operation is remarkable, 
in some instances within a few weeks. 

The question as to the advisability of removing the in- 
guinal glands, Kiittner believes, is of paramount impor- 
tance. It is his opinion that the glands should be extir- 
pated in all cases in which the tumor is of a malignant 
character and has not already too far advanced. If the 
tumor is of slow growth, and the glandsare not enlarged, 
he thinks that, in view of the favorable results obtained 
at the clinic in the cases in which the glands were not 
removed, amputation of the penis may be done without 
removal of the glandsif the paticnt is disinclined to allow 
the latter or if a more extensive operation be contrain- 
dicated. In such cases as come under the surgeon’s care 
at a very early stage of the disease, he even considers it 
advisable not to remove the glands on account of the 
difficulty of keeping wounds in the inguinal region per- 
fectly aseptic, so that the danger from probable wound 
complications may be greater than that from the cancer. 
In all other cases he believes the glands should be re- 
moved on both sides, as a matter of principle. He does 
not approve of total emasculation according to Thiersch, 
a procedure so often recommended of late. 








* Beitr. z. klin. Chir., vol. xxvi., No. 1, 1900. 


The frequency of carcinoma of the penis ranges, ac- 
cording to various statistics, between 1 and 8 per cent. of 
all other carcinomata. He found in 1,188 cases of car- 
cinoma reported between 1885 and 1898, 27 cases, or 2.27 
per cent., of carcinoma of the penis. Excluding cancer 
in women, the total number of cases of carcinoma in all 
localities was 577, with a percentage of 4.68 of carcinoma 
ot the penis. 

Asregards the age at which the disease most frequently 
occurs, he found that out of a series of 562 cases, includ- 
ing his own, 4.3 per cent. had not exceeded the age of 30; 
9.1 per cent. were between 31 and 40 years; 238.3 per 
cent. between 41 and 50; 30.1 between 51 and 60; 22 per 
cent. between 61 and 70; 10:3 per cent. between 71 and 
80; and .9 per cent. between 81 and 90. 

Five of the cases reported by Kiittner gave a history 
of previous injury. 

CANCER OF THE TeEstTIs.—Malignant disease of the 
testis may be either carcinoma or sarcoma, although sar- 
coma is by far the most frequent. Among 17 cases that 
have come under my personal observation, there has been 
only 1 case of carcinoma. Butlin states that malignant 
disease of the testis may occur in children, but seldom in 
children beyond 10 years of age, and rarely in adults 
under 30 years of age. My own experience, although 
the same as regards children, has not been in accord with 
Butlin’s statement with reference to young adults, as 
more than one-half of my cases have been in young men 
between 20 and 30 years of age. 

In regard to diagnosis, careful inquiry should be made 
as to a history of previous injury. In one-half of my 
own cases there was a distinct history of antecedent 
trauma. The physical characteristics of the tumor are 
in most cases sufficiently marked to make the diagnosis 
comparatively easy. <A solid tumor, associated with 
more or less pain, gradually increasing in size, symmet- 
rical in shape, especially if associated with a history of 
previous injury, would make one strongly suspect ma- 
lignant tumor of the testis. The only disease likely to 
simulate it is a syphilitic orchitis or a teratoma. The 
slower development and previous history of syphilis 
would, in most cases, enable one to differentiate the con- 
ditions. The diagnosis of teratoma can be made only 
with the microscope. If the diagnosis is in doubt, ex- 
ploratory operation should be promptly done. 

Treatment.—The only treatment is castration and re- 
moval of the cord as well as cord vessels well within the 
internal ring. The incision which I have usually em- 
ployed in these cases has been similar to that used in 
Bassini’s operation for inguinal hernia, splitting up the 
aponeurosis well beyond the internal ring, which enables 
one to make a thorough removal of the cord. The in- 
guinal glands, if involved—which is seldom the case in 
sarcoma—should be removed at thesame time. Sarcoma 
of the testis is one of the most malignant forms of cancer 
with which we have to deal, and cures due to operation, 
even when undertaken in the early stages of the disease, 
are comparatively rare. Butlin has collected 118 cases 
with only 6 well more than 3 years after operation. The 
valuable statistics of Kober* show 106 cases with 9 well 
more than 8 years after operation. Of the 16 cases ob- 
served by myself, not a single one was cured either by 
operation or by toxin treatment. Recurrent sarcoma of 
the testis seldom attacks the inguinal glands, but almost 
always appears in the retroperitoneal glands. The usual 
course of these cases is speedy recovery from the opera- 
tion, the patient feeling comparatively well fora number 
of months, in rare cases more than a year after operation. 
He then discovers a hard mass in the abdominal cavity, 
due to the development of a sarcomatous tumor in the 
retroperitoneal region. This increases sometimes to the 
size of a man’s head, filling up a large portion of the 
cavity, and causes constipation from pressure. In some 
cases before death occurs, metastatic deposits have formed 
in the liver and lungs. The average duration of life is 
seldom more than 1 or 2 years after operation. The 








* Am. Journ. of the Med. Sciences, 1899, v., p. 35. 


Cancer. 
Cancer, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








usual type of sarcoma in this region is the round-celled. 
In 1 of my own cases the tumor was melanotic. 

CANCER OF THE VAGINA.—Both carcinoma and sar- 
coma occur in the vagina, although carcinoma is more 
common. In sarcoma the growth not infrequently re- 
sembles polypus, and it may reach considerable size be- 
fore ulceration and hemorrhage occur. Carcinoma is more 
frequently found in the posterior than in the anterior 
wall of the vagina. It extends by infiltrating the neigh- 
boring tissues, and ulceration is found in the early stages. 

Cures of malignant disease of the vagina are compara- 
tively rare, and are obtained only by very early and ex- 
tensive removal of the disease and the surrounding tissues. 
Butlin has collected 75 cases, of which 37 were sarcoma, 
88 carcinoma. Seven of the patients were alive and well 
more than 8 years after operation; 5 of these had sar- 
coma, 2 carcinoma. 

CANCER OF THE KipnEyY.—Malignant growths of the 
kidney are comparatively rare, being only five-tenths of 
1 per cent. of all malignant neoplasms, according to Vir- 
chow. Kelynack, however, who has perhaps made the 
most thorough study of this subject, believes this esti- 
mate to be too small, and thinks 2 to 3 per cent. nearer the 
truth. Sarcoma is much more common than carcinoma, 
the reverse of the opinion held a few years ago. Many 
of the cases which in the various statistics were origi- 
nally reported as cancers were undoubtedly sarcoma. 
Fifty per cent. of the cases of sarcoma of the kidney occur 
in children under ‘the age of 10 years. Seventy-four out 
of 160 cases collected by Kelynack were in patients under 
5 years of age. A tumor, situated in the space between 
the border of the rib and the crest of the ilium, is a most 
important physical sign in making the diagnosis. It 
varies greatly in size from a few ounces to 86 pounds. The 
position of the colon overlying the tumor is an important 
point in making the diagnosis. While the consistence of 
the tumor varies, fluctuation can usually be detected 
owing to cystic degeneration. Hematuria is also an im- 
portant sign. In children the growth is usually very 
rapid, and often attains large size before it is noticed 
even by the mother. The conditions most likely to simu- 
late it are omental and mesenteric tumors, cystic kidney, 
tuberculosis, hydronephrosis, and perinephritic abscess. 

Treatment.—Until very recently the consensus of sur- 
gical opinion has been against operation, the results of 
operation having been so uniformly bad that little hope 
of cure was offered. American surgeons, one of whom 
was the first to perform nephrectomy for renal tumor, 
have been largely responsible for a change of opinion. 
At present the mortality of the operation is not far from 
50 per cent. Of 150 cases collected by Czerny only 5 
were beyond five years. Of 145 cases in children under 
14 years, collected by G. Walker (Annals of Surgery, 
1897, p. 529), only 4 survived beyond three years, and 
one of these has since died. 

Careful examination of all the cases of malignant dis- 
ease of the kidneys in which operation has been per- 
formed, and study of the final results, justify the con- 
clusion, I think, that while the prognosis is still extremely 
bad, especially in children, operation should be advised 
in all cases in which there is reasonable probability of 
removing the entire tumor; and every portion of the 
fibrous capsule should be removed along with the tumor 
itself. 


SARCOMA. 


Sarcoma may occur at any age, though it is more fre- 
quent between the ages of 20 and 50 years. Of 186 cases 
observed by Roger Williams only 24 were under the age 
of 20 years. My own series of 516 cases shows a larger 
proportion in young persons; 62 were under the age of 
20 years. I have observed 4 cases of sarcoma of the 
femur in persons under the age of 10 years. 

Sex.—The male sex is more liable to sarcoma than the 
female. Of my 316 cases, 288 were male and 28 female. 

Anatomical Situation.—A thorough knowledge of the 
parts of the body most prone to sarcoma will often be of 
aid in making a diagnosis. It is a remarkable fact that 


640 





the disease very commonly attacks bony structures and 
shows a decided preference for certain bones, and espe- 
cially the femur. Of 316 cases of sarcoma that I have 
personally observed, 84 originated in bones and 282 in the 
soft parts. Of the bones, the femur was most often the 
starting-point of the disease, as shown in the following 
summary : 





LOCATION. No. OF CASES. LOCATION. NO. OF CASES. 

FOMUY 3% csknes cctsn ees 13 Pubic bone... 

TMD Laas = sk locate eae 5 Ribiiecdetatese 1 
FIDUI aie. os trons ceeraeee ne 2 Sacrumcc- een 2 
THU ence ec cians eieeteicee 11 HUMECFUS. scuicuntnte nen 3 
Vertebrate acum eee Clavicle... 2 edeaseseente 2 
Superior maxilla....... 13 Sternum . ic asnh cetientes 1 
Inferior maxilla........ 8 Metacarpal bone....... 1 
Mastoid cacesnis cisirt aati 3 Phalanx 277. -s ses eeeee 3 
Scapulatneh. so. wee ore 2 


Of the soft parts the neck furnished the largest num- 
ber of cases. Inno less than 80 patients the disease began 
as a primary lympho-sarcoma of theneck. In 20 it began 
in the orbit, and in 20 in the thigh. 

SYMPTOMATOLOGY OF SARCOMA.—Pain is rarely pres- 
ent at the beginning of the disease. A “lump” or swell- 
ing is the first thing that attracts the attention of the pa- 
tient. Injury plays a much more important part in the 
development of sarcoma than in that of cancer. Of my 
270 cases analyzed with reference to trauma, about one- 
third, or 31.8 per cent., gave a distinct history of antece- 
dent localtrauma. The injury need not be a severe one, 
a blow or contusion being the usual form of injury. In 
a considerable number of cases (31 that I have personally 
observed) the tumor developed within a few days after the 
receipt of the injury, so quickly that there could be no 
doubt of the etiological relationship between the tumor 
and the trauma. These cases may very properly be classi- 
fied as examples of acute traumatic malignancy. 

Traumatic sarcoma may occur both in the bones and in 
the soft parts. Of my first series of cases 18 occurred in 
the bones and 26 in the so*t parts. All varieties of sar- 
coma were included: 29 round-celled, 5 spindle-celled, 5 
melanotic, 8 mixed-celled, and 2 doubtful. 

At my request Dr. C. J. Kane, late house surgeon to 
the General Memorial Hospital, has recently made an 
analysis of the last 100 cases of sarcoma observed at the 
hospital during the past three years with reference to 
antecedent injury. He found that in 63 per cent. local 
injury of some form was noted at varying intervals be- 
fore the development of the tumor, and that in 27 other 
cases there was a history of chronic irritation, leaving but 
10 cases in which there had been neither trauma nor irri- 
tation. Of 270 personal cases analyzed with reference to 
trauma I found that 86, or 31.9 per cent., gave a history 
of distinct injury prior to the discovery of the tumor. 
In 31, or 11.5 per cent., the tumor developed almost im- 
mediately after the injury. The only reason for separat- 
ing these so-called acute cases or examples of acute 
traumatic malignancy is that in these cases the connec- 
tion between the injury and the tumor is so close and 
definite that it cannot be easily explained away. If we 
can establish an etiological relationship between the 
trauma and the development of sarcoma in this group of 
acute cases, the same relationship will probably be found 
to obtain in the cases of slower development. Various 
theories have been offered to explain the relation between 
trauma and cancer. The opinion that has received the 
most support has been the so-called “ constitutional diath- 
esis.” The person possessing this diathesis is supposed 
to be in danger of developing a tumor after an injury, 
while another not possessing it will be safe. My own 
views already expressed (Annals of Surgery, February, 
1898) are that the relationship between injury and the 
development of sarcoma or carcinoma can be most ration- 
ally explained on the theory that such tumors are of in- 
fectious or micro-parasitic origin. Granting for the 
moment this to be the true origin of malignant tumors, 
their development following an injury would be in per- 
fect accord with tuberculous lesions of the bone that not 
infrequently develop from local trauma. We are also 
familiar with osteomyelitis and periostitis following 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancer, 
Cancer, 








local trauma without any lesion of the skin or known 
source of infection. Any explanation that would apply 
to these lesions would apply tosarcoma. The most prob- 
able explanation would appear to be that the infectious 





Fic. 1104.—Chondro-Sarcoma of the Ilium. 


agent of the malignant tumor exists somewhere latent in 
certain individuals, and is harmless until some local in- 
jury, by diminishing the vitality of the tissues, lowers 
their resisting power, and thus furnishes a favorable 
nidus for the development of the tumor germs. 
Character of Swelling.—This varies with the type of 
sarcoma. In the round-celled variety the consistence 
may be so soft as to resemble an abscess, and in certain 
cases it may be extremely difficult to differentiate a sar- 
coma from a deeply seated abscess, especially a “cold” 
abscess, originating from caries of bone. A sarcoma of 
high vascularity may have sufficient pulsation to simu- 
late an aneurism. Painis of less importance than is gen- 
erally supposed. Sarcoma, like carcinoma, is seldom 
painful at the first, except in certain casesin which, from 
its anatomical situation, there is pressure upon important 
nerves. The most painful sarcomata that I have observed 
have originated in the vertebree. I have observed four 
cases, and in all the pain has been very severe. 
D1AGNnosis.—The conditions most likely to be mistaken 
for sarcoma are tuberculous, syphilitic, and inflammatory 
swellings. A careful history, together with the physical 
signs, will in most cases enable one to make a correct 


Vou. Il.—41 


diagnosis. Sarcoma usually develops more quickly than 
a tuberculous tumor. Pain is more frequent in sarcoma. 
Local heat is also usually present in sarcoma and absent 
in tuberculous swellings, and the superficial veins are 
more prominent in sarcoma. 

Inflammatory swellings may even more closely simu- 
late sarcoma. The more rapid development, greater pain 
and tenderness, together with more or less increase in 
pulse rate and temperature, will in most cases establish 
the diagnosis. We must remember, however, that in 
rapidly growing sarcomas we may also have an increase 
in pulse rate, and also a decided rise in temperature. 
Marked tenderness is, however, rare in sarcoma or car- 
cinoma. 

Sarcoma oF Bonres.—Sarcoma may develop in any 
bone, but occurs most frequently in the long bones, espe- 
cially the femur. It may be of either central or periosteal 
origin. Of Gross’ collection of 165 cases of sarcoma of 
the long bones, 67 occurred in the femur, 46 in the tibia, 
21 in the humerus, 138 in the fibula, 7 in the ulna, 6 in the 
radius. Of 24 personal observations of sarcoma of long 
bones 13 were in the femur, 5 in the tibia, 3 in the hu- 
merus, 2 in the fibula, and 1 in the radius. The peri- 
osteal tumors are of a much higher degree of malignancy 
than are those of central origin. The periosteal sar- 





Fi@ 1105.—Acute Traumatic Sarcoma of Femur in a Case of Recent 
Fracture, Caused by the Kick of a Horse, 


comas usually start in the shaft or at some distance from 
the joint, while the central sarcomas begin near the ends. 
Reinhardt, who collected 54 cases of sarcoma of the long 
bones treated at the Gottingen Clinic between 1880 and 


641 


Cancer, 
Cancer, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








1895, found 18 of the femur and 19 of the tibia. Metas- 
tasis occurred in 33 per cent. of the cases. The duration 
of the disease was from three months to nine years. The 
difference in malignancy between the round-celled and 
spindle-celled varieties was not apparent. Of 15 cases of 
spindle-celled sarcoma 2 were well over three years after 
the operation. Of 10 cases of the round-celled variety 3 
were well over three years after the operation, and of 
the 54 cases, 7 (= 18 per cent.) were well after the lapse 
of the same period of time. 

Periosteal sarcoma of the femur is probably the most 
malignant tumor that exists. Of 68 cases collected by 
Butlin, treated by the most extensive operations—either 
by amputation at the hip-joint or by very high amputa- 
tion—only 1 was known to have been cured. 

The prognosis of sarcoma in the long bones in general 
is better than in the femur alone. Gross found that of 
90 cases traced for a considerable period after operation, 
26.6 per cent. were well after a period of more than 3 
years. His statistics also show that the giant-celled sar- 
comata are much less malignant than the other variety, 
two-thirds of the cases being of this type. 

The only treatment to be recommended for sarcoma of 
the femur is amputation at the hip-joint. The mortality 
of the operation has been remarkably diminished by the 
introduction of more modern methods of controlling the 
hemorrhage and of keeping the wound aseptic. Wyeth’s 
method of steel pins, I believe to be by far the best. I 
have used it in 6 cases of amputation of the hip for sar- 
coma—4 cases of sarcoma of the femur, and 2 cases of 
sarcoma of soft parts—without a single death. Butlin’s 
statistics of 47 cases show a mortality of 25 per cent. 
Wyeth’s recent statistics of 250 cases operated upon by 








Fic. 1106.—Recurrence of Sarcoma of Lower Jaw, Ten Years After 
Resection of One-Half of Lower Jaw. 


this method show a mortality of only 22 per cent. ; and, 
including cases of tumor only, the mortality was but 13 
per cent. 

Even if the patient is not cured, the disease returns in 
the lungs or abdomen, and death is less painful and far 
less distressing than if amputation had not been per- 
formed. 

Of 52 cases of sarcoma of the tibia and fibula collected 
by Butiin, 9 remained well for more than 3 years. 


642 





In cases of giant-celled sarcoma of the bones the ques- 
tion is not entirely settled as to the necessity of amputa- 
tion. Butlin believes that in certain cases these tumors 
may be successfully treated by scooping out, and in others 
resection may be sufficient. He states, however, that for 
the large majority of central tumors (of the tibia or 
fibula) amputation through the lower part of the thigh 
or at the knee must be performed. Personally I do not. 
believe it good surgery to scoop out oreven resect a long 
bone for sarcoma. The mere operation of scooping out 
I believe materially increases the risk of generalizing the 





Fig. 1107.—Recurrent Sarcoma of Lower Jaw Five Years After Re- 
section of One-Half of Inferior Maxilla. 


disease by getting the infected cells into the circula- 
tion. Amputation should be performed above the bone: 
involved. 

Sarcoma of the humerus is rather rare. Butlin’s sta- 
tistics show 32 cases with 2 deaths due to operation, 
and with but 2 cases well long enough to be called cured. 

Sarcoma of the radius and ulna is so rare that it need. 
not be further mentioned. 

Poinsot has collected 25 cases of sarcoma of the scapula 
with 2 deaths from operation, but with only 1 cure. 

Doll (Archiv f. klin. Chir., Bd. xxxviii., p.181) collected 
82 cases in which the scapula alone was removed for sar- 
coma, with a mortality of 25 per cent., and with no. 
known cures. 

SARCOMA OF 'THE UPPER AND LOWER JAw.—The jaw, 
both upper and lower, furnishes a frequent starting- 
point for sarcoma. It occurs usually in patients over 
40 years of age. Martens collected 62 cases of sarcoma of 
the upper jaw operated upon at the Gdttingen Clinic, 
and of these 50 were over 40 years of age and but 12: 
under 40 years. The disease usually begins in the alveo- 
lar process orin the region of theantrum. The first symp- 
tom is usually an irritation at the root of a tooth ora. 
looseness of atooth. The course of the disease is usually 
rapid, and often so rapid that the trouble is mistaken for 
an inflammatory condition. The mortality of resection 
of the upper jaw for sarcoma is about 30 per cent. Re- 
section of the lower jaw for malignant disease gives a. 


‘ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancer, 
Cancer... 





mortality of about 14 per cent. Butlin has collected 104 
cases of resection of lower jaw for sarcoma with 8 deaths. 
Only 4cases passed the 3-year limit. The accompanying 
photographs (Figs. 1106 and 1107) illustrate well the pro- 
longation of life by operation, though final cure was not 
obtained. In 1 case the disease recurred behind the ear 
5 years after operation, and in the other 10 years after 
operation. The recurrence took place in the tissues in a 
region formerly occupied by the angle of the jaw. 
SARCOMA OF THE LyMPHATIC GLANDS (Lympho-Sar- 
coma, Hodgkin’s Disease).—Sarcoma very frequently 
originates in lymphatic glands, especially in the glands 
of the neck. Of my 816 cases of sarcoma no less than 80 
began in the lymph glands of the neck. The prognosis 
is almost absolutely bad. The type is usually small, 
round-celled, and operation, though performed early, 
rarely checks the progress of the disease. Butlin states 
that he “cannot discover a single instance in which a thor- 
oughly successful removal has been accomplished.” The 
accompanying photograph is a good illustration of a well- 
advanced lympho-sarcoma of the neck in a colored man. 
I operated in May, 1900, and apparently removed all of 
the enlarged glands, though some extended down under 
the clavicle to the pleura. I anticipated a speedy recur- 
rence, but thus far, seven months after the operation, there 
has been no return. There is at present no well-recog- 
nized distinction in the use of the terms Hodgkin’s dis- 
ease, lympho-sarcoma, and malignant lymphoma, though 
all are used in describing sarcomatous disease of the 
lymphatic glands. In England there is a tendency to 
restrict the term lympho-sarcoma to the more rapid cases, 
particularly when associated with metastases, and to ap- 
ply the term Hodgkin’s disease to cases in which the 
glands alone are involved, and especially to cases in which 
the glands in different localities are affected. The illus- 
tration here given shows the latter type, the glands in 
neck, axilla, and groin being extensively involved. 
SaRcOMA OF THE Breast.—Sarcoma of the breast is 
one of the rarer forms of tumor found in this locality. 
It is rarer than either adenoma or fibro-adenoma. Of 
100 cases of breast tumors collected by Bryant, only 4 
were sarcoma. The majority of cases occur between the 





Fria. 1108.—Lympho-Sarcoma of the Neck and Axille. 
lymphadenoma. ) 


(Malignant 


ages of 30 and 40. Of my own cases, 8 in number, all 
were over 30 years of age; 4 between 30 and 35; 4 over 
35. Of 12 cases collected at the St. George’s Hospital 
by Shield, 4 were between 30 and 40, 6 between 40 and 
50, and 2 over 50 years of age. 

As pipers the comparative frequency of the various 
types of sarcoma, of 17 cases examined at the Royal Col- 
lege of Surgeons, 7 were spindle-celled, 4 mixed-celled, 
and 6 myxo-sarcoma. Ulceration and fungoid granula- 
tions will frequently occur in rapidly growing sarcoma 


of the breast of high vascularity, and may produce se- 
vere and even fatal hemorrhages. 

An important point in differentiating sarcoma from 
fibro-adenoma is the age of the patient, the latter tumors 
being seldom found after the age of 30. History of pre- 
vious injury, which is found in nearly one-half of the 
cases of sarcoma, furnishes an additional aid in diagnosis. 

Treatment and Prognosis.—The technique of the opera- 
tion does not differ materially from that for carcinoma. 
While recurrence in the axillary glands is not common, 





Fig. 1109.—Lympho-Sarcoma of Neck. Removed by operation. 


it is occasionally observed, and the glands should in all 
cases be removed together with the breast. The tendency 
to recur locally is very great. While the disease, espe- 
cially the round-celled type, usually runs a rapid course, 
occasionally the patient may live for many years in spite 
of repeated recurrences. One of my own cases, an angio- 
sarcoma of the breast in a woman 59 years of age, was 
operated on the first time in 1881. She remained free 
from recurrence 7 years, and then the tumor returned lo- 
cally and grew for 2 years, when a second operation was 
performed. Two years later the disease returned a second 
time and continued to increase in size until the time of 
my first observation, January 20th, 1895. The tumor 
then was very large and entirely inoperable. Under 8 
months’ treatment with the mixed toxins, it decreased. 
so much in size as to be easily removable under ether. 
The patient was well 6 months later, when last observed. 
Shield cites a patient, aged 45 years, who, when operated. 
upon for primary spindle-celled sarcoma of the breast, 
nearly died of hemorrhage at the first operation. The 
disease recurred a number of times and was operated upon. 


643 


Cancer. 
Cancer, 


The patient finally died, at the age of 74, of extensive 
local recurrence. 

Careful microscopical examination of the tissues sur- 
rounding sarcoma of the soft parts shows that infected 
cells are found at considerable distances beyond the sub- 
stance of the tumor, both along the fascia and in the 
bundles of muscle fibres themselves. If we are to im- 
prove the results of operative treatment of sarcoma of 
the breast, we must abandon the old idea that sarcoma is 
an encapsulated tumor that can be easily shelled out, 
and must operate on lines similar to those we have 
adopted in dealing with carcinoma, 7.¢., remove wide 
areas of healthy tissue beyond the apparent limits of the 
tumor. 

MELANOTIC SARCcoMA.—This form of sarcoma was de- 
scribed by Laénnec as early as 1806 under the name of 
melanosis, a term which he applied to all varieties of 
pigmented cancer. Virchow later divided these pig- 
mented tumors into melanoma, melanotic carcinoma, and 
melanotic sarcoma. Most of the melanotic malignant 
growths were at first regarded as carcinomas, but in re- 
cent years there is a growing tendency to class them as 
sarcomas. 

One of the most valuable papers on melanotic neo- 
plasms is that of Ebermann, of St. Petersburg (Deut. Zett. 
f. Chir., vol. xliii., Heft ifi., S. 498). He has collected all 
the cases observed at Koenig’s hospital and private clinic 
at Gottingen, since 1889—15 in number. To these he 
has added 15 cases observed at the same clinic prior to 1889 
and published by Zimmerman. Of these 30 cases, 26 were 
sarcomas and 4 carcinomas. All of the cases of carci- 
noma occurred in the rectum. The round-celled type 
predominated. Of the later series of 15 cases, 12 were 
round-celled and 3 spindle-celled. In 20 cases of Eber- 
mann’s 30 cases the origin of the growth was in the skin, 
7 of which began in congenital pigmented warts. Of 
Hiselt’s large collection of 104 cases, 47 originated in the 
eye and 40 in the skin. 

Melanotic sarcoma may occur at any age, but is most 
frequent between the ages of 40 and 60 years. I have 
personally observed 22 cases of melanotic sarcoma. In 
11 of these cases the starting point was in a pigmented 
mole, and in 7 of these cases it developed shortly after 
some form of trauma (in 4 cases after tying off the mole 
with a thread), or of local irritation. In 17 of my 22 
cases the lymph glands were affected, usually those near- 
est the primary tumor. In more than one-half of my 
cases there was rapid generalization of the disease. In 
one case in which an autopsy was made, metastases were 
found in practically every organ. 

Treatment.—Although rapid recurrence with a fatal 
issue after a varying interval of a few months to two or 
three years is the usual history of cases treated by oper- 
ation, there are a few authentic cases of cure. In my 
article on sarcoma (“ Twentieth Century Practice of Medi- 
cine,” vol. xvii.), I cited 2 cases well 9 and 11 years after 
operation. Hence I believe it justifiable always to oper- 
ate on primary melanotic sarcomas. Operations in these 
cases should be very extensive and should remove wider 
areas of skin than has hitherto been the custom. The 
nearest lymph glands should always be dissected out, 
whether enlarged or not. Ina number of cases in which 
the prognosis was very bad, I have used, with every pre- 
caution, the erysipelas toxins, but with little apparent 
effect. 


Some REcENT METHODS FOR THE TREATMENT OF In- 
OPERABLE CANCER. 


During the last few years several methods for the 
treatment of inoperable cancer have been introduced and 
advocated by distinguished men. 

Treatment of inoperable cancer by means of ovariec- 
tomy combined with administration of thyroid extract was 
first used by Dr. George Beatson (Lancet, 1896, 62-104). 
Two or three cases were reported in which the thyroid 
extract was employed as an adjunct to the operative 
removal of the tubes and ovaries. Beatson’s published 


644 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








cases are of great interest. Some of them undoubtedl 
show great improvement, but none has remained well 
sufficiently long to justify one in considering the disease 
cured. This method was taken up by a number of well- 
known English surgeons, notably Mr. Watson Cheyne, 
who reported two cases with marked improvement in one 
and little effect in the other. Beatson’s conclusions were: 
“We must look in the female to the ovaries for the excit- 
ing cause of carcinoma, certainly of the mammary or- 
gans.” This would seem in general to bea pure hypothesis 
entirely unsupported by facts. It would seem to me that 
the important trophic changes that have been noted after 
removal of the ovaries in ‘cases thus far observed can be 
fully explained in a much more simple way without the 
necessity of elaborating a new theory as to the origin of 
cancer. ‘The explanation that I would offer is that the 
changes were brought about simply by diminished vascu- 
larity of the breast resulting from the ovariectomy which 
diminishes the blood supply of the tumor, which in nearly 
all cases is followed by at least temporary diminution in 
its size and general improvement in its symptoms. The 
administration of the thyroid extract has in a certain 
number of cases been followed by a temporary improve- 
ment. I have myself used thyroid extract in a number 
of cases without any apparent change. Ido not think 
that the results of o6phorectomy thus far offer sufficient 
encouragement to justify a general adoption of the 
method. 

Injections of Alcohol.—This method, first advocated by 
Schwalbe and Hasse in 1872, and recently revived by 
Kuh, of Chicago, gives little promise of success in inop- 
erable cancer. 

Ligature of Arteries or Cutting Off the Blood Supply.— 
Ligature of the arteries giving nutrition to the tumor is 
said to have been introduced by Harvey in 1651. It has 
been much used in non-malignant tumors of the thyroid. 
Ligature of the carotid for malignant tumors of the 
pharynx has been tried in a number of cases, but usually 
only with slight temporary benefit. Dr. J. D. Bryant, 
of New York, has reported a case of inoperable naso- 
pharyngeal sarcoma which disappeared after ligation of 
both external carotid arteries, the patient remaining well 
for nearly ten years afterward. Several other similar 
cases treated by this method showed only temporary 
shrinkage of the tumor. Dr. R. H. M. Dawbarn, of New 
York, believing that the simple ligature of the external 
carotids does not sufficiently cut off the nutrition of the 
tumor, has described a method which he designates as 
excision of the external carotid arteries, which he advo- 
cates in inoperable malignant tumors in those regions de- 
riving their blood supply from these arteries. Simple 
ligature of the external carotid, even in the hands of 
skilled surgeons, has been hitherto attended by consider- 
able mortality. This, however, should not make one 
hesitate to advocate the procedure in hopeless, inoperable 
cases of cancer, provided the results are sufficient to war- 
rant the risk. The operation advocated by Dawbarn con- 
sists in tying the external carotid just above its origin. 
The artery is then caught with forceps, tied, and cut; 
the proximal end is grasped with an artery forceps. 
Then, by working upward, each branch is tied off be- 
tween two ligatures and divided as reached. __ 

The latest results of this method (as stated in a com- 
munication just received from Dr. Dawbarn) are as fol- 
lows: 14 patients have been operated upon by Daw- 
barn and 9 by other men. He states that there have 
been but 4 deaths that could with fairness be attributed 
to the operation, thus showing a mortality of 17.4 per 
cent. -In regard to the actual value of the operation, 
based upon the number of cures or the duration of life 
following the operation, this cannot at present be accu- 
rately estimated. Dawbarn states that all but 2 cases 
have been hospital cases and difficult to trace. In the 
spring of 1900 Dr. Dawbarn presented 5 patients before 
the New York Surgical Society, operated upon between 
1895 and 1898. He states that all of them were either 
carcinoma or sarcoma cases, the diagnosis having been 
confirmed by pathologists. One patient with round-celled 


; REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancer 
Cancer, 





sarcoma of the naso-pharynx was well 5 years and 6 months 
after operation. A second patient operated upon April 
18th, 1896, with sarcoma of superior maxilla, was well 4 
years after operation. In none of the cases did the tumor 
entirely disappear. These results would seem to prove 
that, in a certain percentage of cases of malignant tumors 
deriving their blood supply from the external carotid 
arteries, the disease is temporarily held in check and life 
prolonged. Whether any of these patients have been 
actually cured cannot be determined until a longer time 
has elapsed. I believe that in most of the cases the relief 
will prove temporary. Until the after-history of the 
patients already operated upon has been carefully traced, 
I do not believe the operation should be generally adopted. 

The Treatment of Cancer by Cataphoresis, originally pro- 
posed by W. J. Morton, of New York, is strongly advo- 
cated by G. B. Massey, of Philadelphia. His latest re- 
sults“may be found in 7’he Medical Record of April 7th, 
1900. He states that he has used the method in 387 cases, 
of which 7 were operable and 30 inoperable. Of the 
operable cases 4 were cured and 1 probably cured; 2 were 
failures. Of the inoperable cases, 6 were cured; 2 prob- 
ably cured; probable failure in 2; complete failure in 20. 
Of 37 cases 10 were cured, 7 were doubtful, and 22 were re- 
garded as failures. While many of the cases were recent, 
in several the freedom from recurrence extended over 
more than 8 years. One case, an epithelioma of the cer- 
vix uteri, was well 3 years and 6 months; 1 case of sar- 
coma of the soft and hard palate was well 6 years. An- 
other case of sarcoma of the upper jaw remained well 2 
years; in 2 cases death occurred during application. 

I do not deem that the method should be advocated in 
cases removable by operation. If, however, 6 cases in 
80, or even a much smaller number of inoperable cases 
were cured, the method is certainly worthy of a more 
thorough trial. The duration of the so-called cures is 
manifestly too short at present to permit of estimating 
percentages accurately. 

The treatment of cancer by means of z-rays, or with 
liquid air, is at present in the experimental stage, and no 
results have thus far been obtained to warrant the hope 
that these agents offer any better means of dealing with 
malignant tumors than do the older and more familiar 
methods. 

The Treatment of Inoperable Cancer by the Mixed 
Toxins of Erysipelas and of Bacillus Prodigiosus.— 
The results of this method during the last two years 
have given me no reason to change the conclusions ex- 
pressed in an earlier paper, and I have nothing new to 
add in the way of improvement in technique or of pre- 
paring the toxins. While the results are far better in 
spindle-celled sarcoma than in any other form, a suffi- 
cient number of round-celled sarcomas have been success- 
fully treated to make it advisable to give every patient 
with inoperable sarcoma the benefit ofa brief trial. If no 
improvement has occurred at the end of three or four 
weeks of daily injections, the treatment is not likely to be 
successful. If improvement does occur, the treatment 
should be kept up, either until the tumor has entirely dis- 
appeared or until it has become evident that the injections 
have lost their inhibitory influence. -The toxins may be 
given for long periods in moderate doses without harm 
to the patient. The after-history of my own successful 
cases may be found in the June, 1900, number of the St. 
Paul Medical Journal. The risks of the treatment are 
practically nzl, if proper precautions are observed. In up- 
ward of 200 cases I have had but 2 deaths, both of which 
occurred more than four yearsago. It should be remem- 
bered that the method is advised only in inoperable sar- 
coma; in other words, in the entirely hopeless cases. The 
percentage of probable cures depends largely upon the 
type of cell, varying from perhaps 8 or 4 per cent. in the 
round-celled to nearly 50 in the spindle-celled variety. 
The most promising field for the employment of the 
toxins is, I believe, the adminstration of small and safe 
doses directly after primary operation, without waiting 
for the recurrence to appear. If the toxinscan, in a con- 
siderable number of cases, destroy or permanently cure 


large inoperable tumors, it is quite reasonable to suppose 
that administration after operation would destroy the 
invisible portions left behind, and in a considerable num- 
ber of cases prevent recurrence. 

Method of Preparing the Toxins and Technique of Ad- 
ministration. The preparation that I have used the past 
three years is the one described in my last paper, viz., the 
mixed, unfiltered toxins of the streptococcus of erysipelas 
and the bacillus prodigiosus, made from cultures grown 
together in the same bouillon and sterilized by heating 
to 58° C. In children and patients much reduced in 
strength I have used the filtered toxins prepared by pass- 
ing the mixed living cultures through a porcelain filter. 
This preparation is much weaker than the unfiltered, the 
relative strength of the two being about as 1 to 10 or 15. 
The effect of the filtered solution upon the tumor is less 
marked than that produced by the unfiltered. In the 
earlier cases the toxins were made from cultures of strep- 
tococcus of erysipelas obtained from a fatal case, but 
during the last three years a sufficiently high degree of 
virulence has been obtained by frequently passing the 
cultures through rabbits. This increase in virulence has 
been, Iam convinced, a direct factor in the success of 
the toxins, and, in fact, it was to increase the virulence of 
the erysipelas cultures that, in 1892, I first combined the 
bacillus prodigiosus with the streptococcus of erysipelas, 
Roger, of Paris, having proved that the latter germ had 
the power of making the streptococcus more virulent in 
rabbits, though, so far as I know, it had never been used 
in the human body, nor had the combination ever been 
suggested in connection with the treatment of malignant 
tumors. 

Tam quite convinced that the process of degeneration of 
tumor tissue is greatly increased by the prodigiosus toxin. 
Many opinions have been expressed as to the nature of 
this process, by means of which a cure is effected. The 
aim should be not to cause too much depression, for in 
that case the patient is unable for some time to stand 
even small doses. Many of the successful cases steadily 
gained weight during the treatment, which disproves the 
statement of some writers that the treatment is exceed- 
ingly depressing and causes rapid emaciation. This may 
be true if the doses are too large, but not when the method 
is judiciously carried out. Strychnine may cause speedy 
death or act as an excellent tonic, according to the dose 
administered. 

Aseptic Precautions. Inasmuch as the administration 
of these as well as other toxins undoubtedly increases the 
liability to infection if pathogenic germs are present, too 
great caution cannot be exercised in sterilizing the hypo- 
dermic needle and the skin. If a tumor be ulcerated or 
broken down, great efforts should be made to keep the 
parts aseptic. Lack of such precautions has certainly 
been the cause of death in a number of the fatal cases. 

Duration of Treatment. Fortunately it is possible in 
most cases to tell in a comparatively short time whether 
or not the toxins are likely to be effective. If no benefi- 
cial results are apparent after four weeks’ treatment, I 
believe it useless to continue the injections. In nearly 
all my successful cases marked improvement was seen 
within a week after the first injection, though final cure 
required in some cases several months of treatment. In 
one case, one of inoperable spindle-celled sarcoma of 
the abdominal wall, the tumor entirely disappeared un- 
der thirty injections and the patient is now well, one 
year and a half later. The question of danger of long- 
continued injections of the toxins is an important one. 
One patient with thrice recurrent rapidly growing car- 
cinoma of breast and axilla had the toxins steadily for 
two and one-half years. The doses were moderate, sel- 
dom producing a chill, and averaged two a week. The 
tumor disappeared. The patient gained ten pounds in 
weight and her general health was perfect. The tumor 
finally recurred, ran a rapid course, causing death in six 
months. 

Final Results in Cases Treated Previous to 1899. Of 21 
successful cases treated prior to 1899, the final results are 
as follows: One patient with inoperable, spindle-celled 


645 


Cancrum Oris, 
Cannabis Indica, 


sarcoma of the neck and pharynx, treated with living 
cultures of streptococcus of erysipelas, for four months, 
during which time one severe attack of erysipelas oc- 
curred, was in good health 6 years after treatment. The 
tumor in the pharynx did not entirely disappear, but 
the malignancy was evidently destroyed. Five patients 
were well from 6 years to 8 years after treatment. Of 
these, 3 were afflicted with inoperable spindle-celled sar- 
coma, one with round-celled sarcoma, and one with epi- 
thelioma. In all of these cases the diagnosis was con- 
firmed by the microscopical examination of well-known 
pathologists. The history of one of the patients is of the 
greatest interest. The original growth, a very extensive 
infiltrating, spindle-celled sarcoma of the chest wall, 
entirely disappeared under four months’ treatment with 
the toxins in 1894. After remaining well for 6 years, 
a similar growth has recently developed on the op- 
posite side in a corresponding locality. The patient 
is again under the toxin treatment and is showing im- 
provement. 

Fifteen of the 21 cases remained well for a period of 
from 3 years to 7 years and 6 months. Of these, there 
was recurrence in 2 after 3 and 6 years respectively, 1 
dying of metastases in the abdomen, the other being the 
case referred to as now under treatment. 

The cases were all hopelessly inoperable, and the diag- 
nosis was confirmed by the microscope except in two 
cases. In these two instances the history of the cases 
with the clinical appearances made the diagnosis of sar- 
coma unquestionable. The typeof tumor in the 15 cases 
that passed the 3-year limit was as follows: 


Spindle-celled sarcomas cice..ces cbiaiets cies class kava eirae ees 8 
Round-celled Sarcoma c. <i-leshie.ccscsisaive viviet ie sisieltets sicyeasarets 2 
MixOd-celledSaNCOlia isccicecideje cn cles lela a eiaine eowionineveeiye cscs 2 
Epithelionia gs s.ooe ck Meade en munch cide. rereinmale alee ent neers 1 
Clinical:diagnosis only). .5 22d. ve soe acisiel ole vivacisia sate saieeaters 2 


It is worthy of special note that 2 of the successful 
cases now well, 38 years and 9 months and 4 years and 3 
months respectively, were sarcoma of the parotid gland. 
Butlin, in his last edition of “ Operative Treatment of the 
Parotid Gland,” states that, “up to the present time there 
are very few instances of cure by operation of undoubt- 
edly malignant disease of the parotid.” In my 2 cases 
treated by the toxins the diagnosis was not only con- 
firmed by a competent pathologist, but further by a his- 
tory of repeated recurrences after operation. Another 
case still is also worthy of special mention, inasmuch as 
it shows that the toxins may be taken for long periods of 
time without harm. The patient, a well-known physi- 
cian, with eight times recurrent spindle-celled sarcoma 
of the soft parts of the chest (anteriorly), was treated with 
small doses of the mixed toxins with varying intervals 
of. rest for upward of two years. The patient regained 
his usual health, and has now been perfectly well over 6 
years from the beginning, and 4 years since the cessation 
of the treatment. The tumors, while originally pure 
spindie-celled, were becoming more mixed with round 
cells and more vascular with each recurrence; in other 
words, the disease, as so often happens, was increasing 
in malignancy until the toxins were begun. 

In addition to these 15 cases that have passed the 
3-year limit, I have had 8 others in which the tumors dis- 
appeared. One, a spindle-celled sarcoma of the abdomi- 
nal wall, was well 1 year and 6 months, when the pa- 
tient returned to her home in Europe and was lost sight 
of. One, an extensive round-celled sarcoma of the iliac 
fossa, was well 1 yearand was then lost sight of. A third, 
a spindle-celled, recurrent sarcoma of the leg, is now in 
perfect health, without recurrence, nearly two years after 
treatment. A fourth, a twice recurrent, spindle-celled 
sarcoma of the palm of the hand, disappeared and the 
patient remained well 2 years and 6 months, when the 
tumor recurred. Refusing amputation of the arm, she 
was under the care of a Christian scientist for 8 months, 
during which time the tumor in the hand reached the 
size of a cocoanut and extended above the elbow. I 
then amputated the arm just below the shoulder-joint, 


646 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


but she died of metastases 3.5 months later. Though 
the patient was an especially intelligent girl twenty-two 
years of age, while under the Christian Science treat- 
ment she watched a small tumor, the size of an English 
walnut, grow to the size of a cocoanut, and yet was made 
to believe it was actually getting smaller and improving. 
She also stated that she felt no pain. This is a good 
illustration of the utter impossibility of placing any 
value upon personal statements of patients in regard to 
improvement or cure of malignant tumors by Christian 
Science. 

A fifth case, a chondro-sarcoma of the ilium, of large 
size, disappeared, and the patient after remaining well 
for 7 months, had a recurrence which proved fatal in 
about 1 year’s time. A sixth, a round-celled angio-sar- 
coma of the breast, was well 6 months later, when the 
patient was lost sight of. A seventh, a recurrent fibro- 
angioma of the lip, was well when last heard of; over 
two years after treatment; and ‘an eighth, a recurrent, 
spindle-celled sarcoma of the thigh, disappeared, but the 
patient, after remaining well for a year, had a recurrence 
locally and in the groin, which no longer yielded to the 
treatment, 

In addition to these 23 personal cases, I would mention 
2 other cases in which I directed the treatment, although 
it was carried out by other surgeons. One case (John- 
son’s), a large-spindle-celled sarcoma of the pharynx, 
entirely disappeared, and the patient was well more than 
6 years later. The second (Storrs and Griswold’s), an 
inoperable sarcoma of the breast and axilla, disappeared 
under seventy-eight injections of the mixed toxins, and 
is now well more than 4 years after treatment. The diag- 
nosis in both of these cases was confirmed by microscopi- 
cal examination, in the latter case by the highest author- 
ity in this country, Prof. William H. Welch of Johns 
Hopkins University. William B. Coley. 


CANCRUM ORIS. See Mouth, ete. 


CANELLA BARK.—Cunella Alba. Wild Cinnamon. 
The bark of Canella alba Murray (fam. Canellacee). This 
is a handsome, middling-sized, spicy, evergreen tree, with 
thick, shining, aromatic leaves and small, purple, deli- 
ciously fragrant flowers. The bark of the smaller 
branches is silver-gray. It is a native of the West India 
Islands, esvecially of Jamaica, Cuba, and the Bahamas, 
and also of the southern part of Florida. The bark of 
this tree was first made known in Europe in the early 
part of the seventeenth century, and since then has been 
in continuous but very limited demand. It has been fre- 
quently confounded with Winter’s Bark (Drymis Winteri 
Forster), and with Cinnamodendron corticosum Miers. It 
is now very little used excepting in its home, where it 
is highly esteemed, more as a condiment than as a 
drug. 

Before the bark is collected, the limbs are generally 
beaten all over, in order to loosen the outer layers, which 
are discarded, and then the inner portion is separated in 
quills and. chips and dried. It comes in broken quills, 
sometimes 30 or 40 cm. long and .5 thick (12 to 15 in. by 
din.), but averaging much smaller, say from 5 to 10 em. 
long by 2 or 8mm. thick; the outer surface is roughish 
and bright buff-colored, the inner smooth or finely striated, 
yellowish or creamy white; fracture short and granular, 
odor rather agreeable, cinnamon-like; taste pungent and 
bitter. It contains numerous large oil cells, especially 
in the outer portion. 

The leading constituent is the essential oil, of which it 
contains from three-fourths to one per cent. It isa com- 
posite oil, capable of being separated into several, one of 
which is ewgenol, the leading ingredient of oil of cloves. 
With this there is some cineol. A considerable percent- 
age of mannite can also be separated. The bitter prin- 
ciple needs further study. Canella is a stimulant tonic, 
similar to other aromatics, over which it appears to have 
no other advantage than the possession of a bitter prin- 
ciple. It is not poisonous, and is seldom given alone, in 
doses of .5 to 2 gm. (gr. viii. to xxx.). W. P. Bolles. 


en i i it ME er | 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cancrum Oris, 
Cannabis Indica, 





CANITIES, or grayness of the hair, may be congenital 
or acquired, partial or complete. 

Congenital canities usually occurs in the form of tufts, 
but may occur as round patches. This form of canities 
is rare. In some families it is hereditary, a white tuft 
of hair occurring in a large number of their members. 
General congenital canities is part of that general absence 
of pigment that is known as albinism. 

Acquired canities is the form most often seen. It usu- 
ally begins at about thirty-five years of age, but in some 
families and under certain circumstances it may begin 
much earlier. Beginning in early life, it. constitutes pre- 
mature canities; beginning at middle life, it is one of 
the changes incident to growing old. Few people reach 
fifty years of age without some gray hair. 

The hair on the temples is most often that which first 
changes color, though there is no definite rule as to where 
the disease first appears. The beard may be first affected, 
but usually it is affected secondarily to the scalp hair. 
The pubic and axillary hair may escape all change in 
color, though at last they, too, generally are affected. 
When once grayness begins it is slowly or rapidly pro- 
gressive. Exceptionally and rarely the normal color 
may return to gray hair, just as it is possible to have a 
third set of teeth. The change in color takes place first at 
the root of the hair. As the pigment becomes more and 
more deficient the color of the hair slowly changes from 
gray to a creamy or snowy white. In most cases the 
change in color is the only change that the hair undergoes. 
Alopecia may set in, but it bears no definite relation to 
change in the color of the hair. 

Too many well-authenticated cases are now on record 
to allow of doubt as to the sudden occurrence of canities, 
over night in some cases. Such instances are almost al- 
ways in relation to severe mental shock, such as the re- 
ception of some fearful intelligence. 

Ringed hair isa peculiar and rare form of canities in 
which the hairs are marked by alternate rings of white 
and normal color. The diameter of the hairs is un- 
changed. The white rings are narrower than the colored 
ones. Very few of these cases are on record. 

ErtoLocy.—Canities is due to an interference with the 
pigment formation in the hair papilla. The gray color 
is the combined result of a deficiency of pigment, the 
presence of air bubbles between the cells of the cortex, 
and the essential color of the hair. When the hair is 
white there is no longer any pigment in the hair. The 
occurrence of sudden blanching of the hair is due to the 
entrance of air bubbles between the cortical cells. That 
air between the cells is one factor in causing a gray color 
is shown by placing a gray hair under the receiver of an 
air pump and exhausting the air. It will be seen that 
the hair regains its normal color to a greater or less ex- 
tent. 

Age, heredity, nervous shock or strain, neuralgia, in- 
jury to the scalp, and all debilitating diseases, are pre- 
disposing causes of canities. There is no adequate ex- 
planation for the occurrence of ringed hair. 

TREATMENT.—Nothing can be done for most cases of 
canities. If it is due to some removable cause the color 
may return when the cause is removed, but no promise 
of this should be made. Jaborandi and acetic acid seem 
to have some influence on the color of the hair, and may 
be tried, the first internally and the last externally. 
Hair dyes should never beadvised. Once used they must 
be persisted in. Many of them are harmful, especially 
those containing lead. George T. Jackson, 


CANNABIS INDICA.—IJndian Cannabis. Indian 
Hemp. “The flowering tops of the female plant of Can- 
nabis sativa Linn., grown in the East Indies” (U.S. P.). 
“The dried flowering or fruiting tops of the female plant 
of Cannabis sativa Linn., grown in India, from which 
the resin has not been removed” (B. P.). 

Cannabis sativa is indigenous to Central Asia, but has 
been cultivated throughout Europe and America for its 
valuable fibre, from which hemp is manufactured. It is 
a member of the order Urticacew, and allied, botanically, 





to the commoa hop plant Humulus lupulus Linn. The 
United States Pharmacopceia has adopted the name Indian 
cannabis, as the name of Indian hemp is often given to a 
native plant, Apocynum cannabinum Linn., which is en- 
tirely different and bears no botanical or therapeutic re- 
semblance. As- 
cleptas tncarnata 
Linn. isalso pop- 
ularly known as 
white Indian 
hemp. 

Cannabis sati- 
voaisa large, 
very variable, 
annual herb, 
with an upright, 
slender, usually 
branching stem 
from 1 to 3 me- 
tres high (3 to 
10 feet), long- 
petioled, grace- 
ful, palmately 
divided leaves, 
and small, clus- 
tered, dicecious 
flowers. The 
bark of the stems 
and branches has 
an exceedingly 
tough fibre. 
The leaves are opposite (or alternate above), stipulate, 
and consist of from five to seven (excepting near the top 
of the stem, where they are simpler) linear-lanceolate, 
pointed, sharply serrate leaflets. Flowers in axillary 
clusters. In the staminate on male plant the flowering 
top is in lax, spreading, or drooping panicles, consisting 
of five sepals and as many opposite, large-anthered sta- 
mens. In the female plant it is in small, erect spikes, 
each flower in the axil of an upright, pointed bract, con- 
sisting of a single one-seeded, two-styled carpel envel- 
oped in a broad, spathe-like, one-leaved perianth. Fruit 
(the hemp seed of commerce), a roundish-pointed achen- 
ium containing a single pendulous, oily seed. 

The plant contains a large amount of resin, which ex- 
udes upon the surface of the plant, more particularly 
upon the flowering 
branch. This resin be- 
comes most abundant at 
the period of fructifica- 
tion, and as the fruit 
forms it diminishes in a 
very marked degree. 
During cultivation any 
loss of resin is prevented 
by eliminating the male 
plants or by gathering 
the tops before the fruit 
begins to form. In tem- 
perate climates the plant 
is almost destitute of 
resin, and for medicinal 
purposes that which is 
grown in India and 
Southern Asia is alone 
utilized. 

Indian hemp is col- 
lected in three forms: 
first, the flowering tops 
of the female plant, known as “ gunjah,” which we rec- 
ognize officially in the Pharmacopeeia; secondly, the 
leaves, “bhang,” which are used for smoking; and, 
thirdly, the resin, “churrus,” or “charus,” which enters 
into the composition of “hashish,” and is also used for 
smoking. 

The tops as they reach us consist of compressed masses 
of branches and leaves with flowers, and at times with 
specimens of immature fruit, the whole matted together 





Fig. 1110.—The Hemp Plant—FPistillate Inflo- 
rescence. (Baillon.) 





Fig. 1111. — Staminate Inflorescence 
of the Same. (Baillon.) 


647 


Cannabis Indica, 
Cannes, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





by the resinous secretion. The leaves and bracts bear 
external oleoresin glands, and one-celled curved hairs, 
which are very characteristic and serve to identify the 
plant. The bases of these hairs are enlarged and fre- 
quently contain cystoliths. The tops have a greenish- 
brown color, a narcotic odor, and a slightly acrid taste. 
The medicinal value of the plant varies greatly and is 
very uncertain. This, in a measure, is due to climatic 
influence and the period of collection; but it is also 
accounted for by the time that has elapsed since the 
plant was collected and by its mode of preservation. Ex- 
periments have shown that the plant diminishes in 
strength, after a period of six months, when exposed to 
the air; while control specimens, which are kept in air- 
tight bottles, still remain active. A gradual oxidation 
of the resin is the supposed cause of the change. : 

Our knowledge of the active principles of the plant 
remains very uncertain. The resin as originally sepa- 
rated by T. and H. Smith, of Edinburgh, in 1846, and 
named cannabin, is still accepted as representing the 
active principles, and is almost entirely employed for 
medicinal purposes. It forms the solid extract of the 
Pharmacopeeia, and the fluid extract and tincture are 
alcoholic solutions. In 1857, Personne described canna- 
bene, a volatile oil, which for some time was thought to 
be the active ingredient. It has, however, proved to be 
an impure sesquiterpene, and of no therapeutic value. 
An alkaloid resembling nicotine has been found at differ- 
ent times, but it never has had the characteristic action 
of cannabis. 

Cannabin tannate is a preparation manufactured by 
Merck. It is introduced asa very reliable narcotic and 
devoid of all volatile and toxic principles. 

During the last few years cannabis indica has been very 
thoroughly studied by Professor Marshall and his assist- 
ants, in his laboratory at Cambridge University. As an 
outcome of their investigations there has been produced 
a red oil to which they have given the name of canna- 
binol, and the chemical formula C,sH2;O2. This they 
consider to represent the active properties of the plant, 
but their labors are not completed, and the comparative 
therapeutic value of the new compound is as yet uncer- 
tain. 

Cannabis indica is much used by the natives of India, 
Arabia, and neighboring countries as an intoxicant. 
For this purpose the dried leaves and the resin are 
smoked, either uncombined with other ingredients or 
mixed with tobacco. In Arabia the resin is combined 
with opium and other narcotics to form the well-known 
“hashish.” In some instances a decoction is made from 
the leaves and employed as a beverage to induce the in- 
toxication. The effect produced is an inebriation of an 
agreeable character, exciting the individual to sing and 
laugh. There are pleasant and often gorgeous visions 
and hallucinations, with a sense of ecstasy, and more or 
less delirium, terminating in a deep sleep. The sleep 
may be cataleptic in character, the muscles being slightly 
contracted and the limbs pliable. Later observers have 
described a condition resembling hypnotism. During the 
intoxication the sexual propensities of the individual are 
stimulated, which has established its reputation as an 
aphrodisiac. 

The craving for this stimulant is very prevalent among 
the Asiatics, and many who are addicted to its use are 
more or less continually under its influence. 

The effect produced by cannabis indica varies accord - 
ing to the mode of administration. When the fumes are 
inhaled it isa stimulant and intoxicant. Itseffect begins 
early, and if but a small amount is used, it passes off in 
half an hour or more. If it is taken into the stomach its 
action is slow, an hour or two elapsing before the drug is 
absorbed. In this way its stimulating effects are much 
less marked, and its depressant and narcotic action is more 
evident. Asan anodyne and antispasmodic it is classed 
by many as ranking next to opium. In large doses it 
produces the same effectas when inhaled. Experimental 
work has shown that the primary stimulation rapidly 
passes and is followed by depression, loss of reflexes, 


648 


ataxia, diminished sensibility, a tendency to sleep, and 
stupor, witha certain degree of anesthesia and paralysis. 
The effect upon the heart and respiration is not a promi- 
nent symptom. The early stimulation continues for 
some time, and the depression of respiration and circula- 
tion becomes marked only as narcosis begins. The mode 
of death is uncertain, some observers reporting that death 
takes place from cardiac failure, while others state that 
the heart was observed to beat after the respirations had 
ceased. Upon the kidneys it exercises no direct action, 
but the tendency is to increased excretion of urine. It is 
stated that a decoction of the fresh plant is an active 
diuretic. No specific action upon the sexual organs has 
been detected, excepting that accompanying the general 
stimulation. Cannabis indica is not a dangerous drug. 
The physiological effects may be very marked, but to 
cause death a very large amount would be required. No 
authentic instance of its fatal effects has been recorded. 
In animals it is found that, of the fluid extract, M x. will 
cause marked symptoms, but as much as 3 i. is required 
to produce death. 

The therapeutic value of Indian hemp is due to its in- 
fluence on the nervous system, and by some it is sup- 
posed to.act directly upon the cerebralcells. Its sedative 
effect is most valuable in functional disorders and in pain 
not due to inflammation. It has proved of value in the 
aged when the mental faculties are weakened generally 
and when much restlessness and sleeplessness are promi- 
nent symptoms. In doses of gr. + to $ at bedtime a calm 
and quiet sleep is secured, and the same action may be 
secured for weeks without increasing the dose. In mel- 
ancholia and chronic alcoholic delirium of the aged, ac- 
companied by depression, it has acted as an exhilarant, 
has produced the desired sense of strength, and has 
secured quiet and rest. In the restlessness of general 
paralysis and “temper diseases,” in both adults and chil- 
dren, it has also been of the greatest service. 

In painful maladies it hasacted best in those of a func- 
tional character, such as neuralgia and migraine, either 
alone or when combined with constitutional remedies, as 
iron, quinine, and zinc, when such are indicated. In 
neuritis it proves of service only when given in addition 
to mercury, iodine, and other such remedies. It has also 
proved very serviceable in the formication, tingling, 
numbness, and other sensory disturbances of the elderly 
and gouty. 

It has been very successful in clonic muscular spasms 
such as the convulsions of children and adults due to 
reflex causes, in epileptiform convulsions due to organic 
disease of the central nervous system, and in cases of 
brain tumor accompanied by convulsions and other indi- 
cations of central irritation. In true epilepsy it has 
proved useless. In numerous cases it has been given for 
a prolonged period until its full physiological action was 
produced, and yet it has failed to influence the disease in 
the slightest degree. It relieves the distress of spasmodic 
asthma and has proved very serviceable in spasmodic 
dysmenorrhea not associated with metritis or with other 
inflammatory affections. It has proved of service in 
chorea, whooping-cough, hysteria, migraine, and neu- 
ralgia. It has also proved of particular usefulness in 
painful disorders of the stomach, when not accompanied 
by organic changes. It has proved a better sedative 
than opium, as it exercises hardly any derangement of the 
secretions. Its beneficent effects are increased by atten- 
tion to the state of the secretions, and by the employment 
of alkalies, purgatives, and other stomachic drugs when 
such are indicated. 

In administering this drug the great drawback has been 
the unreliability of the various preparations. To obviate 
this, it is advisable to restrict one’s practice to the use of 
a single preparation, beginning with a moderate dose and 
gradually increasing until its physiological effect is pro- 
duced. Notwithstanding the various active principles 
that have been described, the resin and its preparations 
are much to be preferred. Standardized extracts, both 
solid and fluid, are now carefully prepared, and either 
these or the tincture should be employed. The dose of 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cannabis Indica, 
Cannes, 





the solid extract is from gr. } to gr. i., that of the fluid 
extract is from Mss. to Mi. The advantage of the fluid 
extract is supposed to be due to the fact that only moder- 
ate heat is employed during its preparation. The dose of 
the tincture is from 1 v. M to xxx. The preparations 
should never be added to aqueous solutions as the resin 
immediately separates as an insoluble mass. 
Beaumont Small. 


REFERENCES. 


Pharmaceutical Journal, 1847, 6; 1857, 31. 

London Lancet, 1890, vol. i., 621 

Report on Cultivation and Use of Canja, Calcutta, 1893. 
Journal of Chemical Society, London, 1896, 69 ; 1899, vol. i., 20. 
The London Lancet, 1897, vol. i., 235. 

Journ. Amer. Med. Assn., 1898, October 15th. 

Cambridge Philosophical Transactions, vol. ix., 140. 

British Medical Journal, 1900, vol. i., 135. 

Merck’s Archives, 1900, 247. 


CANNES, FRANCE.—Cannes, a winter resort on the 
French Riviera, is picturesquely situated in a recess of 
the Gulf of Napoule. It is 660 miles distant from Paris, 
120 from Marseilles, 19 from Nice, and 28 southwest of 
Mentone. “Unlike any of the other health resorts on 
the Riviera, Cannes extends over a wide tract of land, 
so that its eastern and western limits are some miles 
apart, and its attractions and beauties are not limited 
and concentrated in one particular spot, but are varied 
and widespread” (Burney Yeo). 

It is well protected on the east, and partially so on the 
west, by an isolated mountain group called the Esterel. 
On the north, however, the higher ridges of the Alps are 
too far distant to afford proper shelter. Like Nice it is 
a windy place, the sharp, violent, and disagreeable ms- 
tral (northwest wind) prevailing frequently in February 
and March. It is less sheltered than Mentone and San 
Remo, and consequently the climate is less equable. 
The general characteristics of the climate of this resort 
are mildness, abundant sunshine, moderate average rain- 
fall, and, for the seashore, a low relative humidity. The 
winds and the lack of equability, particularly between 
the sun and the shade and the day and night tempera- 
tures, are some of the objectionable features. “The 
Riviera,” says Burney Yeo, “is a land of sunshine and a 
land of winds. Itisa land of intense, brilliant sunshine 
and of cold, chilling shade.” “The deceptive combina- 
tion,” says Lindsay, “of brilliant sunshine with cutting 
blasts is the great climatic defect of the Riviera.” The 
great and continued popularity of this, as well as of the 
other resorts of the Riviera, depends not so much on the 
intrinsic excellence of its climate, as on its comparative 
superiority over the usual climate of the more northern 
portions of the Continent and of England. Climates like 
pleasures are often judged by comparisons, and when, 
for instance, we compare the winter climate of London 
or Vienna with that of Cannes, the latter appears quite 
superlatively excellent. But if we compare the climate 
of Cannes with that of some resorts on the opposite 
coast of Africa or in Southern California, or with that of 
many of the resorts in our Southern States, Cannes de- 
cidedly suffers by the comparison. When, on the other 
hand, one considers the beauty of its situation, the vari- 
ety and charm of its scenery, the richness of its vege- 
tation, and all the fascination incident to a resort on the 
beautiful Mediterranean coast, Cannes surely has few su- 
periors. It is to be borne in mind, say Burney Yeo and 
others, that at Cannes one can avail himself of two some- 
what different climates, according as he chooses a resi- 
dence in the neighborhood of the seashore or inland in the 
valley of Cannet, for example, about two miles distant 
from the sea, where greater protection for dwellings and 
promenades is afforded. All writers upon the latter cli- 
mate refer to it as “ bracing ” and “exciting,” with a tonic 
and stimulating atmosphere. 

The following meteorological table arranged from Mar- 
cet’s* personal observations, extending over a period of 
from two to six seasons, will give the reader a means of 





*** Southern and Swiss Health Resorts,” by W. Marcet, M.D. 


comparing this with other climates. The data are for 
the winter season, extending from November to April 
inclusive: 


CLIMATE OF CANNES, FRANCE—OBSERVATIONS OF W. MARCET, M.D. 
(FAHRENHEIT SCALE.) 






































A A { 
i= fon . 
Nd ea Sa od iP 
E EI I S| 4 a 
o =| = S = 
Sane) Fhe | SLB es 
mete Ss | = = < | @o@ 
Temperature— 
Mean average temp..| 52.6°| 46.3°} 48.0°| 48.8°| 51.0°} 55.5°| 50.8° 
Average daily range.| 12.3 | 12.4 | 12 13.4 | 18.2 | 12.8 
Mean of warmest....| 58.8 | 52.5 | 54 55.5 | 57.6 | 62 
Mean of coldest ..... 46.5 | 40.1 | 42 42.1 | 44.4 | 49.1 
Mean maximum sun 
temperature........| 99.7 | 91.6 | 96.1 |106 114.7 |120.7 
Mean lowest night 
temperature....... 38.4 | 31.4 | 32.2 | 33.8 | 85.4 | 41.9 
Precipitation— 
Average in inches...| 5.17} 4.51} 1.69) 1.46 | 3.42] 4.05) 20.32 
Wind— E.and 
Prevalling: GIPCellOh;| aren eu leeirlaciliterte Slt sie ere Ne EK. |S.E. 
Calm'Gayscs smascesss LOST | dla W125) Seeniecs 2.7 | 48.8 
Light to fresh ....... 12.7 | 13825") 13 11.7 | 19.2 | 18.5 | 88.9 
Stormy to gale...... GOZO kh fe soce ) Ves | Sut lS otal 8 
Humidity— 
Average relative ....| 71.2%] 72.7%| 71.7%| 75% | 73 1%| 74.3%| 738% 
Weather— 
Fine days Whe 18.8 | 21 20 21.3 | 18.4 |117 
Overcast . 2. SD GO. Sey On Lah vecOu ee Leo. 16.6 
Rainy ..... 9, Sue Deol leecely 268.6. 40.6 
Temperature of sea....| 61° | 57.1°| 55.7°| 55.5°| 56.7°| 59.3° 











The climatic characteristics of the various months are 
summarized by Marcet as follows: “In November and 
December the weather is usually stormy and wet. Jan- 
uary and February are fine, with occasional visits of the 
dry northwest winds. During these two months the air 
is usually calm in the morning with a pleasant light 
southerly breeze blowing in the afternoon, while a north- 
erly land breeze commences at sunset and is continued 
during part of the night. March and April are windy 
and showery, the winds showing no particular regularity, 
although in general easterly with wet weather.” “At. 
night,” continues Marcet, “there is a sudden accession of 
cold together with the increase of atmospheric moisture 
at sunset and continued at night; therefore the impor- 
tance of the invalid being indoors before sunset.” Fogs 
are unknown, and there is an absence of mist. Occasion- 
ally the temperature sinks to the freezing point, and snow 
sometimes falls. As almost everywhere else, occasionally 
the unexpected happens, and a very wet or very cold 
season occurs, “and then,” says Burney Yeo, “the suffer- 
ings of the visitors are very acute, much more so than at. 
home.” There is a considerable amount of lime in the 
soil, which adds to the disagreeable effect of the dust, 
which is always an annoying feature. 

Dr. J. Henry Bennet wisely warns the visitor not te 
expect perpetual spring or eternai summer in the Riviera. 
“ Although there isso much sunshine,” he says, “so much 
fine weather, such immunity from fog and drizzling rain 
—it is still winter. Wind, rain, chilly atmosphere, and 
occasional cold weather, with snow on the mountains. 
and flakes of ice in exposed situations, have to be en- 
countered.” The Riviera is not Southern California, and 
a climate similar to that of the latter region must not be 
expected. If the reader will turn to the article upon 
California, Southern, in this volume and compare the cli- 
matic tables of San Diego and Santa Barbara with that. 
given here of Cannes, he will realize the difference.. For 
instance, the average mean temperature for January at 
Cannes is 48° F., while at San Diego it is 53.6° F., and 
at Santa Barbara 51.2° F. Further, the rainfall at these 
two California coast resorts is only about half of what it 
is at Cannes, and the number of fair and clear days is 
considerably greater, and there is also less wind. A\l- 
though the relative humidity is almost exactly the same, 
the complete absence of fog would seem to indicate a. 
comparatively drier atmosphere at Cannes. 

It is well to emphasize again the fact of the winds; 


649 


Cannes, 
Cantharis, 





they are the béte noir of Cannes, as indeed of the Riviera 
in general. Moreover, they seem to be quite incapable 
of classification, “ They are legion,” says Burney Yeo, 
and Marcet declares that their direction is so chan geable 
that it is not worth while to record them—they blow hot 
and they blow cold, the sirocce from Africa and the bise 
from the Alps. They blow dry from the west and moist 
from the east. Dr. Cozalis, quoted by Burney Yeo, 
gives his results from several years’ personal experience 
as follows: 

“Toward the last week in October, the wind sometimes 
from the east, sometimes from the west, becomes high. 
In November there is always a windy and rainy period 
lasting for from eight days to three weeks. The wind is 
rarely violent and nevercold. During or after this there 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of cases, is the length of time during which the ew7e can 
be continuously carried out. -For eight or nine months 
long the children can live out of doors and take the sea 
baths. At first the general health improves and the 
weight. increases, and later the local conditions begin to 
show improvement. Nearly all cases of anemia, of what- 
ever age they are, are said to manifest marked ameliora- 
tion at Cannes. Cases of slow convalescence from acute 
diseases; various chronic catarrhal affections—bronchial 
and laryngeal,—emphysema, chronic pleurisy; certain 
forms of chronic gout and rheumatism; Bright’s disease 
and diabetes—all these are said to be benefited by a win- 
ter residence here. On the other hand, this climate is 
unsuitable for hysteria, neuralgia, insomnia, and various 
other nervous maladies, and for febrile cases from what- 





Fig. 11 


may be a few days of mistral; then commences the reign 
of the east wind, a mild wind which lasts till February. 
December and January are the least windy months. 
West winds begin again in February, and the northwest 
(mistral) may blow for two or three days. In March the 
winds are often violent, and bring not infrequently tor- 
rents of rain, as in November. In April the winds are 
very variable.” 

As has been previously mentioned, Cannes offers not 
only opportunities for residence directly on the sea, with 
a purely marine climate, but also situations inland said 
to be more bracing and less exciting, on the Californie 
and in the district of Cannet, where also there is greater 
protection from the winds. The climate along the shore 
is exciting and warm; inland it is more bracing and less 
exciting. 

The class of cases which are suitable for the climate of 
Cannes are, first of all, tuberculous affections, especially 
in children. Grebner* writes of the favorable results 
obtained here with children affected with scrofula, tu- 
berculosis of the bones, joints, and glands, rachitis, and 
anemia. The Dolfus Asylum, a German institution for 
poor children from four to fourteen years of age, is situ- 
ated here. The children come at the beginning of Octo- 
ber and remain until the middle of May. They spend 
the entire day out of doors, sleep in unheated rooms with 
open windows, and bathe in the sea the winter through. 
The advantage of this location over other marine resorts 
upon the Atlantic and north sea coasts, for a similar class 


* Jahrbuch fiir Kinderheilkunde, N. F., 42, 1896, p. 284. 


650 








2.—Boulevard de la Croizette, at Cannes. 


ever cause. “All invalids,” says Burney Yeo, “except 
those who suffer from scrofulous or lymphatic conditions, 
are advised to keep away from the shore.” 

This climate, like any other mild, sunny one, is also 
favorable for the feeble from age or other causes. As to 
pulmonary tuberculosis, the writer does not believe that 
Cannes, or the Riviera in general, is a favorable climate 
for its cure. Certain stages of it, more particularly the 
chronic condition, may be temporarily benefited and life 
prolonged, but, as Lindsay says, “after a prolonged and 
thorough trial of the Riviera, but few authorities report 
many cases of cure.” Undoubtedly sanatorium treat- 
ment in this climate would show better results, but so 
many other more favorable localities are now known in 
Europe, for the strict curative treatment of this disease— 
such, for example, as Davos, Arosa, Leysin, Les Avants, 
and others—that it seems probable that the Riviera will 
not in the future, as in the past, remain the Mecca for 
consumptives. Moreover, the profession is more and 
more becoming convinced that it is better to establish 
sanatoria for consumptives at home, in the country and 
locality where the patients live for almost every where 
a suitable location can be found where the air is pure, 
where there is an absence of high winds and dust, and 
where a reasonable amount of sunshine exists. These 
are the climatic conditions which are really essential to a 
cure, although with them must be united the hygienic- 
dietetic régime which experience has shown to be equally 
important if the best results are to be secured. 

Cannes—derived from Cann, the reeds in which the 
fishermen’s huts originally stood—has now grown to be 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cannes, 
Cantharis, 








a city of 23,000 inhabitants. It owes its prosperity in a 
great measure to the first Lord Brougham, who took up 
his residence here in 1834. It is especially popular with 
the English, who frequent it in great numbers. Ten 
thousand visitors spend the season here, and from fifty 
to sixty thousand pass through the town. It is almost 
unrivalled in the beauty of its situation and the charm 
-of its surroundings, and has been called the “ Pearl of the 
Riviera.” There are innumerable excursions by sea and 
land, and the surrounding country is exceedingly beau- 
tiful. It has a rich and varied vegetation; here flourish 
the eucalyptus, olive, vine, orange-tree, and the myriad 
‘shrubs and flowers of a luxuriant southern growth. 

The accommodations are excellent, but are said to be 
expensive. Most of the hotels, pensions, and villas are 
surrounded with gardens. “One great advantage of 
Cannes,” writes Dean Alford, quoted by Burney Yeo, 
“over other Riviera stations is, that you have actual forest 
‘scenery within fifty yards of your hotel.” The town is 
abundantly supplied with good drinking water. The 
sanitation seems to be well looked after, and the system 
of supervision of apartments occupied by consumptives 
is so complete and thorough that it will be instructive to 
mention it. 

When a physician has a consumptive patient occupy- 
ing a room in a hotel or villa, he notifies the proprietor 
when the room is vacated. The proprietor takes this 
notification to the sanitary authorities, who disinfect the 
premises and return the original card of notification to 
the physician with a note made on it that disinfection has 
been made, and the physician then is assured that the 
room is safe for occupancy again. In addition, there is 
kept, at the mayor’s office, a list of the hotels and villas 
whose proprietors have agreed to conform to all the sug- 
gestions made by the physicians as to disinfection and 
renovation. Whenever a physician is asked to recom- 
mend a hotel or apartment, he has this list, which is 
public, to refer to. This arrangement works for the 
mutual interests of the proprietors and visitors. 

Cannes has become so popular and fashionable that for 
this reason it is objectionable for the true invalid; he is 
tempted to over-exert himself in the social life and gayety 
of the place. Hdward O. Otis. 


CANTHARIDATE OF POTASSIUM.—The application 
of the cantharidins to the treatment of tuberculosis was 
introduced at a meeting of the Berlin Medical Society on 
February 25th, 1891, by Dr. Oscar Liebreich. The value 
of this drug as a remedy rested on its well-known prop- 
erty of promoting exudation of serum from the capil- 
laries; an effect not only directed to the vessels of the 
surface of the body, but also produced in various organs, 
as the kidneys, sexual organs, and lungs, particularly 
when the drug is administered internally. This is the 
special action of the drug on the healthy tissues, and Lie- 
breich assumed that an irritated condition of any set of 
capillaries would favor this process of exudation, or, in 
other words, that a dose too small to produce any effect 
on healthy capillaries would cause an exudation from 
those inflamed. This would relieve the congested cells 
and restore the tissues to a more healthy state; and, 
further, he claimed, as it had been shown that serum pos- 
sessed decided germicidal properties, it should prove an- 
tagonistic to the growth of tubercle and assist in the effort 
at repair. 

A number of cases treated by Liebreich’s method were 
shown by himself and some of his colleagues; cases of 
laryngeal phthisis, lupus, and pulmonary phthisis were 
all said to be benefited. When the diseased parts could 
be observed, the action of the drug was found to be such 
as had been described by Dr. Liebreich, the ulcerated sur- 
face being more healthy and showing signs of repair. 
When the lungs were affected the expectoration became 
free and profuse, the oedema decreased, and the local con- 
dition improved; the fever also diminished, and other 
constitutional disturbances lessened. Liebreich stated 
that no reaction followed its use, but other observers re- 
ported a slight rise of temperature, headache, disturbed 








digestion, diarrhoea, etc. If the dose be too great it pro- 
duces the characteristic symptoms of cantharides poison- 
ing—pains in the loins, albuminuria, strangury, and 
hematuria. 

Pure cantharidin being insoluble in water, the canthar- 
idate of potassium and the cantharidate of sodium were 
selected as the salts most suitable for using the drug 
hypodermically. As the amount of cantharidin in these 
salts varies greatly, Liebreich advised the use of a cer- 
tain solution which he had found by experiment to be 
most suitable. It is prepared as follows: cantharidin, 
.2gm.; potassic hydrate, .4gm., most carefully weighed 
and heated over a water bath in a 1,000 c.c. flask, with 
about 20 c.c. of water, until a clear solution results; then 
add water gradually, while still heating, to the full 
quantity. 

Of this solution T viij. to xvi. are administered hypo- 
dermically. Its use should not be continued for any 
length of time; at least every third day should be al- 
lowed to intervene without the drug being administered. 

The effect on the kidneys must be carefully watched, 
and the dose lessened, or its administration stopped, 
should any symptoms of strangury occur. In kidney 
disease its use is, of course, contraindicated. To over- 
come the painful local irritation that frequently follows 
at the site of injection, it has been recommended to pre- 
pare a solution containing cocaine, which prevents the 
pain. Two parts of the hydrochlorate of cocaine are 
added to one of cantharidin and two of caustic soda; this 
is formed into a solution, and gr. z+ to 74, is used asa 
dose. The addition of cocaine is also thought to lessen 
its tendency to irritate the bladder or kidneys. 

This treatment was extensively applied to all forms of 
tuberculous disease, but it did not prove of sufficient value 
to warrant its continued use, and it is now rarely resorted 
to. It undoubtedly produces the action described by 
Liebreich, causing a freer exudation of serum, etc., but 
this does not lead to any improvement in the symptoms 
or tend to any permanent benefit. Post-mortem exami- 
nations of patients who have been subjected to this treat- 
ment fail to furnish any evidence of repair or beneficial 
effect on the disease. Beaumont Smal, 


CANTHARIS.—Spanish Fly. This rather inaccurate 
name is given to Cantharis vesicatoria De Geer (Lytta 
vesicatoria), order Coleoptera, a brilliant green beetle, with 
a long, cylindrical body, a disagreeable odor, and power- 
fully irritant properties. It is about an inch in length, 
and from one-fifth to a fourth of an inch in breadth. It 
hasa good-sized, ovoid, heart-shaped head, filiform, black 
antenne of eleven joints, a distinct, rounded thorax, and 
long, straight wing covers. The legs are provided with 
five tarsal joints, ex- 
cepting the two pos- 
terior ones, which 
have only four. The 
wings are large, 
brown, translucent. 
The odor, even when 
the insect has been 
dried for a long time, 
is strong and charac- 
teristic. The perfect 
beetle appears in 
great numbers in its 
native countfies, 
about the middle of 
summer, upon pop- 
lars, ashes, lilacs, pri- 
vets, and even upon 
roses and several 
other domestic 
shrubs, whose leaves 
it devours. The acrid efluvium emitted from it can be 
smelled at a considerable distance, and when the insects 
are abundant, it is said to be dangerous to persons sit- 
ting under the trees where they are. 

This beetle is a native of Southern and Middle Europe, 





Fig. 1113.—Blistering Beetle, Natural Size; 
a, Eggs, somewhat enlarged; hb, asin- 
gle egg, greatly enlarged. (Moquin- 
Tandon.) 


651 


Caoutchouce, 
Capsicum, 


Western Asia, etc. It is abundant in Spain, France, Ger- 
many, Italy, etc., and in these countries is collected for 
use. During the middle of warm days it is very active 
and alert, but in the night and early morning, benumbed 
by cold and wet, it is very heavy and clumsy. Advan- 
tage is taken of this time for collecting the beetles, when 
they can be beaten or shaken from the shrubs where they 
hang and caught in sheets or bags held under the boughs. 
They are then killed by boiling water, steam, vinegar, 
ether, or some such treatment, and carefully dried by 
moderate heat. 

The drug, as usually found in the market, consists of 
these bodies whole, excepting what the friction of the 
transportation has done in the way of rubbing off the 
antenne and legs. Ground, it gives a disagreeable- 
smelling, grayish powder, sprinkled with bright metallic 
green specks—the fragments of wing cases and body. 
Taste, resinous and acrid. 

Blistering beetles were known to the ancients, and have 
been used for centuries in many different countries, but 
they have not been generally of this particular species, 
whose employment is comparatively modern. This, 
however, from its abundance, and the ease with which it 
can be collected, has generally supplanted the others, at 
least in English and American commerce. 

ComposiTion.—A_ great variety of ordinary animal 
products, nitrogenous tissues, fat, oil, watery extract, 
etc., and about one-fourth to one-half per cent. of a well- 
defined, crystalline, active principle named cantharidin. 
This energetic poison crystallizes in tables or flakes, is 
white, colorless, and odorless, and at first has but little 
taste. It dissolves in 25 parts of water, and in upward 
of 3,000 of alcohol; in ether and chloroform it is almost 
insoluble. Cantharidin is about thirty times as active as 
cantharides. 

AcTION AND Usres.—Cantharides is an intense irritant, 
whether applied internally or externally; taken into the 
stomach, it causes heat and burning of the fauces on its 
way down, then vomiting, often of bloody mucus, intense 
pain and burning of the stomach and bowels, diarrhea, 
fibrinous and bloody stools, and finally urinary distress, 
strangury, bloody urine, and other evidences of renal and 
vesical irritation. The genitals are also excited—pria- 
pism in the male, swelling of the vulva, etc., in the 
female; uterine tenesmus or abortion may follow. Erotic 
sentiments may be, but are not necessarily, aroused. A 
small, quick pulse, rapid breathing, a hot, dry skin, 
headache, delirium, coma, and death may follow its in- 
troduction. Two grams (gr. xxx.) of powdered canthar- 
ides, or 5 cgm. (gr. #) of cantharidin, would be a danger- 
ousdose. Applied externally, cantharides produces, after 
a few minutes, redness and slight burning of the skin, 
followed, in from one-half to five or six hours, by small 
blisters just beneath the cuticle, which rapidly separate 
it from the skin and soon coalesce into one large bleb 
over the whole surface covered by the blister. A small 
amount of cantharidin is absorbed through the skin, as 
strangury, hematuria, etc., are rather apt to follow very 
extensive blistering. This medicine, like most active 
substances, has been givenina great variety of conditions 
—vesical catarrh, gonorrhcea, dysuria, and incontinence 
of urine—and as a general nervous stimulant. For none 
of these things is it now in vogue. Externally applied, 
it is the safest, surest, and in all ways the best vesicant 
known; easy, comparatively painless, and superficial; 
never leaving a scar. Large and repeated blisters were 
formerly used, with a view of “ drawing off ” serous effu- 
sions from the pleura, peritoneum, the joints, etc.; but 
as derivative effects are not accomplished in so simple 
and direct a way, these blisters are now principally used 
as a means of producing simple counter-irritation. 

ADMINISTRATION.—If it is desired to give cantharides 
internally, the Tincture (Tinctura Cantharidis, U. 8. P., 
strength 5 per cent.) is a suitable form, but the numer- 
ous cerates and liniments which follow show how almost 
exclusively it is employed externally: Ceratwm Canthar- 
idis, U. 8. P., strength 32 per cent.; and the Collodiwm 
Cantharidatum, U. 8. P. (Blistering Collodion), contain- 


652 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ing 60 per cent., are used for blistering. The liniment, 
of 15-per-cent. strength, formerly official, has been dis- 
carded. For the last dozen years or more the cantharidal 
cerates of the Pharmacopeia have been almost super- 
seded by a cantharidal plaster, prepared upon a large 
scale by manufacturing pharmacists, with a rubber basis 
instead of the simple fatty one of those. It is scarcely as 
uniform or quick in its action as the others, but on ac- 
count of its convenience, its durability; and ease of han- 
dling, it is likely to continue in use. The tincture of can- — 
tharides, considerably diluted, is a frequent ingredient 
of “hair renewers ” and other cosmetics. 

ALLIED ANIMALS.—The tribe Cantharide contains nu- 
merous poisonous beetles, whose acrid secretions have 
been put to use as vesicants. Some of these are even 
more irritant than cantharis itself. C0. Vittata, our 
potato beetle, and other species of Cantharis, Meloe, the 
oil beetles, several species of Mylabris (“M. Chiccorii,” 
the “ Chinese blistering fly ”) are examples. 

W. P. Bolles. - 


CAOUTCHOUC. See Rubber. 


CAPE MAY.—The first point on the New Jersey coast 
to which people went to enjoy the ocean was Cape May. 
As early as the opening of the last century there were 
stage lines and sailing vessels which made a business of 
taking visitors to this resort. For many years Cape May 
maintained its prestige, and although at present other 
places have outstripped it in the number of visitors and 
display of fashion, there is no other place on the New 
Jersey coast that possesses so nearly an insular climate. 

Cape May occupies the extremity of the peninsula. 
The ocean lies to the east and south, while the broad 
Delaware Bay stretches to the west and northwest. 
Thus nearly every breeze is from the water, and at the 
“Point” a land breeze is a rarity. Cape May City is 
built on an island three miles east of the point and faces 
the southeast. The underlying soil is gravel with sand 
under the gravel beds, and the surface wells upon which 
the city depends have an excellent supply of pure water. 
The sewerage is by means of terra-cotta pipe eight to 
fourteen inches in diameter; the discharge is by gentle 
but sufficient grades through outlets to tidal creeks. 
Water supply and sewerage are difficult problems at the 
seaside, and particularly on the low and narrow outlying 
strips of land on which many resorts are situated. The 
position of Cape May, at a latitude below 39° and nearly 
surrounded by water, gives it an equable climate and one 
of considerable humidity. The relative humidity ranges 
from 70 per cent. in November to 80 per cent. in July. 
The average for the year is 76.4 per cent.; it is thus 
higher than that of Philadelphia (74 per cent. at 8 A.M. 
and 67.8 per cent. at 8 P.M.), but lower than that of At- 
lantic City (94 per cent. at 8 a.m. and 81 per cent. at 8 
P.M.). The mean annual temperature is 54.4° F., or 2.5° 
higher than that of Atlantic City. While temperatures 
as high as 88° F. may occur in summer, the air is quickly 
cooled as a late afternoon breeze from the ocean sweeps 
landward. The nights are usually cool and afford a grate- 
ful relief from the accumulated heat of the cities, where 
brick dwellings radiate heat long after the sun has set. 

Comparing Cape May with Atlantic City it is found 
that there were in 1898 twenty-two more clear days at 
Cape May, but about two inches more rainfall, the excess. 
occurring in the summer. The average mean annual 
rainfall, however, at Cape May is 33.12 inches against 42. 
81at Atlantic City. The mean daily range of temperature 
is 8° F. at Cape May and 12° at Atlantic City. While the 
maximum at Cape May was 88°, at Atlantic City it was 
94°, the minima being 15° and 7° respectively. The cli- 
mate is more strictly a marine climate. 

Cape May is well provided with hotels and cottages. 
It is freer from the objectionable crowds that throng 
other resorts, and the general tenor of Cape May is above 
that of most places on the New Jersey coast: It is com- 
fortably reached in from one and three-quarters to two 
hours from Philadelphia. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





CLIMATE OF CAPE MAY, N. J., LATITUDE, 38° 56’; LONGITUDE, 74° 58’. 
PERIOD OF OBSERVATION, TWELVE AND ONE-HALF YEARS. 


poe ene 8 
s/2)1s/88| 8 
Pa Gy Fim ao o 
Ss = 45 les Pet 
Temperature (Fahrenheit scale) — 
Average or normal ............... 34.2°) 40.1°) 73.6°| 67.9°| 53.5° 
Average daily range ...........00. 11.8 | 12.6 | 10.7 | 10.7 
MGEIOL WALMCSteccs cccassecencees 41.2 | 47.7 | 80 75.3 
PBA OF COLDESU cis cecusenees cee oe 29.4 | 35.1 | 69.3 | 64.6 
Highest or maximum ............. 58 65 91 87 
Lowest or minimum .............. 1 9 56 42 
Humidity— 
Average relative.........ssceccees 78.2%! 74.9%! 79.7%] 6.8%) 76.7% 
Precipitation— 
average AIPANCHCS siecle ere cee cess: 4,22) 5.14| 3.30} 4.46] 47.67 
Wind— 
Prevailing direction ............+. NeW N. Welt Ss E. |N.W. 
Average hourly velocity in miles..| 14.3 | 16.4 | 10 11.7 | 18.4 
Weather— 
Average number of clear and fair 
LVR ee eas ois owtairies Sees viiee.e 20 19.2 | 28.7 | 21.4 |248.7 
Average number of cloudy days... aonb dare, [cates We reetele uPA’ 


Cape May beach is unexcelled on the coast; it is broad 
and hard, and its descent below the water line is very 
gradual. The beach is, as a rule, a safe one for bathing, 
and at the bathing hour in midsummer presents a most 
animated and beautiful sight. There are times when 
continued easterly or northeasterly winds roll up heavy 
seas, and it requires a certain degree of vigor to venture 
into the surf. Only the most robust can enjoy the 
breakers at such times. It should be borne in mind that 
far more accidents happen to bathers of experience and 
over-confidence than to those who indulge moderately. 
After storms the gradual declivity of the shore may un- 
dergo some alteration, and bathers during a flood tide 
sometimes find to their consternation that between them 
and the shore there is a gully of deeper water than they 
are prepared to encounter. This is an occasional source 
of trouble, and even experienced bathers should never be 
out of reach of the bathing master and his boat. 

The chief advantages of Cape May as a resort are for 
those who have insomnia, neurasthenia, or who are con- 
valescing from acute respiratory affections. Children al- 
ways do well, and it is a good place for those in advanced 
life who wish the sedative effect of the sea air. It cannot 
be recommended for tuberculous affections of the lungs, 
but the climate is not necessarily a disadvantage in chronic 
tuberculous disease of the bones. Guy Hinsdale. 


CAPON SPRINGS.—Hampshire County, W. Va. 

Post-OFFricE.—Capon Springs. Hotels and cottages. 

Accrss.—Via Baltimore and Ohio Railroad to Capon 
Springs Station, thence a drive of 15 miles over mountain 
roads to springs. 

This well-known resort is situated 4 miles from the 
base of the Great North Mountain, at an elevation of 
1,800 feet above tidewater. The scenery here is varied 
and pleasing, and the climatic conditions during the sea- 
son, from May 15th to about the end of October, are all 
that could be desired. The average summer temperature 
is about 65° F., the mercury seldom ranging above 75° F. 
The main hotel is a large building, five stories in height 
and well supplied with modern appliances and accessories 
for the safety and comfort of the guests. There are two 
smaller hotels and a number of cottages. The main 
spring discharges about 12,000 gallons of water per hour, 
at a temperature of 66° F. An analysis by Prof. J. W. 
Mallet shows the following results: 


ONE UNITED STATES GALLON CONTAINS: 


Solids. Grains 
TTL CAL DODD racic ds ecu oiris alk oale's 288 oia'aie syoinseys.s net eitie 0.59 
mT RU CAT DOUALA, certs cieerecloe cee etieie y aisieslelelcisjece ¢ 1.44 
RISSTCHEDOTIGLOR Aaleisars cfete chain acta ha caidiniais eel €'h ola ere. sco'e'e ce s 
MIAN GONEIO CALTDONALG sciatic cle tinise ho) 4 dle\dleie e sletala eles ae Trace. 
ALCAN OATOOTIE LO n tereta males eo sicieva.eisieys Orel ele sielersl ojec= e’eiere 8.32 
SIENA CAT DONATO s «ci \¢ a esis c's'x.0) 6.4! ¢10 #,810/0'e1616/0,0.010)0 v]elsieie.e Trace. 
PMOCIELEL  CHIOVICO sy. iniere caicta’cfetsle ole sid a cco: wrofetovs’e glecieicleees tic .06 
POLAR UI SUID OALAMe sais avitanicc bere tisiel vive lcs eile eins sete 16 


Caoutchoue, 


Capsicum, 

Solids. Grains 
Calcium’ sulphate uns mecaweicss tial -scleedcauesetedee 59 
SiPONMUM SUL PNALG Ksioce creteietere;solnrea'viote ee cise Gineth eisveisteeiste Trace. 
Calcium Dns phate sare tices sees aires eejoaite be.e nance act Trace. 





DOC Sovrercioielctsieteis ain eisai ataninie siete ailment lo n.a tod oisiolelsis, sve 12.14 
Gases. Cu. In 
Carbonic acidin.c syesteadssrcctconiele neice an seistetce ca aes 8.56 
ORY SOMMON arate aece see acted ceed Sea mee mek bets 1.76 
INGO MOTI yocecet eestor sibs soupy es rote, Seaiasol cas Oelwein Slain ote rahe lore coal 3 
TOU A tare na cchicitene ictus ace dee stem ele eetes s mte ue ae ts 14.00 


A second spring, known as the Beauty Spring, has a 
similar composition. 

The waters have been found of service in the treatment 
of gastric catarrh, the acid forms of dyspepsia, uric acid 
gravel, and catarrh of the bladder. A large and taste- 
fully arranged bathing establishment is maintained at the 
resort. A swimming pool 9848 feet is supplied by the 
main spring. Plunge, shower, douche, and warm baths 
may be had at the option of the visitor. The water is 
used commercially, and has the indorsement of many 
well-known Philadelphia medical men. 

James K. Crook. 


CAPSICUM.—Cayenne Pepper. African Pepper. Red 
Pepper. “The fruit of Capsicum fastigiatum Blame (fam. 
Solanacee)” (U.S. P.). 

The species of the genus Capsicum are variously esti- 
mated by different botanists at from two to ninety. So 
extensively have they varied, and the varieties hybridized, 
that hundreds of forms are now recognized. The genus 
is probably wholly native to tropical America, but has 
become everywhere cultivated and naturalized in warm 
countries. The plants bear cultivation, as annuals, in tem- 
perate regions also, and constitute one of the-important 
food plants of the world. Owing to its intensely hot 
taste, the fruit is to be regarded as a condiment rather 
than asa nutrient food. This is true even in the tropics, 
where the amount consumed at a meal is often consider- 
able, and a matter of great astonishment to strangers. 
Cultivation has now developed varieties knownas “Sweet 
Peppers,” which are wanting in acridity and pungency, 
and which can be eaten like tomatoes and other vegeta- 
bles. These products are as yet rather new, and their 
practical nutritive value is not yet determined. 

The fruits of the many species and innumerable culti- 
vated varieties vary in size from that of a large pea to 
the two fists, in form from spherical, or much broader, 
to long tapering, and in color from yellow through scar- 
let to purple. They are eaten both fresh and dried, and 
if carefully dried do not lose any of their pungency. 
The official fruit is, however, of very uniform appearance, 
and is thus described: oblong-conical, from 10 to 20 mm. 
(2 to # in.) long, supported by a flattish, cup-shaped, five- 
toothed calyx, with a red, shining membranous and trans- 
lucent pericarp, enclosing two cells, and containing flat, 
reniform, yellowish seeds, attached to a thick central 
placenta. 

Even the medicinal article is considerably subject to 
substitution by other varieties. All these are readily 
recognized by their form and size, except when ground, 
when such recognition becomes a matter of extreme diffi- 
culty, the color of the powder, which is of a deep orange 
red in the (. annuum, lighter in the genuine, and the 
smaller size of the cells of the latter, rendering the only 
assistance. The powder, especially of the commercial 
article sold for table use, is also greatly subject to adulte- 
ration with other substances, particularly colored sawdust 
and cornmeal. Large quantities of the latter substance, 
finely ground and suitably colored, are sold for this pur- 
pose. The entire absence of tannin and starch from gen- 
uine capsicum is an important characteristic in this con- 
nection, and the ash should not exceed five or six per cent. 

CompositTion.—Besides the active constituent, capsat- 


653 


Captol. 
Carbolie Acid. 





cin, capsicum contains some fat, wax, resin, minute 
amounts of volatile oil and alkaloid, and a large amount 
of coloring matter. 

Capsaicin (CsH,,02) dissolves in alcohol and fixed oils, 
as well asin ether. It is so excessively acrid as to bea 
most dangerous substance to handle. It can be obtained 
in the form of colorless crystals. It should exist in capsi- 
cum in the proportion of about one-fiftieth of one per 
cent., and its estimation is the only sure means of ascer- 
taining the quality of the ground drug. 

“Capsicin” is merely a soft extract, consisting chiefly 
of resin and fixed oil, and of very indefinite strength. 

Action AND Uses.—Externally, capsicum is a power- 
ful counter-irritant, capable of blistering if suitably ap- 
plied. Internally, its recognized effects are due entirely 
to its direct and reflex stimulating action. This action 













» /] 






=< 
——— 


Za 






Fig. 1114.—Capsicum Fastigiatum Blume. 


is seen directly in increased movement and secretion 
throughout the alimentary tract, and in increased renal 
secretion, and reflexly in increased spinal and cerebral 
activity. Its aphrodisiac action is both local and spinal. 

Advantage is taken of these properties for the produc- 
tion of ordinary carminative and laxative effects, but 
more especially for its use as a stomachic. Mild cases of 
dyspepsia and habitual indigestion can be greatly bene- 
fited by its moderate use, its eliminative tendency aiding 
the stomachic effect. In extreme cases of habitual indi- 
gestion, especially that of alcoholism, it is frequently the 
only availableagent. Its mental effects in such cases are 
often quite as notable as its stomachic. Its use is of as- 
sistance in overcoming narcotic habits. It has been sug- 
gested that the alkaloid of the drug may be partly re- 
sponsible for the cerebral effects. As a diuretic, it is not 
ordinarily to be recommended, as its irritating effects are 
apt to be too pronounced. Throughout the tropics it is 
confidently recommended both as a prophylactic and as 
a curative agent against malaria, and it is frequently so 
prescribed in temperate regions also. The statement is 
generally made that red and black pepper have equiva- 


654 


as 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


lent actions, but the statement is not warranted. The 
irritant effect of black pepper upon the mucous mem- 
brane of the stomach is much greater in proportion to its 
stomachic effects proper than is the case with red pepper, 
while the irritation of the urethra is greater with the 
latter. The infusion is very serviceable as a gargle in 
asthenic cases of sore throat. 

The dose of capsicum is .05 to .5 gm. (gr. i. to v. or 
possibly gr. x.). The five-per-cent. tincture is most com- 
monly employed, in doses of .3 to .4 c.c. (mM v. to Ix.). 
The oleoresin is given in doses of TL + to i., and the fluid 
extract, TL i. to x. There is a plaster which contains. 
about .25 gm. (gr. iv.) of the oleoresin of capsicum 
spread evenly upon a surface 10 cm. (4 in.) square. 

The stronger preparations of capsicum are to be re- 
garded as ordinary irritant poisons. 

Henry H. Rusby. 


CAPTOL is a condensation product of tannic acid and 
chloral. It is a dark-brown powder, soluble in warm 
water and in alcohol, and claimed to be free from any of 
the disagreeable effects of its components. It 
is used in the form of the compound spirit as a. 
hair wash and stimulant to the scalp in cases. 
of excessive dandruff. The formula for the 
compound spirit of captol is: Captol, 2; chloral 

hydrate, 2; tartaric acid, 2; castor oil, 
%f 1; alcohol, 65 per cent., to make 1,000. 
Sy W. A. Bastedo. 


CARABANA MINERAL SPRING, — 
Province of Madrid, Spain. 

Post-OFFICE.—Carabana. 

Access.—From Madrid by rail, a. 
twenty-minute ride. 

This celebrated spring has been in 
active use since 1885. The location is 
in a country broken by sandy hills of 
slight elevation. It is not widely used 
as a resort, although a thermal estab- 
lishment for bathing is maintained 
throughout the year. The location is best. 
visited during the cooler months of the 
year. The water of the Carabafia Spring 
has become widely known for its valuable: 
detergent effects. It has been extensively 
imported into the United States since 
1894. The spring yields about twenty-five hundred 
quarts per day. The water is perfectly transpar- 
ent, has an alkaline reaction, and a specific weight. 
of 1,079 gm. per litre. Careful bacteriological ex- 
aminations, both at the Madrid Academy of Medi- 
cine and at laboratories in Paris, show it to be free: 
from microbic contamination. As an additional 
safeguard, however, the water is filtered by the 
Pasteur method before it is put up in bottles. Ac- 
cording to an analysis made under the direction of the 
Paris Academy of Medicine, the Carabafia water is com-- 
posed as follows: 







ONE UNITED STATES GALLON CONTAINS: * 





Solids.- Grains. 
Sodium sulphate..-.... . 7,012.89 
Magnesium sulphate... 214.10 
Sodium chloride ..... 112, 
Magnesium chloride . sa OAL 
OCalcitim ‘ChIGTIGG 3% .eic'c sic ces cinis\e eieie oloje iste e's oreteee tate 13.76: 
SOMIUM PHOSPN AG ss iejeicyesice’eesle c cveleie'e/cielsie sisiaiaetemneetete 1.47 
ALUMINA, 05 5.0: sanivlasisicroare s wlbleie'’ «lelelele'ya sites sivanieate sente 03 

Total S ircta rote: cre atssere ols, le ofatelstatelal stems ereiviaecnta gc leteht earn 7,387.74 


* Converted from grams per litre. 


These findings represent the anhydrous state of the 
components. With the water of crystallization the 
weight of the solid elements would be rather more than 
twice that here expressed. The analysis shows a very 
powerful mineral water. It may be properly classed as. 
a sodic and magnesic sulphated saline. The large pro- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Captol, 
Carboliec Acid, 





portion of sulphate of sodium combined with the sul- 
phate of magnesium gives the water potent properties as 
a saline cathartic. Given in doses of a claret-glassful 
before breakfast it secures a prompt evacuation of the 
bowels. As a laxative it may be given in somewhat 
smaller dosage, and repeated if necessary. The water 
has found its best application in the various intestinal, 
hepatic, and gastric disturbances in which constipation 
is a cause or a symptom. James K. Crook. 


CARAMECUARO.—Huaniqueo, Michoacan, Mexico. A 
bathing establishment has been constructed at this spring. 
The water is hot, and it is recommended for the treat- 
ment of paludal fevers. No analysis of the water has 
as yet been made. NV. J. Ponce de Léon. 


CARAMEL.—A black, semi-liquid substance, brown 
when diluted, into which sugar is converted by depriving 
it of two molecules of water, through the application of 
a temperature of 400° to 420° F. It is not medicinally 
active, and is used asa coloring agent, chiefly for liquids, 
and especially for brandy and whiskey, also for leather. 

Henry H. Rusby. 


CARAWAY.—Carum. The fruit of Carum Carvi L. 
(fam. Umbellifere). The spelling of the specific name 
“Carvi” is a relic of the use of but one character for both 
our wz and vw. The sound is, therefore, that of wu, from 
which comes the pronunciation caraway. 
This is a biennial herb, with a long, 
brown, tapering, edible root, a slender, 
erect, branching, hollow stem, bi- or 
tri-pinnate leaves, with narrow linear seg- 
ments, and small, compound umbels of 
white flowers. It is a native of North- 
ern and Central Europe and Asia, and is 
cultivated and naturalized in nearly all 
temperate countries. The dried fruits, 
usually separated into their respective 
mericarps, are from 3 to 5 mm. long 
(4 in.), slender, slightly curved, tapering 





Fig. 1115. —Cara- 


way Fruit. En- at each end, and marked with five fine 
— ee yellow ribs, alternating with dark brown 
(Baillon.) * intervening spaces. ‘There is one large 


oil tube between every two adjoining 
external ribs, and two between every two adjoining ven- 
tral ones, six in all. The characteristic odor and taste 
are familiar to nearly every one. The active constituent 
is carvol, which constitutes a large part of its four to 
seven per cent. of volatile oil, and which can advan- 
tageously be substituted for the latter. There is also 
some fixed oil, resin, gum, sugar, and tannin. The stim- 
ulant and carminative properties are those of the family. 
The odor and taste are characteristic, and make of it and 
its oil a favorite flavoring. It is mostly used as an in- 
gredient of bread and cakes. The medicinal dose is .5 
to 2 gm. (gr. viij. to xxx.). It enters into the Compound 
Tincture of Cardamomum, the only official preparation. 

The so-called “Black Caraway,” also largely used by 
German bakers, is not at all related, being the seed of 
Nigella. 

Oil of Caraway (Oleum Carvt).—A volatile oil existing 
in caraway to the extent of from four to seven per cent. 
It has the characteristic odor, taste, and properties of 
caraway. Its specific gravity is .910 to .920 at 15° C. 
It is soluble in an equal volume of alcohol. It consists 
of carvol and dextrogyrate limonene (carvene). The 
dose is TL i. to x., but it is preferable to use carvol. It 
enters into the Spiritus Juniperi Compositus, its only 
official preparation. 

Carvol (C;oH,.90).—A ketone which constitutes the es- 
sential constituent of oil of caraway, and which also 
occurs in oil of dill and oil of spearmint. It is a color- 
less, or pale yellow, transparent liquid, having a specific 
gravity of .960 and boiling at 224° C. One cubic centi- 
metre diluted with the same amount of alcohol should at 
most assume only a slightly reddish or violet tint on the 
addition of a drop of a very dilute solution of ferric chlo- 





ride. It has the odor, taste, and properties of oil of cara- 
way, and is, in addition, quite uniform. It is official 
in the German Pharmacopeeia. The dose, if the prepara- 
tion is pure, is 1-5 minims. Henry H. Rusby. 


CARBOLIC ACID.—Phenie Acid.  Phenylice Aleohol. 
Phenol: CcsH;OH. This important substance, though 
commonly called an acid, is, properly, not an acid at all, 
but a member of the group of phenols, bodies regarded as 
derivates of hydrocarbons of the benzene series by the 
replacement of one or more atoms of hydrogen of the 
principal chain by hydroxyl (OH). In carbolic acid a 
single hydrogen atom of benzene itself is so replaced, so 
that this derivate is the simplest possible phenol in point 
of chemical constitution. Being also the best-known 
member of the group it is chemically entitled phenol, 
simply. Carbolic acid is an ingredient of coal tar, and 
is obtained therefrom. The tar abounds in phenols, and 
by fractional distillation and certain special manipula- 
tions carbolic acid is separable from the other constitu- 
ents in varying degrees of purity. In the markets may 
be found pure carbolic acid, crystalline at ordinary tem- 
peratures, and impure acids of different grades, of which 
the best are crystalline, but the others fluid. These im- 
pure acids consist of carbolic acid (phenol) and the closely 
related phenol “ cresylic acid ” (cresol), and other phenols 
in admixture. The lower grades, indeed, may contain 
but little carbolic acid, but yet are efficient, since the 
other phenols of coal tar possess properties similar to 
those of carbolic acid. These impure carbolic acids are 
often sold under the name of coal-tar creosote, and are 
graded “No. 1” and “No. 2,” according to purity. The 
United States Pharmacopeia recognizes as official pure 
carbolic acid, and an impure article corresponding to the 
“No. 1” of the fluid impure acids of commerce. 

Acidum Carbolicum, Carbolic Acid (U.S. P.). By this 
title is designated the pure article, described as follows: 
“Colorless, interlaced or separate, needle-shaped crys- 
tals, or a white, crystalline mass, sometimes acquiring a 
reddish tint; having a characteristic, somewhat aromatic 
odor, and, when copiously diluted with water, a sweetish 
taste with a slightly burning after-taste. Deliquescent 
on exposure to damp air. Soluble at 15° C. (59° F.), in 
about fifteen parts of water, the solubility varying ac- 
cording to the degree of hydration of the acid. Very 
soluble in alcohol, ether, chloroform, benzol, carbon 
disulphide, glycerine, fixed and volatile oils. Almost in- 
soluble in benzin. When gently heated, carbolic acid 
melts, forming a highly refractive liquid. It is also 
liquefied by the addition of about eight per cent. of 
water. If the acid be liquefied by a gentle heat, and 
then slowly cooled, under constant stirring, until it is 
partly recrystallized, the semi-liquid mass should have 
a temperature (remaining stationary for a short time) not 
lower than 35° C. (95° F.). The acid should have a boil- 
ing point not higher than 188° C. (870.4° F.). A lower 
boiling point, ora higher melting point, indicates a purer 
or less hydrated acid. When heated upon a water bath, 
the acid should be volatilized without leaving a residue. 
The vapor of the acid is inflammable. Carbolic acid is 
faintly acid to litmus paper” (U. 8. P.). 

As regards the color of carbolic acid, the tendency to 
acquire a pink tinge is the stronger the purer and more 
anhydrous the sample (Squibb). Good specimens, there- 
fore, unless recently made, are more likely than not to 
be of pinkish hue. As regards the odor, it is much less 
rank and disagreeable than that of other associated 
phenols, a fact that, apart from other considerations, con- 
stitutes a good reason for selecting a chemically pure 
carbolic acid for surgical use. An absence of creosote- 
like odor is a good practical test of the purity of a given 
sample of carbolic acid. The reaction between carbolic 
acid and water is peculiar. On adding water to carbolic 
acid in small measure, the crystals first liquefy by the 
solution of the water, forming a transparent fluid. The 
proportion of water thus soluble in carbolic acid seems 
to be variable. The pharmacopceial description states 
that the acid “is liquefied by the addition of about eight 


655 


Carboliec Acid, 
Carbolice Acid. 


per cent. of water,” but Squibb has reported samples 
of pure acid dissolving as much as thirty-five per cent. 
of water. These saturated carbolic-acid solutions of 
water are fluid, and are themselves soluble in additional 
water only to a limited extent—between five and six per 
cent., according to the degree of hydration of the sample. 
As regards the melting and boiling points, these are 
affected by the amount of water that a sample may con- 
tain, and perfectly anhydrous commercial samples are 
rare, from two to four per cent. of water almost always 
being present. The congealing point is readily further 
reduced by a small addition of water, such as may easily 
occur through spontaneous deliquescence in a stock bottle 
frequently opened. A sample permanently fluid at or- 
dinary temperatures is therefore not to be regarded as 
in any way inferior. So small an addition as that of 
three percent. of water toa good commercial samplemay 
be enough to determine permanent fluidity. Carbolic 
acid should be kept in well-stoppered bottles, protected 
from the light. 

Besides carbolic acid from coal tar, which alone is offi- 
cial in the United States Pharmacopeia, there is com- 
mercial an article of German manufacture, prepared 
synthetically either from benzene or from a pure aniline 
oil. This synthetic carbolic acid is claimed to be excep- 
tionally pure, but it is more expensive than the ordinary 
coal-tar acid. 

Acidum Carbolicum Crudum, Crude Carbolic Acid (U. 
S. P.). This article is a distillate of dead oil, itself a dis- 
tillate of coal tar taken between certain temperatures (165° 
to 190° C.). It corresponds to what was official in a 
former revision of the Pharmacopeia under the title 7m- 
pure carbolic acid, and to what is sold commercially as 
impure carbolic acid No. 1, and must not be confounded 
with what is commercially known as crude carbolic acid. 
According to Squibb, the products of distillation of 
“dead oil” are as follows: A first immediate distillate, 
which is the crude carbolic acid of commerce; this sub- 
jected to redistillation, yields, as secondary products, a 
first redistillate, highly charged with carbolic acid and 
the source of the purified article, and subsequently a sec- 
ond redistillate, coming over between the temperatures 
of 185° and 195°C., which redistillate, mixed with the 
“uncrystallizable drainings and residues” left over from 
the first after separation of the pure carbolic acid, con- 
stitutes the article under present consideration. It thus 
appears, as Squibb justly points out, that this officially 
so-called crude acid is not such in the proper sense of the 
word, but is properly an ¢mpurve acid. The article is 
thus officially defined and described: “A liquid consist- 
ing of various constituents of coal tar, chiefly cresol and 
phenol, obtained by practical distillation. A nearly col- 
orless, or reddish, or brownish-red liquid, of a strongly 
empyreumatic and creosote-like odor; having a benumb- 
ing, blanching, and caustic effect upon the skin or mucous 
membrane; and gradually turning darker on exposure 
to air and light. The aqueous solution of crude carbolic 
acid has a slightly acid reaction on litmus paper. In an 
aqueous solution of the acid, bromine water produces a 
white precipitate. Crude carbolicacid should not be sol- 
uble in less than fifteen parts of water at 15° C. (59° F-.), 
and the aqueous solution should not have an alkaline 
reaction” (U.S. P.). The tests just mentioned are im- 
portant for the reason that the addition of an alkali to 
crude carbolic acid increases the latter’s solubility in 
water, and hence a frequent adulteration is effected by 
watering the acid with the solvent assistance of an alkali. 
Crude carbolic acid is cheaper than the pure crystalline 
acid, equally, if not even more, efficient as a germicide 
and antiseptic, but is rank and offensive in odor—the 
odor in this case really resembling that of creosote,—and 
is more irritant to animal tissues. 

Besides the foregoing, other grades of so-called impure 
carbolic acid or coal-tar creosote are to be found in the 
markets, which are later redistillates from the commercial 
crude carbolic acid, obtained as the immediate product 
of distillation of dead oil, as already described. These 
second grades of so-called impure carbolic acid consist 


656 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





mainly of cresylic acid (cresol), xylol, and other phenols 
of a higher boiling point than carbolic acid, and contain 
none, indeed, of the latter substance, all the carbolic acid 
of the original crude substance having come over in the 
earlier distillations. These latter distillates, however, 
have germicidal and antiseptic powers similar to those of 
carbolic acid, and, being cheap, may be used effectively 
for the purposes of carbolic acid elsewhere than directly 
upon living tissues. “Impure carbolic acid No. 2” of 
commerce is a fluid, soluble in water to the extent of 
from forty to sixty per cent. (Squibb). 

The effects of carbolic acid and of the other phenols as- 
sociated with it in coal-tar distillates are substantially 
identical, so that a single description will suffice. The 
effects of these substances which the physician needs to 
note may be divided into three categories for practical 
study, as follows: (1) effects upon the vital endowments 
of bacteria and allied organisms; (2) local effects upon 
the tissues of the human body; and (8) constitutional 
effects upon the human system. 

1. Hffects upon the Vital Endowments of Bacteria and 
Allied Organisms.—By immersion in carbolic-acid solu- 
tions microbes may suffer temporary arrest or permanent 
loss of vital activity, the degree of the effect depending 
partly on the strength of the solution and partly on the 
vital tenacity of the particular organism, or even of the 
special stage of being of the organism under observation. 
To determine the exact toxic power of carbolic acid in 
this direction, an enormous number of experiments have 
been made, attacking the problem in a variety of ways.- 
Of the more reliable of these experiments the results sub- 
stantially agree, and these at the present writing justify 
the following broad statements: 1. Rod forms of bacteria 
and allied organisms soaking in aqueous solution of car- 
bolic acid tend to suffer arrest of vital activity when the 
strength of the solution reachesa point between one-fifth 
and one-half of one per cent., and to suffer death when 
the strength rises to one per cent. 2. Spore forms, such 
as the spores of the anthrax bacillus, are much more tena- 
cious of life, requiring for their certain killing a solution 
of from four to five per-cent. strength, and a soakage of 
from two to three days’ duration (Koch). 3. Aqueous 
solutions of carbolic acid are far more toxic to microbes 
than solutions in oil or alcohol (Koch). 4. Exposure to 
vapor of carbolic acid under the conditions obtaining in 
practical disinfection is practically without effect upon 
microbes or disease germs, whether these be in rod form 
or spore form, and whether moist or dry. 

2. Local Kffects upon the Tissues of the Human Body. 
—Prudden* has observed under the microscope the effect 
upon living leucocytes and ciliated cells of soakage in 
carbolic-acid solutions, with the following results: Under 
soakage in solutions ranging between one-thirty-second 
and one-fourth per-cent. strengths, amceboid and ciliary 
movements slow or stop, but resume activity upon with- 
drawal of the carbolized fluid, and its replacement by a 
normal one. Under soakage in solutions of from one to 
five per-cent. strength, however, the bodies under observa- 
tion speedily lose their power of movement, without pos- 
sibility of resumption, and their protoplasm soon suffers 
disintegration. Applied to the human skin, comparatively 
weak solutions, such as the one-and two per-cent. solu- 
tions used in surgery, objectively cause a whitening and 
shrivelling of the cuticle, and subjectively a conjoint 
numbness and prickling sensation, followed, if the appli- 
cation be prolonged beyond a few minutes, by smarting. 
These painful sensations Squibb declares to be aggra- 
vated by elevating, and alleviated by depressing, the af- 
fected part—phenomena contrary to those which usually 
obtain under circumstances of painful irritation. After 
withdrawal of the application the skin gradually resumes 
its normal appearance and tactile sensibility, recovery 
from the numbness, however, being slower than the re- 
turn to natural appearance. Touched with the undiluted - 
acid, the skin immediately whitens, while the circum- 
jacent parts redden by irritation. Sharp pain, passing 


* American Journal of the Medical Sciences, January, 1881. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


over into numbness, is experienced, the pain gradually 
subsiding after an hour’s lapse, and the surface present- 
ing the dry, scaly exudation so often seen on surgeons’ 
hands in the days when operating under a carbolized 
spray was in vogue. The results of a continuous appli- 
cation of the pureacid are exemplified ina case reported, in 
which, through a misunderstanding, a finger was wrapped 
in cloths soaked in undiluted carbolic acid, and kept so 
dressed throughout a night. The next morning the 
dressings were removed, and on the third day, when first 
seen by the reporter, the tissues of the finger were found 
black as jet, hard as wood, wrinkled and shrivelled, cold, 
and absolutely anzesthetic, and with a pronounced line of 
demarcation between the unaffected and the mummified 
portion. Strange to say, however, under careful treat- 
ment the parts recovered. 

3. Constitutional Effects upon the Human System.— 
Carbolic acid is very poisonous to all living things. In 
man, in mild poisoning, such as may follow slight ab- 
sorption from carbolized dressings in surgical cases, the 
symptoms are restlessness and rise of temperature— 
symptoms easily mistaken for those of the very septic 
infection sought to be averted by the use of the acid; or 
in other cases occur headache, loss of appetite, languor, 
and cough, followed, if the poisoning continue, by per- 
sistent bronchial irritation, itching of the skin, dragging 
lumbar pains and asense of heaviness, and want of power 
in the legs. In severer poisoning, such as may occur 
again from absorption from surgical dressings, or as will 
certainly result if any considerable quantity of carbolic 
acid be swallowed, the toxic action falls heavily upon 
the central nervous system. The sufferer passes rapidly 
into a condition of coma, with loss of reflex irritability, 
and occasionally, but exceptionally, with convulsions. 
Convulsions, however, are common in cases of poisoning 
of the lower animals. The breathing is stertorous, the 
heart’s action disordered—pulse at first unduly slow, 
afterward rapid, and, perhaps, intermittent, and the 
arterial pressure diminished. The skin is covered with 
sweat, the lips and hands are livid, and the whole aspect 
is that of great prostration. When the poisoning has 
occurred from swallowing the acid in concentrated con- 
dition, there are added to the above symptoms burning 
pain, extending from mouth to stomach, experienced at 
the moment of swallowing, and nausea and vomiting— 
symptoms due to the local action of the poison upon the 
mucous membrane of the alimentary canal. Carbolic- 
acid poisoning may result in death, which may begin 
either at the heart or at the lungs. In such cases the le- 
sions, apart from the local effects when the strong acid has 
been swallowed, are not characteristic. There is a ten- 
dency to congestion of the great viscera; the blood may 
seem unduly dark and fluid, and there may be some fatty 
degeneration of the liver and kidneys, especially the 
latter, but yet none of these changes are invariable. 

Analysis of carbolic-acid poisoning in man and animals 
points to the following specific derangements as wrought 
by the agent: As regards the nervous system, coma and 
convulsions—the latter phenomenon of spinal origin—and 
modification of reflex activity, such activity being at first 
increased, but, later, lessened and finally abolished. As 
regards the circulation, the heart’s action may at first be 
intensified, but, in the later stages of the poisoning, is al- 
ways enfeebled. Death is frequently by cardiac failure, 
and the heart is commonly found, post mortem, in dias- 
tole, with flabby walls. Similarly the arterial pressure, 
which may be increased in the earlier stages of the poi- 
soning, particularly if convulsions be present, notably 
sinks as the case progresses, apparently through paraly- 
sis of the vaso-motor centre. ~Upon respiration the action 
more commonly than not is opposite at the two extremes 
of the poisoning, the breathing at first being unnaturally 
rapid and shallow, whereas, later, it becomes slow, deep, 
and markedly stertorous. Duly devised experiments 
seem to show that these effects are due to a primary ex- 
citation of both the pneumogastric peripheries and cen- 
tres followed by asecondary paralysis. Body temperature, 
in poisoning in the normal human subject, is variably 


Vou. l,—42 


Carbolic Acid, 
Carbolic Acid, 








affected, in some instances rising, in others falling, and in 
still others remaining unchanged. When, however, car- 
bolic acid is administered to a fevered subject, a consid- 
erable fall of temperature may occur, accompanied by 
sweating. In such case the loss of heat is probably in- 
dependent of any effect in that direction wrought by the 
sweating, since a temperature reduction has been ob- 
served in cases in which all action of the sweat glands 
was held in abeyance by duboisine (Raymond). 

The fate of absorbed carbolic acid is obscure. Some 
of it is undoubtedly excreted, since it has been found by 
a number of observers in the urine, by Hoppe-Seyler in 
the saliva, and is believed by Lemaire to be present in 
the breath. Other portions are probably chemically 
transformed within the system. A result of excretion by 
the kidneys is to produce peculiar coloration of the urine, 
a fact furnishing a valuable clew to diagnosis in obscure 
cases of poisoning. The tint of the urine varies in differ- 
ent cases, in some being brownish, in others greenish- 
black, and in others olive green, turning a smoky black 
upon standing. Such urines may or may not have an 
adventitious odor, aromatic, or even distinctly that of 
carbolic acid. Exceptionally, furthermore, albumin, 
blood, or excess of urates may be present. These altered 
urines probably contain both carbolic acid under its own 
form and some product or products of its chemical trans- 
formation; but what these latter substances may be has 
not yet satisfactorily been determined. 

The therapeutic applications of carbolic acid are utiliza- 
tions of its antiseptic, disinfectant, anesthetic, and antt- 
pyretic powers. As regards the antiseptic use, it is to be 
noted that carbolic acid is decidedly inferior in antiseptic 
power to quite a number of available substances, and 
that for surgical employment it has the positively ob- 
jectionable features of strong odor, disagreeable action 
upon the skin, and capability of absorption to the point 
of producing dangerous and even fatal constitutional 
poisoning. For surgical purposes aqueous solutions are 
commonly employed, of strengths ranging from one to 
five per cent., the weaker for dressings to remain in con- 
tact with tissue, the stronger for occasional use or to 
disinfect hands, instruments, ligatures, etc. As a disin- 
Jectant, carbolic acid operates, of course, exclusively by 
its germicidal action, thus holding in abeyance or de- 
stroying, according to strength of application, the septic 
or infective activity that inheres in certain living proto- 
plasms. For certainty of disinfection, as has been seen 
already, actual soakage of the culprit germ in a carbolic 
solution of at least two-per-cent. strength is essential. 
Dainty sprinklings of carbolic lotions are therefore futile, 
and the hanging about a chamber of carbolized cloths 
with a view to aérial disinfection by the fumes there- 
from is but a noisome advertisement of ignorance or 
stupidity. Legitimately and thoroughly used, a two- 
per-cent. solution of carbolic acid is an efficient disinfect- 
ant, with the advantage of cheapness—the impure grades 
of the acid being for this purpose even more powerful 
than the pure—but with the ever-present disadvantage 
of a rank and even offensive odor. A solution of two- 
per-cent. strength does not injure textile fabrics. Car- 
bolic acid has been given internally in the hope that the 
power which proves germicidal without the body will 
oppose within the system the career of so-called zymotic 
diseases. But theoretically, for this purpose, if we are 
to argue from the point of view of germicide action, the 
blood of the subject should be charged with at least one 
per cent. of carbolic acid, a condition involving a dosage 
overwhelmingly poisonous; and practically, the use of 
the remedy in the category of diseases referred to has 
been, so far, barren of important results. The anesthetic 
action of carbolic acid is most strikingly utilizable for 
the relief of the pain of burns, for which purpose noth- 
ing is better than one-half or one per-cent. aqueous solu- 
tion of carbolic acid applied on thin cloths—the cheap 
“crude” acid being here more effective than the pure 
(Squibb). Similar lotions may palliate also the itching 
and burning of skin disease or the irritation from catarrhs 
of mucous membranes. Thus in bronchitis the inhala- 


657 


Carboliec Acid. 
Carbon, 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





tion of the fumes of a bowl of boiling water charged 
with a few drops of carbolic acid may allay pain and 
cough considerably. So, again, irritability of the stom- 
ach may be quieted by this agent, and carbolic acid in 
small doses ranks among the standard means for arrest 
of vomiting. As an antipyretic carbolic acid is undoubt- 
edly powerful, but its poisonousness will probably always 
defeat it in competition with such potent and at the same 
time innocent antipyretics as sodium salicylate, the cin- 
chona alkaloids, antipyrin, etc. 

For internal administration the dose of carbolic acid 
should not exceed from one to four or five drops, and the 
daily allowance should not surpass 1 gm. (gr. Xv. or Tl 
xv.). A convenient way of giving is first to dissolve in 
glycerine, in which menstruum carbolic acid dissolves in 
all proportions, and then dilute the necessary quantity 
of glycerine solution with water. Each dose of acid 
should be diluted to at least the volume of a tablespoon- 
ful for the taking. Under the title, Glycerttum Acidi 
Carbolici, Glycerite of Carbolic Acid, the United States 
Pharmacopeeia makes official a twenty-per-cent. (by 
weight) solution of the acid in glycerine. 

For earternal uses aqueous solutions are most generally 
serviceable, as already so frequently seen. There is 
official in the United States Pharmacopeeia a prepara- 
tion entitled Unguentum Acidi Carbolici, Ointment of 
Carbolic Acid, which consists of official “ointment” 
charged with five per cent. of carbolic acid. 

Edward Curtis. 


CARBOLIC ACID, POISONING BY.—Carbolic acid or 
phenol is one of the most common materials used for sui- 
cidal purposes at the present time. This is especially to 
be wondered at because of its corrosive action and the 
consequent pain it causes. It is, however, easily obtain- 
able without the need of a prescription, and it does its 
work with certainty and generally with despatch. 

Carbolic acid is a name that was given to the substance 
obtained from coal tar on account of its corrosive action 
and because it readily combined with certain basic sub- 
stances to produce so-called carbolates. In its chemical 
relations, however, it has been shown to be closely allied 
to a class of compounds of the fatty-acid series known as 
tertiary alcohols, or, in the case of the aromatic or cyclic 
compounds, as phenols. It seems to unite chemically 
with a few bases, making compounds known as carbo- 
lates in which it acts like an acid. It also unites with 
acids, especially sulphuric acid, and forms salts in which 
it acts like an organic base. 

Phenol is met with in commerce in a number of forms. 
First, as crude carbolic acid used as a disinfectant and 
germicide, ‘This preparation is reddish or dark brown, 
and contains not only phenol but one or more higher 
homologues knownascresols. It has an odor like smoke 
and a strongly caustic and biting action on the skin. 
Secondly, as the carbolic acid or phenol of the United 
States Pharmacopceia, consisting of a mass of interlaced 
crystals, white or slightly reddish in color. These crys- 
tals are deliquescent on exposure to moist air. This 
phenol melts readily to a clear, oily liquid, and as it cools 
again becomes once more a crystalline mass. The addi- 
tion of eight per cent. of water to the melted liquid pre- 
vents its solidifying on cooling. It dissolves in about fif- 
teen parts of water, and also dissolves readily in alcohol, 
ether, chloroform, benzole, carbon bisulphide, glycerin, 
and fixed and volatile oils. Thirdly, a solution of the 
crystals more or less strong kept in every pharmacy as a 
stock material for prescription use. Fourthly, a mixture 
of phenol with lard and yellow wax known as Unguen- 
tum Acidi Carbolici (U.S. P.). 

All these forms of phenol are intensely corrosive and 
deadly in their action. On the skin the strong phenol 
causes a numbness and sense of irritation or burning. 
The surface of the skin becomes white, the cuticle after 
a time falling off and leaving a dark stain. At times the 
sensibility of the skin is nearly destroyed by contact with 
the acid, a sense of numbness only being noticed. 

A number of fatal cases of poisoning have occurred in 


658 





which phenol has either been applied to the surface 
of the unbroken skin or to a mucous membrane, or has 
been used as an antiseptic material in treating wounds. 
In these cases of direct absorption the action of the phenol 
has been very rapid, producing sudden insensibility. 

When swallowed there is at once a hot, burning sensa- 
tion in the mouth, throat, and stomach. The lining 
membrane of the mouth is whitened by the contact of 
the phenol, while the lips are usually more or less brown 
where the liquid has come in contact with them. 

The skin is dry and livid, the pulse is feeble, the pupils 
very much contracted, the breathing noisy, and the 
breath smells more or less strongly of the poison. Cases 
are on record, however, in which the odor has been en- 
tirely absent from the breath. At times vomiting occurs. 
There are usually delirium and giddiness, passing soon 
into a condition of insensibility. The urine, if any, is 
dark colored and cloudy. 

Death usually occurs within a few hours, and in some 
instances has occurred within a few minutes. 

The amount necessary to cause death isunknown. As 
with many other poisons, recovery has taken place after 
a large quantity has been swallowed and death has fol- 
lowed the ingestion of a few drops only. 

The Treatment consists in the use of the stomach 
pump, the administration of saccharate of lime and of 
soluble sulphates, and, recently, very excellent results 
have been obtained by the use of strong alcohol after the 
stomach pump has taken out the most of the poison. A1- 
cohol has proved useful also to check the action of the 
poison when applied to the skin. Stimulants are to be 
used to combat symptoms of collapse. 

In fatal cases the lips where the phenol has come in 
contact with them are stained brown, the mucous mem- 
brane of the mouth is dirty white or brown; the stomach. 
is contracted, and its mucous membrane in folds and 
white in some places, and in some spots greatly inflamed. 
The odor of phenol is generally noticeable on opening 
the stomach. The brain, lungs, liver, and kidneys usu- 
ally show marks of congestion. The left ventricle of the 
heart is usually contracted, while the right is flaccid. 
The blood throughout the body is dark-colored and fluid. 
When phenol is absorbed by the skin there are no char- 
acteristic internal post-mortem changes. 

The odor of phenol gives the best indication of its 
presence, but chemical tests in addition should be made 
to make the identification certain. To this end the mate- 
rial for examination is made acid with sulphuric acid and 
distilled. The distillate may or may not give the odor 
of phenol. 

In a portion of the distillate place a splinter of pine 
wood, and on removal from the distillate moisten the 
splinter with hydrochloric acid. If phenol is present the 
splinter will turn blue or green. This test should be 
corroborated by a known solution of phenol. 

Toasmall portion of the distillate add about one-fourth 
its volume of ammonium hydrate and then a small quan- 
tity of a solution of calcium hypochlorite. A blue color 
appears at once or on standing for a time in the presence 
of phenol. 

To a portion of the distillate add bromine. If phenol 
be present a white precipitate of bromo-phenol is formed. 
This may be further tested, after it has been thoroughly 
washed, by treating it with sodium amalgam (prepared 
by dissolving sodium in mercury), and then making the 
solution acid. If phenol be present the characteristic 
odor of phenol will be developed. Herbert M. Hill. 


CARBON DISULPHIDE.—Cs,. This body, commonly 
called by the older chemical title b¢sulphide of carbon, is 
official in the United States Pharmacopeeia as Carbonet 
Disulphidum, Carbon Disulphide. It is thus described: 
“A clear, colorless, highly refractive liquid, very diffu- 
sive, having a strong, characteristic, but not fetid, odor, 
and a sharp, aromatic taste. Soluble in 535 parts of 
water at 15° C. (59° F.); very soluble in alcohol, ether, 
chloroform, fixed and volatile oils. Specific gravity, 
1.268 to 1.269, at 15° C. (59° F.). Carbon disulphide va- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


¢ 


Carbolic Acid. 
Carbon, 





porizes rapidly at the ordinary temperature, is highly 
inflammable, boils at 46°-47° C. (114.8°-116.6° F.), and, 
when ignited, burns with a blue flame, producing carbon 
and sulphur dioxide. It should not affect the color of 
blue litmus paper moistened with water” (U.S. P.). 
Carbon disulphide should be kept in tightly closed ves- 
sels and away from lights or fire. The “strong charac- 
teristic, but not fetid, odor” of the above description, 
though “not fetid” in a perfectly pure sample, is, in the 
article as commonly met with in the shops, of a rotten- 
egg quality, so disagreeable and so strong as to constitute 
a practical bar toa common medicinal use of the com- 
pound. The high volatility and extreme inflammability 
are also points of inconvenience, and the latter quality 
one of danger also. 

Carbon disulphide is a powerful agent, of the general 
type of the volatile alcohols and ethers. It is locally irri- 
tant while yet specifically anesthetic, and, absorbed into 
the blood, profoundly deranges the nervous functions in 
the same general manner as chloroform does. Habitual- 
ly absorbed, as may occur by breathing the fumes in india- 
rubber factories, where the agent is largely used, carbon 
disulphide produces a peculiar form of chronic poisoning, 
elaborately described by Delpech as observed in Paris 
workshops. The poisoning commonly begins by severe 
headache, sometimes accompanied by an exhilarant in- 
toxication. Later follow depression, mental apathy and 
dulness, loss of memory, impairment of sight, hearing, 
and sexual desire, and a very pronounced loss of muscu- 
lar power. Cramps and various dysesthesiz are also 
common. The poisoning is seldom fatal, but, on the 
other hand, after full development, entire recovery of 
health and strength is unusual. Treatment is upon gen- 
eral principles, the only special agent recommended being 
phosphorus, by the use of which in small doses Delpech 
thinks he has abated the failure of muscular and virile 
power. 

Medicinally the only properly allowable use of carbon 
disulphide is as a local application for the relief of sur- 
face pains. In thisemployment the action is like that of 
chloroform—conjointly anesthetic and sharply irritant. 
An application of carbon disulphide causes for a few 
minutes severe pain, and may or may not be followed by 
subsidence of a neuralgia. The remedy may be used in 
vapor by saturating with carbon disulphide a sponge at 
the bottom of a wide-mouthed flask, and then pressing 
the mouth of the flask to the skin. Carbon disulphide 
has been given internally in doses of a few drops, but in 
the absence of any unique therapeutic powers such ad- 
ministration is certainly not to be recommended. 

Edward Curtis. 


CARBON, HYDRIDES AND OXIDES OF.—There are 
two well-known oxides of carbon, viz., carbon monoxide 
and carbon dioxide, or carbonic anhydride. They are 
both invisible gases at ordinary temperatures and _ press- 
ures; and are of interest to the physician from the fact 
that they are both irrespirable gases with which persons 
are frequently brought in contact, and which frequently 
produce poisonous and even fatal results. Carbon diox- 
ide plays an important rdle in the physiology of the hu- 
man organism. The names used to designate these com- 
pounds are somewhat variable and confusing, and, to 
avoid this uncertainty, we place all the names commonly 
met with at the head of the proper sections. 

Carson DroxmpEe.—Also called curbonic-acid gas and 
carbonic anhydride. (Fixed air, choke damp.) Chemical 
formula, CO,. Specific gravity (air=1), 1.52; density 
(hydrogen =1), 22. 

Sources.—When carbon is burned in oxygen, or with a 
free supply of air, this gas is formed; hence it is a prod- 
uct of the combustion of all combustible bodies contain- 
ing carbon. It is prepared in large quantities, by many 
manufacturing processes, from the combustion of coal. 
The burning of lime kilns sends large volumes of this 
gas into the air, partly from the fire and partly from de- 
composition of the limestone (CaCO;) into lime and COs. 
Respiration is another source of the gas, and the expired 








air may accumulate in a tight room to such an extent as 
to become poisonous,—indeed, in some cases, to such 
an extent as to cause death. An adult man exhales 
about .7 cubic foot (20 litres) of CO, per hour, or 18 
cubic feet (499 litres) per day. Another source of car- 
bon dioxide is the alcoholic fermentation of saccharine 
fluids. This source is usually limited to certain kinds 
of industries, such as beer, wine, alcohol, and whiskey 
manufactories. In badly ventilated fermenting rooms, 
deaths have often occurred from the accumulation 
of this gas. The subterranean heat of volcanic regions 
causes the decomposition of limestone as above men- 
tioned, giving off CO., which either escapes through 
crevices, or accumulates in underground caverns, under 
pressure, and finally becomes absorbed by the water, 
and comes to the surface in the form of effervescing 
spring-water, as at the well-known Saratoga Springs. 
The gradual oxidation of vegetable matters, either upon 
the surface of the soil or buried in it, generates a con- 
siderable quantity of carbon dioxide. The gas from 
these various sources may filter through the soil, crevices 
in the rock, or coal bed, and accumulate in mines, wells, 
cellars, etc., in such quantities that the miners are un- 
able to work in it. It is called by them choke damp, to 
distinguish it from fire damp. It is produced in mines 
by an explosion of marsh gas (fire damp), so that if the 
explosion does not kill persons unfortunate enough to 
be in the mine at the time, they may die from breathing 
the CO, developed by the explosion. The atmosphere, 
as will be seen, is continually receiving this gas in abun- 
dance from the above sources; hence, outdoor air always 
contains about .4 part per 1,000. The air of rooms and 
closed places frequently contains a much larger propor- 
tion than this. A well-ventilated room should contain 
not more than .6 part per 1,000; but owing to poor ven- 
tilation it frequently rises as high as 4 parts per 1,000 or 
more. Even in the open air, the amount depends some- 
what upon the state of the weather, season of the year, 
etc. In still, foggy weather in large cities, the amount 
present in outdoor air may rise as high as .8 part per 
1,000, or enough to give the air a peculiarly suffocating 
effect upon those who breathe it. 

Properties and Preparation.—Carbon dioxide is a color- 
less, transparent, odorless gas, about one and a half times 
heavier than air, and may be poured from one vessel into 
another like water. It hasa faintly acid taste. At ordi- 
nary temperatures it is soluble in its own volume of 
water, with which it probably enters into combination 
to form carbonic acid: CO, + H:,0 = H.CO;. By increas- 
ing the pressure, water will absorb a very large amount 
of the gas, a large portion of which escapes again when 
the pressure is removed. The so-called plain soda is a 
strong solution of carbonic acid (H,COs;) in water, made 
under pressure. The gas may be expelled by heat, by 
freezing, or by removing the pressure. Under a press- 
ure of fifty atmospheres at 15° C. (59° F.), it is con- 
densed to a transparent, colorless, mobile liquid, not 
miscible with water or fixed oils, but readily so with 
ether, alcohol, naphtha, turpentine, and carbon disul- 
phide. When the pressure is removed from the liquid 
it evaporates with great rapidity, freezing a portion of 
the liquid into a snow-like solid, by the heat absorbed in 
the evaporation. The solid evaporates very slowly, and 
may be kept longer than the liquid. By moistening this 
solid-with ether, and placing it under the bell-jar of an 
air pump, a temperature of —110° C. (—166° F.) may be 
obtained. Carbon dioxide is soluble in about one-third its 
own volume of alcohol at the ordinary temperature and 
pressure. Dry carbon dioxide has no effect upon litmus 
paper; but if the latter be first moistened it is reddened. 
On drying, the blue color is restored. Lime water is 
at first rendered turbid by COs, owing to the precipi- 
tation of calcium carbonate; but on conducting the gas 
into the turbid liquid for some minutes, the precipitate 
is redissolved, and the solution becomes clear again, 
owing to the formation of calcium bicarbonate (H:Ca 
(COs)z. This process frequently takes place in natural 
waters to produce temporary hardness, so called, because 


659 


Carbon, 
Carbon, 


the calcium, and at times magnesium carbonate thus 
held in solution, is precipitated by boiling off the excess 
of carbon dioxide. Solutions of caustic soda, potash, 
lime, baryta, ete., rapidly absorb CO, with the forma- 
tion of carbonates of the metals. Such solutions are 
used to dissolve the gas from mixtures containing it. 
The gas does not support either respiration or combus- 
tion, although this property is not peculiar to carbon 
dioxide. It is not combustible. Sodium, potassium, 
phosphorus, boron, carbon, iron, zinc, and magnesium, 
at high temperatures, decompose it by removing its oxy- 
gen and converting it into either carbon monoxide or 
carbon. It is also decomposed by the chlorophyl of 
plants under the influence of sunlight and moisture, the 
carbon combining directly with the water to form formal- 
dehyde, CO.-+ H.O = CH.O-+ O2, while the oxygen 
escapes in the free condition. The formaldehyde then 
readily polymerizes to form dextrose and the other solu- 
ble carbohydrates: 6 CH,O = C.Hi205. Carbon dioxide 
is usually prepared in the laboratory by treating a car- 
bonate, usually calcium carbonate or marble, with a 
dilute mineral acid: CaCO; + 2HCl =CaCl, +H20-+COs. 

Uses.—The following are among the most important 
uses of carbon dioxide: Notably, in the manufacture of 
carbonates and bicarbonates, carbonated beverages, white 
lead, the decomposition of sucrate of lime in the prepa- 
ration of sugar from beets, in setting free the hypochlo- 
rites from chloride of lime, in bleaching, and in giving a 
bead to beer, ale, wine, etc. 

Phystological Action.—The physiological effects of car- 
bon dioxide vary with the degree of dilution or admixture 
with air. When inhaled in the pure state it causes almost 
instant death from spasm of the glottisand apnea. Even 
when somewhat diluted, there is almost immediate in- 
sensibility and loss of muscular power, and the person 
drops as if felled by a blow, and usually dies without a 
struggle, unless immediately removed into pure air. 
Such accidents are most likely to occur from going into 
deep wells, caves, mines, etc., where the gas, termed 
choke damp by miners and well-diggers, has accumulated ; 
or, from putting the head into a fermenting vat which 
has been closed for a time; or from venturing too near 
to the mouth of a lime kiln, burning buildings, or vol- 
canoes. 

When more largely diluted, or, as is most likely to occur, 
when the air is gradually poisoned by it, the first feeling 
is a sense of closeness; then follow weight or fulness in 
the head, pressure in the temples, giddiness, singing in 
the ears, somnolency, sometimes nausea and loss of mus- 
cular power. Death is preceded by coma, with stertorous 
breathing, rarely vomiting and convulsions; the face is 
usually of a leaden hue, or pale, and the heart’s action, 
at first violent, finally stops. It is not poisonous when 
taken into the stomach. 

Post-Mortem Appearances.—The body of a person killed 
by carbon dioxide usually presents a livid, or very pale, 
externalappearance. The face hassometimes been found 
swollen and distorted, but usually it is placid and there 
is no evidence of a struggle. The body is found in an 
easy, natural position, as though in asleep at the time 
of death. The superficial veins are usually prominent, 
and are filled with dark liquid blood. There is nearly 
always congestion of the brain and its membranes, with 
engorgement of the sinuses, and congestion of the lungs. 
The blood is usually liquid and dark-colored. When the 
source of the poisonous gas is from burning coals, the 
carbon dioxide is mixed with carbon monoxide, and the 
blood in this case is bright red instead of dark, and coag- 
ulates with difficulty. Putrefaction of the body after 
carbon-dioxide poisoning takes place slowly, and bodily 
heat and rigidity are retained an unusually long time. 
All the internal viscera are usually found congested. 

Injurious (Non-Fatal) Effects of the Presence of Carbon 
Dioxide in the Air of Rooms.—Thus far we have dis- 
cussed the action of carbon dioxide upon the economy 
when present in the air in sufficient quantity to cause 
death. When the air is not so largely charged with 
this gas, the symptoms and effects are less marked, 


660 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


but may still be sufficient to occasion some distress. 
When the air of a given room or locality contains more 
than 6 or 7 parts per 10,000, it is to be considered 
contaminated or impure. An adult man exhales about 
.7 cubic foot (19 litres) of carbon dioxide each hour. 
This quantity will raise the contents of 3,500 cubic feet 
of air from .4 to .6 part per 1,000 each hour. It is evi- 
dent, therefore, that this amount of air must be supplied 
to each adult man each hour, in order to keep the air he 
breathes from having more than .6 part per 1,000, or so 
as not to add more than .2 part per 1,000. It has also 
been found that the air of a room cannot be changed 
more than three or four times per hour without causing 
draughts. Hence (3,500 + 4 = 875) an adult man should 
have about 900 cubic feet of space for comfort, when 
proper care is had to ventilation. When air moves more 
than 19 inches per second a draught is perceived. If there 
were no ventilation through walls, which is rarely the 
case, an open window, having an opening of 6 square 
feet, would allow 3,420 cubic feet of air to pass, when 
the draught is barely perceptible; or enough fora healthy 
adult man. Parkes, in his “Hygiene,” p. 161 (Wood’s 
Library), gives the following figures as representing the 
average amounts of CO, given off per hour by persons 
of different ages when ina state of repose. For adult 
males (say 160 pounds), .7 cubic foot; for adult fe- 
males (say 120 pounds), .6 cubic foot; for children (80 
pounds), .4 cubic foot; for a mixed community, .6 cubic 
foot. Under these conditions the amount of fresh air to 
be supplied in health, during repose, ought to be: For 
adult males, 3,500 cubic feet; for adult females, 3,000 
cubic feet; for children, 2,000; for a mixed community, 
3,000 cubic feet, per head, per hour. As more CO, is 
evolved from the body on exertion, these figures are too 
low for workshops, factories, mines, ete. In mines it has 
been found that 6,000 cubic feet of air per hour is neces- 
sary to keep up the greatest energies of the men. With 
light work a man weighing 160 pounds throws off .95 
cubic foot of CO, in one hour, while in heavy work the 
same man would throw off 1.96 cubic feet per hour. 
This would require for light work the delivery of 4,750 
cubic feet of fresh air per hour, and for heavy work, 
9,800 cubic feet. The amount of airnecessary for cattle, 
horses, and other large animals, is estimated by Marcker 
(“Proceedings of Civil Engineers,” vol. xii., pp. 298 and 
308) as 1 to 1.5 cubic feet per hour for every pound of 
weight, or 1,000 to 1,500 cubic feet for every 1,000 pounds 
of weight. For small animals (sheep, dogs, cats, etc.), 
150 to 180 cubic feet of air per hour should be supplied 
for each 100 pounds weight. Birds require even more. 
The following table, from Parkes’ “Hygiene,” shows 
the amount of contamination produced by one man in 
different-sized spaces for one hour and each succeeding 
hour: 


TABLE TO SHOW THE DEGREE OF CONTAMINATION OF THE AIR BY 
RESPIRATION (IN TERMS OF COg), AND AMOUNT OF AIR NECES- 
SARY TO DILUTE TO A GIVEN STANDARD OF .2 PER 1,000 VOL- 
UMES, EXCLUSIVE OF THE AMOUNT ORIGINALLY PRESENT IN 
THE AIR. 








Amount of cu-|Ratio per 1,000 of/Amount of air/Amount neces- 
bic space (=| CO, from respira-| necessary to} sary to dilute 
breathing| tionat theend of| dilute to} to the given 
space) for one| one hour,if there} standard of| standard 
man in cubic] has been no| .2 during the} every hour 





feet. change of air. first hour. after the first. 

100 ; 6. 2,900 3,000 
200 3.00 2,800 3,000 
300 2.00 2,700 38,000 
400 1.50 2,600 38,000 
500 1.20 2,500 3,000 
600 1.00 2,400 3,000 
700 .86 2,300 3,000 
800 15 2,200 3,000 
900 67 2,100 38,000 

2,000 3,000 


1,000 -60 


In hospital wards, where sick persons are confined, 
ventilation should supply more air than is required by 
the healthy. This is due not alone to the CO, which 


a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


they give off, but to organic emanations which permeate 
the air and give it an unpleasant odor and closeness. In 
hospital wards, Parkes lays down therule that the quan- 
tity of air supplied should be from 4,000 to 4,500 cubic 
feet per person each hour. The following table from 
Witthaus’ “Chemistry ” gives the amount of air which 
ought to be supplied to each person under the conditions 
annexed: 





Situation. Cubic metres. Cubic feet. 
ATTACK SCARY -OLING) ca'ee sree sie cree va /sis'owleslee 35 1,236 
IBAPPACKSIAMIONt-tIMNG)iocccsciciece see cece ccee 2,472 
Workshops (mechanical) 2,472 
RBCHOOITOOMS ccs cccccscecvee 1,236 
Hospital wards...........+. PAA 3,004 
Hospital wards (surgical) ; 6,004 
Contagious and lying-in wards ............ 170 6,004 

IIe ee ent aictee cies nie'ee Cinine Gabe oo eevee 150 5,297 
MEISIORELCOBL ticles cisveleg sls evsvle'sclerera tiercarne sie 170 6,004 


This table assumes that no artificial light is used; but 
even in this case, the quantities given are smaller than 
most physicians would prefer to supply. No hospital 
ward occupied by a number of persons should supply 
less than 4,500 or 5,000 cubic feet of air, per person, every 
hour, and in the case of most septic diseases, outdoor 
air is to be preferred. 

Carbon Dioxide from Gas-Lights.—A burner which burns 
3 feet of gas per hour (ordinary size) produces about 2 
cubic feet of CO. per hour, and removes a corresponding 
amount of oxygen from the air. It has been calculated 
that each burner of the usual form (not Argand) should 
be supplied with from 4,500 to 5,500 cubic feet of air per 
hour to prevent injurious contamination with CO,. Ow- 
ing, however, to the evolution of heat and watery vapor, 
and the removal of oxygen, a larger quantity than this 
should be supplied to keep the aircomfortable. A cubic 
foot of coal gas produces about from .5 to .8 cubic foot 
of COs, being rather higher for “water gas” than for 
“coal gas.” A burner consuming 3 feet of gas per hour 
would produce from 1.5 to 2.5 cubic feet of CO:, being 
a little more than three adult men, or four average per- 
sons, would produce. Pettenkofer has determined that 
a burner consuming 5 feet of gas per hour, giving 12 
candle power, gives off as much heat as 8 men, more CO, 
than 3 men, and as much watery vapor as5men. Adopt- 
ing this as a basis of calculation, a 3-foot burner should 
be supplied withas much air as 3 persons, or about 9,000 
feet per hour, to keep the air in a comfortable condition. 
In reality, this amount of ventilation is seldom obtained 
in a room of ordinary size. The basis of calculation that 
has usually been adopted is to furnish 1,800 cubic feet of 
air for each foot of gas burned. For the same illuminat- 
ing power, oil does not give a greater degree of contam- 
ination than gas. An ordinary lamp gives about the 
same contamination to the air of a roomas one adult man. 

Tests for Carbon Dioxide.—The physician may be called 
upon to test the air of rooms, or enclosed spaces, for COs, 
either for diagnostic or for medico-legal purposes. The 
following simple tests may be employed: A moistened, 
blue litmus paper suspended in the air of the room is at 
first reddened and then bleached by carbon dioxide. If 
the amount of CO, exceed ten or twelve per cent., and 
if it have been added to the air, without the removal of 
any oxygen, a candle will usually be extinguished. If 
the CO, has been produced by combustion or respira- 
tion, the candle will be extinguished by five per cent. 
An atmosphere in which a candle will burn may be fatal 
to animals or man. Lime water or barium hydroxide 
(baryta water) is rapidly rendered turbid on pouring it 
from one vessel into another in an atmosphere rich in 
CO.. A piece of filter paper dipped in lime water col- 
ored red with phenolphthalein is bleached white by COsz, 
the rapidity of the bleaching depending upon the amount 
contained in the air. Or the same colored solution may 
be poured into a bottle filled with the air of the space as 
follows: Fill a quart bottle with water, and pour it out 
slowly in the room whose air is to be tested, or, better, 
siphon it out, using a piece of rubber tubing as a siphon. 
One cubic centimetre of thoroughly saturated lime water, 
colored pink with phenolphthalein, should be decolorized 


Carbon, 
Carbon, 





by 1.6 litre (1.6 quart) of outdoor air, or one quart 
(roughly) of ordinary indoor air. The air of a room 
should not decolorize more than 1 ¢.c. for each quart. 
The 1 c.c. (™ xv.) of colored lime water may be diluted 
to 15 c.c. (3 ss). with distilled water and poured into a 
quart bottle of the air, and shaken up. If the color be 
discharged, add .5 c.c., and so on until a permanent color 
remains after ten minutes’ shaking. Where proper ap- 
pliances are at hand, it will be much more accurate to 
use the following method :— 

Pettenkofer’s Method for Estimating CO, in Air.—A 
glass globe or bottle holding about 4 litres is carefully 
measured by filling it with water and then pouring the 
water out into a suitable graduated measure. The bottle 
is now filled by an air bellows with the air to be tested. 
Twenty-five cubic centimetres of barium hydroxide solu- 
tion of known strength, in comparison with a ,x, oxalic- 
acid solution, are added, and the bottle is tightly corked 
and allowed to stand for a half-hour, with occasional 
shaking. At theend of this time the stopperis removed, 
a few drops of phenolphthalein solution added, and the ,, 
oxalic acid run in from a burette until the pink color is just 
discharged. The oxalic acid combines with the unused 
BaO.He, but does not decompose the barium carbonate 
formed by the CO, of the contained air. If the number 
of cubic centimetres of acid required to neutralize 25 c.c. 
of the barium hydroxide solution put into the bottle be 
known, or determined by a separate titration, the differ- 
ence between this number and the number of cubic centi- 
metres used in neutralizing the residual BaO.H., will 
represent the acid equivalent of the CO, in the air con- 
tained in the bottle, expressed in cubic centimetres of ,%, 
acid. 

If we make the oxalic-acid solution by dissolving .2863 
gm. of the pure crystalline acid in a litre of water, each 
cubic centimetre will represent 1 mgm. of CO,. The 
volume of 1 mgm. of COz at 15° C. (59° F.) at the average 
air pressure, is .5386c.c. At 17° C. (62.6° F.)the volume 
is .544c.c. At 20° C. (68° F.) it is 546 c.c. At 22° C. 
(71.6° F.) itis .549. By means of these figures the volume 
of the CO, found may easily be calculated by multiply- 
ing the number of cubic centimetres of acid corresponding 
to the loss of saturating power of the BaO.H, solution, 
by the volume of 1 mgm. of CO, at the temperature of 
the room when the sample was taken. From the volume 
thus obtained it is easy to calculate the relation of this to 
the airtaken. Suppose, for example, that the bottle con- 
tains 4,500 c.c. when full. After adding the 25 c.c. of 
barium hydroxide it would contain 4,475 c.c. Assume, 
also, that the temperature of the room at the time of fill- 
ing the bottle is 22° C., or 71.6° F., and that the titration 
of the residual BaO.H, in the bottle required 14 c.c. of 
the oxalic acid. Suppose, further, that 25 c.c. of the 
BaO.Hz solution requires 22 ¢c.c. ofthe acid. Then 22 — 
14 = 8c.c., the acid equivalent of the CO, in the contained 
air, and its weight =8 mgm. At 22° C. the volume of 8 
mgm. of COz is .549 K 8 = 4.392 c.c. 

Then 4475 : 4.392: : 1,000 : 2 = .986 part of COz in 1,000 
parts of air. 

Carponic Acrip (H2CO;) exists only insolution. It has 
not yet been isolated. Whenan attempt is made to con- 
centrate it, the acid breaks up into water and carbonic 
anhydride (CO), which escapes with effervescence. The 
salts of the acid, the carbonates and acid carbonates 
(bicarbonates) are well known. Carbonicacid is a feeble 
acid, and is expelled from its salts by most strong acids. 
The carbonates all effervesce when treated with the min- 
eral acids, and this serves as a ready test. Some of the 
metals are dissolved by this acid, but with great slow- 
ness. Copper and lead are corroded by it, and hence 
these metals may contaminate “soda water,” beer, etc., 
drawn through pipes composed of these metals. 

CARBON MonoxipE.—Carbonous Oxide, Carbonic Oxide 
(CO). This gas was discovered in 1799 by Priestley. It 
is always formed when carbon, or combustibles contain- 
ing carbon, are burned with an insufficient supply of air. 


- It does not occur free in nature except as the result of 


certain manufacturing processes. It is produced by the 


661 


‘Carbon, 
Carbon, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





heating of coal with certain ores, such as those of iron 
and zinc. It is always prepared in an ordinary coal fire. 
The air entering through the grate produces at first COs, 
which, on coming in contact with the glowing coals above, 
is reduced to this lower oxide: 2CO,.-+ C, =4CO. 

This gas is the one which is frequently seen burning 
with a blue flickering flame at the surface of the coals in 
an open grate fire. The gas may be prepared for experi- 
mental purposes by passing carbon dioxide through an 
iron tube loosely filled with charcoal, heated to redness, 
or by heating in a flask a mixture of oxalic and suphuric 
acids. In the last method the gas is mixed with an equal 
volume of CO., which may be absorbed by passing it 
through wash bottles containing milk of lime. 

Properties.—Carbon monoxide is a colorless,. transpar- 
ent, odorless, tasteless gas, which may be liquefied by a 






Paw) 


w 


| 
a 
Be 


Fig. 1116.—1, Absorption bands of oxyhzeemoglobin (Hoppe); 2, absorption bands of CO hemoglobin, 
The same appearance is seen in the blood of 
3, absorption band of reduced hemoglobin, 
1.€., itis No. 1, with a drop of ammonium sulphide added (Hoppe); 4 and 5, the same as Nos. 


showing displacement of the bands (Hoppe). 
persons poisoned by charcoal fumes or coal gas. 


1 and 3, according to Hensen. 


pressure of 35.5 atmospheres at —139° C. (—282° F.), or 
at ordinary pressures at a temperature of —190° C. (—374° 
F 


The density of the gas is 14 (H=1), and the specific 
gravity, .9678 (air =1), or nearly that of air. 

It is but slightly soluble in water or alcohol. It dis- 
solves in hot caustic potash (KOH) solutions, with the 
formation of potassium formate (KOCOH). It also 
unites directly with potassium, oxygen, and chlorine. 

It dissolves readily in a solution of a cuprous salt in 
ammonium hydroxide; consequently, ammonio-cuprous 
chloride is used in the analysis of mixtures of gases to 
absorb the CO when present. 

It burns readily in air, with a blue non-luminous flame, 
the sole product of the combustion being carbon dioxide. 
At high temperatures it has a very strong affinity for 
oxygen, and will take it from many of the metallic oxides. 
It is by its agency that iron ores are reduced to the me- 
tallic state in the blast furnace. The diffusive power of 
the gas is much greater than that of carbon dioxide, COs, 
and cast-iron plates, when red hot, allow it to diffuse 
through them with comparative ease. In this way a 
small quantity of the gas finds its way into the air of 
rooms heated by stoves, and especially by ordinary hot- 
air furnaces. 

Sources.—The most frequent sources of carbon mon- 
oxide, likely to produce it in poisonous or dangerous 
quantities, are open charcoal or stove coal fires, defective 


662 





el ocr 
i 







stove pipes or furnace flues, and the escape of illuminat- 
ing gas, especially the variety known as water gas. 

A frequent cause of fatal poisoning by this gas is an 
open charcoal fire. This is sometimes used with suici- 
dal intent, especially in some European countries. Le- 
blanc gives the following analysis of the air of a confined 
space in which charcoal was burnt, and which proved 
rapidly fatal to a dog: Oxygen, 19.19 per cent.; nitro- 
gen, 76.62 per cent.; carbon dioxide, 4.61 per cent.; car- 
bon monoxide, .54 per cent. ; marsh gas, .04 per cent. 

In this case, however, the poisonous effects might not 
be due alone to the carbon monoxide, for 4.6 per cent. of 
carbon dioxide in an air containing 1.4 per cent. less oxy- 
gen than normal air would forma poisonous atmosphere. 

Another source of carbon monoxide, and one which is 
frequently overlooked, is from escape of the gas through 

defective flues, or even through 
the red-hot walls of the flues or 
pipes of stoves and hot-air fur- 
naces. The gas thus finding its 
way into rooms frequently gives 
rise to headache, dizziness, loss 
of appetite, nausea, debility, and 
bronchial irritation, which last 
effect is sometimes very severe. 
Indeed, severe cases of capillary 
bronchitis in children have been 
traced to an escape of poisonous 
gases from a defective flue. The 
ordinary hot-air furnace, in com- 
mon use at the present day, is 
the cause of a considerable and 
undetermined amount of chronic 
poisoning, and is on this account 
open to very serious objection. 
From ordinary stoves, when the 
draught is rendered imperfect 
by the downward direction of 
the pipe before entering the 
chimney, carbon monoxide and 
other gases frequently escape 
into the room. 

Perhaps the most frequent 
source of fatal quantities of this 
gas in the air, especially in large 
cities, is the escape of illuminat- 
ing gas. From thoughtlessly 
blowing out the gas, or accident- 
ally turning the stopcock, or 
having it turned by children, as 
occurred to a number of persons coming under the care 
of the writer, or from accidental leakage of pipes, the 
gas may find its way into a room in sufficient quantities 
to give fatal results. Even in waking hours, when the 
gas escapes slowly, the odor does not seem to be a per- 
fect safeguard. (For a further discussion of this sub- 
ject, see the section that treats of coal gas.) 

Physiological Action.—Carbon monoxide is a very poi- 
sonous gas, entering the blood and combining with the 
hemoglobin of the red corpuscles and expelling the oxy- 
gen. When the blood is pretty thoroughly saturated 
with this gas, death is usually, if not always, the result. 

The blood of persons poisoned with this gas retains its 
bright cherry-red color for a long time after death, both 
in the body and out of it, and in the veins as well as in 
the arteries. . 

Properly diluted, the blood shows in the spectroscope 
two absorption bands situated between the lines D and 
HE, but slightly nearer # than the similar bands of oxy- 
hemoglobin (see Fig. 1116). 

These bands do not readily disappear when the blood 
is treated with ammonium sulphydrate, 7.e., the blood 
resists the action of reducing agents. In ordinary arte- 
rial blood, reducing agents change the spectrum, so that 
the two bands seen in 1 disappear, and one broad band, 
represented in 8, makes its appearance. Vogel has pro- 
posed to employ this peculiar behavior of hemoglobin as 
a means of detecting CO in the air. 






REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Carbon, 
Carbon. 





The process consists in shaking the mixture of gases 
with a drop of blood diluted with 2 or 3 ¢.c. of distilled 
water, and observing the spectrum of this blood solution. 
This method is said to detect 2.5 to 4 parts per 1,000, of 
this gas in the air. 

Blood charged with carbon monoxide, in the absence of 
oxygen, resists the action of putrefaction for a long time. 
The CO may be expelled from blood by allowing any 
inert gas to bubble through it, or by placing it in a 
vacuum. The very poisonous character of CO is ex- 
plained by the behavior of the hemoglobin of the blood 
toward it. 

Toxicology.—The poisonous action of carbon monoxide 
has been known since 1802, when Guyton Morveau 
first observed it. Leblanc and Dumas’ experiments show 
that air containing 1 per cent. of the gas will kill a dog 
in one minute and a half. Dr. Letheby found that air 
containing .5 per cent. killed birds in three minutes. One 
per cent. of the gas in air renders it fatal to most animals, 
and .5 per cent. to some, even if the oxygen is normal or 
in excess of normal. 

Symptoms of Acute CO Poisoning.—The symptoms of 
carbonic-oxide poisoning are singularly persistent. The 
first subjective symptoms are dizziness, excruciating 
headache, debility, and a feeling of prostration; nausea 
and vomiting are not uncommon; convulsions are fre- 
quently seen in experiments upon lower animals, as well 
as in human beings poisoned by it. This gas seems to act 
as a narcotic poison, death usually occurring by coma. 
The face is usually, though not always, livid, and the pu- 
pils are dilated. When the quantity of gas is not suffi- 
cient to produce such pronounced results as those above 
mentioned, and when this small quantity is breathed for 
days or weeks, the symptoms are those of malaise, de- 
bility, anemia, anorexia, and usually headache. There 
is frequently a dry, irritative cough. These symptoms 
are sometimes mistaken for those of malaria, and proba- 
bly are benefited by the tonic effect of quinine. When 
the severer symptoms are well marked, the chances of 
recovery decrease with the length of time the patient has 
been exposed to the gas. When the time of exposure 
has exceeded eight hours, and coma has set in, the prog- 
nosis is very unfavorable. If the time is less than eight 
hours, and the coma is not too profound, there is reason 
to hope for recovery. This statement is based upon ex- 
periments upon the lower animals, and the histories of a 
number of recorded cases. Much will depend upon the 
amount of gas breathed; but, other things being equal, 
the longer the blood is exposed to the gas, and the more 
thoroughly it becomes saturated with CO, the more per- 
manent is the injury, and the less chance there is for re- 
covery. The characteristic post-mortem appearances are: 
the bright red color and persistent fluidity of the blood, 
and hyperemia of the brain and meninges. The heart is 
usually nearly empty and flaccid. 

Chronic Poisoning.—The symptoms of chronic poison- 
ing with carbon monoxide are somewhat different from 
those of acute poisoning. In this case the amount of gas 
is small and the time of exposure is long. The hemo- 
globin absorbs the CO very slowly, while it also absorbs 
oxygen freely. Under these circumstances, a part of the 
CO-hemoglobin is decomposed, but a part of it remains 
in the blood. The symptoms are generally vague, incon- 
stant, and very often overlooked or attributed to other 
causes. The chief symptoms are malaise, anemia, ano- 
rexia, and disorders of digestion. The person never feels 
well, but he seems better when in the open air. Indeed, 
fresh air and change of residence are the best and only 
treatment. Thesymptoms are such as to suggest chronic 
malarial infection. The origin of this form of poisoning 
is usually from leaking gas pipes either in the house or 
in the ground near the house, whence the gas reaches 
the dwelling by diffusion through the soil. 

The treatment of cases of poisoning by CO are, briefly, 
fresh air, cold affusions, stimulants, and artificial respira- 
tion when demanded. Even with all these, death will 
result in those cases in which the exposure has been of 
long duration, and the coma pronounced, 7.e., when the 


blood has become well-nigh saturated with the gas. In 
such cases transfusion, or displacing the poisonous with 
pure blood, or even with normal salt solution, seems more 
likely to succeed. Good results have followed this 
method of treatment in a number of cases. 

Ittuminating Gas, Fuel Gas, or Coal Gas.—These names 
are applied to Gomplex mixtures of gases, made from 
coal, wood, oils, resin, petroleum, shales, etc., by a proc- 
ess of destructive distillation. The most of these gases 
contain more or less of the oxides of carbon, especially of 
CO, and in this country they are the most frequent 
sources of poisoning by carbon monoxide. Much of what 
has been said as to the effects of this gas applies to illu- 
minating gas. 

Coal gas was first used for house lighting by William 
Murdock in London in 1792. It was first used for street 
lighting in London in 1812, and in Paris in 1815. In this 
country, especially in the larger cities and in some towns, 
the so-called water gas enriched with naphtha has nearly 
replaced coal gas. The complete apparatus for its prep- 
aration consists of: 1. A set of semi-cylindrical iron or 
clay retorts, set horizontally ina furnace. 2. A series of 
horizontal and upright iron pipes acting as condensers, in 
which the liquid products of the distillation are condensed 
and separated from each other, and from the gases. 3. 
One or more purifiers, which consist of upright stacks, 
containing moistened coke, freshly slaked lime, ferric 
hydrate, or mixtures of these with sawdust. The object 
of these purifiers is to absorb the most of the carbon 
dioxide, sulphuretted hydrogen, etc., before the gas is 
stored for use. 4. A gasometer or gas-holder, which 
consists of an inverted iron tub of large size floated in a 
well of water. The gas is conducted into this gasometer 
by a pipe leading from below and terminating above the 
water, where it is stored ready for use. 

The coal is heated in the retorts to a cherry-red heat, 
or about 1,500° F. This temperature breaks it up into 
coke (which remains in the retort), liquid and volatile 
products, and gases. Ordinary bituminous coals yield 
about ten thousand cubic feet of rather poor gas per ton. 
It is acommon practice to mix with these coals about 
five to ten per cent. of a rich boghead or cannel coal, to 
improve the illuminating power of the gas produced. 

Composition.—The gas ordinarily used is a mechani- 
cal mixture of various gases, some of which are illumi- 
nating agents, while others have no value in this respect, 
but are combustibles furnishing considerable heat, while 
there are usually some present which are inert either as 
combustibles or as illuminants. Besides the true gases, 
there are present vapors of certain hydrocarbons, which 
are of value as illuminating agents. The chemical com- 
position of the gas varies with the coal used, and the 
temperature to which it is subjected. The chief con- 
stituents of coal gas, with the quantities of each, are 
given in the following table from Letheby: 


Volume per cent, 


Ver ELV GNOGOM ie cotatateve svetesais ce etitarsreraiete\sis/s/ sini sis's/s\/ sys" 25 to 50 
MASI WAS iretovtciacerete evetereieiersisicre cusie’s oral cieiosteleisicreie 35 to 52 
3. Condensible hydrocarbons: Olefiant gas(C2H,4), 

propylene (C3H¢), butylene (C4Hg) ......... 8 to 20 
AS BenZol ang Its Seriesiianncctes vsicee a ie ce oases (?) 
A PACELYIONGNCoH a) a ctintsiteeiiees espana tedeeeeecs (?) 
GS Naphthalene' (Cy oH pg) tsielctete siete cess petcielsisivisicieels (?) 
ee CATDOMCIOXIGE COOg) aelaciclesisiciscels elnlcielelviaisteisletsis 0 to 2 
8. Carbon monoxide (CO) .......ccceessccesevees 5 to9 
DS CVANOCLEN (ONON)ialscisicsis vtciaeiciecisteteivisiee ctabevatels Traces. 


MOPPATHIMNONIA CN High teretouiecstele: ccoparatatatetalevaiel ota eich evalerecete Oto .06 





Li Bisulphide of carbon (OSa)iscen cess ae vietes ose 010. 004 to .05 
T2eAGUEOUS VADOM CHgO)s vives cess vey cine velscswes 6 to 2.5 
13. Oxygen 0 to 10 
14. Nitrogen 0 to 8 
LOPES NOCV ENO LOM vercatclestelcletr.s ejrisiaisiare-a.eiere siete Hse or0 traces. 


It will be seen that this table presents wide variations 
as to the percentage of the various gases. The illumi- 
nating power of the gas varies with the proportion of 
ethane, C,H, ethylene (ethene), C.H,, acetylene, C2Ha, 
and benzene, C.He, and their homologues, and the heating 
value with the hydrogen, marsh gas, and carbon mon- 
oxide present. The specific gravity of coal gas is about 
from .400 to .650, air being taken as 1. 


663 


Carbon, [Water. 
Carbonic-Acid 





The illuminating power of gas is measured by compar- 
ison with a standard spermaceti candle of six to the 
pound, and consuming, as near as may be, one hundred 
and twenty grains of spermaceti per hour. It is as- 
sumed that the light given off is in direct proportion to 
the sperm consumed. The gas to be tested is to be 
burned at the rate of five feet per hour.- Such a burner 
should give as much light as sixteen or eighteen standard 
candles. It may reach as high as twenty-five or thirty 
candle-power. 

WATER GAS may be referred to here asa gas manu- 
factured and sold for the same purposes as coal gas. Its 
manufacture is conducted on a large scale in most cities, 
and to a large extent it has taken the place of coal gas. 

This gas is manufactured as follows: Steam froma 
boiler is forced through a bed of glowing anthracite 
coals, previously heated to a very high temperature by 
an air blast. Thesteam from the boileris passed through 
pipes or flues over the fire box, so as to superheat it to a 
temperature of 800° to 900° F. In passing this hot steam 
through the coals the water is decomposed, the oxygen 
combines with the carbon of the coal to form carbon di- 
oxide, which is reduced, by the heated coal above, to the 
monoxide: C 4 2H.O = CO; -- 2Ho. (COzg = C = 2CO). 
The hydrogen of the steam remains ina free state. After 
the steam has passed through the coal for about six 
minutes, the latter cools off and the process stops. The 
air blast is now turned on until the coal is again heated 
to the required degree—/.e., for about eight minutes— 
when the steam is again passed into it. It is, therefore, 
an alternating process. The gas thus produced has very 
little illuminating power, but answers well for heating 
purposes. To give illuminating power it must be charged 
with hydrocarbons. This is accomplished as follows: 
Naphtha, or light benzin, is placed upon shelves ina 
carburetter, and the gas passed through the apparatus. 
A small quantity of the vapor of the naphtha is taken up 
by the gas. This mixture is now passed through retorts 
heated to bright redness, by which process the vapors are 
decomposed and converted into permanent gases instead 
of condensible vapors. This is the Tessie-du-Motay 
process. By the Lowe process the carburetted gas is 
made in one operation instead of in two, as above de- 
scribed. Water gas is cheaper and usually of higher illu- 
minating power than coal gas, and is consequently super- 
seding the latter. 

The principal differences in the chemical composition 
of coal gas and water gas are, that the latter, as usu- 
ally manufactured, contains a larger percentage of illu- 
minating agents and of carbon monoxide than the 
former. 

The following analyses of the two gases, by Professor 
Remsen and Dr. Love, will serve to illustrate these dif- 
ferences: 


























REMSEN. LOVE 
Constituents. Coal | Water | Water 

gas. gas. gas. 

Carbon Gioxid ®...:c Sex cieldesis vicieslaiaislare'e ee eaiee 0.0 0.3 0.0 

Nluminants (ethylene, propylene, butylene, 

ethane, propane, butane) 4.3 12.85 15.75 
Carbon monoOxides..enarere secs 7.9 28.25 21.51 
Hydrocens.ciuweer iene 50.2 30.30 | 46.49 
Marsh gas (Methane) meresnsaaseeeseoniee 29.8 21.45 11.75 
INGETORON sacle ce rere amea ebis ses eweee 7.8 6.85 4.30 
OXYREN. wewsecnscrekcaeah cane ne cn conic ieee Rane 20 





OIL GAS is now largely made by heating petroleum, 
tar, or shale oils in a retort to a temperature of about 
1,000° C. This gas, especially that made by the Pintsch 
process, is much used in lighting cars. Oil gas is fre- 
quently used to enrich other gases of low illuminating 
power. 

AIR GAS, so called, is produced by passing air through 
layers of very light petroleum distillates, known as gaso- 
lene, when it takes up enough of the light hydrocarbons 
to form a combustible mixture. Air gas is much used 
where other gas is not available. It cannot be stored 


664 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





long or piped a long distance because of the condensation 
of the illuminants. 

ACETYLENE, C.He, has recently become prominent, and 
is used as an illuminant insmalllamps. Itis prepared by 
treating calcium carbide with water, when the following 
reaction takes place: 

CaC, + 2H2O = Ca(OH). + CoHa. 

The calcium carbide is prepared by heating a mixture 
of powdered coke and lime inan electrical furnace. One 
ton of calcium carbide of eighty-per-cent. purity is said 
to produce 1,000 cubic feet of acetylene gas. Its illumi- 
nating power is very high, and when burned in an ordi- 
nary burner gives off considerable soot. When burned 
in a specially constructed burner it gives a light of great. 
brilliancy. The cost of production prevents its general 
adoption for illuminating purposes. Acetylene combines 
with copper and silver, forming acetylids, which are ex- 
plosive. It combines with the hemoglobin of the blood, 
and thus acts asa poison. The gas has a pungent, suffo- 
cating, disagreeable odor, by which its presence in the 
air can usually be detected. 

FUEL GAS AND FURNACE GASES.—Gases of more or less 
poisonous character are produced during various smelting 
and roasting processes and which may be the cause of 
serious accidental poisoning. The most commonly met 
with are arsine (arseniuretted hydrogen), stibine (anti- 
moniuretted hydrogen), and sulphurous oxide, obtained 
by roasting ores containing arsenic, antimony, or sulphur, 
and CO, and CO obtained in smelting processes gener- 
ally. ‘ 

Carbon monoxide is an important constituent of fuel 
gas or producer gas. Producer gas is made by forcing air 
through a bed of incandescent coal or coke in specially 
constructed furnaces. It contains from twenty-five to 
thirty per cent. of CO, to which it owes its value as a. 
fuel. It also contains some CO, and free nitrogen. In 
another form of furnace steam is forced through the 
heated coal, when CO and hydrogen are produced, as in 
making water gas. It is needless to say that both these 
gases are poisonous. 

NATURAL GAS is so called because it exists already 
formed in the earth whence it issues spontaneously, or is. 
obtained by boring wells. The gas is found chiefly in 
localities where petroleum is found. In this country this. 
gas is found in western Pennsylvania, in eastern Ohio, in 
West Virginia, andin Fredonia, N. Y. At the last-named 
place it was used as an illuminating gas as early as 1821. 

The “Burning Springs” of Baku, on the Caspian Sea, 
have been known since the sixth century B.c. The com- 
position of natural gas is fairly uniform, and it consists 
of about ninety per cent. of marsh gas (methane) with 
small quantities of ethane, C.H., propane, C;Hs, and 
other paraffin hydrocarbons, hydrogen, carbon monoxide, 
and carbon dioxide. 

It is a valuable fuel, burning with a feebly luminous. 
flame, but giving out an intense heat. In many localities 
it is the chief fuel. When heated ina suitable furnace: 
with petroleum or the higher hydrocarbons, its illuminat- 
ing power may be greatly increased and it is then used for 
illuminating purposes. 

ACTION OF ILLUMINATING GASES ON THE Economy. 
—All forms of illuminating gas are irrespirable and more 
or less poisonous. ( 

They are irrespirable because they do not furnish oxy- 
gen. The chief poisonous agents are carbon monoxide 
and the heavier hydrocarbons mentioned above under the 
name of dlluminants. 

The physiological action of carbon monoxide has al- 
ready been discussed in the section which treats of that. 
subject. 

The heavy hydrocarbons are more or less poisonous. 
when mixed with air. The symptoms produced are diz- 
ziness, headache, nausea, and prostration. These com- 
pounds are more deleterious than is the lighter marsh gas, 
but their exact physiological action is not well under- 
stood. The physiological effects of illuminating gas are 
due not alone to the carbon monoxide, as some have sup- 
posed, but to the combined effect of this gas and the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Carbon, [Water. 
Carbonic-Acid 





heavier hydrocarbons, together with the loss of oxygen 
due to the displacement of air by the gas. 

Symptoms.—The symptoms of acute poisoning by ordi- 
nary illuminating gas are: headache, dizziness, nausea, 
a staggering gait, great muscular weakness, prostration, 
loss of memory, and finally, unconsciousness and com- 
plete asphyxia. Convulsions frequently end the scene. 
There is usually little difficulty in making the diagnosis, 
as the circumstances under which the patient is found, 
the odor of the gas, etc., will prevent deception. The 
only diseases likely to be confounded with this form of 
poisoning are, cerebral apoplexy and uremic coma. 
Should the physician not see the patient before the odor 
of the gas has escaped, such difficulty might arise. In 
both of these diseases the symptoms are pretty constant, 
while in coal-gas or water-gas poisoning they are apt to 
fluctuate; the patient will frequently rouse up fora time, 
and answer questions intelligently, and then lapse into 
unconsciousness, or be seized with convulsions. 

A marked difference in the symptoms will be noted, 
dependent upon whether the gas is admitted into the air 
rapidly or slowly. In the first condition the person rap- 
idly becomes unconscious, and recovers rapidly when re- 
moved into fresh air. When the gas is admitted to the 
air of aroom slowly, the headache, dizziness, nausea, and 
muscular weakness are the prominent symptoms, and 
they are remarkably persistent. The condition of the 
patient often seems to remain constant for days after the 
accident; and when entire unconsciousness has occurred, 
recovery is very unusual. We should distinguish be- 
tween asphyxia by illuminating gas and poisoning by 
carbon monoxide obtained by breathing the diluted gas. 
The first is produced by a rapid displacement of the air 
of the room with the gas, while the second results from 
a slower and very gradual admixture of gas with the air. 

Fresh air and stimulation will usually suffice to restore 
the patient in the first case; but in the second, while these 
measures should not be neglected, they are much less 
useful, and, when the time of exposure has been consid- 
erable, of slight benefit. It may be well to name here 
some of the sources of coal-gas poisoning other than 
leakages directly from fixtures in the room. 

The odor of the gas is so characteristic that this will 
in most cases give its warning. Repeated instances, 
however, prove that people may be killed by this gas 
without detecting the odor. 

Cases of poisoning have occurred when the leak in the 
pipes occurred in an adjoining room, or in a cellar or 
other room underneath. Most of such accidents occur in 
the night while the victims are asleep, even though they 
were exposed to the same influences during the preceding 
day. 

It should be known that these poisonous gases may 
diffuse themselves through walls, soil, and partitions. 
It should also be remembered that the odorous vapors 
may be almost entirely removed by diffusion through a 
thick wall or several feet of soil. The gas deprived of 
its odor may thus pervade the air of a sleeping- or 
sitting-room, and give no warning of its presence. 

In winter, when the ground is frozen, and the upper 
layers are impervious to the gas, this may diffuse itself 
several feet laterally from a broken street main, reach 
the cellar, pass thence to the rooms above, and so do its 
deadly work unperceived. That this accident has fre- 
quently occurred is shown by abundant evidence taken 
from the statistics of any large city. Aside from the 
fatal cases of poisoning from this source, we can easily 
see that there must be a much larger number of cases in 
which headache, dizziness, loss of appetite, general de- 
bility, anzemia, etc., may be dependent upon a smaller 
amount of the same gas continually finding its way into 
the air of houses. 

It is evident, from the above, that cases of poisoning 
may occur in houses where gas is not used, and where 
the pipes do not even enter the house. 

There has been, at various times, not a little discussion 
as to the relative poisonous effects of coal gas and water 
gas. This question has been made the subject of a great 








number of investigations. We may note that of Com- 
missioner Raymond, of Brooklyn, N. Y., Health Depart- 
ment, 1883, and that of the Committee on Manufactures 
of the Massachusetts Legislature of 1884. 

The weight of experimental evidence, however, goes 
to show that water gas is decidedly more dangerous than 
coal gas. 

With a given amount of gas, the danger line is reached 
sooner with water gas; and, indeed, in many rooms it is 
not easy to get a fatal mixture of coal gas and air with 
the escape from a single burner jet, owing to natural 
ventilation through walls, floors, windows, etc. That is, 
dogs, cats, rabbits, and pigeons will endure almost in- 
definitely an atmosphere containing one per cent. of coal 
gas, while the same animals die in from five to eight 
hours when exposed to an atmosphere containing one 
per cent. of water gas. 

The post-mortem appearances, in cases of poisoning by 
lluminating gas, are similar to those found after poison- 
ing with carbon monoxide. There is generally an odor 
of the gas about the body, especially on compressing the 
chest, so as to expel the residual gas from the lungs. 

The countenance may be pallid, pink, or purple, vary- 
ing in different cases. Frequently more or less froth will 
be found issuing from the mouth, due probably to the 
nausea which precedes death, and which is one of the 
marked symptoms. Occasionally, rose-colored patches 
will be found on the thighs or other parts of the body. 

When the body is opened the blood will generally be 
found everywhere in a fluid condition, and uniformly of a 
light red color on both sides of the heart. It shows the 
spectroscopic bands of carbon-monoxide hemoglobin 
see Fig. 1116, p. 662). The lungs will usually have a 
brilliant red hue, while the bronchial tubes will be filled 
with a frothy mucus. The venous sinuses of the brain 
and the vertebral nervous system wiil be found engorged 
with blood. 

The above appearances are not always found, however, 
for there is great variation in this form of poisoning, both 
as to the symptoms and as to the post-mortem appear- 
ances. ‘These variations are probably explained by the 
fact that in some instances the cause of death is a true 
asphyxia, while in others it is CO poisoning. In the 
former we may expect a livid hue of skin, dark, clotted 
blood, and engorgement of the venous sinuses; while in 
the latter we may expect the light, fluid blood, the rose- 
colored spots upon the skin, a lingering death, ete. More 
careful observation is needed upon these points. 

Treatment.—We have incidentally mentioned nearly all 
that can be said of the treatment of coal-gas poisoning. 
If the case is one of suffocation, and the time of exposure 
has not been too long, fresh air, stimulants, and rest will 
usually suffice to restore the patient to consciousness. 

No antidote for poisoning by the gasis known. Trans- 
fusion of blood has been tried with apparent success. 

In experiments upon the lower animals the introduction 
of normal salt solution into the veins has occasionally 
been successful in saving life. 

Inhalations of oxygen have often been tried, with 
temporary benefit, but it does not seem to expel the car- 
bon monoxide from the blood. If persisted in, it may 
save life when the blood is not too nearly saturated with 
the gas. Elias H, Bartley. 


CARBON TETRACHLORIDE. — TZetrachloromethane, 
Chloro-carbon: CCly. This body is a colorless, thin, 
ethereal fluid, of a pleasant aromatic smell, insoluble in 
water but miscible freely with alcohol and ether, It has 
been tried as an anesthetic and has been found to operate 
after the general manner of chloroform, but with sucha 
depressing effect upon heart action that it is little likely 
ever to come into practical use. Hdward Curtis. 


CARBONIC-ACID WATER.—“ Soda water.” Carbonic- 
acid water is the product of the solution of carbon dioxide 
(carbonic-acid gas) in water. In such solution there is a 
chemical union between the gas and the water, molecule 
for molecule, producing the body carbonic acid proper 


665 


Carbo-Sapol. 
Carbuncle, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





(H.COs;), which is known only in solution. At the ordi- 
nary pressure of the atmosphere water dissolves about 
one volume of carbon dioxide, but will take up increased 
quantities under artificial increase of pressure in direct 
proportion to the pressure. The carbonic-acid water of 
commerce contains from five to ten volumes of gas forced 
to dissolve by pressures varying from five to ten atmos- 
pheres. Such supercharged solutions appear as color- 
less aqueous fluids, effervescing briskly on release from 
confinement, from spontaneous evolution of the excess of 
carbon dioxide. The reaction isacid and the taste pleas- 
antly acidulous and pungent. For obvious reasons com- 
mercial carbonic-acid water must be kept strongly con- 
fined in well-stoppered vessels, and special care is neces- 
sary that there be no exposed surface of lead or copper 
in the storing vessel, else contamination of the water with 
those metals will result. A carbonic-acid water charged 
with five volumes of gas was formerly official in the 
United States Pharmacopeeia, but was dismissed in the 
revision of 1880. 

Carbonic-acid water is valuable medicinally as a drink, 
and as a vehicle for medicines. Asa drink its virtues are 
that, like all acids, it tends to excite the secretion of saliva 
and buccal mucus, and so relieve thirst more permanently 
than plain water, and that it is peculiarly grateful to the 
stomach, tending to expel flatus and allay nausea. Asa 
vehicle for medicines, carbonic-acid water is especially 
adapted for the solution of mawkish salts, such as the 
purgative salts and alkaline carbonates, bromides, and 
iodides. Not only is disagreeable taste thus disguised, 
but the salt, whatever it be, is much less liable to disorder 
the stomach. 

It is almost needless to say that all effervescing drinks 
—mineral waters and sparkling wines or malt liquors— 
owe their effervescence to carbonic acid formed by the 
solution in the liquid of carbon dioxide under pressure. 

Edward Curtis. 


CARBO-SAPOL is a mixture of 50 parts of carbolic 
acid, 25 parts of yellow soda soap, and 25 parts of potash 
or soft soap. These substances are heated together on a 
water bath until they form aclear solution. Carbo-sapol 
is miscible with water in all proportions, and hasa strong 
antiseptic action. The combination of soap with carbolic 
acid makes it decidedly useful for cleansing the skin be- 
fore an operation, or for soaking the hands. <A one-per- 
cent. solution may replace creolin or lysol as a vaginal or 
intra-uterine douche. It may be used for instruments in 
one- to five-per-cent. solution, and these must be rinsed 
off before they are employed, as the soapy solution makes 
them slippery. W. A. Bastedo. 


CARBUNCLE.— Carbunculus simplex seu benignus. (See 
also Anthraz and Bozls in this HANDBOOK.) 

[Some eminent authorities consider simple carbuncle to 
be a form of anthrax (Anthrax furonculeux), and apply 
this designation to the local lesion. This seems calcu- 
lated to create confusion, as the nature and course of the 
two diseases are widely different; and the essential ele- 
ment of malignant pustule—the bacillus anthracis—is not 
found in the fluids or tissue in cases of simple non-malig- 
nant carbuncle. | 

Carbuncle is an inflammation of the skin and con- 
nective (cellular) tissue of a greater or less degree of se- 
verity, accompanied by the loss of a certain amount of 
tissue, and exhibiting a tendency to mortification of 
the skin. 

Carbuncle commences in the subcutaneous structures 
and works its way through the planes of connective tis- 
sue, as well as toward the surface. A brawny inflam- 
mation around an acutely inflamed central tumor is 
formed, with multiple points of suppuration, with a 
strong tendency to lateral extension. It is this latter 
tendency, and the consequent much larger size of the car- 
buncle, and the multiplicity of the points of suppuration 
which distinguish the carbuncle from the boil. Car- 
buncles are chiefly situated on the nape of the neck, and 
on the back or buttock, but they may also occur on the 


666 


extensor surface of the forearm, and on the scalp or face, 
or in other locations. 

The symptoms belonging to carbuncle are of a much 
graver character than those attending furuncle (see under 
heading otis), and are accompanied by more or less 
significant signs of constitutional disease, such as fever, 
headache, anorexia, etc. The formation of a carbuncle 
is always preceded by more or less serious impairment of 
the general health, by a feeling of malaise, and sometimes 
by successive chills. These symptoms become intensified 
until the local disease is manifested by elevation of tem- 
perature, and by redness and swelling of the part, ac- 
companied by a feeling of deep, and at times ill-defined, 
induration. 

ErroLocy.—Carbuncle is now generally believed to be 
caused by the infection of the site of the disease by means 
of a bacterial germ, which gains admission to the subcu- 
taneous tissues through some wound of the skin, such as 
a minute scratch, a slight abrasion, or possibly by find- 
ing its way downward through the follicle of a cutaneous 
hair, without previous injury of the skin. The organ- 
isms most frequently found in the pus of a carbunele are 
the Staphylococcus pyogenes aureus and albus (Warren). 
A state of general debility places the tissues in a condi- 
tion to furnish a favorable soil for the growth of the bac- 
teria. Certain constitutional diseases, such as diabetes, 
are frequently accompanied by carbuncle. Carbuncle is 
rarely observed in childhood. It is most frequently seen 
in persons over forty years of age. It first appears as a 
minute papule on the surface of the skin, which is usu- 
ally the seat of considerable irritation, and sometimes of 
acute pain. From this point the area of commencing in- 
flammation gradually enlarges, extending laterally, and 
involving also the deeper tissues of the part, until a 
cone-shaped area of the tissues is involved in the process. 
Warren explains the peculiarities of carbuncular in- 
flammation by reference to the anatomy of the skin in 
the regions most frequently the seat of the disease. He 
says (op. cit.): “The skin in this region is extremely thick 
(neck, back, etc.), probably thicker than in any portion 
of the body; it forms a mass of dense fibrous tissue, well 
calculated to sustain burdens, or to protect a compara- 
tively defenceless portion of the body. The hair follicles 
being those supporting downy hair only, and therefore 
shallow, project downward only a short distance into the 
uppermost layers of the subcutaneous tissues. Commu- 
nication with the adipose tissue is by oblique columns of 
fatty tissue which extend upward from below. These 
fat columns [first described by Warren] are found beneath 
each hair follicle. They contain besides loose connective 
tissue, fat cells and vessels, and a coil of sweat gland 
suspended midway in the shaft. At the point where 
these columns open into the parts immediately below this 
dense sheet of cutis is found a broad band of fibrous tis- 
sue, given off from one side and extending obliquely 
down into the subcutaneous structures, finally to be at- 
tached to the fascia, beneath which lie the muscles. 
These fibrous bands which interlace in various directions, 
are very different from the delicate cellular tissue under- 
lying other portions of the skin, and form a dense net- 
work which holds firmly in place the tough hide to 
which they are attached.” When further developed, 
the carbuncle presents a broad, flattened surface of 
round or oval outline, elevated to a greater or less de- 
gree above the surface of the surrounding skin, which 
is of a bright or dull red, or sometimes of a tawny 
color, and which is very tender to the touch. The 
skin is tense and hard, and the density of the surround- 
ing tissues is greater than in ordinary inflammations of 
these structures. 

CouRSE OF THE DisEAsE.—When the inflammation 
has involved an area of a certain diameter, its periphery 
becomes fixed, and it rarely afterward progresses beyond 
this boundary. Soon a slight elevation of the epidermis 
is noticeable, which speedily ruptures and gives exit to 
a clear gelatinous or sero-purulent discharge, which 
quickly dries and forms crusts about the orifice of exit. 
This is not accompanied by amelioration of the pain, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Carbo-Sapol, 
Carbunele, 








redness, heat, or swelling, nor does it in the least check 
the progress of the disease. 

As the carbuncle increases in size, the distress, which 
at first is usually not excessive, becomes gradually more 
intense, until it reaches a stage when it can be compared 
to nothing but a violent burning pain located deep in 
the tissues, and accompanied by throbbing and often by 
agonizing exacerbations, owing to the fact that the skin 
is held down firmly to the fascia by the fibrous bands 
already described. The dense cutis vera also does not 
yield to the pressure from below; the disease therefore 
advances from one columnar interspace to another and 
thus gradually implicates the deeper tissues. The pus 
makes its way to the surface through the points of least 
resistance, these points being the columne adiposve, and 
thus the carbuncle becomes the seat of numerous small 
openings scattered irregularly over its surface, which 
lead down to the seat of the disease in the deeper tissues 
of the part. After atime the centre of the carbuncle 
usually becomes gangrenous. 

The infiltration and disintegration of the tissues and 
the overlying skin are often so complete, and coagulation 
necrosis is so extensive, that large sloughs are formed. 
The centre of the carbuncle thus becomes an open crater. 
This may be confined toa small portion of tissue, and 
-does not always lead to any considerable destruction in 
the part; but it usually occasions a loss of substance to 
a greater or less amount, sometimes reaching an area of 
25 to 30 cm. in diameter. This stage is often accompa- 
nied by a notable relief from the pain. 

Irregular fragments of necrosed connective tissue or 
aponeurosis are often separated during the process of 
healing, and appear at the orifices upon the summit of 
the carbuncle, where they are discharged spontaneously, 
or may be extracted by operative measures. When the 
necrosed tissues are retained beneath the skin, they fre- 
‘quently give rise to abscesses in the periphery of the 
original seat of disease, and thus increase the severity of 
the local lesion and augment the danger to the patient, 
as well as enlarge the surface to be subsequently healed. 
The change of the livid color at the border of the indura- 
tion to a yellowish hue is an indication that the disease 
has reached its limit in extent. 

When the gangrenous tissue which forms the centre of 
the carbuncle has been entirely eliminated, the process of 
repair commences, by the gradual formation of a cicatrix 
over the seat of the disease. This is generally a slow 
process, and in some cases is not completed on account 
of exhaustion of the healing power of the system. 

In the milder cases there may be little or no fever; but 
large carbuncles are usually associated with considerable 
cachexia, and the condition of the patient at times be- 
comes critical. 

The duration of the disease varies according to the age 
and condition of the patient, and the means employed 
in itstreatment. If the carbuncle is early and thoroughly 
incised, a complete cure may sometimes be attained in 
from one to three weeks, although cases ofte1 require six 
months for healing. The average duration of the disease 
is considered by competent authorities to be from one to 
two months. 

Draenosis.—In its early stages it may be impossible to 
differentiate carbuncle from the ordinary furuncle; but 
the diagnosis would soon be rendered positive by the 
course of the disease. The furuncle is quite superficial, 
affects only a limited amount of tissue, may be located 
upon any part of the body, is not accompanied by grave 
constitutional symptoms, is developed quickly, is not 
limited to any particular period of life, and is relieved 
by spontaneous opening or by surgical incision. The 
carbuncle, on the contrary, is situated in the deeper tis- 
sues, especially in parts like the neck, back, scalp, etc., 
in which are broad aponeurotic expansions. It usually 
occurs in patients already the subjects of diminished 
vitality from other causes, and should excite suspicion of 
diabetes, alcoholism, or marked uric-acid diathesis. Car- 
buncle is accompanied by grave and often alarming con- 
stitutional symptoms, by high fever, and by extreme 


restlessness; it is the seat of great and continuous pain, 
which is not relieved by the formation of an opening. 
The inflammation extends a considerable distance beneath 
the surrounding tissues, and is sometimes followed by 
extensive gangrene of the superficial structures or by 
phlegmonous inflammation of the adjacent parts, and is, 
par excellence, a disease of advanced life. 

The simple non-specific carbuncle may properly be 
regarded as a group of deep-seated furuncles, situated 
beneath a dense and resisting cutaneous surface, which 
undermine and cause necrosis of a reiatively large 
amount of tissue, with subsequent gangrene of the 
overlying skin, sometimes to a very alarming extent. 
The simple furuncle has a tendency to heal as soon as 
an opening occurs; the carbuncle shows no such ten- 
dency. 

Carbuncle may be confounded with commencing ery- 
sipelas, and with a simple phlegmon of the subcutaneous 
connective tissue; but these diseases lack the localized 
character, the surrounding induration, the punctated sur- 
face, and the extensive sloughing of a circumscribed 
portion of connective tissue. Phlegmon is more boggy 
and diffused than is commencing carbuncle, the pain and 
fever are not so marked or constant, and the course of 
the symptoms is more rapid. Erysipelas is accompanied 
by intense febrile reaction, a more diffused swelling of 
the skin, vivid redness, and a clearly marked boundary 
of the disease, with lines of inflammation over the lym- 
phatic channels and infiltration of the lymphatic glands. 
There is usually no tendency on the part of a carbuncle 
to extend beyond its original limit. 

Carbuncle often presents a striking similarity to an- 
thrax (malignant pustule), and might sometimes be mis- 
taken for this malady, during its early stages, at the time 
when a small phlyctenular elevation of the epidermis 
upon an indurated and swollen base is the only visible 
variation from the normal condition. But carbuncle is 
rarely accompanied by the glandular enlargement, by 
the peripheral or extended oedema, or by so profound 
signs of constitutional disturbance as is the more grave 
disease. Aside from these points in diagnosis is the im- 
portant fact that malignant pustule is observed chiefly, 
if not exclusively, among those who have been in some 
way brought in contact with some substance containing 
the infection, and therefore is more especially confined to 
those persons who are obliged to handle the flesh, hair, 
wool, skins, etc., of animals, or to those who are engaged 
in the care of animals already diseased, as grooms and 
shepherds (in the grazing regions of North America the 
disease might be expected among cowboys). The dried 
hides of animals, particularly those received from South 
America, frequently contain the virus of malignant pus- 
tule, and constitute a source of infection to curriers, tan- 
ners, and others employed in their manufacture; and in 
persons following these occupations any form of boil or 
carbuncle should be regarded with suspicion until an- 
thrax can be excluded. 

The more frequent seat of carbuncle is the neck and 
back; then the scalp, thorax, face, and limbs. Cases 
have been reported in which the eyelid and the lip were 
the seat of carbuncle, but these must be exceedingly rare. 

PaTHOLOGy.—Carbuncle may be regarded as the mani- 
festation of a septic invasion of the affected tissues with 
subsequent coagulation necrosis and gangrene of the in- 
fected structures, accompanied if not preceded by a de- 
praved condition of the general system. It has been 
noticed that other signs of a constitutional affection are 
often present in carbuncle. Thus Prout observed, in 
1840, that the outbreak of the local disease was frequently 
accompanied by the urinary symptoms of diabetes; 
though it is quite possible that the diabetic phenomena 
and the carbuncle may belong to the outward manifesta- 
tions of some grave constitutional affection, possibly of 
some department of the nervous system. The local fea- 
tures of carbuncle are essentially those of a septic infec- 
tion, and are to be regarded as such so far as prognosis 
and treatment are concerned. 

Proenosts.—In speaking of the lesion of carbuncle, 


667 


Carbuncle. 
Carcinoma, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





allusion was made to the ordinary furuncle as the mildest 
form of this affection. In prognosis the same relation 
holds true. The furuncle is superficial in location, runs 
its course without fever, and is uniformly followed by 
rapid recovery, leaving a small cicatrix, which is usually 
but slightly depressed below the level of the surrounding 
skin. The prognosis of carbuncle, however, depends 
upon three factors, viz.: the age and vigor of the patient; 
the gravity of the constitutional symptoms, the amount 
of pain, etc., and the degree of interference with the 
process of alimentation; and the situation and extent of 
the local disease and the degree to which gangrene of the 
skin or sloughing of the deeper tissues occurs. 

Death may occur from exhaustion, or from the devel- 
opment of secondary abscesses in the vicinity of the orig- 
inal carbuncle, especially if these take a phlegmonous 
course. <A fatal issue also results in some cases from 
profound depression of the vital powers, apparently due 
to the absorption of the toxic poison of the disease. 
Hemorrhage and embolism have also been the cause of 
death in carbuncle. When the disease is situated on the 
neck or scalp, septic meningitis has not infrequently been 
a fatal complication. 

When the carbuncle is situated-upon the neck it may 
produce dyspnea by pressure upon the air passages; 
when it is located upon the chest or abdomen the pleura 
or peritoneum may become inflamed; when upon the face, 
distortion of the features may ensue; and when situated 
upon the scalp it may be followed by meningitis. 

TREATMENT.—Carbuncle is believed to arise from an 
infection of the skin and subjacent tissues by a definite 
bacillary organism, and is accompanied by a depraved 
condition of the general health; and therefore the first 
indication would be to restore as far as possible the nor- 
mal vigor of the system and to bring about a better 
nutrition of the body. Some of the most celebrated au- 
thorities recommend the employment of active emetics, 
followed by cathartics, forthe purpose of increasing the 
eliminative function of the digestive canal, and possibly, 
also, as a means of derivative action upon the seat of the 
disease by assisting in the removal of the toxins produced 
by the bacillus. When we consider, however, that the 
patient with carbuncle is generally already in a state of 
impaired vigor, any active depletory measures should 
either be entirely abstained from or should be adopted 
with great caution, lest they induce a dangerous degree 
of exhaustion or be followed by sudden collapse. 

A careful regulation of the food, in regard both to 
quality and to quantity, is generally necessary, and at 
the same time active tonics and stimulants must be ad- 
ministered. The distress is frequently so great as to re- 
quire the use of anodynes, and often the degree of febrile 
reaction is an indication for the employment of large 
doses of quinine. Cod-liver oil has also been found use- 
ful. If rapid exhaustion supervenes, the administration 
of champagne has sometimes been followed by great 
benefit. When convalescence is established, iron should 
be given, a generous and strengthening diet should be 
ordered, and, if possible, sea bathing or a change of cli- 
mate and surroundings should be advised. 

Locally, the treatment must depend much upon the 
symptoms belonging to each particular case. At times 
the application of cold is of great service in relieving the 
pain and modifying the severity of the inflammation, but 
generally hot and moist applications are most comfort- 
able to the patient. These may consist of simple hot com- 
presses, but the most common mode of treatment is by 
means of large poultices which should be frequently 
changed. At times the local abstraction of blood by 
means of leeches affords temporary relief, but the bleed- 
ing is liable to be excessive in amount, and may induce 
a condition of collapse. 

The surgical treatment of carbuncle should have for 
its object the liberation of the sloughing tissue in the 
centre of the carbuncle, and the free exposure of all sup- 
purating parts. For this purpose many methods of pro- 
cedure have been advised, such as the circular incision 
around the base of the carbuncle; the cauterization of the 


668 


summit of the swelling by means of potash or ferrum 
candens; the crucial incision of the entire carbuncle, the 
subcutaneous stellar incision through its substance; and 
the treatment by compression of the entire carbuncle; or 
of its peripheral portions, by means of firm or elastic 
bandages. 

All operative measures should be carried out with the 
strictest attention to antiseptic precautions. The seat of 
the disease should be previously rendered as nearly asep- 
tic as possible. 

The treatment by circular incision consists in cutting a 
channel quite around the base of the carbuncle, so as to 
divide the skin and the superficial blood-vessels, and has 
for its object the diminution of the vascular supply, with 
the result of relieving the tension and reducing the fe- 
brile action in the part, and thus modifying the severity 
of the process and hastening the recovery. It is more 
especially to be employed in the early stages of the dis- 
ease before gangrene has occurred, and while the central 
slough may yet be quite small. 

The application of caustic potash or the hot iron to the 
summit of the carbuncle has the aim to provide a path 
for the release of the sloughing centre of the diseased 
part, and at the same time to avoid the unnecessary loss 
of blood from hemorrhage. The tissue to which the 
cautery is applied is destroyed without bleeding, and the 
interior of the carbuncle is rendered accessible to direct 
treatment. This mode of treatment is not often em- 
ployed, as it is painful in its action and the resulting 
benefit is not’ greater than that from other and less dis- 
tressing methods. During the last few years the anti- 
septic treatment has superseded all other forms. In cases. 
of great debility or in aged patients, as well as in mild 
forms of carbuncle, the use of carbolic acid in dilute 
solution, either as a lotion or on compresses as a poultice, 
is of service. 

The crucial incision of the entire carbuncle from base 
to summit is doubtless the most useful and effectual 
manner of exposing the interior of the swelling to view, 
and of liberating the sloughing centre in the most rapid 
manner. When the operation is completed the carbuncle 
presents four deep incisions radiating from the centre to 
the periphery. By this means the whole interior of the 
diseased part is made accessible to direct treatment and 
the most favorable conditions for rapid and complete re- 
covery are at once established. The incision of the skin 
over the inflamed part, however, may be attended with a 
considerable loss of blood, which in the debilitated con- 
dition of many of the subjects of this disease is of no 
small importance. To obviate this, and thus to save the 
strength of the patient, the method of subcutaneous 
stellar incision has been adopted in many cases of exten- 
sive carbuncle. 

This mode of treatment consists in the internal division 
of the seat of disease into many small sections, and has 
for its object the rapid and easy evacuation of the slough- 
ing tissues of the centre of the carbuncle and the libera- 
tion of purulent matter, with the avoidance of excessive 
hemorrhage. 

In performing this operation the surgeon makes use of 
a long and narrow knife, which is inserted into the per- 
forated centre of the carbuncle and carried directly to the 
bottom of the disease. Its point is then directed outward 
toward the periphery of the carbuncle, and when the ex- 
ternal boundary has been reached the edge of the knife is: 
turned toward the skin, and the tissue is carefully cut. 
from below toward the surface. The incision should not 
be allowed to reach the skin, on account of the bleeding 
which would ensue, but should comprise all the diseased: 
tissues below the skin. This process should be repeated 
in all directions until the carbuncle consists of only a. 
superficial covering of sound skin overlying the thor- 
oughly divided and broken-up mass of the carbuncle, 
which should then be removed by curetting or in some 
other effective manner. The amount of hemorrhage is 
usually very slight. If the strength of the patient is not. - 
ne much reduced, recovery is usually rapid and com- 
plete. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Carbuncle, 
Carcinoma, 





Warren maintains that a more radical form of opera- 
tion should be carried out in many cases. He says: “The 
most radical treatment consists in total excision of the 
earbuncle. <A circular incision should be made round 
the edge of the infected portion of the skin, and all the 
diseased tissues should be removed. The effect is imme- 
diate. The fever and delirium disappear and the pain is 
relieved.” 

Carbuncle of the lip often causes very grave symp- 
toms. Evacuation of the contents and extirpation of the 
infected tissues should be carried out, and any simpler 
mode of treatment is here usually insufficient. This 
should be done from inside the mouth when possible on 
account of the diminished scar or deformity thus secured. 

The application of heat, preferably by dry or moist 
compresses, should follow any operative measures. 
Should the necessity for disinfection arise, this may be 
accomplished by the use of chlorinated soda, which is 
preferable to carbolic acid on account of the somewhat 
greater danger of poisoning by this agent in carbuncle 
than in ordinary surgery, owing to the more extensive 
surface for absorption and the age and weakened condi- 
tion of the patient. If it should become desirable to em- 
ploy an antiseptic, a solution of mercuric bichloride or 
some other efficient agent of this nature, of which we 
now possess a considerable number, may be used in the 
wound, 

The cicatrix following carbuncle is generally more or 
less depressed, and may at times become so retracted as 
to produce deformity, and occasionally to interfere with 
the functional activity of parts or organs (neck, jaw, 
eyelid, etc.). Albert N. Blodgett. 


REFERENCES. 


Ashhurst: International Encyclopeedia of Surgery, ii., p. 317. 
Dennis: System of Surgery, vii., p. 499. 

Park: System of Surgery by American Authors, ii., p. 17. 
Warren-Gould: International Text-Book of Surgery, i., p. 68. 


CARCINOMA.—The carcinoma is a tumor which arises 
from epithelium and is formed of masses of epithelium 
growing in a connective-tissue stroma. It is further 
characterized by unlimited local growth and by giving 
rise to the formation of tumors of a similar structure in 
other parts of the body. The tumor may arise from the 
surface epithelium of the exterior of the body, from the 
epithelium lining the alimentary canal, from that lining 
the lung, or from the various involutions of epithelium 
constituting the glands. Tumors having all the charac- 
teristics of true carcinoma may also arise in places where 
no epithelial structures are normally present. Such 
tumors do not form an exception to the general rule of 
origin, for they arise from embryonic epithelium which 
in the course of development has become included in 
mesodermic tissue and cut off from connection with the 
epithelial surface. Examples of such tumors are found 
in carcinoma of the deep tissues of the neck originating 
from the epithelial remains of the branchial clefts, in car- 
cinoma arising in the walls of dermoid cysts, etc. Tu- 
mors having a structure very similar to that of carcinoma 
may arise from the endothelium of blood and lymphatic 
vessels. The carcinoma may also arise from the germi- 
nal tissue of the ovary and the testicle. 

It has long been known that all epithelial surfaces are 
not equally liable to carcinoma. In general, we find that 
the tumor is more likely to form about the orifices of the 
body where skin and mucous membrane come in contact, 
as in the lips and anus, or where the course of embryonic 
differentiation has been complicated, as in the lower third 
of the esophagus. Carcinoma arising from the glands is 
particularly apt to occur in those glands which are gen- 
erally inactive but which have the power of extreme pro- 
liferation and functional activity, as the mammary gland 
and the uterus. In certain places the occurrence of car- 
cinoma is probably to be explained by the action of re- 
peated traumatic stimuli, but the influence of trauma in 
producing carcinoma as well as other tumors, has proba- 
bly been greatly overestimated. 








On microscopic examination the carcinoma is found to 
be composed of two kinds of tissue: first, epithelial cells 
arranged in masses which vary in size and form, and 
which are enclosed in spaces called alveoli; secondly, con- 
nective tissue which surrounds the alveoli and bears the 
blood-vessels for the nutrition of the cells in the alveoli. 
This connective tissue is called the stroma. Neither 
stroma nor blood-vessels penetrate the epithelial masses. 
Normal epithelial structures show a similar arrangement 
of tissue, epithelial cells growing in the closest juxta- 





Fig. 1117.—Small Carcinoma of Forehead Showing Network of Epi- 
thelial Cell Masses Surrounded by Connective-Tissue Stroma. (No.3 
Leitz, without eyepiece.) 


position with connective tissue, but the latter never 
penetrating between the cells. Whether we consider the 
covering epithelium or the glandular epithelium the ar- 
rangement of the tissue is the same. 

If, in the normal epithelial structures, the cells at some 
point begin to multiply and penetrate into the adjoining 
connective tissue, the structure of carcinoma is produced. 
The mere proliferation of the epithelium does not produce 
the carcinoma. Epithelial tissues are the most active of 
any tissues of the body. Both the covering and the 
glandular epithelium are constantly used up in the course 
of their physiological activity, and the lossis as constantly 
repaired by the formation of new epithelial cells. - This 
power of regeneration is sufficient not only for the ordi- 
nary wear and tear of the tissues, but also for the repair 
of even extensive losses. Furthermore, the epithelium 
may be excited to greater activity by various means, 
and large masses of tissue composed principally of epi- 
thelium may be produced. Such a growth of epithe- 
lium is constantly accompanied by a growth of young 
connective tissue bearing blood-vessels. An epithelial 
growth of this character repeats in a general way the 
structure of the normal tissue and is called typical, but 
there is no normal prototype for the structure of the car- 
cinoma. The penetration of the connective tissue by the 
epithelium is atypical. It is possible, however, to have 
such anatypical growth of epithelium giving the general 
structure of the carcinoma without the other characteris- 
tics which constitute the tumor. When the proliferating 
epithelium comes in contact with a loose cellular connec- 
tive tissue, such as is produced by chronic irritative con- 
ditions, it may grow down into it, thus constituting an 
atypical growth. Such conditions are found around the 
edges of chronic ulcers of the skin and in other condi- 
tions. The growth of the epithelium may be very active, 
but it will extend only to the limits of the altered con- 
nective tissue. 

When we compare the epithelium in different parts of 


669 


Carcinoma, 
Carcinoma, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





the body we find differences in the size and form of the 
epithelial cells and in their arrangement. These differ- 
ences are to a certain extent apparent in the carcinomata 
which arise in different parts, and from the histological 
examination of the tumor we can say with considerable 
accuracy from what epithelial tissue it has arisen. From 





Fig. 1118.—Carcinoma of Stomach, Involving the Submucosa, and 
Showing Masses of Cells Lying in Spaces Lined with Flat Cells. 
(8 mm. Zeiss.) 


this it is possible to divide the carcinomata into three great 
classes, originating respectively from squamous, from 
cylindrical, and from cuboidal glandular epithelium. 

To explain the growth of the carcinoma it is necessary 
to consider the structure of the connective tissue. This 
is formed of fibres between which there are cells. It 
carries in it the blood-vessels and lymphatics. The cells 
jie in spaces in the tissue which communicate with ad- 
joining spaces, and from the enlargement and coalescence 
of these spaces the lymphatics arise. If the carcinoma 
begin by the proliferation of epithelium, the new cells 
not passing to the surface as in a typical growth but into 
the connective tissue, they must at once enter into this 
system of communicating spaces and continue to grow 
inthem. Every mass of epithelial cells is withina lymph 
space in the tissue. It is easy to show this in various 
ways. The epithelial masses follow the general direction 
of the lymphatics. In a carcinoma of the skin the most 
superficial epithelial masses have a general direction per- 
pendicular to the surface, while those lower down are 
horizontal, corresponding to the course of the lymphatics. 
By staining the fresh tissue with nitrate of silver and 
washing out the cells, a lining of endothelial cells similar 
to that lining the lymphatics can be shown in the alveoli. . 
In hardened sections the cell mass often shrinks away 
from the wall, and the flat nuclei of the lining cells can 
be demonstrated, 

It will scarcely be possible to give any general descrip- 
tion of the epithelial cells constituting the main mass of 
the tumor. Their resemblance to the normal epithelium 
from which they have arisen is much more apparent 
when they are examined in mass than when the single 
cells are compared. Both the protoplasmic body of the 
cell and the nuclei are, in general, larger. There is enor- 
mous variation in shape due to the pressure to which they 
have been subjected. Degenerative processes of various 
kinds are apparent in the protoplasm. Vacuoles filled 
with fat, or hyaline droplets, are often seen. Various 
cells, such as polynuclear leucocytes or lymphoid or 
plasma cells, and even red blood corpuscles, are fre- 


670 














quently found enclosed within them. The enclosed cells. 
lie in vacuoles and may be so well preserved that their 
character may be recognized, or they are only represented 
by degenerated fragments. There is a marked difference 
in the character of the nucleus as compared with the 
normal. It is larger, stains more actively, and is rich in 
chromatin. The cells often contain several nuclei and 
may approach the character of giant cells. Occasionally 
single cells of great size and irregularity of form, con- 
taining a single immense nucleus, may be found. If the 
process of cell division as shown by the nuclear figures 
be studied the same irregularity is seen. In the place of 
the simple division into two nuclei the most complicated 
nuclear figures, showing simultaneous division of the 
nucleus into a great number of daughter nuclei, may be 
found. The examination of the single cells shows almost 
as great a departure from the normal type as does the 
tumor considered as a whole. All the changes found in 
the cells are indicative of very active growth. This is 
necessarily accompanied by degenerations of all sorts, for 
the closely packed masses of cells cannot obtain sufficient 
nutrition. 

The examination of the masses of epithelium lying in 
the alveoli shows great variation in sizeand shape. Serial 
sections of young tumors, especially those of the skin, 
show that the epithelium for the most part forms a solid 
mass ramifying in the connective tissue. In the periph- 
ery small epithelial masses may be found which have no 
connection with the main mass. In the glandular car- 
cinomata the connection between different parts of the 
epithelial mass exists to some extent, but is not so evi- 
dent as in the small carcinomata of the skin. Generally 
there is a sharp separation between the epithelium and 
the surrounding stroma, but in places it may be difficult. 
to make it out. When the stroma is rich in cells some 
of these may be very similar to the epithelium, and it is. 
difficult to distinguish the limits of the epithelium when 
growing into such a cell mass. It is often impossible 
to distinguish single epithelial cells separated from the 
main mass and growing between the cells of the stroma. 
When the growing carcinoma invades a loose connective 
tissue, the cells penetrate in all directions, growing 





Fic. 1119.—Large Alveolus from a Carcinoma of the Breast with 
Numerous Cell Inclusions. These inclusions are not to be con- 
founded with the supposed parasites described by Plummer and 
others. (8 mm. Zeiss.) 


without any regularity, and the arrangement, into cell 
masses and stroma may be lost. This is seen in the 
invasion of muscle. The epithelial cells grow in the 


: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Carcinoma, 
Carcinoma, 





most irregular manner in long rows between the mus- 
cular fibres and in the loose connective-tissue septa. 
It is also seen to a less degree in the invasion of fat, 
the cells at first growing in the connective-tissue frame- 





Fig. 1120.—Longitudinal Section of Pectoral Muscle Invaded by 
Carcinoma of Breast, Showing the: Masses of Epithelial Cells Partly 


Between and Partly Within the Muscular Fibres. The muscular 
fibres are atrophied and some of them necrotic. (8 mm. Zeiss.) 


work between the fat cells and afterward filling up the 
spaces. The cells of a skin carcinoma have a much 
greater tendency to adhere together, and there is a much 
sharper separation into cell masses and stroma, than is 
the case in the glandular carcinoma. The ‘cell masses 
vary greatly in size; in some cases they are large with 





21. 


Fie. li 
Figs. 1121 anp 1122.—The Invasion of Fat by Carcinoma of Breast. 


In Fig. 1122 the fat has largely disappeared and the spaces are filled by the epithelial cells. 


but little stroma between them, in others they may be 
reduced to simple rows of cells in a dense stroma. These 
two forms are known as medullary and scirrhous car- 
cinoma. We may commonly find both types in the 
same tumor, One or the other predominating. Prolifera- 





tion takes place almost exclusively in the cells on the 
outside of the mass. These cells are in contact with the 
stroma carrying the blood-vessels for their nutrition, and 
are larger, and the nuclei richer in chromatin, than the 





Fig. 1123.—Section Through the Periphery of a Carcinoma of the 
Breast, Showing the Medullary Type of Tumor. There are large 
epithelial masses and a small amount of stroma. (8 mm. Zeiss.) 


cells in the interior. By the increase of the mass in size, 
the cells in the interior are removed further from the 
source of nutrition and degenerate. Very often the in- 
terior of the mass is a cavity filled with degenerated and 
necrotic cells. The forms of the cells may be preserved 
or they may soften and the individual cells can then no 
longer be recognized. In such cases the softened mate- 
rial usually contains great numbers of polynuclear leuco- 
cytes. The softening may extend to the periphery, and 





In Fig. 1121 the Epithelial Cell Masses are Chiefly Between the Fat Cells. 


(8 mm. Zeiss.) 


not only leucocytes but connective-tissue-forming cells 
may enter the mass and a process of organization take 
place leading to the absorption of the necrotic tissue 
which is replaced by young connective tissue. When 
this is the case a mass of growing connective tissue may 


671 


Carcinoma, 
Carcinoma, 





be found within the alveolus surrounded by epithelium. 
Occasionally single blood-vessels surrounded by a small 
amount of connective tissue may push their way from 
the stroma into the mass of epithelium. 

The epithelial cells of the tumor retain to a marked de- 
gree the physiological properties of the cells from which 





Fig. 1124.—Section from Centre of Same Tumor Showing Scirrhous Type. There 
are small masses of epithelial cells which are to a large extent degenerated, 
separated by a dense hyaline cicatricial stroma which contains few cells. 


they are derived. In a carcinoma of the skin the cells 
around the outside of the alveolus have the properties of 
the Malpighian layer, and the central cells represent the 
horny layer. Proceeding from the periphery of the alve- 
olus to the centre the eleidin granules begin to appear, 
and, finally, the cells become flattened and converted into 
keratin. The flat, horny cells are subject to pressure 
from all sides, and in consequence concentric masses of 
horny cells are formed which have been called epithelial 
pearls or onion bodies, and which form one of the 
distinguishing features of carcinoma of the skin. 
A more interesting example of this tendency to 
the physiological type is seen in the cylindrical- 
cell carcinoma, which forms one of the most com- 
mon tumors of the lower alimentary canal. In 
these tumors the epithelium rarely forms solid 
masses filling the alveolus. When these cells enter 
into a lymph space in the tissue they tend to grow 
in the same manner as in the normal structure— 
that is, in close contact along their long axes. In 
consequence of this the spaces become lined with 
cylindrical cells simulating a normal gland struc- 
ture with a lumen in the centre. In consequence 
of the continued active proliferation groups of 
cells retaining their form and mode of growth be- 
come forced into the centre of the space, and 
grow there, forming complicated loops or round 
masses with a central cavity. These tumors so 
greatly resemble the adenomatous or true glandu- 
lar tumors that they are often called by this name, 
or their malignant character is expressed by the 
term adeno-carcinoma or malignant adenoma. 
They do not differ from the carcinoma in other 
situations save in the character and the arrange- 
ment of their cells. The same tendency to a nor- 
mal arrangement of ceils may be seen in such a 
typical carcinoma as that arising in the mammary 
gland. Within the single alveoli of this, peculiar 
round spaces are often seen among the cells (Fig. 
1123). These are generally interpreted as being 


672 








Degenerated Cells. 
mass. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


formed by the degeneration and absorption of certain 
cells. No remains of such cells are found within the 
spaces, nor can the steps in their formation be fol- 
lowed. The cells on the outside of the small cavity 
have a definite arrangement with their long axes par- 
allel. In other cases spaces very similar to these may be 
found containing connective tissue and blood- 
vessels, which represent strands of the stroma 
that have become surrounded by the grow- 
ing epithelium, and thus included in the cells 
mass. It is probable that cavities may be 
formed by the degeneration and absorption of 
such masses of connective tissue. In other 
cases careful examination will show that the 
epithelial cells within the alveolus are arranged 
in rows with their long axes in contact, though 
the rows of cells are distorted from pressure. 
Most of the cavities and the arrangement of 
the cells in rows and columns are due to a ten- 
dency of the cells to follow their physiological 
mode of growth. Such tendencies are more 
especially seen in those tumors in which the 
growth is slower; in these the newly formed 
cells keep up their nutrition longer and have 
time to attempt a typical arrangement. It may 
be found in one part of the tumor and be ab- 
sent in another part» I have seen a typical 
scirrhous carcinoma of the breast with central 
degeneration and diffuse extension into the sur- 
rounding tissue. On one side of this, appar- 
ently growing out from it, was a tumor of a 
totally different character, of the size of a hen’s 
egg. This tumor was softer, more homogene- 
ous, and more vascular than the scirrhous. It 
was sharply circumscribed and did not infil- 
trate the surrounding tissue. On section it 
was found to be composed of large alveoli filled 
with well-preserved cells. There were numer- 
ous large, round, and oval spaces in each alveolus. The 
metastases in the axillary lymph nodes were of the scir- 
rhous type. 

The character of the stroma varies nearly as much as 
does that of the cell masses. It formsa part of the tumor 
and grows with it, a large part being undoubtedly newly 
formed. In part, it represents the old connective tissue 


which has been invaded by the epithelium. All the con- 


stituents of the normal tissue which have been invaded are 





Fig. 1125.—Large Alveolus from Carcinoma of Breast with Central Mass of 


There are large numbers of leucocytes in the necrotic 
(8 mm. Zeiss.) 





EXPLANATION OF 
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Fic. 1.—Cylindrical-cell carcinoma of rectum, showing the invasion of the submucous tissu i 
muscular coat. X 20. 


processes of carcinoma cells, The muscular fibres are cut transversely and show vari 
grees of atrophy. X 150. 


Fic. 3.—Extension of carcinoma by implantation. ‘Section of a nodule on the surface of the perito- 
neum secondary to carcinoma of the ovary. The tumor growing on the surface has formed 
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Fic. 4.—Section through a small carcinoma of the breast, showing the rapid peripheral ext 
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REFERENCE HANDBOOK 
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MEDICAL SCIENCES Plate XX. 





PHOTOMICROGRAPHS SHOWING SOME OF THE CHARACTERISTICS OF CARCINOMA. 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. yi ahve tog 


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stroma and the epithelial masses may be affected 
by the rapidity of growth of these. When the 
alveoli are numerous, by their constant enlarge- 
ment the stroma may be reduced to mere shreds 
of connective tissue which lie within the cell 
masses, giving the tumor, or certain foci in it, 
the appearance of a sarcoma. In the scirrhous 
type the stroma changes its character, becoming 
converted into a tissue similar to cicatricial tissue. 
In this the cells are very few, the fibres are 
fused together and hyaline. Giant cells are 
sometimes found in the stroma. Their forma- 
tion here is analogous to their formation around 
foreign bodies, and is.a point in favor of con- 
sidering the stroma a growth excited by the 
epithelial cells acting as foreign bodies. They 
are found especially in carcinoma of the skin, 
in the vicinity of large epithelial pearls which 
sometimes occupy almost the entire alveolus, 
and the giant cells often contain the single 
scales of horny epithelium. Numbers of large 
epithelioid cells may be found in the vicinity 
of the giant cells, the group somewhat resem- 
bling a miliary tubercle. 

The growth of the carcinoma as a whole is 
analogous to that of a single alveolus. This can 
be best studied in sections which are made 
through small tumors (Plate XX., Fig. 1). The 
most active growth is found in the periphery. 
The alveoli here are round or oblong, numerous, 
and the cells show but little degeneration. In 
the centre the alveoli are very small and angular, 
Fig. 1126.—Large Epithelial Pearl from Carcinoma of Tongue. The section the cells are small and degenerated, and there 

was stained with iron hematoxylin which colors the keratin an intense are butfewnuclear figures. In places the alveoli 

black. (8 mm. Zeiss.) have disappeared altogether, and there is a dense 
hyaline cicatricial tissue and a depression is 
contained in the stroma. In a carcinoma of the skin the | formed corresponding to the atrophic centre. The atro- 
stroma contains sweat glands, and in the mamma atro- | phy of the centre is partly to be explained by the com- 
phic glandular tissue. It also contains nerves and blood- | pression and occlusion of the blood-vessels by growing 
vessels. We may partly explain the new formation of | epithelial masses between which they must pass, and 
stroma as a formation of tissue to carry new 
blood-vessels to the masses of epithelium 
which demand nutrition, just as the inter- 
stitial tissue is formed in a developing 
gland. In part, it is due to the presence 
of the epithelial cell masses acting as for- 
eign bodies. In some cases it contains large 
numbers of cells, in others but few are 
present. The most numerous cells in it are 
small round cells corresponding to the 
lymphoid cells of the blood and of the 
lymph nodes. These are found both as a 
general infiltration of the tissue and in 
small circumscribed masses somewhat re- 
sembling lymph nodules. These cells are 
usually found in the greatest numbers in 
the periphery of the tumor, and may even 
form a compact mass into which the tumor 
grows. Next to these cells, the plasma cells 
are most numerous, and are more generally 
present in carcinomata of the skin. There 
are also evidences of proliferation of the 
connective-tissue cells, but these are not 
present in very great numbers and are con- 
cealed by the infiltrating cells. In a carci- 
noma of the uterus, where the cells grow 
out into a tissue composed of smooth mus- 
cle fibres, the stroma is formed of muscular 
tissue. The stroma should not be consid- 
ered an integral part of the tumor, but it 
is only an accidental growth due to the 
mode of development and growth of the 
tumor. Although the connective - tissue - 
cells in it are usually not very numerous, 
they may be so abundant that the stroma 
resembles the tissue of a sarcoma. Mucoid 
and other degenerations of the stroma are 

















¢ Fig. 1127.—Section of Carcinoma of Stomach. The cells have a general cylindrical 
not uncommon. The relation between the type and are arranged around the walls of the spaces. (8 mm. Zeiss.) 


Vou. II.—43 


673 


Carcinoma, 
Carcinoma, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





partly by the active peripheral growth consuming the 
nutriment. The centre of the tumor often shows the 
most typical scirrhous character, while the periphery has 
the medullary type. 

The boundary of the tumor is never sharp (Plate XX., 
Fig. 1); it extends in lines into the surrounding tissues. 





Fig. 1128.—Atrophic Glandular Tissue from the Stroma of a Carci- 
noma of the Mamma. (8 mm. Zeiss.) 


Small masses are found in the vicinity either separated 
from or connected with the main tumor by a thin line of 
tissue. There is never any formation of a capsule, and 
from the nature of the tumor—a mass of epithelium grow- 
ing into the lymph spaces and lymphatics—it is impossible 
that there should bea capsule formation. 
cell masses are often surrounded by infiltrating cells, but 
they may be found in tissue perfectly normal. Growing 
as it does, the tumor enters into a tissue, and the essential 
constituents of the tissue give way beforeit. The destruc- 
tion and invasion of tissue in contact with it is one of the 
most marked characteristics of the carcinoma. The de- 
struction of the tissue doesnot seem to be brought about 
by the pressure exerted by the growing cells, nor do the 
invading cells remove it by phagocytosis. This process 
can best be studied in the skin and inmuscle. When the 
tumor extends toward the skin this usually becomes thin 
and atrophic before coming into actual contact with the 
cell masses. The cell layers diminish in thickness until 
there may be but a series of two or three cells below the 
horny layer. No nuclear figures are seen in the cells. 
Occasionally in a few places single carcinoma cells and 
even single groups of them may be found within the cells 
of the epidermis. The skin over the tumor is not ele- 
vated, but more generally depressed. The atrophy of 
the skin is due to the demands for nutrition made by the 
advancing tumor. No new cells are formed, and the old 
cells gradually become horny and are cast off. Where 
the tumor enters into the dense connective tissue of the 
skin there is usually a peculiar relation of cells and 
stroma. Thesmall lymph spaces of the skin here cannot 
dilate under the pressure of the cells infiltrating it, so 
that there is an interlacing system of small alveoli filled 
with epithelial cells lying in a dense unchanged stroma. 
There is usually no appearance suggestive of new forma- 
tion of stroma. In contact with the muscle, as where a 
carcinoma of the breast comes in contact with the pecto- 
ralis major, the tumor extends first along the connective- 
tissue septa and coarsely infiltrates the muscle. In places 
the growth is more rapid and small nodules may be 
formed in addition to the general infiltration. At this 
stage the muscular fibres are small and atrophic. Later 
there is extension between the fibres themselves, The 


674 








The advancing. 











fibres lose their striation and are converted into hyalin.. 
In places the degenerative increase in the nuclei is prom- 
inent. Phagocytic giant cells may be formed in the stroma. 
and these take part in the absorption of the necrotic 
fibres. . The epithelial cells may push their way into the 
sarcolemma and extend within this. A section through. 
such a place shows a general infiltration of epithelial 
cells arranged with some regularity in long lines parallel! 
to the muscular fibres, and among them, small, generally 
angular remains of the fibres may be seen. The epithelial 
cells infiltrate the loose tissue, and there is no sharp dis- 

tinction between cells and stroma. The same process of’ 
atrophy and gradual disappearance of tissue is seen in. 
the extension of the tumor into such a parenchymatous 
organ as the liver. There is more evidence of the effect 
of pressure here than elsewhere. The liver cells in the 
vicinity are usually flattened or have a cylindrical form. 

In some cases, especially where the extension is very 
rapid, there is but little evidence of pressure even here. 

When the tumor comes in contact with the fat it extends. 
in the larger connective-tissue septa, then along the fine 
septa between the fat cells. These become reduced to- 
small spaces which finally disappear, the cells of the 
tumor filling the entire tissue. There is but little stroma. 
in the tissue, Nothing shows better how little part the: 
stroma playsin the tumor than the study of the periphery 
of a rapidly growing tumor. The abundance of the- 
stroma has a direct relation to the amount of connective: 
tissue in the tissue invaded. Different tumors vary enor- 
mously in the degree of their infiltration. One occasion- 
ally sees tumors in which the growth is almost as homo- 
geneous as is that of a benign tumor, in which it is almost. 
possible to determine the limit of the growth by the naked 
eye. As the direct opposite to these are tumors with: 
such extensive infiltration that small extensions may be 
found far beyond what appears to be the periphery. 

Not only is there this general growth by infiltration. 
but small nodules of the tumor are found in the surround- 
ing tissue, this being termed dissemination. These small 
nodules may be connected with the main mass by small: 
lines not visible to the unaided eye, or they may be inde- 
pendent. They are found in carcinoma of the breast,. 





Fig. 1129.—Pectoral Muscle Invaded by Carcinoma of the Breast. 


with great Numbers of Lymphoid Cells in the Stroma. The larger 
dark areas represent the atrophied muscular fibres cut obliquely. 
(8 mm. Zeiss.) ' 


more generally beneath the skin than in the deeper tissue. 
They repeat all the characteristics of the main tumor. 
Their presence is easily explained by a careful examina- 
tion of the tissue in the vicinity of the tumor. This often. 


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shows dilated lymph vessels filled with small masses of 
epithelial cells, or, in some cases, with single cells. I 
have sometimes been able to see the beginning of a per- 
ipheral nodule in an extension of the epithelial growth 





Fig. 1130.—Cross Section of Muscular Fibres Invaded by Carcinoma. 
The fibres are small and irregular in shape. (8 mm. Zeiss.) 


from such a vessel into the surrounding tissue. The 
cells are carried passively in the lymph stream. Exam- 
ination of the fresh tissue of a carcinoma ona warm stage 
shows that the cells have slight amceboid movement, 
limited to the extension and retraction of processes. There 
is no evidence of such an extent of amceboid movement 
as would lead to a voluntary progression of 
the cells into the tissue, nor is it necessary 
to assume such to explain these secondary 
nodules. 

It is characteristic of the tumor not only 
to grow by infiltration and dissemination, 
but small tumors similar to the original are 
formed in distant parts. These are termed 
metastases. They are due to the convey- 
ance of tumor cells, by means of lymphatic 
and blood-vessels, from the primary tumor 
and their deposit in the places where the 
metastases appear. The relation between 
the epithelial masses and the lymphatics is 
so close in the carcinoma that the metastases 
appear first in those lymph nodes into which 
the lymphatics of the tissue in which the 
primary tumor is seated enter. Thus in car- 
cinoma of the breast the first metastases are 
in the axillary lymph nodes, in carcinoma of 
the uterus, in the post-mesenteric lymph 
nodes, etc. 

We have already spoken of the fact that 
single tumor cells and small connected 
masses of them may be found in lymph 
vessels in the vicinity of the primary tumor. 

The affected lymph nodes are enlarged 
and may contain small, grayish masses or be 
entirely converted into tumor. They may be 
affected and yet show to the naked eye no 
evidence of this. So general is this second-. 
ary affection of the lymph nodes that surgeons in all cases 
of operation for carcinoma of the breast remove the axil- 
lary nodes. Microscopic examination of the nodes, partic- 
ularly those which to the naked eye show no lesion, often 
give clear indications of the manner in which the infec- 





Carcinoma, 
Carcinoma, 











tion has taken place. The metastasis begins in the per- 
iphery of the node at the place of entrance of the afferent 
lymphatics. These are often dilated and contain masses 
of tumor cells. There may be one or a number of small 
tumor foci in the periphery of the node in immediate re- 
lation with the lymphatic sinuses, or these may be gen- 
erally injected with tumor cells. The peripheral sinus 
of the node is not infrequently seen filled with growing 
masses of the tumor which from here extend into the 
lymph nodules. Between the masses of epithelial cells 
there is in the beginning only the lymphoid tissue of the 
node. After this atrophies, its place is taken by connec- 
tive tissue. The character of the original tumor is re- 
peated in the metastases, although in general the cells of 
the metastatic growth show less of a physiological ten- 
dency than do those of the original tumor. In the metas- 
tases of carcinoma of the skin the tendency to pearl for- 
mation is less marked, and in those from glandular 
carcinomata the cells do not usually show the tendencies 
to physiological arrangement which may be marked in 
the primary tumor. The extension of a primary carci- 
noma into adjoining tissue may involve other sets of 
lymph vessels. When a carcinoma of the breast extends 
deeply into the tissue beneath, metastases may develop 
in the lymph nodes of the anterior mediastinum. Only 
the lymph nodes which are primarily connected with the 
original tumor may be affected, or the process may ex- 
tend from these into adjacent nodes. The tumor growth 
may affect the entire node, and the cells find their way 
into the efferent lymphatics, or they may pass through 
the node by means of the lymph stream without produc- 
ing a growth. In extensive metastatic formation in the 
axillary nodes the clavicular nodes also are usually in- 
volved. The detection, by microscopic examination, of 
metastases in the lymph nodes is usually easy, though 
in some cases the lymph sinuses are filled with large 
endothelial cells which have some resemblance to carci- 
noma cells and may be mistaken for these. 

Metastasis by means of the blood circulation is less 
common in general than that which takes place by way 
of the lymphatics, although in carcinoma of the intesti- 
nal canal the former mode of disseminating the disease 








FG. 11381.—Superficial Lymphatics of Skin Dilated and Filled with Masses of Carcinoma 
Cells. From a carcinoma of the scrotum with numerous metastases. (No. 3 Leitz.) 


is the rule. The tumor cells may enter into the blood 
by means of the lymph circulation, or there may be a 
direct growth of the primary tumor into the blood-ves- 
sels. In carcinoma of the liver a growth of the tumor 
into the portal and hepatic veins is so common that it 


675 


Carcinoma, 
Carcinoma, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





may almost be regarded as the rule. The frequency of 
metastases by blood-vessels in carcinoma of the intestinal 
canal is probably to be explained by the presence, in 
the latter situation, of numerous and thin-walled veins, 
which offer less resistance to the extension of the tumor 
into them. Where the metastases take place depends 
upon the distribution of the blood-vessels coming from 
the part. The metastases transported, by way of the 
blood channels, from the primary tumors of the intestinal 
canal, are found in the liver, while those coming from 
tumors in other parts of the body are found in the lungs. 
There are certain exceptions to this because the tumor 
emboli may pass like other emboli in the direction op- 
posite to that of the blood current. Thus metastases 
may be found in the liver secondary to carcinoma of the 
lung, or in the kidney secondary to carcinoma of the 
liver. In these cases the emboli are probably larger 
and are carried by the force of gravity in the reverse 
direction to that of the blood stream. Very interesting 
combinations are often found of metastases by both 
blood and lymph circulation. Thus I have seen in car- 
cinoma of the uterus metastases in the post-mesenteric 
lymph nodes, and from these a growth of the tumor into 
the thoracic duct, converting this into a large carcino- 
matous cord which extended into the subclavian vein. 
There were numerous very minute metastases in the lung 
simulating miliary tubercles, and from these extension 
had taken place into the subpleural lymphatics, which 
were actually injected with the tumor masses, and into 
the bronchial nodes. The metastases by way of the 
blood-vessels may be single or so numerous as to simu- 
late a case of acute miliary tuberculosis. In such cases 
the condition is spoken of as a general carcinomatosis. 
Extension of the tumor may also take place at various 
places on the surface, due to the implantation of masses 
of a tumor along an adjoining surface (Plate XX., Fig. 
4). We find examples of this in the appearance of nu- 
merous nodules on the surface of the peritoneum in car- 
cinoma of the ovary which extends to the peritoneum. 
Such metastases are most apt to be found in those situa- 





Fic. 1132.—Section of Ovarian Tube in a Case of Carcinoma of the Ovary. There are 
numerous tumor masses both in the wall and in the lumen. The involvement of the 
tube was most marked at the distal end. The process probably began in the lumen and 


from this extended into the wall. (80 mm. Leitz.) 


tions where solid particles are carried by the force of 
gravity. There may also be extension by implantation 
along the surfaces covered by epithelium. In carcinoma 
.of the kidney tumors may be found along the course of 
the ureters or in the bladder. In carcinoma of the ovary 
they may be found in the Fallopian tubes. The carci- 
noma often shows a marked tendency to extension along 


676 








the course of the nerves by means of the perineural 
lymphatics. The nerve as a whole may be surrounded 
and compressed by masses of epithelial cells or these 
may be found between the single nerve fibres. In carci- 
noma of the tongue involvement of the inferior maxillary 
branch of the fifth nerve is common. The extreme pain 
which so often accompanies carcinoma can be explained 
either by extension of the tumor into the nerves or by 
their compression in the contracting stroma. ‘Tumor 
cells are rarely found free in the blood-vessels as they 
are in the lymphatics, but are usually associated with 
thrombi, and the main mass included in the thrombus 
may be degenerated. I have frequently found a ves- 
sel entirely occluded by a mass which was composed of 
fibrin and necrotic tumor cells, and along the wall of 
the vessel, where they could obtain nutrition from with- 
out, there could be seen a line of growing cells. In one 
case of carcinoma of the breast I found a small, round 
mass of epithelial cells, the centre of which was degen- 
erated and filled with leucocytes, around this a small 
layer of fibrin, and on the outside evidently circulating 
blood. Such a mass was probably broken off from a 
fresh tumor thrombus and may have been actually in 
process or transportation. 

It is important to determine, in carcinoma, whether the 
tumor originates in single cells or groups of cells which 
continue to grow, or whether it starts from a compara- 
tively large area of tissue, or, finally, whether tissues of 
a similar character coming in contact with the growth 
can develop the same tendencies. It is very difficult to 
determine these points by microscopic examination. In 
carcinoma of the skin we undoubtedly often find large 
areas of epidermis in direct association with the tumor. 
It is also possible to find the epidermis in the vicinity 
of the tumor, but not immediately connected with it, 
apparently taking part in its growth, and growing in 
the same manner. The same thing is true in carcinoma 
of other epithelial surfaces, as in the alimentary canal. 
Here we often find the tumor in continuity with the 
glands over a large extent of the surface, the glands ap- 

parently growing into the tissue be- 

neath and branching in this. Ribbert, 
who holds that the origin of the car- 
cinoma is due to the separation of 
single epithelial cells and their inclu- 
sion in the connective tissue, believes 
that this connection of the tumor with 
the epithelial tissues is really second- 
ary, and due to the extension of the tu- 
mor to the surface with the formation 
of a connection between the cells of the 
tumor and the epithelial surface. It 
is certainly true that when metastasis 
takes place the parenchymatous cells 
of the organ invaded take no part in 
the growth. Thus, in the secondary 
nodules in the liver, the liver cells are 
never converted into those of the tu- 
mor. When a glandular carcinoma 
comes in contact with epidermis, al- 
though this may actually be invaded 
by the single cells of the tumor and be 
in contact with tumor epithelium, there 
is no transformation. In.a carcinoma 
of the breast the glandular tissue is 
usually atrophic. The tumor tends to 
extend along the ducts which may be 
surrounded by lymphatics filled with 
. tumor cells, and yet the epithelium of 
the duct may show no change. In 
other cases the epithelium certainly ap- 
pears to take part in the growth. There may be a sim- 
ple proliferation of epithelium leading to the formation 
of projecting papillary masses within the duct, or in 
combination with this there may be an outward growth 
of the epithelium into the surrounding tissue. The cells 
change their character, becoming larger and taking on 
all the characteristics of the tumor cells. Undoubtedly, 


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Carcinoma, 
Carcinoma, 





for most of these conditions the explanation of secondary 
tumor extension given by Ribbert applies. In favorable 
sections, and especially in series of sections, the tumor 
evidently extends from the outside into the duct, and the 
tumor epithelium grows over or replaces the epithelium 
of the duct. It is often possible to distinguish definitely 
between the epithelium of the duct and the ttmor cells 
in connection with it. In other cases this explanation 
will not suffice. The clearest evidence of a participation 
of the general epithelial 
structures of a part in the 
growth of the tumor was 
given in a case of carcinoma 
of the skin, ih which there 
were undoubtedly prolifera- 
tion and outward growth of 
the epithelium of several 
hair follicles which were in 
the immediate vicinity of 
the tumor, but in no way 
connected with it. I have 
seen a similar condition in 
the ducts and alveoli in car- 
cinoma of the breast. 

I have already spoken of 
the necrosis in the centres 
of the cell masses (Fig. 
1125). In addition to this 
there may be more exten- 
sive necrosis involving 
either entire alveoli or 
masses of alveoli with stro- 
ma. Such necrosis is due 
to disturbances of circula- 
tion, usually by compres- 
sion of arteries or veins, or 
both, by the growing tu- 
mor masses between which 
they run. In other cases it is due to the formation of 
thrombi. The necrotic tissue may remain, undergoing but 
little change, or it may be absorbed and its place taken by 
dense cicatricial stroma. The boundaries of the necrotic 
tissue are often extremely irregular, unchanged tumor tis- 
sue projecting irregularly into it. Hemorrhage may ac- 
company the necrosis, but is not common. Where the ne- 
crotic tissue comes in contact with the surface bacteria may 
enter, producing gangrenous softening accompanied by 
suppuration. Ulceration is a common accompaniment of 
both the glandular and the surface varieties of carcinoma. 

When the tumor extends to the surface the epithelium 
over this gradually disappears by atrophy, and the tumor 
appears as a raw uncovered mass resembling somewhat 
the base of an ordinary ulcer, although it is smoother and 
paler. There is always on the surface a thin line of ne- 
crosis due to the action of traumatic causes. In addition 
to this there is more extensive necrosis extending irregu- 
larly from the surface into the tumor tissue. The cells 
of the tumor at the surface are placed under more unfa- 
vorable conditions as regards their nutrition than are the 
cells in any other part of the tumor, for they receive their 
blood-supply from one side only, and constriction of the 
vessels is constantly going on. Necrosis due to this takes 
piace and assists in the extension of the superficial trau- 
matic necrosis. The necrosis is always assisted by the 
action of bacteria, and extensive gangrenous sloughs may 
be produced. There is continuous new formation of tis- 
sue pushing up from below, so that the ulceration is usu- 
ally not deep and gives but little idea of the extent of the 
loss of substance. The destruction of tissue may be so 
extensive that in spite of rapid growth the resulting 
tumor may be insignificant in size. In carcinomata of 
the lip the surface of the tumor may appear as an ulcer 
somewhat depressed, or be covered by a scab formed 
principally of a mass of cast-off epithelial scales. When 
a glandular carcinoma extends to the surface it is not 
usually covered by a scab, because but little exudation 
can find its way from the tissue beneath to take part in 
its formation. 








Fic. 1133.—Longitudinal Section of a Large Duct in Carcinoma of the Breast. 
of the duct is partly preserved but in places it is covered by a growth of the carcinoma cells which 
extend into the lumen from the walls. 


Ulceration plays a very important part in carcinomata 
of the intestinal canal, especially in those of the stomach, 
and the results of the process differ somewhat from the 
results of the process elsewhere. The necrotic tissue is 
destroyed by the action of the gastric juice, leading to 
the formation of a smooth, clean ulcer, and the tumor 
grows in elevated masses around the edge of this. The 
process of necrosis may be so active that the ulcer may 
resemble a simple ulcer and only by microscopical ex- 


UP ae Se 
SERS os 


CA 


2 


The cylindrical epithelium 


(No. 8 Leitz.) 


amination of the edge can its character be determined. 
in other parts of the intestinal canal necrosis with result- 
ing gangrene is more common, though we may have in 
the rectum carcinoma with ulceration, of the same char- 
acter as that in the stomach. In the alimentary canal 
the contraction which so constantly accompanies the 
growth and which is due to the conversion of the stroma 
into cicatricial tissue, leads to constriction and occlusion 
of the lumen. The occlusion is assisted by the action of 
the elevated tumor masses around the ulcer. 
Constitutional E7ffects.—The effect of a carcinoma on the 
individual remains to be considered. The most constant 
condition accompanying it consists in emaciation and the 
production of cachexia. The cachexia is probably due 
to a number of conditions. The malnutrition is due in 
the first place to the loss of sleep induced by pain. The 
absorption of the toxic products coming from the necro- 
tic tissue may interfere with the nutrition and produce a 
condition of chronic toxemia. To this must be added 
the absorption of toxic substances from bacterial action, 
and finally a general infection produced by bacteria which 
have invaded the tumor. The evidence of such condi- 
tions is seen not only in general degeneration of the organs 
but in such special degenerations as amyloid. Changes 
in the blood are unimportant. In the later stages there 
may be considerable diminution in the number of red cor- 
puscles. The leucocytes may remain normal or show 
some increase, this particularly when ulceration is present. 
Htiology.—The cause of carcinoma remains in absolute 
obscurity. A fair measure of our absolute ignorance of the 
subject may be found in the number of theories which have 
been advanced, each of which has its advocates and each 
of which is favored by certain conditions associated with 
the tumor. The first of these theories and the one which 
probably still has the most adherents is the traumatic the- 
ory which supposes the tumor to be due to the continuous 
action of an irritant which excites the cells to prolifera- 
tion. Virchow has been the most prominent defender of 
this theory and many surgeons have supported it. Car- 
cinoma of the lower lip, which is practically confined to 


677 


Carcinoma, 
Carcinoma, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





males, is used in support of the traumatic theory, being 
supposed to be due to smoking. The development of 
carcinoma in the site of old cicatrices, particularly those 
resulting from burns, is also used in favor of the trau- 
matic origin. Probably the facts of the infrequency of 
carcinoma in those parts of the body most exposed to 
trauma and its frequency in those parts least exposed are 
the strongest arguments against the traumatic theory. 
No parts of the body are so exposed to traumata of various 
sorts as the hands and feet, and yet the tumor is exceed- 
ingly rare in the former and almost never occurs in the 
latter. No parts of the body are less exposed to trauma 
than the mammary gland and the uterus, and the tumor 
is very frequent in these situations. Even in the pessary 
days of gynecology, when the uterus was possibly the 
most abused organ in the body, carcinoma of this was 
not rendered more frequent. In the example given 
of the association of carcinoma of the lower lip and smok- 
ing, the infrequency of the tumor in the upper lip, in 
spite of the fact 
that this must be 
as much exposed 
to the traumatic 
or irritative ac- 
tion of the tobac- 
co, is not explain- 
ed. Carcinoma is 
not more frequent 
in those who by 
reason of occupa- 
tion or conditions 
of life are more 
subject to trau- 
mata. Another 
example often 
cited to show the 
influence of trau- 
ma is the associa- 
tion between gall 
stones and carci- 
noma of the gall 
bladder. This tu- 
mor is about four 
times as common 
in women as in 
men, and lacing in 
association with 
gall stones is sup- 
posed to be a fa- 
voring cause. It is undoubtedly true that gall stones are 
constantly found associated with the tumor, but this may 
be due to the fact that their formation is favored by the 
production of necrotic tissue which may serve as a nidus 
in the formation of the concretion. It has also been 
urged that in cases of metastatic tumor formation in the 
gall-bladder calculi are not found, but here again the in- 
frequency of ulceration and other conditions which 
would favor their formation must be considered. 

It would not do to dismiss the influence of trauma 
in the production of the tumor as altogether incredible, 
but if it plays any part it must be a very minor one, or 
it may help in the action of other causes. 

There is much that may be said in favor of the germinal 
theory of origin. This assumes that in the course of em- 
bryonic development remains of embryonic tissues may 
be included within the normal tissues, and from such 
embryonic remains, or from certain cells which have re- 
tained their embryonic capacity for growth, the tumor 
may develop. In favor of this theory it may be said that 
such remains of embryonic tissues do become included 
within normal tissues and from them tumors often de- 
velop. This theory, though not original with Cohnheim, 
was taken up by him and advocated with all the force 
and charm which characterize his work. 

Ribbert has of late advanced a theory of formation 
which may be said to be a modification of the germinal 
theory. He supposes that not only such embryonic re- 
mains of tissue may be included in other tissues, but in 


678 








Fig. 11384.—Bile Duct of the Rabbit from a Case of Psorospermosis of the Liver. 


is dilated and partly filled with a papillary growth. 
lumen. The younger forms are in the epithelial cells. 





the course of pathological processes epithelial cells may 
be separated from their connection with one another and 
enclosed in the connective tissue. The stroma, for him, 
forms an integral part of the growth, and the tumor usu- 
ally begins with cellular infiltration of the connective 
tissue. There is much that is opposed to this theory of 
Ribbert’s. The cellular infiltration around the edge of a 
young carcinoma, though commonly present, may be 
entirely absent. I have regarded it as due to the reac- 
tion of the connective tissue to the presence of epithelial 
cells out of place and which act as foreign bodies. It 
is not at all an uncommon thing in the course of surgical 
operations to have both collections of epithelial cells 
and single cells included in the connective tissue, as in 
the suturing of wounds of the skin or intestine, and the 
same thing probably takes place in any operation on a 
glandular organ. The cells may remain in the tissues 
for a considerable time and may even show evidences of 
growth, but they are finally destroyed by the phagocytic 
action of cells de- 
rived from the tis- 
sue. Another 
point against the 
theory of Ribbert 
is his assumption 
that the small-cell 
infiltration is in- 
dicative of activ- 
ity on the part of 
the connective tis- 
sue and the cells 
are derived from 
this. They are 
really chiefly 
lymphoid and 
plasma cells, and 
the condition may 
not betoken any 
activity whatever 
on the part of the 
connective tissue. 
Boll, in 1876, 
spoke of the im- 
portance of the 
stroma in the car- 
cinoma. He says 
also that in the de- 
velopment of the 
tumor there is 
marked proliferation of the connective tissue, leading to 
the formation of a vascular germinal tissue into which 
the epithelial growth takes place. He thinks that the 
formation of such a tissue is the one essential condition 
for the formation of carcinoma, When it is formed the 
old strife between the epithelium and the connective 
tissue breaks out anew. ‘Thiersch, also, says that the fre- 
quency of carcinoma in old people may be due to de- 
generative conditions of the connective tissue which can 
no longer successfully oppose the growth of the epithe- 
lium. In this connection it must further be remembered 
that the epithelial cells of a carcinoma do not grow as does 
ordinary epithelium. The cells may retain something of 
their physiological tendencies as shown in their manner 
of growth, but they have a capacity for growth and an 
activity of growth far in excess of any normal tissue. 
Hansemann has called particular attention to the very 
marked difference in structure and in the manner of 
multiplication in the cells of the carcinoma as contrasted 
with normal epithelium. The enormous capacity for 
growth is not due to the abnormal situation in which the 
cells find themselves, but to certain qualities in the cells 
themselves. In their abnormal situation they are not 
placed in the most favorable conditions for nutrition, but 
in spite of this their growth is so rapid that the increase 
more than compensates for the cell destruction that takes 
place. Normal epithelium placed in the same situation 
shows only a limited power of proliferation and finally 
disappears. 


The duct 
The empty capsules are seen in the 
(8 mm. Zeiss.) 


————— Shc 


m REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


This being the case, nothing was more natural than to 
‘suppose that some influence was exerted on the cells 
giving them other properties, and with this came the idea 
of the parasitic origin of carcinoma. In the first place, 
there seems much analogy between a carcinoma and such 
an infectious disease as tuberculosis. Both arise in some 
primary point, and from there the same process extends 
farther by means of the blood and lymphatic vessels. 
But the analogy does not go further. In tuberculosis 
the nodules are due to proliferation of the ordinary cells 
of the tissue and to exudation. The tissue formed has 
certain characteristics due to its arrangement and ten- 
‘dency to necrosis, but the same elements which compose it 
may be found ina variety of conditions. In carcinoma the 
new formation of tissue has a definite structure and could 
not arise from simple proliferation of the tissue elements. 
In infection of certain epithelial surfaces by protozoa 
there may be marked epithelial proliferation which may 
‘somewhat simulate a tumor, but the growth is typical 
and if the infection proceeds further the character of 
the formation in which it appears is modified by the 
character of the tissue. Examples of this are seen in the 
psorosperm infection of the alimentary canal and liver of 
the rabbit. In the infectious disease the pathogenic 
organism alone is necessary; in the carcinoma the cell 
is the infectious agent. The infectious disease may be 
transmitted from one individual to another. There is no 
evidence to show that carcinoma is ever transmitted from 
one individual to another under natural conditions, and 
even inoculation experiments which have been made 
from man to man and from man to animals have always 
been without any result. There have been cases, however, 
of successful inoculation from place to place on the same 
individual. In animals it has been possible to transfer 
carcinoma from one animal to another by implanting 
pieces of the tumor. Even if the carcinoma could be 
inoculated from man to man, or even from man to ani- 
mal, it would be nothing in favor of its parasitic origin. 
Wher the disease once develops, when the epithelial cells 
once take on the peculiarities of growth which character- 
ize the tumor, these cells are practically parasites. They 
live in strange situations and at the expense of the tissue 
which is their host, and have the power of unlimited in- 
crease. It might even be possible to suppose that favor- 
able conditions for their increase might be provided out- 
side of the body, and the disease might be transmitted 
by inoculation with generations of cells which have de- 
veloped in vitro. It seems most remarkable that it is not 
possible to place these cells, still growing and contained 
in tissue, in another individual and have them retain 
their power. It is possible that there may be certain 
‘chemical differences in the tissue fluids of an individual 
with carcinoma which are favorable or essential for such 
a growth of the cells. 

The carcinoma is easy of explanation after it has begun; 
the difficulty is in finding its primary cause. Ground for 
the assumption of a parasitic origin has been found in 
the supposed increase in the frequency of carcinoma. 
If it is due to embryonic causes or trauma or any such 
constantly acting cause, there should be no likelihood of 
increase. If due to parasites, carcinoma, like other in- 
fectious diseases, should show periods of increase and de- 
cline. There seems to be little doubt, from the numerous 
statistics which have been gathered on this subject, that 
there has been a marked increase in the mortality from 
carcinoma in the past twenty-five years. There are a 
number of things to be considered in connection with 
this increase. There has been an increase in longevity, 
due principally to diminished mortality in the infectious 
diseases. Carcinoma is essentially a disease of later life, 
and more people reach what may be termed the carci- 
noma age. The diagnosis of carcinoma, especially of the 
internal organs, has become more accurate and deaths are 
now properly attributed to this disease which were for- 
merly put down under other heads. Deaths from carci- 
noma were formerly concealed as much as possible, due 
to a horror of the disease and fear of a supposed heredi- 
tary family taint being known. Hospital surgeons have 








Carcinoma, 
Carcinoma, 


a general idea that the disease is increasing, from the in- 
creased number of cases which come to the hospitals for 
operation, due to the much greater success which now at- 
tends such operations. There still remains a great deal 
of work to be done on the statistical side, with a careful 
consideration of the operation of other causes, before we 
can say*how much the disease is increasing or if it is in- 
creasing at all. The increase as generally shown is not 
in favor of the parasitic theory, for it has been gradually 
progressive, and not marked by exacerbations and remis- 
sions as would be the case with an infectious disease. 
Although from a theoretical point of view all that we 
know about the carcinoma would oppose the parasitic 
theory, the proof of this is believed by some to have been 
shown by the actual presence of parasites in the cells 
themselves. No consideration need be given to the old 
works on this subject, in which bacteria were found in 
cultures made from tumors. No connection was ever 
shown between the tumor and the bacteria and no results 
followed from inoculation. Following this there have 
been numerous descriptions of other organisms than bac- 
teria, and attempts have been made to cultivate these sup- 
posed organisms and to reproduce the disease by inocu- 
lation. At first these problematical organisms were 
supposed to be protozoa, and in some cases the entire life 
history of the organisms was described. Since the work 
of Busse the protozoic idea has been given up and most 
of the present writers on the subject describe the organ- 
isms as belonging to the blastomycetes. All of these 
descriptions depend upon certain bodies which are in- 
cluded in the cell protoplasm. These bodies included in 
the protoplasm differ in their size, form, and staining 
reactions. There are certain among them which have 
about the same size and apparently the same structure, 
and these have been especially selected as being varieties 
of the yeasts. They are not universally present in all 
carcinomata. They are found more frequently in carci- 
nomata of the breast than in those developing from any 
other part, and have seemed to me to be more frequent in 
those tumors and portions of tumors in which degenera- 
tions are more frequent. They are not present in carci- 
nomata of the skin. These bodies are in the vicinity of 
the nucleus and as arule they have about the diameter 
of a red blood corpuscle, though they may be much 
smaller or larger. In some cases they are as large as 
the nucleus of the cell. They usually have a sharp 
edge separating them from the protoplasm and occasion- 
ally a small space may be seen at one side, but they do 
not lie in definite vacuoles. They have a homogeneous, 
non-granular structure, and usually there is a single 
granule in the centre of about the size of the nucleolus 
of a cell and which stains in the same manner. Not in- 
frequently there are radiating lines which extend from 
the central granule to the periphery of the body. ‘ 
Plimmer, an English investigator, has laid great stress 
on these bodies and regards them as the specific organ- 
ism which produces the tumor. The number of these 
bodies varies enormously. In some tumors almost every 
alveolus contains several of them, in others they are 
wholly absent. They have no specific staining reactions. 
Plimmer has devised a special stain to demonstrate them, 
but they may be shown by the ordinary stain of hama- 
toxylin and eosin. They are certainly the most distinc- 
tive of all bodies included in the protoplasm, but there is 
nothing in their size, form, structure, or staining reac- 
tions w vhich should lead us to consider them living para- 
sites. The other objects included in the protoplasm 
may be divided into two classes. One class is composed 
of bodies generally round, sometimes single, sometimes 
in groups, always homogeneous and closely invested by 
the protoplasm. They stain in various ways, and many 
of them have a special aflinity for certain dyes and in 
this way may be sharply differentiated from the proto- 
plasm. Russel described certain of these which are 
sharply stained with fuchsin, and which have since been 
generally known as Russel fuchsin bodies, and he regarded 
them as probable parasites. Bodies similar to these may 
be found in a large number of pathological conditions, 


679 


Carcinoma, (Skin, 
Carcinoma of the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








and they are obviously nothing but various forms of de- 
generation of the protoplasm. The third group of bodies 
are the most variable of all. They always lie in vacuoles 
in the protoplasm. They are irregular in size, and care- 
ful study will show every variation between the most in- 
definite of these bodies and structures which may cer- 
tainly be recognized as cells, and even the special variety 
of cells may be distinguished. The cells of carcinoma 
differ further from ordinary epithelial cells in their 
marked phagocytic properties. The included cells may 
be cells or portions of cells from the tumor itself, poly- 
nuclear leucocytes, or the lymphoid and plasma cells of 
the stroma. The last two groups of inclusions are easily 
explained; they are in no way peculiar to carcinomata or 
any of the tumors. 

The various transformations which included cells may 
undergo can probably be better studied in the large cells 
of typhoid fever than elsewhere. They are also very 
numerous in the proliferating connective-tissue cells of 
granulation tissue. The bodies first described are more 
difficult of explanation and probably no single explana- 
tion of their origin can be given. Iam convinced that 
many of them are due to degeneration of the nucleus. 
Ina tumor which developed ina cicatrix after the opera- 
tion, and in which they were very numerous, it was 
possible to see transitions in the nuclei leading to 
these bodies. The chromatin of the nucleus disap- 
peared, the whole structure becoming homogeneous, and 
the nucleolus remaining as the central granule. They 
may also be referred to degeneration of segments of the 
nucleus which are occasionally thrown off and which 
represent the degenerative direct division. Borel be- 
lieves that some of them are certainly to be referred to 
changes taking place around the centrosome, the radiate 
bodies being the spindle, and the granule in the middle 
the remains of the centrosome. In the giant cells of a 
sarcoma I have seen degenerations of the numerous cen- 
trosomes which become swollen up and the spindle 
around them more definite, but none of these bodies 
were found. Whatever the explanation given, there is 
nothing in the present state of our knowledge which 
should lead us to regard them as parasites. The de- 
fenders of the parasitic theory have been able, in a small 
number of cases, to cultivate yeasts from carcinomata. 
They have inoculated animals with these cultures and in 
a very few instances, not more often than could be ex- 
plained as a coincidence, epithelial tumors have resulted. 
Almost invariably the new formation of tissue which has 
resulted from the inoculation has been granulation tissue 
of a sort which would follow from the introduction of 
any injurious agent. 

It would not be justifiable to deny the possibility that 
carcinoma may be due to a parasite, but no evidence of 
this has been adduced up to the present time. On the 
contrary, everything we know of the tumor speaks 
against this idea. Ifa parasite is the cause, it must be 
different from any form of parasite we know, and its 
relations to the tissue must be different. It would be 
difficult to assume that a parasite could infect the tissues 
at a certain point, giving to the cells certain properties 
which would be retained “by all following generations 
of cells. Otherwise we must assume a symbiosis be- 
tween cell and parasite, as the parasite must be present 
in all cells and be carried with the cell to produce a 
metastasis, for a metastasis cannot be due to a parasite 
alone. 

When the carcinoma once starts the cells themselves 
act as parasites. In the removal of a carcinoma, if the 
operation is to be successful, all the parasitic cells must 
be removed. It is not sufficient to remove the primary 
tumor and the lymph glands connected with the tissue, 
but the tissue between the two, in which the lymph 
vessels run and which may contain straggling cells, 
must also be removed. It may be extremely difficult to 
do this, for the blocking of the glands by metastases and 
the occlusion of the ordinary lymph channels may bring 
other collateral channels into play. The frequency with 
which the tumor reappears in the cicatrix after opera- 


680 





tion may possibly often be due to infection of the in- 
cised part by the knife of the surgeon. 
W. T. Councilman. 


CARCINOMA. (CLINICAL.) See Cancer. (Clinical.) 


CARCINOMA OF THE SKIN.—A uniform nomencla- 
ture of malignant growths of epithelial tissue is, even in 
the present state of our pathological knowledge, by no 
means employed by writers. 

In a general way, however, carcinoma is used to desig- 
nate all varieties of malignant growths of epithelium, in- 
cluding both the glandular and the surface varieties. 
The majority of writers use the term epithelioma when 
referring to primary cutaneous cancers. 

Fabre and Domergue* make a clinical and pathological 
distinction between epitheliomata and carcinomata of the 
surface in the manner of growth (orientation) of the cells 
and the relationship of the cells to the basal layer of the 
epidermis. 

In the present article carcinoma is employed as a com- 
prehensive term embracing all the varieties which have 
their starting-point in the surface epidermis or its ap- 
pendages. 

SyMPTOMATOLOGY.—The primary forms which skin 
cancers assume depend to some extent on their seat and 
minute structure. We are unable, because of so many 
exceptions to this statement, to formulate any rule which 
will always associate a definite clinical type with a fixed 
histological structure. 

The old division of carcinomata of the skin into (1) the 
superficial, flat, or discoid, (2) the deep-seated, nodular, 
or infiltrating, and (3) the papillary, is still largely em- 
ployed as furnishing convenient terms for use in descrip- 
tions. 

This classification is more or less imperfect, as the flat 
or discoid form may become deep-seated, the latter in- 
volving the skin secondarily asa superficial growth, while 
both are at times complicated by papillary outgrowths, 

Unna+ has attempted to reduce the majority of skin 
carcinomata to a few types according to the gross histo- 
logical appearances or architecture of the growths. He 
obtains in this way three chief forms which he designates 
(1) the fungating, (2) the cylindrical, (8) the alveolar, each 
of which is further subdivided. A fourth or sub-form 
(carcinomatous lymphatic infarction secondarily affecting 
the skin after breast cancer and in metastases) is added to 
this classification. 

The classification proposed by Unna is based chiefly on 
the histological structure of the growth, and in the fungat- 
ing form the macroscopic appearance of the tumor is 
considered as well. 

To one unfamiliar with the histological details of carci- 
noma of the skin the classification is too involved for 
practical purposes. A further reference will be made to 
it in describing the minute anatomy of these new growths. 

To avoid confusion in the clinical picture of the malady 
certain primary types of more or less uniformity will be 
described, and then reference will be made to the forms 
which follow or develop on some pre-existing morbid 
condition of the skin or constitute the final stage of such 
affections, as xeroderma pigmentosum, Paget’s disease, 
lupus vulgaris, syphilis, ete. 

An important fact to be borne in mind is that carci- 
nomata of the skin are not infrequently multiform in their 
manifestation and often have a relatively benign course. 

Superficial Epithelioma.—One of the most frequent 
forms in which carcinoma of the skin begins is as a 
small, hard, pearly gray nodule generally found on the 
upper two-thirds of the face in individuals over forty 
years of age. These nodules are often multiple, may re- 
main for years with little or no change, or even may dis- 
appear spontaneously. If they are removed during their 
primary stage before ulceration begins they show only a 
slight tendency to recur. ; 





*** Les Cancers Epithéliaux,’’ Paris, 1898. 
+ Unna, “ Histopathology of the Diseases of the Skin,” p. 670. 


: 
: 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Carcinoma, [Skin, 
Carcinoma of the 





After a time one or more of these small growths may 
slowly increase in size, the centre at the same time sink- 
ing in and eventually becoming fissured or excoriated as 
the result of scratching or other irritation. At this 


stage, the new growth consists of a superficial ulcer 


covered with crusts made up of blood and secretions from 
the affected surface, and surrounded by a hard, elevated, 
waxy looking margin (Fig. 1, Colored plate XXI.). 
The central ulceration may heal but is sure to recur, 
each time becoming somewhat larger, but seldom involv- 
ing the deeper tissues; it hasared, granular base, secretes 
but little pus, and rarely causes pain. The floor and 
edges of the ulcer, consisting of soft friable tissue ex- 
tending beneath the overlying epidermis, are easily re- 
moved by the curette. Instead of extending in a regular 
and progressive manner the ulceration may heal in the 
centre while continuing to spread at the margins, or one 
side may cicatrize, asa result of which gyrate and irregu- 
larly outlined ulcers with new foci may develop in the 
scar tissue (Fig. 1135). Such a carcinomatous ulcer may 





Fig. 1135.—Superficial Epithelioma of the Face (Rodent Ulcer Type) 
of Fifteen Years’ Duration. Showing scar tissue and peripheral 
ulceration. 


generally be differentiated from syphilitic or lupous ul- 
ceration by the presence of the elevated, waxy, or pearly 
gray margin. 

The progress of the affection is excessively slow, last- 
ing ten, twenty, or even forty years before the patient 
dies from this or some other malady. It may even- 
tually, however, invade the orbit, destroy the greater 
part of the skin of the face, the malar bones, the upper 
jaw, and penetrate the skull, causing the death of the 
patient from hemorrhage, exhaustion, or the involvement 
of vital organs. Fungating tumors reaching a consider- 
able size may spring up from these ulcerating surfaces. 

This variety of malignant growth, which has its pri- 
mary seat near the eye, beginning as a minute, pearly gray 
nodule and spreading in a slow but progressive manner, 
is the so-called rodent or Jacob’s ulcer, regarding the na- 
ture of which there has been so much discussion and di- 
vergence of opinion. It seldom or never invades the 
lymph nodes, and does not produce metastases or give rise 
to cachexia. It waslooked upon by the older writers, such 
as Brodie and Paget, as a disease distinct from carcinoma 
and some modern authors even now deny its carcinoma- 
tous nature. Probably several varieties of superficial 
skin carcinoma during their course may assume the ap- 
pearances described, so that the name, if retained, should 
be used in its clinical significance rather than to indicate a 
distinct species of epithelial new growth. Unna, on the 
other hand, opposes the view that every flat, superficial, 
carcinomatous ulcer should be called rodent ulcer. He 
believes that the latter affection has certain definite clinical 








as well as histological features which are characteristic, 
and that it should not be confused with other varieties of 
carcinoma. 

In addition to the early lesion in the form described, 
epitheliomata about the face may begin as brownish-red 
tubercles, hemispherical in outline, quite smooth, and 
of medium consistence. When first observed they are 
smaller than a split pea, slightly elevated, and may reach 
the diameter of half an inch before breaking down. 
These small nodules are readily scraped away with the 
dermal curette and apparently show little tendency to 
recur. They are seen about the ala of the nose, the eye- 
lid, and the forehead. Sections of such growths under 
the microscope are found to contain proliferating bands, 
tubular processes, and acinous-shaped masses of small 
epithelial cells which correspond to those in the basal 
layer of the epidermis. These proliferating tracts and 
masses of cells are surrounded by a layer of columnar 
cells which represents the basal layer and probably limits 
their rapid growth. They are enclosed in a loose mesh- 
work of connective tissue which is generally poorly de- 
veloped or may be almost absent. 

If undisturbed these nodules grow slowly for a num- 
ber of years, then, under the stimulus of some irritant, in- 
crease more rapidly in size, finally resulting in open ulcers. 

Disseminated Epithelioma of the “ Sebaceous Type.” — 
Multiple epitheliomata which are met with especially 
about the face, sometimes on the hands and trunk, are 
usually preceded by certain definite changes in the skin 
to which the name “senile keratosis” has been applied. 

The skin at first becomes somewhat rough, and is cov- 
ered by scales adherent to the follicular openings. Later, 
scabby concretions of a dirty yellowish-brown color form, 
and beneath them is found a warty condition which bleeds 
readily on slight irritation. Small cup-shaped depres- 
sions are subsequently noted beneath the thickened and 
altered horny layer; these coalesce and give rise to open 
epitheliomatous ulcers having hard, elevated edges and 
bases. A number of years may elapse from the time 
when the first changes in the skin appear before a malig- 
nant development takes place. 

The same patient is frequently affected with several epi- 
theliomatous ulcers in different stages of growth as well 
as with encrusted papillomatous areas which have not 
yet undergone the malignant change. The severer cases 
occur among those patients who are exposed to vicissi- 
tudes of weather and to the heat of the sun and in whom 
the earlier alterations in the skin which predispose to the 
condition are overlooked or neglected. 

Other senile changes in the skin, as pigment deposits, 
papillomata, alterations in the blood-vessels, atrophy of 
the subcutaneous connective tissue, predispose to malig- 
nant new growths. These changes are allied to those 
which occur in the young in a more aggravated form, 
constituting the disease known as xeroderma pigmento- 
sum, which, as a rule, terminates in the development of 
one or more malignant tumors. They are also met with 
in the condition known as sailors’ skin, which Unna* has 
observed and investigated. The changes which take 
place on the exposed portions of the face and hands are 
at first a cyanotic redness, followed by pigment deposits 
and leucodermatous spots. Localized thickening of the 
horny layer of the epidermis next occurs, and this, at 
certain spots, assumes a warty character, to be followed 
by papillary and ulcerating epitheliomata. While in 
their early stages these ulcers pursue an indolent course, 
and involve only the superficial tissues; at a later date 
they are more rapidly destructive than the rodent ulcers. 

In Paget’s disease of the nipple a superficial, moist, 
crusted, slightly scaling dermatitis may exist for a 
number of years as a precancerous condition. Healing 
cannot be brought about by the ordinary applications 
and eventually a superficial or deep-seated carcinoma 
appears in or beneath the chronic dermatitis. It is usu- 
ally of the alveolar type, and more frequently begins in 
the lactiferous ducts than in the epidermis itself. Swell- 





*Unna, “Histopathology of Diseases of the Skin,” p. 719. 


681 


Carcinoma of the 
Skin, 








ing of the lymph nodes is met with in the later stages of 
the disease. 

Multiple epitheliomata at times develop on old patches 
of psoriasis. The prolonged use of arsenic in this and 
other chronic skin diseases is at times followed by patches 
of keratosis and horn-like lesions especially on the palms 
of the hands and soles of the feet, beneath which can- 
cerous ulceration begins. These malignant changes are 
usually multiple, and in fifty per cent. of the cases re- 
corded they developed before the age of forty. Among 
arsenic miners carcinoma, beginning as arsenic warts on 
the fingers, has not infrequently been observed. 

Hutchinson has repeatedly called attention to the etio- 
logical relationship supposed to exist between the internal 
use of arsenic and the development, on the palms and 
soles, of keratoses which terminate in carcinoma; and 
lately Hartzell* has reviewed the subject, giving at the 
same time the report of a case of his own which showed 
this sequence of development. 

Chimney-Sweeps’ Cancer of the Scrotum.—This variety 
of cancer, which at one time was often met with in Eng- 
land, has become less frequent since the enforcement of 
laws forbidding sweeps to ascend flues. The retention 
of soot in the folds of the scrotum gives rise to a chronic 
dermatitis and warty outgrowths. After a time one or 
more of these warts ulcerate and eventually involve the 
superficial as well as the deep tissues. The inguinal 
lymph nodes after a time become implicated. 

Tar and Paraffin Cancer.—Volkmann + first called at- 
tention to the occurrence of cancer of the scrotum and 
forearms in workers in coal tar and paraffin. The an- 
tecedent changes in the skin are similar to those met 
with in chimney-sweeps’ cancer. The follicular open- 
ings are occluded, the skin becomes dry, thickened, and 
the seat of warty growths which subsequently become 
malignant. 

It isnot improbable, as has been suggested by Esmarch 
and Langenbeck, that tobacco, soot, tar and paraffin are 
closely allied in their power to stimulate epithelial growth. 
Abnormal cell division has been experimentally produced 
by treating the dividing cells with poisons and chemical 
agents, thus rendering more probable the relationship 
which is believed to exist between the long-continued 
use of arsenic and the development of cancer, and at the 
same time favoring the view that this variety of new 
growth may owe its origin to the stimulation furnished 
by such chemical agents as tobacco, tar, etc. 

Chronic affections of the derma, as lupus, syphilis, 
etc., seem to favor the development of carcinoma by 
lessening or removing the normal barrier which sep- 
arates the epithelium from the connective tissue. At 
the same time a constant irritation is exerted on the 
epithelial layer which causes it to undergo hypertrophy 
and ultimately may lead to its becoming the seat of a 
malignant growth. 

Carcinomata develop from active lupus or from its scar 
tissue so frequently as to indicate more than an accidental 
relationship. They are apt to assume fungating forms, 
to prove rebellious to treatment, and to pursue a more 
rapid course than when they develop independently of 
such a connection. They have also not infrequently 
been observed to start from late syphilitic lesions of the 
skin, in which case there is danger that they may be over- 
looked because the original disease often obscures their 
characteristic features. 

Syphilis of the tongue is one of the most frequent 
precancerous affections of this organ. Late syphilitic 
neoplasms, interstitial glossitis, and leucokeratosis may 
be followed by rapidly growing carcinomata. Indifferent 
scar tissue of the skin, when exposed to long-continued 
irritations, forms a favorable soil for the development of 
a malignant tumor. The course of such growths is less 
rapid than when they start from the scar-tissue of lupus. 
In the latter case there is nearly always more or less ac- 


*‘* Epithelioma as a Sequel of Psoriasis and the Probability of its 
ee Origin.”” The Amer. Jour. Med. Sci., vol. exviii., 1899, 
p. 265. 

+ Beitrage zur Chirurgie, 1875, p. 380. 


682 

















REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tive tuberculous disease and thus less resistance is offered 
to the epithelial ingrowths. 

Papillary Carcinoma. — Papillomatous tumors bear 
much the same relationship to epitheliomata as the ade- 
nomata do to glandular carcinomata. They consist of a 
rapid growth of the cells comprising the Malpighian layer 
with a consecutive hypertrophy of the papille beneath. 
As long as the basement membrane remains unimpaired 
the invasion of the underlying tissues by the growing 
epithelium is prevented. 

Papillary growths frequently spring up from the base 
and periphery of carcinomatous ulcers, especially when 
a mucous membrane is involved, and obscure by their 
rapid development the features of the primary tumor. 
The scalp is sometimes the seat of these secondary 
growths (Fig. 3, colored plate XXI.), which assume a 
cauliflower-like appearance and convey the impression 
of a more malignant tumor than is warranted by their 
clinical course. These outgrowths are usually broader 
at their surface than where they are attached to the mor- 
bid growth, and they spread over the healthy skin in a 
radiating manner for a considerable distance. 

The seats of predilection of a primary papillary carci- 
noma are the glans penis and the lips. An absence of a 
firm epithelial covering facilitates the surface growth of 
the prickle layer (Unna). The horny layer may in the 
early stages be thickened and firmly attached, but, later, 
cornification becomes abnormal, and the enlarged papilla 
with the rapidly growing and unprotected prickle cells, 
bleeds readily on slight irritation. Surface infection takes 
place with consecutive necrosis of the superficial layer of 
cells. As long as the epithelial proliferation is superficial, 
these growths are easily removed. When the deeper 
tissues are invaded they spread at times with alarming ra- 
pidity owing to their active cell-growth. Sooner or later 
ulceration takes place and the early features of the affec- 
tion may be lost. In Fig. 2 of the accompanying col- 
ored plate a carcinomatous ulcer is depicted which began 
as a wart, but at the time when the picture was taken 
the papillomatous growth had entirely disappeared. 

These carcinomata differ from the growths of the ro- 
dent-ulcer type in their tendency to form horny or hya- 
line pearls as well as in their more rapid and malignant 
course. 

Cutaneous horns are modified papillomatous tumors in 
which cornification is greatly exaggerated. Epithelio- 
mata sometimes start from the base of such growths and 
terminate in open ulcers, which pursue the ordinary 
course of the malignant new growth. 

Carcinomata from Nevi.—Pigmented and non-pig- 
mented moles often present the structure of an alveolar 
carcinoma, and while the great majority of such con- 
genital malformations retain their benign character, they 
occasionally give rise to growths of great malignancy. 

Unna* and Gilchrist + have shown that these nevi are 
caused by the snaring off of epithelium from the surface 
epidermis in embryonic life or in early youth. Malig- 
nant tumors arising from such a matrix later in life are 
therefore carcinomata and not sarcomata, as has been so 
long held by the majority of pathologists. 

It has not been clearly determined that all malignant 
melanotic tumors are carcinomata, but if certain of these 
are of mesodermic origin it is impossible to differentiate 
the two classes clinically. These melanotic tumors may 
develop on any part of the body, generally on the ex- 
tremities or genitals. They are at first bluish-black or 
slate-colored growths assuming wart-like or fungous 
forms. : 

Secondary tumors may develop in the vicinity of the 
parent growth, and, spreading along the lymphatic ves- 
sels, give rise to large nodular growths in the lymph 
nodes. Metastatic tumors rapidly form in the viscera, 
and cachexia soon appears, followed by a fatal termina- 
tion, sometimes within a few months after the appear- 
ance of the primary tumor. 


* ‘* Histopathology of Diseases of the Skin,”’ p. 745. 
+ Journ. of Cutan. and Genito-Urinary Dis., vol. xvii., p. 117. 


EXPLANATION OF 
PLATE XXII. 


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Fic. 


Fig. 


Fia. 


EXPLANATION OF PLATE XXI. 
(Illustrating Dr. Fordyce’s article.) 
The colored pictures have been copied from photographs of author’s cases. 


1.—Early stage of superficial epithelioma of the face, the so-called rodent-ulcer type of the 
affection. ; 
In this variety of epithelioma the new growth is made up of small epithelial cells which cor- 
respond to those in the basal layer of the epidermis or in the outer root-sheath of the hairs. 
The growth began in this case as a small pearly-gray nodule which slowly ulcerated in the 
centre while spreading with an elevated margin. The progress of this type of epithelioma is 
exceedingly slow. 


2.—A more advanced stage of epithelioma of the skin. The growth here portrayed is of eight 

years’ duration. It beganas a wart which rapidly spread after the application of some caustic. 
The post-cervical lymph nodes were enlarged. The microscope showed the tumor to be a 
squamous-celled epithelioma, the prognosis of which is more grave than that of the rodent- 
ulcer type. 


3.—The tumor here shown was seen when fully developed on the scalp of an old woman. It 
was attached by a broad peduncle, its margin resting on the healthy skin. The body of the 
growth was made up of moist, warty vegetations which readily bled on slight irritation. 
Under the microscope the tumor was found to resemble an alveolar carcinoma, the connective- 
tissue framework being rich in newly developed blood-vessels. 


REFERENCE HANDBOOK 
OF THE 


MEDICAL SCIENCES. PEATE XX. 


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FIG. 1. EARLY STAGE OF RODENT ULCER OF THE FACE. 





; FIG. 3. PAPILLARY OUTGROWTH WHICH DEVELOPED ON EPITHELIOMA OF THE SCALP. 


CARCINOMA OF THE SKIN. 


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"REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. — 


eS 


Carcinoma of the 
Skin, 





Deep-Seated or Nodular Carcinoma.—The great majority 
of cutaneous cancers conform to one or more of the types 
which have been described and are in their early stages 
more or less superficial. Many preserve such a location 
during their entire evolution, the new growth ulcerating 
as soon as it develops. Othersmay early tend to involve 
the deeper tissues, giving rise to distinct indurations or 
veritable tumors which invade the muscles or bones. 
The deep-seated or nodular carcinoma is, therefore, usu- 
ally secondary to a surface ulceration, but it may occur 
near the cicatrices of former operations for malignant dis- 
ease, a group of cells in the subcutaneous tissue acting as 
a focus for the relapsing growth. 

Metastatic cancers of the skin from visceral or breast 
carcinoma are usually first detected as small subcutane- 
ous nodules which, in exceptional cases, may enlarge, 
assume an irregularly rounded shape, and become firmly 
attached to the underlying tissues. 

Certain carcinomata of the surface epithelium, more 
especially of the tongue and lip, show an early tendency 
to deep infiltration and are apt to pursue a more malig- 
nant course from the beginning. The only plausible ex- 
planation that has been given as to why these growths 
tend to involve the deeper structures, is, that the down- 
ward growth of the epithelium can take place more readily 
in these localities where the tissues are rather succulent. 
Fabre-Domergue, however, attributes their more malig- 
nant course to the character of the new cell growth, 
which is favored by the absence or non-continuity of the 
basal layer about the masses of growing epithelium. In 
carcinoma of the tongue there is little or no disposition 
on the part of the epithelial cells to form concentric 
globes containing horny or hyaline masses, but the con- 
stituent cells grow, multiply, and end their existence 
independently and simultaneously. There is, conse- 
quently, in these tumors of the tongue an absence of 
those histological features which limit cell growth in 
many of the surface epitheliomata. 

Deep-seated epitheliomata, when primary, may begin 
as single or multiple pea-sized nodules of a whitish or 
purplish color. They increase slowly in size, become 
more irregular in outline, and form adhesions to the 
overlying skin. Eventually there is produced a firm, 
projecting tumor, which may reach the size of a hen’s 
egg, over which dilated blood-vessels are prominently 
seen. Ulceration subsequently takes place, leading to 
the formation of cavities which increase in a progressive 
manner as the infiltration spreads and breaking down of 
the tissues occurs. 

Papillomatous growths sometimes spring up from the 
base or walls of the ulcerating surface, the edges of 
which may contain waxy nodules like those seen in the 
superficial varieties. The lymph nodes may be involved 
at a comparatively early period and metastases may de- 
velop in the internal organs; then follow marasmus and 
death. 

Under the name of tuberose carcinoma cases of this 
kind have been described in which multiple, deep-seated 
tumors developed simultaneously and broke down into 
ulcers which soon led to the patient’s death. 

Carcinomatous Lymphatic. Infarction.—This is the name 
given by Unna to a sub-form of cancer of the skin. It is 
generally described as lenticular carcinoma. It is met 
with, in the great majority of cases, in the skin covering 
the female breast as a development secondary to mam- 
mary carcinoma; it may also develop in the cicatrix fol- 
lowing operation for cancer of the gland. Epithelial cells 
from the primary growth are conveyed by the lymph 
vessels and give rise to the formation of small white or 
pinkish papules from the size of a small shot to that of 
apea. Infiltrated patches at times result from the con- 
fluence of numerous primary nodules which may or may 
not undergo ulceration. 

When the lymphatic infection is active and extensive 
the entire cutaneous surface over the front and Wack of 
the chest may be involved, the process even extending 
to the skin of the abdomen and arms. In the later stages 
the skin becomes hard and leathery in consistence from 











the growth and contraction of the connective tissue, pro- 
ducing the condition known as cancer en cuirasse. 

The constriction produced by the new growth may be 
sufficient to interfere with respiration or may give rise 
to edema of the arm from interference with the lymph 
circulation. A fatal result may follow within a few 
months after such a development occurs, but in certain 
cases general infection is delayed for a number of years. 

Carcinoma of the Sweat Glands.—The most divergent 
opinions exist as to the réle played by the sweat glands 
in tumor production. Certain pathologists at various 
times have attempted to show that many small-celled 
epitheliomata, in which the cells grow in tubular proc- 
esses, have such an origin. It has, however, been clearly 
demonstrated that neither the shape, size, nor arrange- 
ment of the cells furnishes sufficient criteria on which to 
base the diagnosis of sweat-gland cancer. Darier* has re- 
ported a peculiar case that occurred in the service of Bes- 
nier, in which multiple, deep-seated, and painful tumors 
developed with great rapidity on the trunk of a man aged 
seventy-one. Darier’s examination showed that each 
tumor started with a proliferation of the sweat-gland 
epithelium, which filled the lumen of the canal, broke 
through the membrana propria, and infiltrated the con- 
nective tissue. He gave to his case the name “ diffuse 
multiple epithelioma of the sudoriparous glands,” and 
believed it to be unique in the number, the rapid evolu- 
tion, and the structure of the tumors. The author was 
able to find but two analogous cases in medical literature, 
one of which was reported by Malherbe, the other by 
Creighton. In the latter case a dog was the subject of 
the affection. In Darier’s case death resulted within a 
few months after the beginning of the affection. 

The author of the present article some years ago ex- 
amined a tumor which had been removed by Dr. Bronson 
from the anterior surface of the leg of a man thirty-five 
years old, and which proved microscopically to be a car- 
cinoma originating in the coil gland. The growth in 
question was composed of distinct lobules, separated by 
the ingrowth of connective tissue; it was soft to the feel, 
about half the size of a small egg, and defined from the 
surrounding tissue without being distinctly encapsulated. 
It extended about one inch below the skin, and measured 
an inch and a half in its long diameter. An open ulcer, 
somewhat larger than a dime, was present over the tumor. 
The cancerous nature of the new growth was not sus- 
pected prior to the microscopic examination. 

Neither the duration of the tumor nor its onset as a 
surface or deep affection was noted. 

Carcinoma of the Lip.—Cancer of the lip, by reason of 
its frequency, malignant course, and the importance of 
an early diagnosis, demands a separate consideration. 
Its seat of predilection is the lower lip, at the junction 
of the skin and mucous membrane near the median line. 
It may occur near the angle of the mouth. The develop- 
ment of a tumor on the upper lip has been noted in one 
or two instances. In these cases contact with the primary 
growth on the lower lip may have served as a cause. 
Cancers of the upper lip, as a rule, occur at some dis- 
tance from the vermilion border and are usually of the 
rodent ulcer or superficial type of growth. When the 
mucous membrane is involved by the extension of such 
a tumor of the upper lip its clinical course differs from 
that of the typical cancer of the lower lip. It does not 
penetrate deeply nor infect the lymph nodes as in the 
latter case. 

A number of primary changes in the surface epithelium 
may precede ulceration or tumor formation. Hyperker- 
atosis over a limited area, followed by a fissure and later 
by ulceration, is often observed. The ulcer is irregular in 
outline and surrounded by thickened and elevated mar- 
gins (Fig. 1136). The base of the ulcer becomes indu- 
rated and the infiltration gradually extends to the deep- 
est issues. 

In another case the epithelium may become eroded in- 








*** Contributions a l’étude de l’épithéliome des glands sudoripares.”” 
Arch. de méd. expérimentale et d’anat. pathol., 1889, pp. 115, 267. 


683 


Carcinoma of the 
Skin, 


“REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





stead of thickened and covered by closely approximated 
granulations which enlarge until they assume a warty 
character. This papillomatous growth may spread lat- 
erally until almost the entire lip is covered with granula- 
tions before deep extension takes place. Instead of the 
ragged ulcer which is portrayed in Fig. 1137, a shallow, 





Fig. 1136.—An Early Stage of Cancer of the Lip. Showing super- 
ficial ulceration. 


oval and regularly outlined loss of tissue may constitute 
an early form of lip cancer (Fig. 1186). (Figs. 1136 and 
1137 are reproduced here by the kind permission of the 
New York Medical Journal.) 

Changes in the epidermis may be overlooked and the 
patient’s attention may be first directed toa hard growth 
below the surface. This soon ulcerates, leaving a cavity 
surrounded by hard walls and base from which the de- 
generated epithelial cells forming the centre of the epithe- 
lial “ pearls” may be squeezed out as comedo-like bodies. 

In neglected cases the infiltration and ulceration in- 
volve the entire lower lip and the floor of the mouth; the 
teeth become loosened and all the adjacent tissues are de- 
stroyed. The submaxillary and submental lymph nodes 
are involved, as arule, before such extensive tissue de- 
struction occurs. The average duration of life in un- 
treated cases is from three to five years, death taking 
place from sepsis or metastasis. 

Cancer of the lower lip occurs in about fifty per cent. 
of surface epitheliomata. The male sex furnishes an 
overwhelming percentage of all cases, variously estimated 
at from eight to one to twenty to one. Statistics show 
that the large majority of those so afflicted are addicted 
to the use of tobacco, and of the few cases met with in 
women three-quarters were smokers. 

Diagnosis.—The initial lesion of syphilis is often mis- 
taken for cancer of the lip. Chancres of the lip are usu- 
ally protuberant with an eroded or encrusted surface; they 
develop rapidly and very early involve the lymph nodes. 
The initial sore of syphilis is more likely to be met with 
in young adults, while epithelioma is a disease of later 
life. Numerous exceptions to these rules, however, are 
found. 

Late ulcerating syphilides of the lip have also been 
mistaken for cancer, but these neoplasms of syphilis are 
usually multiple, rapidly break down or undergo ab- 
sorption with atrophy, and lack the hard base which is 
always present in cancer. 

In a doubtful case appeal should be made to the 
microscope. 

Prognosis.—The course of carcinoma of the lip is much 
more rapidly fatal than is that of the flat variety of epi- 


684 


thelioma of the skin. An early and radical excision by 
the knife is the only method of treatment which promises 
subsequent immunity to the patient. Ifthe operation is 
performed while the affection is superficial the outlook is 
not unfavorable. Even in such cases early operations 
sometimes fail to prevent general infection. 

PATHOLOGY AND Morsrp ANATOoMy.—Carcinomata of 
the skin in the great majority of cases start from the 
surface epithelium or the epithelium lining the hair folli- 
cles. The sebaceous and sweat glands only exception- 
ally are primarily implicated. 

It is not possible in all instances to associate a definite 
clinical type with a fixed histological structure. 

Unna’s plan of classification, which reduces the major- 
ity of skin cancers to a few types according to the archi- 
tecture of the growths, involves the mutual relationship 
of the growing epithelium to the resisting connective 
tissue. A proper presentation of his views would in- 
volve an extended discussion, which is scarcely in place 
in this connection. A distinction of some clinical as well 
as pathological importance is that which separates these 
new growths of epithelium into two groups, in one of 
which the cells are chiefly of the squamous variety, while 
in the other they are of the small or columnar type. As 
a rule the squamous-celled epithelioma is found about the 
muco-cutaneous orifices, more readily involves the lymph 
nodes, and is more malignant than the small-celled variety 
of the disease. The difference in malignancy between 
these two types of growth is perhaps not so decided as 
it was at one time believed to be. 

Squamous-celled epitheliomata are seen at a distance 
from the orifices. They may persist for a period of ten 
years without invading the lymph nodes, and then ex- 
ceptionally the rodent-ulcer type of growth is met with 
in which the communicating lymph nodes are involved. 

We are as yet ignorant of the factors which render 
rodent ulcer a relatively benign affection and the squa- 
mous-celled epithelioma a more malignant growth. ‘The 
superficial seat of rodent ulcer and the early occurrence 
of ulceration are supposed by some writers to prevent 
the absorption of the cells by the lymph vessels. The 
resisting power of the connective tissue, which in rodent 
ulcer early assumes a structure like that met with in 





Fig. 11387.—Early Form of Cancer of the Lip. A shallow concave ulcer 
near angie of the mouth. 


scirrhous cancer, is looked upon by Unna as an important 
factor in determining the clinical course of the affection. 

Although the new growth of epithelium which we 
see in rodent ulcer isalways made up of small cells which 
correspond to those in the basal layer of the epidermis or 
the outer root sheath of the hair follicle, it is possible that 
there are a number of other clinical varieties of small- 


- 








, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Carcinoma of the 
Skin, 





celled skin cancers which are not identical, at least clini- 
cally, with rodent ulcer, 

Carcinomata of the surface epithelium, according to 
the classification of Fabre-Domergue, may develop in the 
direction of the adult type of cell, giving rise to cornifi- 
cation of individual cells or to rudimentary epidermic 





Fig. 1138.—From a Rodent Ulcer of the Face. Showing cylindrical 
processes of small epithelial cells surrounded by a basal layer, 
(Spencer one-quarter inch, projection ocular 2.) 


“ globes, ” between which type and the true epitheliomata 
there are many transitional forms. They may further- 
more assume the embryonic type of growth and simulate 
so closely glandular carcinomata that it is not always 
possible to differentiate them by their: histological struc- 
ture. 

In carcinomata of the adult there are, beside the em- 
bryonic type of cell, the same tendency to general cell 
activity throughout the growth, a non-continuity or 
absence of the basal layer, and consequently in both the 
same tendency to deep infiltration and general infection. 

The clinical gravity of the tumor depends, therefore, 
on its structure rather than on its location. 

The embryonic epithelioma (Fabre-Domergue), the tu- 
bular epithelioma of Cornil and Ranvier, and the small- 
or columnar-celled epithelioma correspond in all essential 
points and are identical in structure with rodent ulcer in 
its earlier stages. The tumor originates from the lower- 
most layer of the rete Malpighii or from the outer root 
sheath and preserves with rare exceptions its embryonic 
cell structure throughout its entire course. The new 
growth of epithelium develops in the form of cylindrical 
processes throughout the lymph spaces of the derma (Fig. 
1188). It is preceded by the appearance of a dense mass 
of mononucleated leucocytes (plasma celis, Unna). The 
connective tissue between the masses of growing epithe- 
lium becomes thickened and sclerotic and probably limits 
the down growth of the cylindrical processes, which 
may later assume elongated shapes owing to the greater 
resistance which they encounter. 

The tubular processes of young epithelium are sur- 
rounded, in the earlier stages of the process, by a layer 
of cells which correspond to the basal cells of the epi- 
dermis (Fig. 1138). As the affection extends it is more 
difficult to identify this layer and it finally disappears. 
The loss of this protective layer is probably one reason 
for the more rapid extension of the growth in its later 
stages. 

No good reason has as yet been advanced why the 
lymph nodes are not involved in rodent ulcer unless it is 
owing to the greater resistance interposed by the connec- 
tive tissue. That they may exceptionally become in- 
fected was shown in a case which recently came under 


the observation of the writer. A patient, sixty years old, 
presented a typical rodent ulcer, of ten years’ duration, on 
the side of the nose, extending to the inner canthus. He 
had at the same time, behind the ear, an epithelioma 
with identical clinical features. The lymph node over 
the mastoid process was enlarged and after excision was 
found to be invaded by typical cylindrical processes of 
epithelium which could not be distinguished from those 
in the derma. 

The exceptional situation of the epithelioma in this 
case, at a point where the integument is thin and where 
the growth was subjected to pressure against the under- 
lying bone, was probably the factor which determined the 
invasion of the lymph node in the immediate proximity. 

Sweat-Gland Cancer.—The case of sweat-gland cancer 
which came under the observation of the writer and to 
which reference has been made, had the following histo- 
logical structure: Under a low power the derma was found 
to be the seat of numerous bands, masses, and gland-like 
arrangements of small epithelial cells which extended 
from beneath the epidermis to the subcutaneous connec- 
tive tissue. They differed in their arrangement from 
that met with in other varieties of skin cancer, and sug- 
gested to the observer an attempted reproduction of 
glandular tissue. Under a higher amplification a com- 
plicated network was seen; it was formed by the inter- 
lacement of bands of epithelial tissue enclosing cavities 
which were partially or completely filled with degen- 
erated cells or with a homogeneous substance allied to 
colloid matter. Cyst-like cavities were found in other 
parts of the microscopic field. They were lined by a 
single layer of columnar epithelial cells, and presented 
a striking resemblance to overgrown sweat ducts. 

Fig. 1189 represents a group of enlarged and proliferat- 
ing sweat ducts cut transversely. The columnar shape 
and regular arrangement of the peripherally located cells 
are well shown, These cells are situated upon a base- 
ment membrane, and are an almost exact reproduction 
of those normally met with in the sweat glands, although 
here very much hypertrophied. The lumen of the 
tubules is completely filled by the growing and multi- 














Fig. 1139.—From a Cancer of the Leg. Showing a group of enlarged 
and proliferating sweat ducts cut transversely. Spencer one- 
quarter inch, projection ocular 4.) 


plying cells, and in places the basement membrane is 
penetrated and the surrounding connective tissue in- 
fected by them. The other anatomical structures of the 
skin were not implicated in the cancerous process, neither 
was there any evidence of a tendency to cell-nesting or 
the formation of epidermic “globes.” The epithelial 
processes met with in the small-celled carcinoma of the 


685 


Cardamom, 
Cardiac Depressants, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








skin, starting in the rete Malpighii, resemble to some ex- 
tent the cell arrangements observed in the case under 
consideration. In the epidermic cancer, however, the 
cells are larger, and do not rest upon a distinct basement 
membrane, as in this case. Furthermore, the epithelial 
bands or tubules starting from the rete have no distinct 
calibre, and do not reproduce so perfectly the glandular 
structure. 

Errotogy.—The development of cancer of the skin is 
favored by a number of antecedent conditions to which 
reference has been made under Symptomatology. Ina 
general way the statement is true that chronic irritation 
of slight intensity is one of the most potent factors which 
precede the malignant change in epithelial growths. The 
origin of highly malignant tumors from certain con- 
genital moles has given some support to Cohnheim’s 
theory of latent embryonic “remains.” In xeroderma 
pigmentosum a congenital weakness of the skin is pres- 
ent which strongly predisposes to malignant growths. 
Heredity probably has some influence in favoring the 
evolution of some forms of malignant disease. 

Inflammatory changes in the papillary region of the 
derma, by impairing the integrity of the basement mem- 
brane, favors the downward growth of epithelium. 
Atrophic changes in the connective tissue in advanced 
life exercise a similar influence. 

The advocates of the parasitic origin of cancer consider 
the association of the malignant affection with pre-exist- 
ing lesions as accidental. According to them the changes 
in syphilis and other chronic skin diseases merely furnish 
a favorable soil for the superadded infectious agent. 

Cancer of the skin is more frequent after the age of 
forty, though no time of life is exempt. Kaposi has ob- 
served itanumber of times between the ages of eight and 
eighteen. Rodent ulcer begins, as a rule, about the age 
of forty, but it may make little or no progress for several 
years. 

DraGnosts.—Superficial cancer of the skin is frequently 
mistaken for late syphilitic infiltration and ulceration or 
for lupus. These late nodular and ulcerative syphilitic 
lesions are usually more rapid in their evolution and in- 
volution, are frequently multiple, and lack the char- 
acteristic elevated and waxy border which distinguishes 
malignant ulceration. When syphilitic ulcers or those 
of lupus are complicated with epithelioma the diagnosis 
is more difficult. Lupus generally develops early in life, 
pursues a chronic course, and spreads on the margins of 
the patch by brownish-red nodules deeply embedded in 
the skin. These nodules or tubercles are as characteristic 
of lupus as the waxy margin is of superficial epithelioma. 

Tuberculosis verrucosa cutis might be mistaken for 
papillary cancer of the fingers or hands. Induration 
about the base of a wart or cutaneous horn should excite 
suspicion of a malignant change. 

In case of doubtful diagnosis resort should always be 
made to the microscope. 

Proenosis.—In superficial cancer of the skin the prog- 
nosis is more favorable than in any other form of the dis- 
ease, as the progress is slow and the lymphatic system 
seldom implicated. If the growth is radically removed 
in its early stages there is little tendency to recur. 

Cancers from moles are decidedly malignant, as they 
early involve the lymphatics and may soon be followed 
by a general metastasis. Papillary cancers are usually 
rapidly growing, and when they infiltrate the deeper 
parts, if not removed, lead to a fatal issue within from 
one to three years. 

Rodent ulcer in its later stages almost invariably re- 
turns after removal, though preserving its local seat. 

It is well to bear in mind that a superficial growth 
may become deep-seated and pursue a rapidly fatal 
course, as in the galloping or phagedenic epithelioma 
described by Besnier. 

TREATMENT.—Early and complete extirpation with 
the knife is the only method of treatment that should be 
employed in cancer of the mucous membrane of the 
mouth, or of the lip. 

On other parts of the body, as the neck, scrotum, etc., 


686 








when the skin is freely movable and union by first inten- 
tion can be secured, an excision offers the most rapid, 
painless, and satisfactory method of cure. If the opera- 
tion is resorted to before the lymph nodes are invaded 
and if the incisions are made at a sufficient distance from 
the morbid growth, a cure may be looked for in the ma- 
jority of cases. 

Associated lymph nodes when invaded should be re- 
moved in as thorough a manner as possible. 

Partial removal of cancer of the skin, even the most. 
superficial, by the knife, curette, or caustics, accom- 
plishes no good result and frequently stimulates these 
new growths to increased activity. 

Superficial cancers of the skin are sometimes so situated 
that a cutting operation is followed by more deformity 
than after the employment of curettage and caustics. 
Many patients are so prejudiced against any cutting 
operation that they will endure the more prolonged and 
painful action of caustics rather than submit to the use 
of the knife. Under these circumstances the diseased 
tissue may be scraped away with the dermal curette and 
some suitable caustic applied to the resulting ulcer. 

Numerous cures of cancer of the face have been ob- 
tained in this way by the writer, the caustics employed, 
as a rule, having been arsenic, in the form of Marsden’s. 
or Bougard’s paste, or pure chloride of zine. Arsenic is. 
perhaps the best of all caustics as it is more certain in its. 
action and presumably has a selective action on the mor- 
bid tissue. Marsden’s paste is made by mixing two. 
parts of arsénious acid with one part of powdered gum 
acacia and sufficient water to make the mixture of a firm 
consistence. 

Robinson, who has devoted much time and considera- 
tion to the use of caustics in the treatment of cancer, pre- 
fers to vary the strength and duration of the application 
according to the cancer to be treated. He uses the paste 
in the strength recommended by Marsden and somewhat 
weaker, but never uses less than equal parts of arsenic 
and gum acacia. The paste is applied somewhat beyond 
the diseased area and is left on for from eight to twenty 
hours (Robinson). If the desired destruction of tissue is. 
not obtained within the shorter limit a second but weaker 
application should at once be made until the necessary 
necrosis is accomplished. 

The advantages claimed for the caustic treatment of 
cancer are the lesser degree of deformity which results 
and the greater certainty of reaching foci of diseased cells 
in the lymph vessels outside of the parent growth. It 
is, however, painful, and the separation of the resulting 
slough is somewhat slow. 

Pain during the action of the caustic may be controlled 
by morphine, and the after-treatment should be conducted 
on the usual lines. 

Before scraping away the morbid tissue as preliminary 
to the use of the caustic agent, the parts may be rendered 
anzsthetic by aspray of chloride of ethyl. If this is fol- 
lowed by the application of tampons saturated in a five 
or ten per cent. solution of cocaine the slight surgical 
procedure may be rendered absolutely painless. 

Instead of employing destructive chemical caustics 
like arsenic and chloride of zinc the Paquelin or galvano- 
cautery may_be used to complete the treatment. The 
actual cautery is, however, not so certain to reach all the 
diseased cells as is the arsenical paste. 

Patients who. have been operated on for cancer should 
remain under observation for one or two years or longer, 
and the slightest recurrence should immediately be re- 
moved, i 

The internal use of arsenic for several months after the: 
removal of malignant tumors has, perhaps, some influ- 
ence in preventing or limiting recurrences. 

John A. Fordyce. 


CARDAMOM.—CARDAMOMUM. The fruit of Het- 
tarta repens (Sonnerat) Baillou (fam, Zingiberacee). Since: 
the seed is the only active part, the above definition should. 
be so restricted. The cardamom plant isa tall, reed-like, 
perennial herb, from six to twelve feet high. The flow- 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cardamom, 
Cardiac Depressants,. 





ers and fruits are borne upon special short, scaly stems, 
partly prostrate among the bases of the leafy culms. 

The plant is a native of Southern India, where also it 
has been long incultivation. It has been introduced into 
other tropical countries. The cardamoms of commerce 
are mostly the product of cultivated 
plants, which are grown in the moist 
shade, either in clearings of the nat- 
ural forests or in plantations of betel 
palms. The fruits are gathered before 
they are quite ripe. They are thor- 
oughly washed, partly with soap and 
partly with a solution of a saponace- 
ous fruit, and then bleached for some 
hours. They are frequently rubbed 
between the hands with a mixture of 
starch and buttermilk. They are ovoid or oblong, 
pointed, rounded-triangular, three-valved, and three- 
celled capsules. The husk, when dried, is of a pale 
yellowish-gray or brown, flexible, and tough. Those 
which have been starched have a white and almost 
chalky surface. The seeds, five or six in each cell, 
are irregularly compressed, brown, and spicy. The 
fruits of the best varieties are usually short, about 
once and a half or twice as long as broad (1 to 1.5 cm. 
= ;% to ;% in.), very plump and full. They are com- 
mercially called “shorts.” Others, longer and more 
angular, are denominated “short-longs” and “longs.” 
The larger and longer cardamoms are mostly the produce 
of other species of Elettaria, and are therefore unofficial. 
Their odor and taste are not so pleasant. In selecting 
cardamoms, the point of chief importance is to see that 
they are short, plump, and well-filled, as otherwise the 
proportion of husk is too great, and the strength is thus 
weakened through the diminution of the active portion. 
This difficulty can be avoided by specifying the amount 
of the seeds instead of the fruits. The seeds from un- 
filled fruits are themselves defective, however. 

Cardamoms are also distinguished, according to the 
countries or ports from which they are exported, as 
Malabar, Aleppo, Madras, etc. The former are the most 
esteemed. 

The seeds contain about five per cent. of a pale yel- 
low aromatic oil, of complex composition, which repre- 
sents them in odor and taste. The ash of cardamom is 
rich in manganese. Cardamom is a typical aromatic, and 
is usefulin all the conditions which call for articles of that 
class. As an agreeable flavor and appetizer, as a stimu- 
lant to digestion, and as a carminative in flatulence and 
in simple colic, it is sometimes, but not often, given alone. 
In combinations, as a pleasant and useful adjuvant and 
corrective, it is in more frequent use, acting favorably 
with cathartics, bitter tonics, stimulants, etc. But the 
principal use of cardamom is as a condiment or house- 
hold flavor, for which purpose, especially on the conti- 
nent of Europe and in the East, it is extensively em- 
ployed. It is also used in flavoring liqueurs, and 
in curry-powder, etc. It is Jess irritating than the spices 
proper, and more so than anise and the milder carmina- 
tives. The dose of cardamom as an aromatic by itself 
would be from .5 to1 gm. (gr. viij ad xv.). There isa 
ten-per-cent. official tincture which represents it com- 
pletely. The compound tincture contains two per cent. 
each of cardamom and cinnammon, one of caraway, five 
of glycerin, and one-half per cent. of cochineal, in diluted 
alcohol, and is given in doses of 8 to 15 c.c. (2 to 4 fl. 3). 
It also enters into the aromatic powder and the aromatic 
fluid extract. W. P. Bolles. 


CARDAMOM, OIL OF.—This term is understood as 
applying to the volatile oil, and not to the ten per cent. 
of fixed oil which the seeds yield. It is yielded to the 
extent of five or six per cent. It is of a pale yellow 
color, highly aromatic, has a specific gravity of about 
.900 and a rotation of +13°. Itsimportant constituent is 
terpinene (CioHis). Its properties are identical with 
those of cardamom. It is, however, chiefly used for fla- 
voring, especially liqueurs. Henry H. Rusby. 





Fig. 1140.—Malabar 
Cardamom. 
(Natural size.) 


“ 











CARDIAC DEPRESSANTS AND CARDIAC STIMU- 
LANTS.—I. Carpiac Drepressants.—The term cardiac: 
depressant is applied to drugs which lessen the force and 
frequency of the heart’s action and are employed for 
this purpose in therapeutics. Since all classes of verte- 
brates and many invertebrates are provided with a ner- 
vous mechanism (the cardio-inhibitory apparatus) through 
which such changes in the heart are brought about in 
the normal animal, we should expect to find that those 
drugs-which experience has shown to have the power of 
reducing the heart’s action would exert their influence 
through this mechanism. As a matter of fact, the two 
drugs which are most used for their depressing influence 
upon the heart, aconite and veratrum viride, do exert 
their influence through the cardio-inhibitory nerves. It 
is conceivable that the part affected by these drugs might 
be any point in this mechanism—the nerve centres in the 
medulla, the nerve fibres, which in the higher animals 
are contained in the vagi trunks, or that which is rather 
vaguely (since the exact anatomical elements are not. 
well known) termed the endings of the nerves in the 
heart. As is well known, nerve fibres are, as a rule, less. 
easily affected by drugs than are nerve cells or the termi- 
nations of nerve fibres; and no drug is known which is 
able to exert a special influence upon the cardio-inhibitory 
nerve fibres, although there are many which stimulate 
the nerve cells in which these fibres originate and also 
their terminations in the heart. There are, moreover, 
drugs which seem to increase simply the sensitiveness of 
the vagus terminations without actually stimulating 
them, or at least without stimulating them sufticiently 
to slow the heart; the increased sensitiveness may, how- 
ever, cause them to respond to a slighter stimulus than 
usual or with greater energy to a norma! stimulus. 

Another class of drugs, of which tartar emetic is a 
good example, depress the action of the cardiac muscle: 
directly and so have been used as cardiac depressants; 
but such drugs are not considered as safe as those which 
work through, so to speak, more physiological channels. 
In fact, the depression brought about by a direct action. 
upon the cardiac muscle is often associated with the con- 
dition known as collapse. 

For the sake of completeness it may be added that the 
heart’s action may be depressed by drugs acting in ways 
other than those just mentioned. Thus, if a drug causes 
a great fall of blood pressure the heart may be imper- 
fectly supplied with blood and beat very feebly and 
slowly. If the blood pressure be much increased by 3 
drug causing contraction of the arterioles, the high blood 
pressure may act as a stimulus to the vagus centre and 
so depress the action of the heart. The vagus centre 
may be stimulated reflexly by drugs having a powerful 
local action; it may also be stimulated by the accumula- 
tion of carbon dioxide in the blood if some drug which 
interferes with the respiration has been given. Again, 
it is probable that there are drugs which can slow the 
heart by depressing the accelerator nerves. Since these 
nerves are in a condition of tonic activity, any interfer- 
ence with their activity would lead to a slower rate. 

While the most typical cardiac depressants exert their 
influence through the cardio-inhibitory mechanism, their 
action upon the organism is not by any means confined 
to this apparatus. Not only may many other functions 
—as, for instance, those of the central nervous system, 
the respiration, secretion, etc.—be influenced, but other 
parts of the vascular mechanism (the vaso-motor centres 
and nerves, the blood-vessels, the accelerator nerves of 
the heart, the cardiac muscle, etc.) may undergo changes 
which exert a profound influence on their action as car- 
diac depressants. In fact, a drug may stimulate the 
vagus and thus slow the heart and at the same time 
stimulate the cardiac muscle and in this way antagonize 
the effect of the vagus; sometimes one and sometimes 
the other effect will predominate. The condition be- 
comes much more complicated when the preparation 
used contains several active principles, each with its. 
peculiar action. For this reason it is desirable to use 
simple preparations and to determine as accurately as 


687 


Cardiac Depressants, 
Cardiac Depressants, 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





possible all their effects; in this way reasons can some- 
times be found for the failure of the drugs to produce 
the desired effects under certain circumstances. 

The three drugs which have been used most exten- 
sively as cardiac depressants are aconite, veratrum viride, 
and tartar emetic. 

Aconite.—The action of aconite as employed in medi- 
cine is almost identical with that of its chief alkaloid, 
aconitine. Asmost of the physiological experiments have 
been made with the alkaloid, its action will be considered 
first, and then the manner in which the other substances 
present in the ordinary preparations of aconite influence 
its action will be discussed. 

Aconitine affects the circulation in three ways: it has 
a direct action upon the heart muscle, it stimulates the 
centre of the cardio-inhibitory nerves, and it influences the 
vaso-motor centre. With medicinal doses the second of 
these effects, the stimulation of the cardio-inhibitory 
nerves, is the most prominent and important and is the 
one desired in therapeutics. 

When aconitine is administered to man or to one of the 
other mammals the first effect upon the circulation is 
usually a slight acceleration of the heart. This is usually 
attributed to a direct action upon the cardiac muscles, al- 
though it is not improbable that in some cases the effect 
may be brought about reflexly through the local irritant 
action which the drug is well known to have upon the 
terminations of sensory nerves. This slight acceleration 
may be accompanied by a small increase in arterial press- 
ure. Theacceleration of the heart, which with mammals 
is never marked and does not always occur, is followed 
by a remarkable slowing and weakening of the heart 
beat. In man a pulse rate of 86 to 40 not uncommonly 
follows a moderate dose of aconite. In cases of poison- 
ing a still slower rate is occasionally seen; it is said to 
have been reduced to 10 per minute in one case. At the 
same time the pulse is much weakened. Sudden exertion 
at this stage may lead to a very rapid, irregular heart 
action and fatal syncope has occurred. Achscharumow 
(Archiv fiir Anat. und Physiol., 1866, p. 255) showed 
that this slowing of the heart is due almost entirely to a 
powerful stimulation of the centre of the cardio-inhibitory 
nerves in the medulla oblongata. Section of the vagi 
prevents the slowing in nearly every case. At times, 
however, there seems to be a slight stimulation of the 
peripheral endings of the vagi, for some slowing may 
ye observed when the drug is administered after section 
of the vagi; this slowing is abolished by atropine. This 
action upon the vagus terminals is of very slight im- 
portance in comparison with that upon the medullary 
centres; in fact, there is probably no drug which stimu- 
lates these centres as powerfully as does aconitine and 
has at the same time so little action, in small doses, 
upon other parts of the vascular mechanism, The 
amount of blood expelled by the heart under the in- 
fluence of aconitine is much reduced and the blood press- 
ure falls markedly. Some of the general symptoms 
of aconite poisoning are attributed to this fall of blood 
pressure. Thus there is a marked lowering of the body 
temperature, and this is usually ascribed to the depression 
of the circulation which leads to lessened oxidation and 
to an increased loss of heat from the surface of the body. 
Experiments of Brunton and Cash, however, indicate 
that there is also some action upon the nerve centres 
regulating the temperature of the body. The convulsions 
which frequently occur in cases of severe poisoning by 
aconite have been ascribed by some to the low blood 
pressure. While it is very probable that the latter is one 
factor in causing the convulsions, these seem to be due to 
a greater degree toa direct action upon some of the nerve 
centres, for convulsions occur in animals in which the 
fall of blood pressure is prevented by paralyzing the 

yagi with atropine. Moreover, there is ample evidence 
that several other parts of the medulla oblongata—the 
cardio-inhibitory, the vaso-motor, and the vomiting cen- 
tres—are stimulated by aconite, and it is very probable 
that the nerve cells causing convulsions are similarly 
stimulated, The severe dyspnea which is one of the 


688 








first symptoms of aconite poisoning seems to be depenaent 
to some extent upon the low blood pressure, for von Anrep 
(Archiv fir Anat. und Physiol., 1880, Supple. Bd., p. 
180) found that if the blood pressure was raised by com- 
pressing the abdominal aorta the first symptoms of dysp- 
neea disappeared. Later there is a direct action upon 
the respiratory centre. The great muscular weakness so 
often observed seems to be due to anzemia of the spinal 
cord. 

The details of the action of aconitine upon the mam- 
malian heart have been recently studied by Matthews 
(Journal of Experimental Medicine, ii., p. 598) and Cash 
and Dunstan (Phil. Trans. of Roy. Soc., London, exce., 
p. 248). By the use of a modified. form of the Roy- 
Adami myocardiograph (an instrument by which the rate 
and force of the contraction of the cardiac muscle can be 
recorded) Matthews found that during the above, or 
first, stage of its action aconitine causes the following 
changes: the diastolic pauses of the ventricle are pro- 
longed, the systolic contractions are weakened, while the 
relaxations of the ventricle are little changed or are a 
little increased. The relaxations of the auricle are little 
affected, but the diastolic pauses are much longer than in 
the ventricle. The auricular systolic contractions are 
greatly weakened and in some experiments are entirely 
suppressed, the auricle remaining in diastole; in such 
cases the ventricle assumes a slow, spontaneous rhythm. 
If the drug be administered in small doses, the rhythm 
can be reduced to one-half or to one-third of its original 
rate and the blood pressure lowered to a corresponding 
degree. 

If the administration of aconitine be continued the heart 
beat becomes irregular and extremely rapid. Sometimes 
this effect is the first one seen in man, even after a moder- 
ate dose of the drug; it would seem that in such cases 
the cardio-inhibitory centre is not very irritable. The 
cause of this acceleration is frequently said to be the 
paralysis of the vagus terminations, but direct stimulation 
of the cardiac muscle seems to be a much more important 
factor. In fact, the effect of aconitine upon the peripheral 
endings of the vagi in the later stages of the intoxication 
has been a matter of considerable dispute. Some writers 
state that these structures are paralyzed, others that they 
remain intact, while a third group state that they may 
seem paralyzed at one instant and not at the next. 
Matthews has observed that sometimes stimulation of 
the vagus in the later stages of poisoning causes a change 
in the form of the contraction but no diminution in the 
rate. The explanation of the above results is probably 
that while the irritability of the vagus terminations is 
depressed that of the heart muscle is greatly increased so 
that inhibition is much more difficult. One reason why 
stimulation of the vagi causes slowing of the ventricle at 
one instant and not at the next may be found in the vary- 
ing irritability of the muscle fibres connecting auricle 
and ventricle; these may be in a condition to transmit 
impulses from the auricle to the ventricle at one time but 
not at another. 

Simultaneously with this acceleration, and often pre- 
ceding it, there appear marked irregularities in the 
rhythm of the heart. These irregularities affect both the 
strength and the rate of the heart beat; they will be dis- 
cussed somewhat fully here as similar irregularities occur 
after poisonous doses of many of the drugs acting upon 
the heart. At first, certain ventricular beats seem 
“missed ”; when the number of such beats increases, the 
rate may seem but half as fast as before; but closer ex- 
amination usually shows that there is an alternation of 
large and small beats and that only the former are dis- 
tinctly recorded. The blood pressure falls during these 
imperfect systoles. This period of alternate large and 
small beats may be followed by a very rapid but regular 
rhythm during which the extent of the contractions is 
very limited. The auricle departs but little from the 
position of diastole and the ventricle from that of systole. 
Then periods of rapid beats may alternate with periods 
of slow beats. So far the auriculo-ventricular rhythm 
may have remained unaltered, each beat of the auricle 





. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, C2®rdiac Depressants, 





being followed by one of the ventricle; but this rhythm 
is soon disturbed and contractions of the ventricle may 
occur independently of the auricle. The ventricular 
beat may dissociate itself entirely from that of the auricle 
and the two chambers beat independently of each other. 
At the same time there seems to be an effort on the part 
of the heart to maintain a simple ratio between the beats 
of the auricle and the ventricle; frequently this ratio is 
two to one or one to two—7.e., the ventricle beats one-half 
or twice as fast as the auricle. Sometimes, when no such 
simple ratio exists, if one chamber becomes accelerated 
the other may become slowed until such a ratio is estab- 
lished. Many varieties of pulse may develop during 
this stage; but they may at any time yield to a regular 
one fora brief period, and stimulation of the vagi or ac- 
celerators will usually bring about the same result. The 
chief cause of this irregularity seems to be an increase of 
the irritability of the cardiac muscle which enables the 
ventricle to beat independently of the impulses received 
from the auricle. Tworhythms (one ventricular, the other 
auricular) are thus established, and they may interfere 
with each other. The extent of this interference is deter- 
mined by the condition of the muscle fibres connecting 
auricle and ventricle and which transmit the impulses 
from one chamber to the other. As the intoxication 
continues the irritability of the cardiac muscle becomes 
greater and greater, and the ventricle contracts exceed- 
ingly rapidly and imperfectly and finally passes into 
delirium. These cardiac irregularities caused by aconite 
are antagonized to a considerable extent by atropine. 
The latter does not prevent the acceleration, but it reduces 
the tendency to arhythmia and tends to approximate the 
speed of the ventricle to that of the auricle when the 
auriculo-ventricular rhythm is disordered, and it averts or 
delays the very rapid and feeble action of the systole 
which is the precursor of death. In fact, atropine often 
enables the heart to stand several times the fatal dose of 
aconitine. Although the usual cause of death in aconite 
poisoning is failure of the respiration, it is necessary to 
pay attention to the condition of the heart, and probably 
as much good is to be expected from atropine as from 
any drug. ; 

The blood pressure is extremely irregular during the 
second stage of the action of aconitine. When the heart 
is very irregular the pressure falls to nearly zero, but it 
rises again during the periods in which the heart beats 
more regularly. It is also fairly high when some simple 
ratio is maintained between the rate of the auricular and 
ventricular beats and is lowest when the asequence of 
the two chambers is most marked. These sudden changes 
in the blood pressure are undoubtedly due largely to 
changes in the heart beat, but there is evidence that the 
vaso-motor centre is also affected. If atropine be ad- 
ministered to an animal in quantity sufficient to paralyze 
the vagus terminations, aconitine causes a rise instead of 
a fall of blood pressure. The cause of this rise of press- 
ure is usually considered to be a stimulation of the vaso. 
motor centre, but it is also stated that there is a constric- 
tion of peripheral vessels due to-a direct action of the 
drug upon their walls. In the second stage of poisoning 
the vaso-motor centre is depressed; asphyxia now causes 
but a slight rise of blood pressure, and the same is true 
of a stimulation of a sensory nerve (although in this case 
the possibility of the paralysis of the sensory nerve itself 
must be considered). The peripheral vaso-motor nerves 
remain intact, as is shown by the fact that stimulation 
of the medulla or of the splanchnic nerves causes a rise 
of blood pressure even late in the intoxication. 

Most preparations of aconite contain besides aconitine 
certain of its decomposition products, especially benza- 
conine and aconine. Benzaconine, which differs from 
aconitine only in that one acetyl group has been removed, 
has an action upon the heart having little resemblance to 
that of aconitine; in fact, it acts to some extent as an 
antagonist of aconitine. Instead of causing a great ac- 
celeration of the heart as do large doses of aconitine, it 
slows the heart, especially the ventricles, and if inco- 
ordination between auricle and ventricle is produced the 


Vou. I1.—44 


Cardiac Depressants, 





latter beats more slowly than the former; with aconitine 
the opposite is usually the case. The slowing of the 
heart is due largely to a direct depression of this organ. 
It is not due toa stimulation of the inhibitory nerves, 
either centrally or peripherally, as it occurs after atropine. 

Aconine, which differs from benzaconine in that a 
benzoyl group has been removed, has an action just the 
reverse of aconitine. Instead of being a cardiac depressant 
it is a cardiac stimulant and strengthens the heart beat; 
the blood pressure rises and no disturbances of the 
rhythm are produced. In fact, it is an antagonist of 
aconitine and tends to prevent asequence of the auricle 
and ventricle by facilitating the transmission of im- 
pulses from one chamber to the other. It also opposes 
the tendency of the ventricle to go into delirium. 

The action of benzaconine and aconine is, however, so 
feeble in comparison with that of aconitine that it is im- 
probable that they do more than simply to weaken the 
action of the latter. It is due largely to these decom- 
position products that the preparations of aconite vary 
so much in strength. 

A number of other alkaloids derived from the Aconi- 
tum genus have been isolated, but they have at present 
little interest and their action upon the heart is not well 
known. Among these are pseudaconitine (the alkaloid 
of Aconitum ferox); lappaconitine, septentrionaline, and 
cynoctonine—all derived from Aconitum septentrionale ; 
and lycaconitine and myoctonine from Aconitum lycoc- 
tonum. In addition to these certain artificial derivatives 
of aconitine have been prepared recently and studied by 
Cash and Dunstan. 

Another alkaloid closely resembling aconitine, but one 
which is little known, is delphinine. It is found in Del- 
phinium staphisagria, or stavesacre, along with a num- 
ber of other bases which may be products of its decom- 
position. 

Veratrum viride. Several species of the genus Vera- 
trum have been found to contain alkaloids which re- 
semble aconitine in their action upon the heart. The 
only preparations in use as cardiac depressants are de- 
rived from the rhizome and roots of the American or 
green hellebore, veratrum viride. After the adminis- 
tration of veratrum viride to man the first effect upon 
the circulatory system is a reduction of the force of the 
pulse; the rate is not at first influenced. A little later 
the pulse rate is much reduced; in exceptional cases it 
may fall to 35 or even 80 beats per minute, any alarming 
symptoms which may arise passing away when the ad- 
ministration of the drug is discontinued. The pulse 
may be moderately full, but it is soft and compressible. 
If any exertion be made at this stage the pulse becomes 
very rapid and may become almost imperceptible. The 
slowing is especially marked during sleep, the patients 
thus exhibiting an intensification of the ordinary physio- 
logical law in virtue of which the pulse falls during 
sleep. The reduction in pulse rate is often accompanied 
or followed by nausea and vomiting; there seems, how- 
ever, to be no connection between these, for if the drug 
is administered with care a very marked reduction of the 
pulse rate may occur without any nausea being produced. 
Decided muscular weakness accompanies the depression 
of the pulse. Profuse perspiration also occurs; this is 
frequently attributed to the low blood pressure, but as 
the drug stimulates the cutaneous glands of frogs it is 
not improbable that it has some direct action upon the 
terminations of the sweat glands. After toxic doses 
there are also a fall of temperature and convulsions as in 
aconite poisoning and a running, almost imperceptible 
pulse. 

Efforts have been made to analyze the action of the 
veratrum alkaloids by experiments upon animais, but 
these have not as yet been entirely satisfactory. This 
result is due largely to the confusion which has prevailed 
as to the chemistry of these bodies, so that it is not 
always certain with what substances the various in- 
vestigators have worked. According to Wright and 
Luff the following alkaloids occur in veratrum viride: 
jervine, pseudojervine, cevadine, very little rubijervine 


689 


Cardiac Depressants, 
Cardiac Depressants, 





and traces of veratrine and veratralbine. The alkaloid 
called by Wright and Luff “cevadine” has the empirical 
formula C32:H4,NOx,; this is usually called “ veratrine” or 
the “crystalized veratrine of Merck,” and will be so 
designated here. There are three modifications of this 
veratrine, one crystalline and two amorphous; they all 
have the same physiological action. The alkaloid called 
by Wright and Luff “veratrine” has the formula 
C3:HssNO;1; its physiological action is not well known. 
Bullock discovered an alkaloid in veratrum viride which 
he named veratroidine; this seems to have been a mix- 
ture of rubijervine and an almost inert resin. Wood 
studied the physiological action of jervine and the so- 
called veratroidine. The alkaloids the physiological ac- 
tion of which have been most studied in Europe have 
been derived from veratrum sabadilla (Asagroea offici- 
nalis) and VY. album. The seeds of the former contain 
veratrine (Cs2H4.NOy,), the veratrine of Wright (C37Hs5s- 
NO,,;), and cevadine. A mixture of these alkaloids con- 
stitutes the Veratrina of the United States Pharma- 
copeia. Of these alkaloids only veratrine has been 
carefully studied, but it is not certain that the earlier in- 
vestigators worked with pure preparations. Veratrum 
album contains protoveratrine, jervine, pseudojervine, 
rubijervine, protoveratridine, and others; of these the 
physiological action of protoveratrine is best known. 

Thus the alkaloids of veratrum viride the physiological 
action of which is known are jervine, veratrine, and rubi- 
jervine. The effects produced by preparations of the 
entire drug are doubtless due largely to these three 
bodies, and a brief résumé of their action will be given. 

The principal investigation of the physiological action 
of jervine has been made by Wood (Amer. Jour, of the 
Med. Sciences, 1870, and Philadelphia Medical Times, iv., 
1874), and the following account is taken from his papers. 
After the administration of jervine to an animal the pulse 
is generally, if not invariably, lessened in frequency, 
provided the animal is quiet. When there are convul- 
sions or even marked tremors the pulse becomes very 
rapid. The arterial pressure is greatly lowered, falling 
progressively from the beginning to the end of the ex- 
periment. The force of the individual beats appears not 
to be much altered at first. According to Wood these 
effects are not due to a stimulation of the cardio-inhibi- 
tory nerves, for they occur after section of these nerves. 

Stimulation of the peripheral ends of the vagiin animals 
under the influence of jervine caused the usual cardiac 
results. The alkaloid lessens the arterial pressure after 
division of the spinal cord—/7.e., after vaso-motor paraly- 
sis; it also paralyzes the heart of the frog or turtle when 
placed directly upon it. From these experiments Wood 
concludes that jervine lowers the force and frequency of 
the cardiac beats by a direct action upon the cardiac 
muscle or its contained ganglia. Apparently, however, 
Wood did not exclude the possibility of the slow heart 
being due to a stimulation of the vagus endings. Stimu- 
lation of sensory nerves or asphyxia caused little or no 
rise of arterial pressure, indicating a paralysis of the vaso- 
motor centre. 

Wood also studied the action of an alkaloid which he 
called veratroidine; this, as has been already noted, 
seems to be a mixture of rubijervine and a resin. This 
substance caused at first a slowing of the heart and a fall 
of arterial pressure. After a time, the pulse still re- 
maining very slow, the individual beats became unusu- 
ally powerful and the blood pressure became normal; 
then suddenly the pulse rate became very rapid, the in- 
dividual heart beats losing much of their extraordinary 
vigor, but the arterial pressure rising nearly fifty per 
cent. beyond its original position. If the alkaloid was 
thrown directly into a vein there was a very rapid fall, 
and then a remarkable rise of blood pressure; the latter 
is due to asphxyia and did not occur if artificial respira- 
tion was maintained. The slowing of the heart was due 
to stimulation of the cardio-inhibitory centres in the 
medulla; it did not occur if the vagi had been divided. 
If, moreover, marked slowing had occurred with intact 
vagi, section of these nerves was followed by a great 


690 














REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


acceleration. The slowing was especially marked when 
the spinal cord had been cut so as to paralyze the ac- 
celerators; under these circumstances Wood saw gr. 35 
of the alkaloid completely stop the heart, which how- 
ever commenced to beat again when the vagi were di- 
vided. After large doses the slow pulse was replaced by 
a very rapid one; that this was due, at least in part, to 
paralysis of the vagus termination was shown by the 
fact that stimulation of the vagus now had no effect 
upon the heart. Enormous doses thrown directly into 
the circulation killed the cardiac muscle directly. Ver- 
atroidine (rubijervine) had little or no effect upon the 
vaso-motor system. Asphyxia or stimulation of a sensory 
nerve caused a great rise of arterial pressure just as in 
normal animals. 

The action of veratrine upon the mammalian heart 
resembles in general that of aconitine, except that the 
stimulation of the cardiac muscle is not so marked. 
Bezold and Hirt (“ Untersuchungen aus dem physiolog. 
Laboratorium in Wiirzburg,” 1867, p. 95) describe the 
effect upon the circulation in mammals as follows: The 
first effect of a small dose is a slight acceleration of the 
heart, probably due to direct stimulation to the cardiac 
muscle; then comesa slowing of the heart. With a large 
dose the latter is the first effect; the pulse rate may be 
reduced to one-half or one-third the previous rate. Sec- 
tion of the vagi now is followed by an acceleration of 
the heart; this shows that the medullary centres of the 
cardio-inhibitory nerves are stimulated just as in aconite 
poisoning. At the same time there is an increase in the 
irritability of the vagus endings in the heart, for electric 
stimulation of the peripheral end of this nerve, which in 
the unpoisoned animal had no effect, produces a marked 
slowing after the administration of the drug. If the 
vagi be divided before the administration of the alkaloid, 
then this causes an acceleration of the heart, showing 
that the cardiac muscle is affected directly. This ac- 
celeration is followed by a slowing of the heart; this 
seems to be due toadirect poisoning of the heart muscle. 
With larger doses the heart is slowed still more, and now 
the strongest stimulation of the vagi has no effect upon 
the heart, showing that the vagus endings are paralyzed. 
These facts indicate that large doses reduce the irritabil- 
ity of the cardiac muscle and paralyze the terminations 
of the vagi, whereas small doses increase the irritability 
of both. 

After a very large amount of veratrine the heart be- 
comes irregular; unlike the heart in aconitine poisoning, 
however, it remains slow. The irregularity consists 
chiefly in the ventricle assuming a rhythm slower than 
that of the auricle; the ventricular beats then become 
weak and of a peristaltic character. Little blood is ex- 
pelled, and the ventricle becomes widely distended and 
finally stops in diastole; even electrical stimulation does 
not cause a contraction—indicating a profound poison- 
ing of the cardiac muscle. 

Small amounts of veratrine stimulate the vaso-motor 
centre; this and the slight stimulation of the cardiac 
muscle cause a rise of blood pressure. After larger 
amounts the vaso-motor centre is depressed; this in- 
creases the fall of blood pressure caused by the slow 
heart. Bezold and Hirt ascribed the fall of pressure in 
part to a stimulation of the depressor nerve, but later in- 
vestigators have failed to confirm this view. Lissauer 
(Archiv fir experiment. Path. und Pharmakol., xxiii., p. 
36, 1887) -has obtained results slightly different from 
those of Bezold and Hirt. Thus, he thinks the chief 
action of veratrine is upon the vaso-motor system and 
that the heart is not as much depressed as was thought 
to be the case by Bezold and Hirt. Lissauer found no 
paralysis of the vagus endings. 

Hedbom (Skand. Archiv fiir Physiologie, viii., p. 197, 
1898) has recently contributed a very interesting article 
on the action of veratrine upon the isolated mammalian 
heart. The heart (of the rabbit) was kept alive by the 
circulation of a mixture of blood and normal saline solu- - 
tion through the coronary arteries—7.é., by a modification 
of Newell Martin’s method. The contractions were 


j 
, 
2 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, C2Ta1a¢ Depressants. 


Cardiac Depressants, 





recorded by a thread attached to the ventricle and mov- 
ing a small lever. When a very small amount of vera- 
trine was mixed with the circulating blood there was 
first a sudden and very considerable (up to forty per 
cent.) increase in the amplitude of the contractions. This 
increase in the amplitude was due to a more complete 
systole, z.e., to a greater shortening of the muscle fibres. 
Soon the relaxation became less complete and so the 
amplitude decreased again. There was usually a slight 
acceleration of the heart (as described by Bezold and 
Hirt); this was followed by a marked slowing. During 
these slow, large heart beats the individual contractions 
were much prolonged—up to three and a half seconds. 
As is well known, one of the most characteristic of the 
physiological actions of veratrine is the peculiar effect it 
exerts on ordinary striated muscle; the contraction is in- 
creased and enormously prolonged. Bezold and Hirt, 
Bohm, and others have shown that the ventricle of the 
frog’s heart is affected in a way similar to that of the 
skeletal muscle. The experiments of Hedbom show that 
veratrine has a similar action upon the mammalian heart. 
The slight acceleration of the heart seen immediately 
after the injection of the drug seems to be due to a direct 
stimulation of the cardiac muscle; the more marked 
slowing which follows is probably due to a stimulation 
of the vagus terminations in the heart, as it is often re- 
moved by the administration of atropine. A secondary 
acceleration follows this slowing of the heart. This ap- 
pears to be due in part toa paralysis of the vagus termina- 
tions, in part to a stimulation of the cardiac muscle. 
This secondary acceleration is often accompanied or pre- 
ceded by marked irregularities, resembling those seen in 
digitalis poisoning. This irregularity is marked by the 
formation of groups and by the appearance of “ missed ” 
beats—7.e. strong contractions are followed by very weak, 
almost imperceptible ones. Finally, the heart muscle is 
paralyzed. 

Thus the action of three of the alkaloids of veratrum» 
viride upon the heart is tolerably well known; that of 
the others is very imperfectly known, but they seem to 
resemble those already described. No complete experi- 
ments seem to have been made with any of the ordinary 
preparations of veratrum viride in which all of the alka- 
loids are present, and it is not altogether easy to forma 
clear idea of the details of the action of such preparation 
from what is known concerning these three alkaloids. 
While chemical analyses show the proportion in which 
the various alkaloids occur in veratrum viride, we have 
few dataas to the comparative toxicity of the individual 
alkaloids. It seems, however, that veratrine is more 
powerful than most of the others, and since, according 
to Wright and Luff, it is the most abundant alkaloid in 
veratrum viride, it probably plays a much more impor- 
tant part in the action of the preparations of the crude 
drug than has been generally recognized. Rubijervine 
is also very poisonous, but it occurs in small quantities. 

From the various experiments described above, assum- 
ing that all are trustworthy, we may perhaps draw the 
following conclusions as to the action of veratrum viride 
upon the circulation: The slowing and weakening of the 
heart are due to the stimulation of the medullary centres 
of the cardio-inhibitory nerves by the veratrine and rubi- 
jervine (veratroidine). This slowing may be increased by 
the stimulation of the vagus terminations by the action of 
the veratrine. The slowing may be due in part to the 
direct action upon the cardiac muscle by the jervine, but 
this effect is doubtless antagonized to some extent by the 
stimulating action of the veratrine described by Hedbom. 
In therapeutics this slowing of the heart is the only effect 
desired, and it will be seen that it is produced to a large 
extent in the same way as when aconite is used—/?.e., by 
a stimulation of the vagus centre in the medulla. With 
veratrum viride there is another action, however, which 
is scarcely shown at all by aconite, viz., a stimulation of 
the vagus terminations in the heart, and it is possible that 
veratrum viride may thus cause slowing in some cases 
in which aconite would fail. The rapid pulse after large 
doses of the drug is due to a paralysis of the vagus 











terminations by veratrine and rubijervine and perhaps to 
some stimulation of the cardiac muscle. At the same 
time jervine and larger amounts of veratrine weaken the 
heart by a direct action upon the cardiac muscle. Vera- 
trum viride in large amounts does not tend to produce 
as rapid a pulse as does aconite, probably partly because 
all the alkaloids have a less stimulating action on the 
cardiac muscle and partly on account of the peculiar 
action of veratrine upon all kinds of striped muscle. 
The fall of blood pressure caused by veratrum viride is 
due largely to the slowing of the heart; at the same time 
the vaso-motor centre is depressed by the jervine and 
when larger amounts are given, by the veratrine. 

The physiological action of protoveratrine, the chief 
alkaloid of veratrum album, has been studied by Eden 
(Archiv fiir exper. Path. und Pharmakol., xxix., p. 440, 
1892). As faras its action upon the circulation is con- 
cerned this alkaloid does not differ very much from 
veratrine. 

Tartar Emetic.—Tartar emetic is classed with the car- 
diac depressants for clinical and not for pharmacological 
reasons. Although it depresses the circulation to a 
marked degree, it has no such special action upon the 
heart as have aconite and veratrum viride; in fact its 
action does not differ greatly from that of several other 
drugs which, since they have never been used clinically 
for this purpose, are never thought of as cardiac de- 
pressants. 

The action of tartar emetic upon the pulse in small 
doses is closely connected with, and to a considerable 
extent dependent upon, its action as an emetic, for ordi- 
narily it is absorbed very slowly and in very small 
amounts. The effect upon the circulation of man is de- 
scribed by Ackermann (Virchow’s Archiv, xxv., p. 581, 
1862) as follows: After a small dose the pulse becomes 
accelerated as feelings of nausea arise and reaches its 
maximum rate just before the act of vomiting. Thus 
in one case the normal pulse rate was 71 per minute; 
during the period of nausea it rose to 110. The strength 
of the pulse decreases with the increase in rate, and vice 
versa. It is not necessary for vomiting to occur; the 
mere sensation of nausea is sufficient to cause an ac- 
celeration of the heart. Any drug (such as apomor- 
phine) or any condition (as sea-sickness, swinging, etc.) 
which causes feelings of nausea is accompanied by a 
similar acceleration of the pulse. This acceleration is 
sometimes attributed to a reflex stimulation of the ac- 
celerator nerves, but it is more probable that it is due to 
a reflex diminution of the tonus of the cardio-inhibitory 
nerves. Accompanying this change in the pulse rate 
and probably dependent upon it there is a fall of tem- 
perature of the extremities and other symptoms of mild 
collapse. Thus Ackermann found the temperature of 
the hands to fall .2 to 3.5° C. during the period of nausea; 
the temperature under the tongue did not vary. After 
large doses the pulse becomes very feeble, then slow, in- 
termittent, and irregular and the other symptoms of col- 
lapse are very marked. The depression of the central 
nervous system and of the respiration is doubtless due in 
part to the circulatory disturbances. These more pro- 
nounced effects upon the circulation are probably due in 
part toa direct action of the poison upon the heart. That 
antimony does exert a depressing action upon the heart 
is shown by experiments upon the lower animals; the 
action is most marked in the case of the frog’s heart. 

Soloweitschyk (Archiv fiir exper. Path. und Pharmakol., 
xii., p. 441, 1880) found that for some time after the ad- . 
ministration of antimony (in the form of the antimony- 
sodium tartrate) to a frog the heart continued to beat 
regularly; the contractions were at times unusually vig- 
orous and the rate was slightly increased. Then the con- 
tractions became irregular and peristaltic; arhythmia of 
auricle and ventricle soon developed, the latter beating 
but one-half, then one-third, one-fourth, etc., as rapidly 
as the former. Finally the ventricle stopped in diastole 
while the auricles continued to beat feebly. The cardiac 
muscle does not seem to be paralyzed, for a little helle- 
borein will cause it to commence beating again; only the 


: 691 


Cardiac Stimulants, 
Cardiac Stimulants, 


power to contract rhythmically seems to be destroyed by 
the antimony. That this stoppage of the heart is not 
due to a stimulation of the vagi is shown by the fact that 
atropine has no influence upon it. 

It is difficult to state exactly the effects of antimony 
upon the mammalian heart, for in the experiments hither- 
to recorded the effects upon the heart were not differen- 
tiated from those upon the vaso-motor system. It is 
very probable, however, that after large amounts of 
antimony the mammalian heart muscle is influenced in a 
way very similar to that of the frog, but that this action 
is obscured by the vaso-motor changes. Injected into, a 
vein or an artery of an animal antimony causes an almost 
immediate acceleration of the pulse. At the same time 
the blood pressure falls; this fall of blood pressure is 
gradual but continuous until it reaches zero and the ani- 
mal dies. When the fall of blood pressure has become 
very marked (in many cases when it has fallen to about 
one-half or one-third its previous height) the heart be- 
comes slow and irregular. The diastolic pauses are 
greatly prolonged, but the chan ges in the blood pressure 
followi ing each contraction are very great, indicating that 
the heart beat is fairly strong and that the vessel “walls 
are much relaxed. This fall of arterial pressure cannot 
be ascribed to the weakening of the heart, for it precedes 
this, and there is no constant relation between the con- 
dition of the heart and the height of the blood press- 
ure. The cause of the fall of blood pressure seems to 
be a paralysis of the peripheral vaso-motor system; the 
blood-vessels, especially those of the splanchnic area, are 
dilated and the most powerful stimulation of the medulla 
oblongatais powerless to contract them. It isnot known 
whether the vaso-motor nerves or the muscle of the vessel 
walls or both are poisoned; the fact, however, that other 
unstriped muscle (that of the intestines for example) is 
not paralyzed points to the nerves or their ganglia being 
the structures acted upon. It is not impossible that the 
changes in the heart are in reality due to the great fall 
of arterial pressure, but the fact that antimony has such 
a poisonous action upon the frog’s heart makes it prob- 
able that the mammalian heart is similarly affected. The 
heart finally stops in diastole; just before the final stand- 
still there is frequently a very brief period during which 
the heart beats with great rapidity, but the contractions 
are exceedingly weak and the blood pressure remains 
very low. The cardiac nerves do not seem to be involved 
in the later stages of the poisoning. Some have stated 
that the vagus terminations are paralyzed, but this does 
not seem to be the case. Immediately after death the 
heart is found to be unirritable to electrical stimulation. 

There are a number of other drugs which affect the 
circulation in ways similar to the above and which might 
be classified with the cardiac depressants; that they are 
not so classified is due to the fact that they have never 
been used to any great extent for their action upon the 
heart. Among these substances may be mentioned 
salicylic and carbolic acids, potassium salts, double salts 
of copper, zinc and some other heavy metals, chloral, 
saponin, apomorphine, emetine, muscarin, cholin, pilo- 
carpine, hydrocyanic acid, and the various mineral and 
organic acids. With some of these drugs it is largely a 
matter of dosage; small amounts may stimulate the 
heart while larger amounts depress it. 

There are also drugs which may at times relieve, in 
one way or another, the heart and so act as cardiac seda- 
tives. Thus atropine seems to reduce the sensibility of 
the nervous structures of the heart to increased pressure, 
and Brunton has found it useful in some cases of palpita- 
tion with high blood pressure and in persons suffering 
from the effects of cardiac strain followi ing violent mus- 
cular exertion. Digitalis was at one time called a car- 
diac sedative from its power to cause a rapid, irregular, 
irritable heart to beat slowly and regularly; in such 
cases the action is exerted largely through the inhibitory 
nerves and so has a certain resemblance to the action of 
aconite and veratrum viride, although there are other 
ae for placing these drugs in entirely different 
classes 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Some drugs may have the effect of cardiac sedatives 
by reducing irritation which has caused, reflexly, palpi- 
tation of the heart; thus hydrocyanic acid will sometimes 
relieve the palpitation caused by indigestion. In some 
cases local irritation will prevent the most powerful of 
the cardiac depressants from exerting their normal ac- 
tion. An interesting case of this kind is described by Percy 
(Trans. Amer. Med. Ass’n, 18638, p. 268). Large repeated 
doses of veratrum viride had no effect upon the pulse of 
a patient until two large and very active ascarides were 
removed from the stomach by vomiting; after this had 
occurred there was an immediate and marked reduction 
in the pulse. There are certain mechanical means which 
produce effects analogous to those caused by the cardiac 
depressants. Thus pressure over the heart—such as that 
caused by a plaster—removal of blood by venesection, 
and the application of cold to the cardiac region all re- 
duce the force and frequency of the heart beat and may 
be used instead of drugs. 

It is difficult to form an opinion as to the extent to 
which the three chief cardiac depressants—aconite, vera- 
trum viride, and tartar emetic—are employed at present, 
the practice of physicians varying so much. The gen- 
eral indication for their use has been said to be “increased 
arterial excitement, sthenic fevers, and severe local in- 
flammations.” In the first condition they are used ae 
ply to reduce the force and frequency of the pulse; 
sthenic fevers they are used not only to lessen the ieee 
of the heart but to obtain a relaxation of the peripheral 
vessels, while in local inflammations it is desired to divert, 
by their use, the blood into other channels. Pneumonia 
was formerly thought to be pre-eminently a disease in 
which these drugs were to be used and all three have 
been employed very extensively init. At present they 
are used to a much more limited extent; this is especially 
true of tartar emetic, and although many use aconite and 
veratrum viride, some have discarded all three and use 
the lancet when they think it desirable to depress the 
circulation. The reader is referred to the articles in this 
HANDBOOK on the various disturbances of the circulation 
for a discussion of the use of these remedies, but a few of 
the cases in which they are employed will be simply 
mentioned here. 

Aconite seems to give the best results in inflammations 
of limited extent, especially in tonsillitis, quinsy, and 
acute sore throat. Much of the relief in these cases seems 
to be due to the perspiration which follows the depression 
of the circulation. By diverting the blood away from 
the inflamed tissues these become less painful and the 
swelling subsides. Aconite is often serviceable in severe 
colds, in otitis, and in certain forms of asthma. It is 
sometimes used in nervous palpitation of the heart and 
in that occurring in excessive hypertrophy of the heart— 
although here it may become a very dangerous remedy. 
Occasionally it will relieve restlessness and give the pa- 
tient refreshing sleep. 

Veratrum viride seems to be used as a cardiac depress- 
ant to a more limited degree than aconite; it is probably 
used more extensively in pneumonia and puerperal fever 
than in the numerous other conditions for which it has 
been recommended. 

Tartar emetic is probably used still less for its action 
upon the circulation, although it is praised very highly 
in typhus and other fevers when there is much excite- 
ment .and wild delirium. It is used much more exten- 
sively as a diaphoretic, although its action as such may 
depend to some extent upon its power to depress the 
circulation. . : 


II. Carprac STIMULANTS. 


There are a great many drugs which can increase, in 
one way or another, or under certain circumstances, the 
force of the circulation; to a few of these which are used 
largely by physicians for this purpose the name “ cardiac 
stimulants” is applied. Aside from their action on the 
circulation, these drugs have little in common in either 
their chemical or their physiological properties. Their 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cardiac Stimulants, 
Cardiac Stimulants, 





action upon the circulation is, moreover, brought about in 
the most diverse ways, and is often determined to a consid- 
erable extent by the previous condition of the circulation. 
Some act chiefly upon the blood-vessels, others upon the 
heart; some act reflexly, others directly; while some 
may cause one kind of change reflexly and just the op- 
posite when absorbed; some slow, others accelerate, the 
heart. The action of some is very rapid while that of 
others is slowly developed and long continued. The last- 
named difference has served as a basis for the only classi- 
fication of these drugs it seems possible to make. Those 
which act rapidly are called “cardiac stimulants proper ” 
or simply “cardiac stimulants,” those with a slower ac- 
tion “cardiac tonics.” 

Cardiac stimulants, used in the narrower sense, bring 
about their effects largely reflexly and are used to pre- 
vent or counteract sudden failure of the heart’s action. 
They are used especially in fainting fits or syncope due 
to sudden emotion, physical injury, poisoning by car- 
diac depressants, or when the heart fails suddenly in 
fevers, after snake-bites, etc. The action of most of 
them is primarily upon the blood-vessels, and the heart 
is usually influenced only secondarily. They may be 
administered by inhalation (as is the case with ammonia 
in smelling salts), by the stomach or subcutaneously or 
intravenously. When applied to a mucous membrane 
they exert their influence largely through their local 
irritating action; some have little action after absorption 
while others (such as alcohol and ether) are essentially 
cardiac depressants when they once get into the circula- 
tion. These drugsare seldom used when there are organic 
changes in the heart. 

The most important members of this group are alcohol 
and the various liquids containing it in concentrated 
form, ether and chloroform—these three only when 
brought into contact with a mucous membrane or in- 
jected subcutaneously—the various preparations of am- 
monia, camphor, and the volatile oils. 

One of the most powerful of all cardiac stimulants is 
heat applied to the cardiac region. In addition to the 
above there are many drugs which, under certain cir- 
cumstances, may act as cardiac stimulants but which are 
not ordinarily included under that heading. 

Axconont.—Dr. J. J. Abel, who has given considerable 
attention to the subject of alcohol, has prepared the fol- 
lowing summary of its action upon the circulation. (For 
amore complete account see Dr. Abel’s paper in the re- 
port of the “ Committee of Fifty.”) 

It has long been a matter of discussion how best to 
define the action of ethyl alcohol and of alcoholic fluids 
on the circulatory apparatus. The term “circulatory 
stimulant,” as applied to alcoholics of all kinds, is firmly 
fixed in medical literature, but it has become impossible, 
in view of modern analyses, to retain this term in its 
original significance. The appearances of so-called 
stimulation are manifest especially in those individuals 
who are unaccustomed to the use of alcohol, and who 
possess an excitable vascular apparatus. In such the 
eyes become more brilliant, a sensation of warmth is ex- 
perienced in the stomach and on the surface of the body, 
the sweat glands, the salivary and gastric glands are 
stimulated, the pulse is fuller and faster, gestures and 
muscular movements in general are more frequent and 
more pronounced, and the respiration responds by an in- 
crease in rate and depth. The environment often sup- 
plements the action of the wine or other beverage in 
its emotional or intellectual effect. In view of these 
phenomena it is not strange that mankind speaks of al- 
cohol as a cerebral, circulatory, or respiratory stimulant. 

When it comes to the action of alcoholics on the cir- 
culatory apparatus, numerous difficulties are encountered ; 
secondary or reflex must be separated from primary ac- 
tions. But nowhere has modern analysis given us a 
clearer idea of the true action of a substance than in that 
of alcohol on the various parts of the circulatory ap- 
paratus. What is to follow holds, strictly speaking, for 
pure ethyl alcohol only. Yet it will be found to hold 
also for wines, spirits, and other forms of alcoholics 


which mankind has accepted after long and frequent 
empirical trials. It must be borne in mind that esters, 
aldehydes, the small quantities of higher alcohols, the 
salts, etc., in short the sum of the by-products of alco- 
holic fermentation, are quantitatively insignificant in 
comparison with the ethyl alcohol contained in all alco- 
holics. This becomes strikingly evident when they are 
studied in the light of toxicology. Thus, 1 litre of 
brandy will kill 64.9 kgm. of living animals (dogs, rab- 
bits, etc.), while the ethyl alcohol alone of this litre of 
brandy will kill 64.38 kgm. It is not denied that these 
by-products have a very important action on the sense 
of taste and that of smell, and on the functions of the 
digestive tract, nor that they noticeably enlarge the effects 
about to be described. It is especially the esters of 
wines and spirits which are to be thought of in this con- 
nection as slightly increasing the action of the ethyl 
alcohol, as their action is similar to that of alcohol, though 
more intense, quantity for quantity. 

When we inquire into the direct action of alcohol on 
each of the several parts of the vascular apparatus taken 
by itself, we reach the following conclusions. 

I. Action of Alcohol on the Isolated Heart.—Al\cohol in 
small and moderate quantities, that is, in such amounts 
as are to be fonnd in the blood in any condition far short 
of intoxication, does not have a direct stimulating action 
upon the isolated heart of either warm- or cold-blooded 
animals; indeed, moderate quantities show no appreciable 
action either in the way of stimulation or depression. 
The experiments of Martin and Stevens, Hemmeter, 
Ringer and Sainsbury, Dreser, Diaballa, Bock and others, 
furnish incontrovertible proof of this statement. But 
such a statement does not refer to the long-continued 
daily administration of small and moderate quantities of 
alcohol, but solely to its administration during brief 
periods, as in physiological experiments. 

In very large doses, such, for example, as result in 
helpless and perhaps fatal intoxication, alcohol is seen to 
be a direct and powerful depressant of the heart, weak- 
ening first the auricular, later the ventricular systole, 
causing more or less distention of both cavities, marked 
slowing of its movements and great diminution of its 
output of blood. As we shall see later, these positive 
statements do not stand in contradiction of the fact that 
alcohol is of frequent and beneficial use in conditions of 
great depression of the heart or central nervous system. 
In experiments like those from which the above conclu- 
sions were deduced, the heart was severed from all vital 
connection with the rest of the body. 

Il. Direct Action on the Walls of the Arteries and Veins, 
that ts, the Blood- Vessels Removed from all Central Nervous 
Control.—Small and moderate quantities of alcohol have 
no direct action on the walls of the blood-vessels. Very 
large amounts no doubt have a direct dilating action on 
the vessels, like that shown for the heart itself. The 
flushing of the face and other parts of the body so fre- 
quently observed after moderate quantities of alcohol is 
brought about by an action on the central nervous 
mechanism which controls the calibre of the vessels. 

Ill. Influence on the Arterial Blood Pressure.—Here we 
are dealing with a resultant effect of the work of the 
heart, and of the peripheral resistance offered by the 
smallest blood-vessels. These interdependent variables 
are affected through controlling nerves, and it is evident 
that here is an opportunity for indirect influences of 
various kinds. 

It must be admitted that blood-pressure measurements 
are of minor importance to the clinician. It is well 
known that minor fluctuations in the arterial pressure 
are of frequent occurrence, and Hensen even affirms that 
daily changes of 40 to 60 mm. Hg are not uncommon in 
individuals lying in bed. Arterial pressure, as usually 
measured, gives us only the lateral pressure on the walls 
of the larger arteries, and without additional data it 
gives us no information on that important question, the 
intensity of the blood flow—in other words, the amount 
of blood which passes in the unit of time through a given 
capillary area. Whether an organ will receive its re- 


693 


Cardiac Stimulants, 
Cardiac Stimulants, 


quired amount of oxygen and other necessary material 
must all depend on this. Now the state of constriction 
of the peripheral arterioles is a factor of the greatest im- 
portance in determining the value of this resultant as 
well as of the arterial pressure. As Krehl, Hensen, and 
others have pointed out, even during periods of little or 
no variation in the aortic pressure, considerable varia- 
tions are possible in the unit quantity of blood passing 
through the aorta. In other words, variation in the 
peripheral resistance may be offset in such a way by re- 
sponsive variations in the action of the heart that a 
change occurs, either in the way of an increase or de- 
crease in the amount of blood passing through the organs 
of the body, although aortic pressure remains practically 
unchanged. As a rule, however, an increase in arterial 
pressure means an increase in the intensity of the periph- 
eral circulation. Being an important item in the study 
of the hemodynamics, blood-pressure determinations can- 
not be neglected; yet it is necessary to point out, as Hensen 
has well said, that what we most need to know is not 
the arterial blood pressure, but rather the relation of the 
quantitative blood flow in any given organ to the actual 
needs of that organ, a relation which at present it is im- 
possible to determine. 

In regard to the action of alcohol on the arterial press- 
ure, we may say that, given in moderate quantities and 
in such a dilution as to avoid the consequences of local 
irritation, it has no appreciable effect on it. When so 
large a quantity is given that a change in the pressure be- 
comes apparent, it is always in the direction of a fall and 
not of arise. In the early stages of its action it usually 
causes some degree of flushing of the skin and brain, and 
later, when very large quantities have been taken, dilata- 
tion of the abdominal vessels occurs. A marked fall of 
blood pressure due to such large quantities is a toxic 
phenomenon, and is never met with under ordinary cir- 
cumstances. It is due to a sedative or depressant action 
of the alcohol on the vaso-motor centres, and also in part 
to its action in weakening the heart. 

IV. Action of Alcohol on the Pulse Rate.—When alcohol 
or beverages containing alcohol are administered to 
healthy persons in small doses, or even in such doses as 
will produce transient psychical changes, no alteration 
of the pulse rate is usually observed, provided that local 
irritation in the mouth and stomach is avoided, and the 
indirect effects of the mental action of the alcohol, such 
as bodily movements, are not allowed to influence the 
experiment. It is not improbable that in some excitable 
individuals the cerebral effects of the alcohol and the cir- 
cumstances of its administration may combine to induce 
such mental effects that slight changes in the pulse rate 
occur. 

As a rule, when the quantity of alcohol administered is 
not too small, the character of the pulse wave undergoes 
a slight change, the pulse becomes fuller and softer in con- 
sequence of a dilatation of superficial arteries. The heart 
is not weakened at this time, and the fuller pulse may 
give a false impression and lead to the belief that the 
arterial tension has been raised. The pulse tracings of 
Marvaud, Parkes, von Jaksch, Jaquet, and others, show 
that moderate quantities of alcohol influence the form of 
the pulse wave in like manner with chloral and other 
hypnotics, though less markedly from a quantitative 
point of view. The slight dilatation of the superficial 
arteries is due to the sedative action of the alcohol on 
the vaso-constrictor centre of the medulla, and is not 
sufficient to lower the arterial tension as measured in the 
carotid. 

By virtue of its local action on mucous membranes, 
and also by virtue of its cerebral effects, alcohol is 
capable of influencing the several parts of the vascular 
apparatus in a number of ways often directly opposed to 
those mentioned above. Such indirect effects are com- 
mon to its pharmacological congeners, and are familiar 
in the use of alcohol in daily life and in medical practice. 
Of these none is more often observed than a quickening 
of the pulse rate. Such indirect effects must not be 
allowed to obscure its true inherent action, which is al- 


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ways depressant in kind. When once in the blood and 
tissues, it must be classed with the anesthetics and 
narcotics. 

It is not to be inferred that the above statements for- 
bid a reasonable and prudent use of alcohol in thera- 
peutics. The records of clinical medicine show that 
alcohol, by virtue of its numerous indirect as well as 
direct influences, often serves the purpose of a “circu- 
latory stimulant.” In conditions of shock the weak pulse 
may become fuller and stronger, the feeble heart may beat 
more vigorously. Again, a quick pulse may become 
slower as the rapidly beating, fluttering heart is induced 
to slow down to a regular rhythm. Otherexamples need 
not be cited. The day is happily past when the thera- 
peutist plied his patient with a number of bottles of wine 
a day in the belief that he could stimulate the heart, 
lower the temperature, supply nutriment, and effect 
other good ends, without detriment of any kind, by giv- 
ing these large quantities. Certainly its administration 
in excessive doses can only do harm. 

Though the pharmacologist cannot admit that this 
agent is capable of stimulating the isolated mammalian 
heart, it would be rash to assert that it cannot serve as a 
cardiac stimulant in the human system. Gutnikow, 
who accepts it as a proved fact that alcohol can only 
lower the arterial pressure, when once it has reached the 
circulating blood, has made it the object of his researches 
to harmonize this with the equally well-known fact that 
it is often used in medical practice as an analeptic, as an 
agent that “strengthens and fortifies the heart.” Ac- 
cording to this author the sum total of the action of 
alcohol on the circulation is to the effect that, although 
there is a condition of lowered arterial tension, yet the 
mutual relations of the pressures in the cavities of the 
heart and in the arteries and veins are such that the heart 
works as tf tt were strengthened. It now has an easier 
task to keep all the minute arteries and veins and the 
capillaries well filled; under the new conditions its 
propelling power is not injured but rather improved. 
It may well be the case in certain clinical conditions, in 
the light of the remarks made in a previous paragraph 
on the relations existing between aortic pressure and the 
volume of the peripheral circulation, that alcohol will 
give cause for a better peripheral circulation, although 
the aortic pressure is slightly lowered. 

Whatever may be the future theories in regard to its 
clinical uses, the old position of alcohol as a blood-press- 
ure-raising agent and heart stimulant can no longer be 
defended, and it remains for the practitioner to use this 
agent with care and great discretion. 

Ammonia.—The preparations of ammonia which are 
used for their effect upon the circulation are solutions of 
the gas in water or in alcohol and the carbonate; the 
latter is a rather complex mixture of the carbonates and 
carbamates of ammonia, which give off ammonia on ex- 
posure and hence has an action similar to but less power- 
ful than that of the solutions of ammonia. 

Ammonia has a very powerful local action as well as 
an action upon the nerve centres when it reaches the cir- 
culation and it is important to distinguish between these. 
When ammonia reaches the circulation it is converted 
into urea'very rapidly; hence unless considerable quanti- 
ties are injected at once into the circulation no symptoms 
are produced. While ammonia is absorbed with con- 
siderable rapidity from the stomach, it is doubtful whether 
after the use of medicinal doses it reaches the circulation 
in sufficient concentration to have any appreciable ef- 
fect. Hence the effects of ammonia (and of ammonium 
carbonate) when given by the stomach are due largely, 
if not entirely, to the reflexes caused by its local action; 
the effects of the intravenous injection of considerable 
quantities will be discussed later. 

The effects of ammonia can be elicited by applying it 
to either the respiratory or the digestive tract or subcuta- 
neously, and consist of a powerful reflex stimulation of the 
vaso-motor and respiratory centres. The result is a rise 
of arterial pressure and an improvement in the pulse; 


‘ the latter is probably dependent upon the rise of blood 


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Cardiac Stimulants, 








pressure, for the heart, so far as it is affected reflexly at 
all, seems to be slowed by a stimulation of the vagus 
centre. The rise of blood pressure will rouse the patient 
from a fainting spell, from a condition of sudden collapse, 
from failure of the circulation during anesthesia and from 
similar conditions. The effect is very transitory, but is 
often sufficient to carry a person through a dangerous 
period. Both the physiological action and practical ex- 
perience point to the conclusion that ammonia is of little 
service when the failure of the circulation is dependent 
upon some slow and persistent cause. If ammonia is 
applied to the nostrils for too long a period or in too 
concentrated a form it may produce inflammation of 
the respiratory passages; also when it is swallowed in 
large quantities some of the vapor may reach the re- 
Spiratory passages and cause death by cedema of the 
larynx. 

When ammonia or one of its neutral salts is injected 
directly into the circulation of a mammal the effects are 
those observed whenever a powerful stimulant to the 
medulla or spinal cord is injected—increase of respira- 
tion, convulsions, tetanus, and a rise of blood pressure. 
‘These effects are probably due to the irritating action of 
the ammonia upon the nerve cells rather than to any 
specific stimulation of them, as is the case with such an 
alkaloid as strychnine for example. Very similar effects 
follow the subcutaneous application of ammonia or of its 
salts, although here the effect is complicated by changes 
brought about reflexly. The results are the same what- 
ever the salt used, provided the acid in combination has 
not, of itself, a poisonous action; this shows that, the 
results are due to the ammonium ion. 

A considerable amount of a salt of ammonia may be 
injected into the circulation of an animal without pro- 
ducing any toxic symptoms, provided the injection be 
made very slowly. Thus Marfori (Archiv fiir exp. Path. 
and Pharmakol., xxxiii., p. 71, 1893) showed that .03 gm. 
of ammonia (in the form of the carbonate) per kilogram 
could be injected per hour into a dog without causing 
‘any symptoms. The explanation of this is that the am- 
monia is rapidly converted into urea. 

The effects of ammonia and its salts when injected 
rapidly into the circulation or subcutaneously into an 
animal have been investigated by Blake (Hdin. Med. and 
Surg. Jour., lvi., p. 1, 1841), Lange (Archiv fiir exp. Path. 
und Pharmakol., ii., p. 875, 1874), Funke and Deahna 
(Archiv fiir die ges. Physiol., ix., p. 416, 1874), and For- 
manek (Archives internat. de Pharmacodynamie et de 
Therapie, vii., p. 229, 1900). The first effect is usually a 
‘slowing of the heart and a slight fall of blood pressure; 
then there is a marked rise of blood pressure, the heart 
‘sometimes remaining slowed, sometimes being acceler- 
ated. Theslowing of the heart and the first fall of blood 
pressure are due almost entirely to a stimulation of the 
‘centre of the cardio-inhibitory nerves, for they usually 
‘disappear immediately upon section of the vagi. There 
‘may sometimes be a slight, unimportant slowing of the 
heart after section of the vagi; this is probably due to a 
‘slight stimulation of the vagus endings in the heart, for 
these are stimulated by a great many of the drugs which 
‘stimulate the medullary centres of the vagus. Ifa very 
large amount of ammonia is injected into a vein the 
heart may be poisoned directly and may either beat very 
‘slowly or be arrested at once in diastole. 

The rise of blood pressure has been attributed by some 
to a stimulation of the heart, by others to a stimulation 
of the vaso-motor system; it is due to both of these, but 
probably more to the latter than to the former. The 
-action of the salts of ammonia when directly applied to 
the frog’s heart has been studied by Ringer and Sains- 
bury. These results are of especial value because no 
‘similar experiments have been made upon the mam- 
‘malian heart. Briefly stated, Ringer finds that am- 
monium salts added to the nutrient fluid circulating 
through the isolated frog’s heart increase, in small doses, 
the strength of the-ventricular contractions, but that 
larger doses destroy muscular contractility; spontane- 
yous action, however, continued until contractility was 


lost; in the end stage there was no response even when 
the ventricle was strongly stimulated electrically. Ringer 
also finds that ammonia lessens dilatation of the ventricle 
and arrests it insystole. If the heart has been weakened 
by chloroform or other anesthetics, the beat is strength- 
ened by ammonia, and a heart stopped in diastole by 
chloroform passes into the condition of systole under the 
influence of ammonia. Since these experiments were 
made upon the ventricle of the frog’s heart we are 
justified in concluding that ammonia stimulates the car- 
diac muscle directly. It isnot known to what extent 
ammonia has a similar action upon the mammalian heart. 
An acceleration and strengthening of the heart beat some- 
times follows its injection, but this stimulation is usually 
of short duration and does not always occur. Some think 
that the improvement in the heart beat is to be attributed 
to the rise of blood pressure rather than to a direct effect 
upon the heart, while Formanek thinks it is due in part 
to a stimulation of the accelerator nerves. 

The great rise of blood pressure following the injection 
of ammonia is usually attributed to a stimulation of the 
vaso-motor centre, and this view is made very probable 
by the fact that the other medullary centres are so 
powerfully stimulated by this substance. Funke and 
Deahna found that in frogs section of the cord or of the 
sciatic plexus greatly diminished or abolished altogether 
the constriction of the blood-vessels following the sub- 
cutaneous injection of ammonia. On the other hand, 
there is considerable experimental evidence that the 
peripheral vaso-motor system (the nerves or the muscles 
of the vessels) is stimulated directly. Thus Lange ob- 
tained a marked rise of pressure after division of the 
cord, 7.e., after the vaso-motor centre had been separated 
from the arterioles. Beyer (Medical News, 1886) trans- 
fused the vessels of terrapins (from which the heart had 
been removed) with Ringer’s solution to which salts of 
ammonia had been added. There was first an increased 
then a diminished outflow from the veins, 7.e., a dilata- 
tion followed by a constriction of the blood-vessels. We 
are probably justified in concluding that the rise of blood 
pressure caused by ammonia is due partly to a stimula- 
tion of the vaso-motor centre and partly to a direct ac- 
tion upon the arteries; it is very probable that direct 
stimulation of the heart also is a factor, especially if this 
organ has been previously weakened by anesthetics, 
etc. Binz (Centralbl. fiir klin. Med., ix., p. 26, 1888) 
found that if the arterial pressure of an animal was made 
very low by the administration of chloral hydrate, am- 
monia would cause it to rise; the improvement was, 
however, temporary and when the ammonia was pushed 
convulsions followed. 

Intravenous and hypodermic injections of ammonia are 
sometimes made in cases of sudden and dangerous col- 
lapse, as in failure of the heart during anesthesia, in 
cholera, after injuries, etc. It has been used extensively 
in cases of poisoning from snake bite but the improve- 
ment in these cases seems to be temporary. When 
ammonia is administered by the mouth or by the respi- 
ratory tract the only effect upon the circulation is the 
reflex stimulation of the vaso-motor centre; by its intra- 
venous use the peripheral vaso-motor system as well as 
the medullary centre is stimulated and there is further 
probably some direct action upon the heart. When am- 
monia is given intravenously in very large amounts there 
is danger of causing convulsions; animals, however, 
usually recover quickly from such convulsions. 

Camphor.—Camphor has long been used, especially in 
Germany, as a cardiac stimulant in cases of collapse and 
cardiac weakness from fevers and other causes; the pulse 
becomes fuller and stronger under its influence. State- 
ments as to the action of camphor upon the heart are in- 
complete and in some cases contradictory ; moreover, its 
cardiac action is undoubtedly much obscured by its ac- 
tion on the central nervous system, the respiration, and 
the vaso-motor centre. The beneficial effects in collapse, 
etc., are probably due quite as much to these effects as 
to the effects upon the heart. Camphor has, moreover, 
a well-marked local action and it is not easy to distin- 


695 


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Cardiac Stimulants, 





guish between the effects produced reflexly and those 
produced after its absorption. 

Some of the rather fragmentary statements as to the 
action of camphor will be given. Lewin (Archiv fir 
exper. Path. und Pharmakol., xxvii., p. 229, 1890) found 
that camphor administered to rabbits in which the blood 
pressure was extremely low as a result of large doses of 
chloral hydrate caused a marked rise of pressure; fre- 
quently it was doubled. The rise of blood pressure was 
longer continued when the camphor was given by the 
stomach than when it was injected into a vein. Lewin 
argues that since the vaso-motor centre was paralyzed 
by the chloral the rise of blood pressure must have been 
due largely to a stimulation of the heart (for camphor 
has, so far as is known, no direct stimulating action 
upon the peripheral vessels). If the chloral anesthesia 
was not so very deep then the vaso-motor centre was 
stimulated, as was shown by the fact that it became sensi- 
tive to the effects of asphyxia. 

It is a significant fact, however, that Wiedemann 
(Archiv fiir exper. Path. und Pharmakol., vi., p. 228, 
1876) failed to obtain any rise of blood pressure from the 
administration of camphor after section of the spinal 
cord—as would be expected if Lewin’s conclusions are 
correct. It is very probable that there was some source 
of error in the experiments of one or the other investi- 
gator. Their results could, however, be brought into ac- 
cord if we suppose the medullary centres of the acceler- 
ator nerves to be stimulated by the camphor. There 
is, however, no experimental basis for the latter sup- 
position. 

Small doses (five to ten grains) administered to a 
healthy man usually cause an acceleration of the pulse, 
although sometimes they have little effect or may even 
cause slowing. Larger doses (twenty grains or more) 
slow and weaken the pulse; after toxic doses the pulse 
may be accelerated again. 

When from any of a number of causes the pulse is 
very weak or almost imperceptible, camphor will make 
it fuller and stronger. Binz and Baum found that in 
animals in which fever had been induced by the injection 
of putrid matter, camphor increased the strength of the 
heart beat and caused it to continue longer after death 
than in the case of control animals. 

Heubner (Archiv fiir Heilkunde, xi., p. 3834, 1870) and 
Harnack and Witkowski (Archiv fiir exper. Path. und 
Pharmakol., v., p. 427, 1876) state that camphor causes 
the frog’s heart to beat more slowly but more powerfully ; 
this is due, according to these authors, to a direct action 
upon the heart, for the latter can be made to beat again 
after it has been brought to a standstill by muscarine, 
and, on the other hand, neither muscarine nor stimulation 
of the vagus can stop the heart poisoned with camphor. 
Lewin (doc. cit.) found the frog’s heart to be slowed by a 
prolongation of the systole; the diastole was less complete 
and so the output was diminished. Thus the effect of 
camphor upon the frog’s heart is similar in some respects 
to that of digitaline. 

The blood-pressure in mammals is usually considerably 
increased by camphor; this seems to be due in part to an 
action upon the heart, in part to a stimulation of the 
vaso-motor centre. Whether the latter is stimulated 
directly or reflexly isnot known. In some cases rhyth- 
mical variations of the blood pressure appear; these are 
especially marked if convulsions occur, but they are also 
seen when convulsions are prevented by curare (Wiede- 
mann, loc. cit.). It has been suggested that these rhyth- 
mical variations are due to a direct action upon the vaso- 
motor centre, just as the convulsions are due to a direct 
action upon the cerebral cortex; or the cerebral cortex 
may send rhythmical impulses to the vaso-motor centre 
independently of those causing the convulsions. 

Thus, as far as we are able to judge from the avail- 
able data, camphor has an action upon the circulation 
similar to that of ammonia, and it seems to be of use in 
similar conditions. Like that of ammonia the action of 
camphor is very transitory. Van der Helm (“ Versuche 
tiber einige arzneiliche Erregungsmittel,” Dissert., Bonn, 


696 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





1887, p. 28) says that the action of camphor upon the 
blood pressure, as well as upon the respiration, is longer 
continued thanis that of ammonia. Attention was called 
above to the fact that the effect of camphor is more last- 
ing when it is given by the stomach than when injected 
intravenously ; the explanation of this is probably that in 
the latter case the camphor is very rapidly destroyed in 
the organism. Moreover, when the drug is given by the 
stomach, the reflex as well as the direct effects of its ac- 
tion are obtained. The slight solubility of camphor in 
water and the consequent great irregularity of its rate of 
absorption from the digestive tract are two of the chief 
drawbacks to its employment in therapeutics. A num- 
ber of the other members of the camphor group have 
been studied, but as yet no good substitute for camphor 
has been discovered. Camphorol, amido-camphor, and 
camphoric acid resemble camphor in their physiological 
action but are less powerful. 

Musk has also been used as a cardiac stimulant in con- 
ditions similar to those for which camphor has been pre- 
scribed; it has been especially recommended in certain 
cases of advanced typhoid fever. Almost nothing is 
known as to its physiological action, but it seems to 
strengthen the heart beat; it has a more decided action 
upon the respiration. 

Most of the volatile oils when taken into the stomach 
act as mild cardiac stimulants. Their action is entirely a 
reflex one, for when injected into a vein they depress the 
vaso-motor centre and, in large doses, the heart. 

Cardiac Tonics.—Those drugs which are employed to. 
produce a more lasting effect upon the heart are called. 
cardiac tonics. They act chiefly upon the cardiac muscle; 
to a less extent upon the cardiac nerves and the vaso- 
motor apparatus. Their action is usually slow; fre- 
quently no change in the circulation can be made out for 
many hours, sometimes not for days, after their adminis- 
tration has been begun. It is chiefly in diseases of the 
heart, especially those associated with valvular lesions in 
which dilatation has occurred, that these drugs are used. 
Among them are some of the most valuable remedies. 
known to medicine. 

The most important members of this group are those 
belonging to the “digitalis series,” including digitalis. 
itself, strophanthus, scilla, convallaria, adonis, erythro- 
phlceum, helleborus niger, etc. Caffeine and strychnine, 
as far as their action upon the heart is concerned, also 
belong to the group of cardiac tonics. 

The Digitalis Series.—The “ digitalis series” embraces. 
a number of substances derived from various families of 
the vegetable kingdom and having little in common as. 
regards their chemical’ composition; some substances. 
found in the animal and even in the mineral kingdoms. 
may be included in this series. The bond that unites. 
these various substances is a peculiar and specific influ- 
ence upon the heart; the action of any one member is. 
almost identical with that of all the others and different. 
from almost all other substances. So great is this similar- 
ity of action that pharmacologists do not hesitate to apply 
the discoveries made concerning one member to all the 
others and speak of the action of “digitalis,” although 
the experiments in questions were made with some other 
member. | 

The three drugs of this series which are most used are: 
digitalis, strophanthus, and scilla, and most of the physio- 
logical experiments have been made with these, especially 
with the first two. : 

Few. drugs in the Pharmacopeia have been the subject. 
of so much discussion as digitalis, and even yet writers. 
are not in accord as to some of its physiological actions. 
Clinicians formerly classed it with the cardiac sedatives, 
although now it is placed first in the list of cardiac stimu- 
lants or tonics. Different experimenters have credited it 
with having nearly every action upon the vascular mech- 
anism which it is possible fora drug to have. These 
discordant results are all the more remarkable as they are: 
not due to the workers having used different prepara- 
tions; almost any preparation of these drugs, provided it. 
is active at all, will produce the effects typical of the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cardiac Stimulants, 
Cardiae Stimulants, 





series. The real source of trouble has been that the 
pharmacologists and physicians have failed, until very 
recently, to make use of the advances in methods of work 
and of the facts discovered by modern physiology 

Very little knowledge of the action of digitalis upon 
the circulation can be obtained by its administration to 
healthy men beyond the fact that the pulse first becomes 
very slow and later intermittent and irregular. The 
apex beat is stronger and the arteries feel more tense. 
At the same time the irritability of the heart seems to 
become abnormally great; slight exertion may cause it 
to assume a rate of 120 to 130. 

Experiments upon the frog’s heart have played a very 
important part in the history of the study of the physio- 
logical action of digitalis; the greatest service such ex- 
periments have rendered is the proof that the action of 
digitalis is primarily upon the cardiac muscle. The 
changes brought about in the frog’s heart are readily 
observed by exposing the heart and injecting the drug 
into a lymph space. The heart soon becomes slowed, 
but the essential feature is that the ventricular systole 
becomes more complete. The blood is more completely 
expelled from the heart, and during each systole the ven- 
tricle becomes almost white; it also remains contracted 
for a longer period. The diastole becomes shorter and 
then less complete; the time relations between systole 
and diastole become almost reversed. Instead of a short, 
sudden systole and a long-continued diastole, as normally, 
the systole becomes very long while the diastole is a 
sudden, imperfect relaxation of very short duration 
which merely interrupts for an instant the prolonged 
contraction. Finally the ventricle stops in systole; it is 
firmly contracted and white, while the auricles are dis- 
tended with blood and may contract feebly for a short 
time. Before the ventricle is finally arrested certain 
irregularities usually appear. One part of the ventricle, 
usually the apex, does not relax during diastole and the 
blood is thrown against the relaxed walls of the other 
parts causing little bulgings. Or the ventricle may 
assume a mottled appearance from there being numerous 
small areas of muscle which remain contracted. The 
blood may be thrown from one side of the ventricle to 
the other, the heart undergoing the “ peristaltic contrac- 
tions” so often mentioned by German writers. 

The picture of the frog’s heart under digitalis is an 
extremely characteristic one, and such an experiment as 
the above is of much more value as a means of identify- 
ing one of this series in toxicological examinations than 
are most of the chemical tests. 

If, after the ventricle has stopped, the intracardiac 
pressure be increased, the heart will commence beating 
again, showing that the cardiac muscle is not in a condi- 
tion of rigor. If apomorphine, or some other drug which 
tends to paralyze the heart muscle, be applied to the 
contracted ventricle, the latter will relax and commence 
beating again. These facts led Schmiedeberg to the 
view, which has been widely accepted, that the essential 
action of digitalis upon the cardiac muscle is a change in 
its elasticity. There are certain facts which make it diffi- 
cult to accept this view of Schmiedeberg’s, and the only 
statement we can safely make is that digitalis tends to 
increase and prolong the contraction of the heart and to 
diminish and shorten diastole. The absolute power of 
the heart muscle—/.e., the pressure against which the 
heart is able to contract—does not seem to be increased 
by digitalis. Since the extent of the contraction is in- 
creased, the effect of digitalis has been compared to an 
increase in the length of the muscle fibres while their 
cross section (which determines the absolute power) re- 
mains the same. That this action of digitalis is upon 
the cardiac muscle itself, and not upon nervous structures 
contained in the heart, is shown by the fact that entirely 
similar changes are produced in the apex of the frog’s 
ventricle and in the hearts of certain invertebrates which 
are free of nerve cells. So specific is the action of digi- 
talis upon the heart that this organ may be completely 
stopped in systole and yet the frog jump about very 
much as if it were normal, 7.e., the central nervous 











system and skeleta] muscles are very little affected when 
the action upon the heart is at its maximum. 

These effects of digitalis upon the cardiac muscle are 
sometimes obscured by the results of a stimulation of the 
vagus caused by the drug. In some cases after the ap- 
plication of digitalis the ‘systole is incomplete while the 
diastole is much prolonged and the relaxation during it 
very great; the heart may even stop temporarily in 
diastole. Rection of the vagi or the paralysis of their 
endings by atropine causes “this picture to change in- 
stantly and the results are now as those described above. 

One other action of digitalis upon the frog’s heart is to 
be noticed, viz., an increase in its irritability. That the 
irritability ‘of the muscle is increased is shown by the fact 
that a preparation of the apex of the ventricle which has 
been exhausted by the transfusion of normal saline solu- 
tion through it and which has ceased to beat will com- 
mence again when digitalis is applied to it. Sometimes 
there is a slight acceleration of the heart immediately 
after the injection of digitalis; this is doubtless due to 
an increase in the irritability of the muscle, 

The study of the effects of digitalis upon the frog’s 
heart is of importance because the changes produced by 
it in the mammalian heart can be traced back to the same 
two factors—an alteration of. the cardiac muscle combined 
with a stimulation of the cardio-inhibitory nerves 

The action of digitalis upon the circulation of mam- 
mals is usually divided into four stages (Schmiedeberg, 
Archiv fir exper. Path. und Pharmakol., xvi., p. 175, 1882). 

1. Rise of arterial pressure accompanied as arule by 
slowing of the heart. 

2. Continued rise of blood pressure with increase in 
the pulse rate. 

3. Continued high pressure with great irregularity of 
the heart. 

4. Rapid sinking of the blood pressure, failure of the 
heart, standstill, and death. 

Such a division of the action into stages serves a use- 
ful purpose in so far as it emphasizes some of the salient 
points; but as a matter of fact these stages merge into 
each other and frequently some of the features of one 
appear in the others. Some of the chief points to be 
considered, then, are (1) the slowing of the heart, (2) the 
rise of blood pressure, (8) the secondary acceleration of 
the heart, and (4) the cause of the irregularity and death 
of the heart. 

The slowing of the heart was observed in man by 
Withering, by whom digitalis was introduced into medi- 
cine (“An Account of the Foxglove and Some of its 
Medical Uses; with Practical Remarks on Dropsy and 
Other Diseases,” Birmingham, 1785). Withering was 
chiefly interested in the ‘diuresis produced by digitalis 
and paid but little attention to its action upon the heart, 
although he remarked “that it has a power over the 
motion of the heart to a degree yet unobserved in any 
other medicine and that this power may be converted to 
salutary ends.” John Ferriar wrote an essay in 1799 on 
the action of digitalis in which he states that the chief 
action is to slow the heart. The first efforts to discover 
the cause of this slowing of the heart seem to have been 
made by Traube in 1851. Traube found that the slow- 
ing was removed by section of the vagi, and he therefore 
ascribed it to a stimulation of the cardio-inhibitory centre 
in the medulla—an explanation which has received 
abundant confirmation. Occasionally digitalis causes a 
slight slowing of the heart after section of the v: igi; this 
has been shown to be due toa stimulation of the vagus end- 
ings intheheart. The irritability of the vagi is increased 
by digitalis, for a stimulation of these nerves which was 
inefficient before, will slow the heart after, its administra- 
tion. An attempt was made to show that the stimulation 
of the vagus centre was not a direct effect of the digitalis 
but a secondary effect due to the rise of blood pressure ; 
this is disproved by the fact that the heart is often 
slowed although there is no rise of blood pressure. 

Thomas observed that digitalis sometimes failed to 
slow the heart in pneumonia; Brunton and Cash investi- 
gated the cause of this and reached the conclusion that it 


697 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





was due to a partial paralysis of the medullary centres 
of the vagi by the fever so that they were no longer 
easily stimulated by the drug. Hence if digitalis is given 
in a case of fever, the rate of the pulse is not always a 
safe guide as to whether the drug has been given in sufli- 
cient quantity to affect the cardiac muscle. 

The acceleration of the heart which occurs in the later 
stages of digitalis poisoning was at first attributed to a 
paralysis of the vagi, for a number of investigators failed 
to obtain any slowing of the heart by stimulating these 
nerves during this stage. This explanation has proved 
insufficient because in some experiments the vagi retain 
their control over the heart up to the end, and, moreover, 
digitalis causes an acceleration of the heart after the vagi 
have been paralyzed by atropine. Attention was called 
above to the fact that the irritability of cardiac muscle 
of the frog isincreased by digitalis, and, as will be shown 
later, there is abundant evidence that the same occurs 
with the mammalian heart. Hence at present it is con- 
sidered that the acceleration may be due in part to the 
paralysis of the vagi, but that the increased irritability 
of the cardiac muscle which renders the heart more diffi- 
cult of inhibition is a more important factor. Ofcourse, 
the acceleration may be due in part to a stimulation of 
the accelerator nerves, but there is no clear proof that 
this is the case. 

The rise of blood pressure caused by digitalis has been 
a matter of much dispute. Blake (Hdinburgh Med. and 
Surg. Jour., April, 1889) was the first to make blood- 
pressure experiments with digitalis; he concluded that 
the rise was due to a contraction of the capillaries and 
other peripheral vessels. A group of German investigat- 
ors (among them Schmiedeberg and his pupils) have al- 
ways maintained that the increased strength of the heart 
beat is the cause of the rise of blood pressure. They based 
their view upon experiments upon the frog’s heart as 
well as upon deductions drawn from the behavior of the 
mammalian heart. There has been much discussion as to 
whether the vaso-constrictor centre is involved in the rise 
of pressure; there isno question that a marked rise occurs 
after section of the spinal cord, but it is not yet settled 
whether, in the intact animal, stimulation of the vaso- 
motor centre may not be a factor in the cause of the rise 
of blood pressure. A large amount of evidence has 
accumulated which shows that the peripheral vessels are 
constricted by digitalis. Thus Donaldson and Stevens 
(Journal of Physiology, iv., p. 165, 1888) observed a 
marked diminution in the outflow from the veins of a 
terrapin (in which the central nervous system had been 
destroyed and the heart removed) when digitalis was 
added to the solutions transfused through the vessels. 
Similar results have been obtained in transfusion experi- 
ments with the kidneys and other “surviving ” organs of 
mammals. On the whole the evidence is very strong 
that, ina normal animal, the constriction of the arterioles, 
due to a direct action upon their muscular walls, is a 
very, perhaps the most, important factor in the rise of 
blood pressure. Stimulation of the cardiac muscle is an- 
other factor, and it is probable that there is also some 
stimulation of the vaso-constrictor centre. In the case of 
a man with incompetent valves, the heart action is prob- 
ably a much more important factor in causing the rise of 
blood pressure than it is in a normal individual. This 
point will be discussed later. 

The fall of blood pressure and the irregularities of the 
heart in the late stages of digitalis poisoning are attributed 
entirely to changesin the heart. It has been shown that 
there is no dilatation of the arterioles, as was once sup- 
posed to be the case, even after very large amounts of 
the poison. 

Until comparatively recently very little was known as 
to the details of the changes produced by digitalis in the 
mammalian heart; that the strength of the beat is in- 
creased was generally inferred from the experiments upon 
the frog’s heart. Moreover, several English physicians in 
the earlier part of the century (e.g., Beddoes and King- 
lake, 1801) had reached the conclusion, from studying the 
pulse, that while digitalis slows the heart, the strength 


698 





of the beat is not decreased, but is, on the contrary, in- 
creased. The increased energy of the heart’s contraction 
is also evident froma study of the pulse waves in an 
animal deeply poisoned with chloral. Chloral causes a 
complete relaxation of the arterioles. If digitalis be ad- 
ministered to an animal in which this has occurred the 
pulse waves are greatly increased, indicating that the 
heart is expelling more blood at each contraction. It. 
has been a debatable question whether this increased out- 
put of the heart is due to a change in systole or in dias- 
tole. Schmiedeberg (“ Grundriss der Arzneimittellehre,” 
dritte Auflage, p. 168, 1895) and Williams (Archiv fir 
exper. Path. und Pharmakol., xiii., p. 9, 1880) maintain 
that there is an increased diastolic extensibility without 
any change in the contractility. According to these au- 
thors, the elastic resistance of the heart is diminished and 
there is an increased diastole. As the heart contracts to 
its former volume in systole more blood is expelled and 
consequently more work accomplished. 

More recent workers have adopted the view that the 
essential change is one in systole, but that this is com- 
bined with the effects of a stimulation of the vagi (Cushny) 
or of the vagi and accelerators (Francois-Franck). Fran- 
cois-Franck (Clinique Médicale de la Charité, Potain, p. 
549, 1894) pointed out the resemblance between the 
action of digitalis upon the heart and the effects of the 
simultaneous stimulation of the vagi and accelerators; 
in each case there is a slowing of the pulse but an in- 
crease in its force. At the same time the increase in 
force is due, according to this author, in part to a direct 
muscular action. Ina later paper (Comptes rendus de la 
Société de Biologie, 1897, p. 111) he seems to lean toward 
the view that the change in the muscle is a more im- 
portant factor than he at first supposed. Cushny (Jour- 
nal of Experimental Medicine, ii., p. 254, 1897) advanced, 
independently, a theory for the action of digitalis very 
similar to that of Francois-Franck, except that he ascribes 
those changes which the French writer thought to be due 
to a stimulation of the accelerators entirely to the mus- 
cular action. 

As the methods used by Cushny are probably more 
exact than those of others his results will be given in 
some detail. Cushny studied the effect of digitalis upon 
the heart by means of the myocardiograph and the cardi- 
ometer of Roy and Adami. The former is an instrument 
with which the distance between two points on the 
heart’s surface and their movements relative to each 
other are recorded. The curve made by this instrument 
is similar to an ordinary muscle curve and shows not 
only the rate of the heart beat but also its strength and 
changes in tonicity; 7.e., whether the heart tends to as- 
sume the position of systole or that of diastole. The 
cardiometer measures the volume of the heart in its suc- 
cessive phases and therefore records the amount of blood 
expelled from the heart. The experiments of Cushny 
were made upon dogs and cats. The action of digitalis 
may be divided into two stages: the first stage is char- 
acterized by a slow pulse due tostimulation of the vagus, 
while in the second stage the heart is accelerated. In 
both stages there are very important changes in the car- 
diac muscle. The first stage may be divided into the 
“therapeutic stage” and a stage of “excessive inhibi- 
tion”; the latter stage doesnot always occur. The early 
part of the first stage is the one of greatest interest as it 
is the only one desired in the medicinal use of digitalis. 

Within one or two minutes after the intravenous in- 
jection of a very small amount of digitalis changes in the 
heart occur which are characterized by a slowing of the 
beat and increased excursions of the recording levers 
toward systole and generally toward diastole. The 
slowing of the heart, being caused by stimulation of the 
vagi, is due largely to a prolongation of the diastolic 
pauses. At the same time the duration of the systole is 
somewhat increased; but this seems to be due entirely to 
the slowing of the heart, for there is no evidence that the 
contraction of the mammalian cardiac muscle is pro- 
longed, as is so markedly the case with the frog’s heart. 
The increased excursion toward systole of the lever fixed 


sr ae 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ©27diac SUmulants, - 


Cardiac Stimulants, 





to the ventricle shows that this cavity is emptying itself 
much more completely than it normally does. It is gen- 
erally recognized that normally the ventricles do not 
empty themselves completely so that at the end of systole 
they containsome blood. Under the influence of digitalis 
the blood remaining in the ventricle at the end of systole 


Dy N’ D 


Fig. 1141.—Tracings of the Ventricular Contractions under Digitalis in Experiments on 
Two Dogs. NV, N’, Normal contractions; D, D’, contractions under digitalis. The 
levers move upward during systole. In D the rhythm is slower and the movements 
extend further upward and downward than in JN, i.e., the contractions are more 
complete and the dilatation during diastole is greater. In D’ the rhythm is slower, and 
the tracing extends further upward than in N’, but reaches almost the same point 
below, i.é., the contraction is stronger, but the dilatation is scarcely changed. (From 


Cushny.) 


is much less than before. This increased contraction of 
the ventricle is due to an action of the drug on the cardiac 
muscle, just as in the frog’s heart. The papillary muscles 
undergo the same change as the rest of the ventricular 
wall, contracting more strongly and more completely than 
before the administration of the drug. The intraventricu- 
lar pressure during systole was found by Francois-Franck 
to be much increased. The relaxation of the ventricle 
during diastole varies considerably in different conditions. 
As is well known, stimulation of the vagus always tends 
to increase the relaxation of the ventricle, but in the case 
of digitalis this action is opposed by the direct effect of 
the drug upon the heart muscle. The result depends 
upon these opposing factors, and the effect of these again 
depends, largely, upon the condition of the heart. If the 
heart is normal or does not dilate much during diastole, 
digitalis increases the relaxation (Fig. 1141, D). If, how- 
ever, the heart is weak and dilated digitalis tends to 
lessen this dilatation so that the relaxation of the ven- 
tricle during diastole is less than before the administra- 
tion of the drug; this is always the case if the vagus 
terminations have been paralyzed by atropine (see Fig. 
1142, B). 

In the auricles the same forces are at work as in the 
ventricle. The direct muscular action tends to cause a 
more complete contraction in systole while the stimula- 
tion of the vagus opposes this action as well as causes a 
slowing of the beat. As is well known, stimulation of the 
vagus produces a much greater effect upon the auricle 
than upon the ventricle, while there is a much smaller 
amount of muscular tissue upon which the digitalis can 
act directly. Hence after even a comparatively small 
dose of digitalis the inhibitory action may at times pre- 
dominate and thus greatly reduce the extent of the con- 
traction of the auricles and so the volume of blood ex- 
pelled. With ordinary medicinal doses, however, the 
effect upon the auricles is very much the same as that 
upon the ventricles: the heart beat is slowed, but the 
contraction in systole is increased while the relaxation in 
diastole is not much influenced. — 

It is clear that the output of the ventricle at each beat 
must be increased by digitalis, for the ventricle usually 
contains more blood at the beginning and less at the end 
of systole than normally. If the rate of the heart re- 
mained the same, it is evident that the output per unit of 


- time would also be increased. But the slowing of the 


heart tends to reduce the total output; hence only 
cardiometer records can show which of these opposing 
factors prevail. Asa matter of fact, Cushny found that 
the output of the heart per unit of time (e.g., ina minute) 








was uniformly increased by small doses of digitalis; this 
increase amounted at times to fifty per cent. With 
somewhat larger doses the inhibitory action may become 
extreme and now the output is diminished. The output 
is increased again when the heart becomes more rapid. 
During all the early part of the first stage the rhythm 
of the heart is normal; each beat of the 
auricles is followed by one of the ven- 
tricles, and the two sides of the heart 
beat together. If the drug is pushed 
the slowing becomes extreme and, as 
always happens when the vagus is 
strongly stimulated, the rhythm is dis- 
turbed. The muscular action may be 
} . . “Le: 
entirely concealed by the inhibitory 
action so that the systoles become 
weaker and less blood is expelled; as 
a rule, however, the output per beat 
is still greater than normal while that 
N per unit of time is less owing to the 
slow rate of the heart. The auriculo- 
ventricular beat may be more or less 
dissociated and the two chambers beat 
at different rhythms. Sometimes this 
is due to the excessive inhibition pre- 
venting the impulses from the auricle 
reaching the ventricle, a “block” being 
formed between the two chambers. At 
the same time the irritability of the ventricular muscle 
may be so increased that the ventricle assumes a rhythm 
entirely independent of the auricle; this “idio-ventricu- 
lar” rhythm may be more rapid or slower than that of 
the auricle (see Fig. 1148). These changes in the rhythm 
of the heart always indicate a grave condition of poison- 
ing and are not met with in the therapeutic use of digitalis. 
During the second stage of the action of digitalis the 
muscular prevails over the inhibitory action. The pulse 
becomes very rapid, the inhibitory nerves no longer being 
able to keep the heart in check. The auricles are often 
later in being accelerated than the ventricles because the 





re 


B A 


Fic. 1142.—Tracings of the Movements of the Ventricle (Lower) and 
Auricle (Upper) under Digitalis. During systole the levers make 
an up-stroke. In this experiment the inhibitory terminations had 
been paralyzed, so that only the muscular action is developed. A, 
Normal; B, after digitalis. The rhythm of the heart is slightly 
accelerated in B, and the levers extend further upward, indicating 
a more perfect systole in both auricle and ventricle. The ven- 
tricular lever does not reach so far downward in B, i.é., the ven- 
tricular diastole is less complete. (From Cushny.) 


inhibitory nerves have a greater influence over them. 
The difference in rhythm of the two divisions leads to 
very characteristic variations in the strength of the con- 
tractions of both auricles and ventricles. Numerous 
other forms of irregularities occur which it is impossible 


699 


Cardiac Stimulants, 
Cardiac Stimulants, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





to describe ina few words. They have many points of 
resemblance to those described under aconitine and can 
all be traced to the increased irritability of the cardiac 
muscle and to the interference of the (independent) 
auricular and ventricular rhythms. (For detailed ac- 
counts of these irregularities, which are of toxicological 
rather than of pharmacological interest, see the elaborate 
descriptions of Cushny, Knoll [Sitzb. der Wiener Akad., 
xcix., Abth. iii., p. 31, 1890, and ciii., Sitz. November 8th, 
1894], and Francois-Franck.) Many of the forms of 
irregularity can be imitated in the normal animal by 
electrical stimulation of different parts of the heart 
(see Cushny, Journal of Physiology, xxv., p. 49, 1899). 
Stimulation of the accelerators or of the vagi will often 
cause the most irregular heart to become regular again, 


gall 

































































































































































UII 


| JULI UUUUULUULIU UU | 


Fic. 1143.—Tracing of the Auricular (Upper) and Ventricular Movements (Lower) under Dig- 
italis, as the First Stage Passes into the Second. During systole the leyers move upward, 
during diastole downward. The rhythm of the two chambers is at first the same, but soon 
changes, the auricle maintaining its rapid beat, while the ventricle becomes slow and 

At the end of the tracing the ventricle again becomes rapid, while the auricles 

The strength of the contractions and the extent of relaxation of the ven- 

tricular muscle remain little altered, while the auricle rapidly weakens in strength, but 


irregular. 
become slow. 


improves again at the end of the tracing. (From Cushny.) 


and there is some evidence that the tonic activity of the 
accelerators is an important factor in counteracting the 
tendency of the heart to become irregular from digitalis. 

Eventually the heart passes into delirium cordis owing 
to the excessive stimulation of the cardiac muscle. After 
death the mammalian heart is found widely dilated in 
diastole, not contracted in systole as is the case with the 
frog’s heart. Thus there seems to be a difference be- 
tween the effects of digitalis upon the hearts of warm 
and of cold blooded animals—the former stopping in 
diastole, the latter in systole. Francois-Franck main- 
tains, however, that this difference is only apparent; 
that the heart stops in systole in both cases, but that the 
mammalian heart is incapable of remaining long in this 
condition. 

There has been considerable discussion as to whether 
the two halves of the heart are influenced alike by 
digitalis. Some have claimed that one ventricle was 
more powerfully stimulated than the other and that they 
at times beat at entirely different rhythms. Later 
writers, using more exact methods, have failed altogether 
to confirm these results. The auriculo-ventricular rhythm 
may be disturbed but the two aruricles and the two ven- 
tricles always beat at the same rate, although variations 
in the strength of the beat may occur in one chamber 
independently of the other. 

Experiments upon the isolated mammalian heart give 
results in entire accord with those obtained by Cushny 
upon the heart in connection with the nervous and vascu- 
lar systems. Tschistowitsch (Centralbl. fiir Physiol., i., 
p. 133, 1887) showed, several years ago, that helleborein 
stimulates the isolated heart and increases its output per 
unit of time. Recently Hedbom (Skand. Archiv fiir 
Physiol., viii., p. 185, 1898) has described in detail the 
action of digitalin upon the isolated rabbit heart. Im- 
mediately after the drug reached the heart there was a 
slight acceleration, just as we have seen to be the case 
when digitalin isapplied to the frog heart. This primary 
acceleration was followed by a long-continued slowing 
during which, however, the amplitude of the beats was 


700 








} 


much increased. If the heart had from any cause be- 
come irregular, small doses of digitalin caused it to be- 
come more regular as well as more powerful. If the 
amount of digitalin was increased, the heart beat became 
rapid and the various kinds of irregularities described by 
Cushny were produced; then there was a sudden short- 
ening of the ventricle (amounting in some cases to four- 
teen per cent. of its length) and the heart soon stood still. 
Bock (Archiv fiir exper. Path. und Pharmakol., xli., p. 
175, 1898) studied the action of helleborein upon the iso- 
lated mammalian heart, using a method differing in some 
respects from that of Hedbom; the results were, how- 
ever, essentially the same. Bock emphasizes especially 
the rise of pressure which occurred in the tubes by which 
the peripheral vessels were replaced in his experiments 
and which resulted from the: in- 
creased output of the heart. In one 
experiment in which the heart had 
been beating feebly, helleborein 
caused the pressure to rise from 29 
mm. to 80 mm. of mercury—a strik- 
ing example of the power of the 
drug to stimulate the cardiac 
l muscle. 

To sum up the results of these ex- 
periments upon the heart, digitalis 
in small doses slows the heart, but 
| its chief action is to increase the 

contraction in systole. This in- 
creased contraction leads to a more 
complete emptying of the ventricle 
and so to a greater output of the 
heart and a rise of blood pressure. 
In the normal animal, with perfect 
valves, and in which there is no 
dilatation of the heart, constriction 
of the arterioles caused by the di- 
rect action of the drug upon their 
wallsis probably as important a factor in the rise of blood 
pressure as is the increased output of the heart. But ex- 
periments upon animals have shown that the increased 
output of the heart is especially marked when there is 
even a slight dilatation of the heart; and the experiments 
of Bock show what a marked rise of pressure may be 
produced by the cardiac action alone. When it comes 
to certain cases of chronic valvular lesions in man in 
which the dilatation is far in excess of anything we 
ever have in experiments upon animals, we are justi- 
fied in concluding that the cardiac action of the drug 
is by far the most important factor in the rise of blood 
pressure which undoubtedly occurs. The heart action 
of digitalis also has a different effect upon the pressure 
in the veins in cases of valvular insufficiency from its 
effect in normal animals. In the latter mere increase 
in the output of the heart is powerless to lower the 
venous pressure and so relieve venous congestion; only 
a constriction of the arterioles can bring this about. 
With incompetent valves, however, the greater con- 
traction of the cardiac muscle caused by digitalis will 
lessen the regurgitation and so the backward pressure 
in the veins; this leads to a fall of venous pressure and 
so to a lessening of venous congestion. The constric- 
tion of the arterioles caused by digitalis will add to this 
result, but the cardiac action alone is often sufficient. 
Too much emphasis is sometimes laid upon what are, 
after all, but minor features of the action of digitalis— 
the slowing of the heart and the constriction of the 
arterioles. Both of these actions are undoubtedly im- 
portant in many, perhaps in most cases, but they are en- 
tirely subordinate to the action upon the cardiac muscle. 
Aconitine or veratrum viride will cause as great a slow- 
ing of the heart as will digitalis; strychnine or the extract 
of the suprarenal glands will constrict the vessels even 
more strongly, but none of these drugs or any combina- 
tion of them can replace digitalis. 
So far we have spoken of the action of “digitalis,” 
ignoring the fact that several active principles are con- 
tained in the usual preparations. Our knowledge of the 



















































































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Cardiac Stimulants, 
Cardiae Stimulants, 





active principles is, however, so unsatisfactory and the 
isolation of some of them is attended with such difficulty 
and expense that they are not used very extensively in 
medicine. Schmiedeberg (Archiv fiir exper. Path. und 
Pharmakol., iii., p. 19, 1874) described three active prin- 
ciples in digitalis and named them digitalin, digitalein, 
and digitoxin. Kiliani (Archiv der Pharmacie, 1892-99) 
has published a series of papers in the earlier of which he 
stated that the digitalein of Schmiedeberg was probably a 
mixture of digitalin and some inert substance; he also de- 
scribed a new glucoside occurring in the leaves which he 
named digitophyllin. According to these earlier investiga- 
tions of Kiliani the leaves, from which the pharmacopeial 
preparations are made, contain three glucosides, digitoxin, 
digitophyllin, and a body resembling digitalin; digitalin 
itself is probably absent. All of these glucosides have a 
similar action, but digitoxin seemed to be the most abun- 
dant and was found to be by far the most active. In fact 
digitoxin is one of the most toxic substances known. 
From these investigations of Kiliani it seemed that the 
pharmacopeeial preparations owed their activity largely 
to digitoxin, although the almost complete insolubility of 
this body in water and its extremely irritating properties 
made it difficult for some to accept this view. Very 
recently Kiliani (Archiv der Pharmacie, ccxxxviii., p. 
464, 1899) has confirmed the old statement of Schmiede- 
berg that there is a distinct body, digitalein, easily solu- 
ble in water and which occurs in both the seeds and 
leaves. Bohm (quoted by Kiliani, loc. cit.) believes that 
the activity of the infusion is due very largely to this 
digitalein. This work is so recent that no experiments 
seem to have been made to determine to what extent 
digitalein can be used instead of the galenic preparations. 
Experiments had already indicated that neither digitalin 
nor digitoxin could entirely replace the tincture and 
infusion in therapeutics. 

A very large number of other plants contain substances 
witha physiological action very like that of digitalis. A 
few of these are used in medicine, while others are of in- 
terest chiefly because they have been used as arrow or 
ordeal poisons. It is known that there are minor differ- 
ences between the action of some of these substances and 
that of digitalis; some, for example, have a greater 
effect upon the heart and a less effect upon the blood- 
vessels, others stimulate the vagus centre very power- 
fully, etc. Few comparative studies have been made, 
however, although they are extremely desirable. 

Some of the other members of this series will be men- 
tioned, and the-points in which their action differs from 
that of digitalis noted when this isknown. Strophanthus 
hispidus and 8. Kombé contain a body, strophanthin, 
which is usually considered to be a glucoside. Strophan- 
thin acts as powerfully upon the heart as does digitalis 
but has less effect in constricting the vessels; it does not 
cause as great a rise of pressure in the pulmonary artery 
‘as does digitalis. Erythrophleein (a glucosidal alkaloid, 
derived from Erythrophlceum, sassy or casca bark) seems 
to act less upon the cardiac muscle and more upon the 
vagus centre than the others. Squills contains a gluco- 
side, scillain, about which very little is known. Prepara- 
tions of squills act upon the heart like digitalis, but they 
are used less for this action than for their action as ex- 
pectorants and diuretics; it is very probable, however, 
that their cardiac action is an important factor in bring- 
ing about the changes in the respiratory mucous mem- 
brane and in the kidneys, for the circulation through 
these parts is improved by the drug. Helleborein (the 
glucoside found in Helleborus niger) and convallamarin 
(derived from the lily of the valley) are both very solu- 
ble in water, and it was hoped that they might prove 
valuable remedies when it was desired to use pure sub- 
stances. Extended observations have shown them to be 
unreliable, and when they are used at all it is in the form 
of the galenic preparations. Euonymin (from Euonymus 
atropurpureus, wahoo) is used as a purgative rather 
than as a cardiac stimulant. 

Some of the other substances belonging to this series 
are apocynein (from Apocynum cannabinum, Canadian 


’ 


hemp), adonidin (from Adonis vernalis, pheasant’s eye), 
antiarin (from Antiaris toxicaria, the upas tree), one of 
the most powerful substances of the series; neriin and 
neriodorin (to which the poisonous properties of nerium 
or the oleander are partly due), thevetin and cerberin 
(from thevetia), coronillin (from coronilla) and tanghinin 
(from Tanghinia venenifera). The arrow poisons quabain 
and echujin also belong to this series. 

The skins of certain toads were formerly used as 
remedies for dropsy. Modern investigations have shown 
them to contain a poison, phrynin, which has an action 
upon the heart-very similar to that of digitalis. Epine- 
phrin, the active principle of the suprarenal glands, also 
resembles digitalis in some of its physiological proper- 
ties. The salts of barium have an action upon the heart 
and blood-vessels similar in many respects to that of the 
digitalis series. 

For a discussion of the use of these drugs in thera- 
peutics the reader is referred to the articles on Heart 
Diseases; only a few of the more general indications 
for their use can be given here. It has been shown 
that the circulation is influenced in three principal ways 
by medicinal doses of digitalis: the pulse is slowed, the 
heart contracts more completly in systole so that the 
pulse volume is increased, and the peripheral arterioles 
are constricted. Of these the second action is by far the 
most important in therapeutics. The action of digitalis 
in slowing the heart is taken advantage of in treating 
some cases of palpitation, of “irritable heart,” and in a 
number of other cases, as in certain stages of valvular 
diseases, acute febrile conditions, etc., in which the heart 
is beating feebly, but rapidly and irregularly. On the 
other hand, the slowing of the heart is in some cases an 
undesirable feature of the action of digitalis, for, as has 
been already shown, it is due to a stimulation of the in- 
hibitory nerves, and the latter has an effect just the op- 
posite of the action of the drug upon the cardiac muscle. 
It is the inhibitory action which often prevents an in- 
crease in the contraction of the auricle; in fact, a diminu- 
tion of the force of the auricular contraction is often 
observed. The same effect is produced upon the ven- 
tricle, but here the muscular action is able to overcome 
the inhibitory action to such an extent that the latter is 
not usually a disturbing element. A drug in which the 
muscular action of digitalis was well marked while the 
inhibitory action was minimal, would doubtless be much 
more valuable in many cases than digitalis. In erythro- 
phiein the inhibitory action is well developed while the 
muscular action is but little marked; unfortunately no 
drug is at present known in which the opposite is the case. 

The constriction of the arterioles by digitalis is in many 
cases a desirable feature of its action, for by it the general 
blood pressure is raised and the blood accumulates in the 
arteries and excessive venous pressure is relieved. The 
constriction of the arterioles seems to be a factor in the 
production of diuresis; at least strophanthin which does 
not have so marked an effect upon the arterioles causes 
much less diuresis than does digitalis. In many cases, 
on the other hand, it has been found desirable to counter- 
act the effect of digitalis upon the arteries while retain- 
ing its action upon the heart. This result is obtained by 
combining the digitalis with some drug (usually a mem- 
ber of the nitrite group) which causes a dilatation of the 
peripheral vessels; or the difficulty may be got around 
by the use of strophanthin, which does not constrict the 
vessels very greatly. 

It isin virtue of its action upon the cardiac muscle that 
digitalis is chiefly used in medicine and by which it is en- 
abled to play a role which can be filled by no other sub- 
stance. Dilatation of the heart from almost any cause, 
provided that extensive degeneration of the cardiac muscle 
is not present, is the indication for its use, In such a case 
the action is very simple and is almost specific. In dilata- 
tion the heart is not only abnormally relaxed in diastole, 
but the amount of blood remaining at the end of systole 
is greatly increased. Digitalis causes a more complete 
emptying of the ventricle, ¢.e., the pulse volume is in- 
creased; this and the constriction of the arterioles lead to 


701 


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Carlsbad, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





a higher blood pressure and a more uniform flow through 
the capillaries. Venous congestion is relieved and the 
nutrition of the various organs, including the heart, is 
improved. At the same time the relaxation in diastole is 
usually lessened so that the heart assumes more nearly its 
normal form. It is especially in dilatation in cases of 
valvular disease that digitalis is used; in such cases in 
addition to the above action the drug causes a contraction 
of the ring of muscle surrounding the diseased valve, and 
this tends to limit the regurgitation. Asa result of the 
increased work of the heart and its better nutrition the 
condition of the muscular tissue is improved to such an 
extent that after a time the drug can often be dispensed 
with for longer or shorter periods. 

The question is often debated whether digitalis should 
be used in aortic insufficiency; the theoretical objection 
has been made that the prolonged diastole might allow 
time for sufficient 
blood to regurgi- 
tate to lead to 
syncope. Physi- 
cians seem to 
hold now that 
digitalis is just as 
serviceable in the 
dilatation accom- 
panying aortic in- 
sufficiency as in 
other cases, pro- 
vided it is given 
with care. A lit- 
tle experiment of 
Dreser’s (Archiv 
fiir exper. Path. 
und Pharmakol., 
Xxiv., p. 238, 1888) 
may be mentioned 
in this connection. 
The valves of the 
ventricle of a 
frog’s heart were 
destroyed, the 
ventricle was tied 
to a perfusion can- 
nula on one limb 
of which was an outflow tube. This arrangement repre- 
sented roughly the condition in aortic insufficiency; the 
pressure of the liquid in the upright tube represented 
the aortic pressure, while the side tube, from which the 
blood was collected, represented the peripheral circula- 
tion. Blood was led to the heart and the amount ex- 
pelled from the side tube measured. Digitalis (or helle- 
borein) was now added to the blood; the heart was 
slowed so that there was a greater opportunity for the 
blood to drain back through the broken valves into the 
ventricle, and if the above theory were correct the out- 
flow from the side tube (¢.e., the peripheral circulation) 
should be diminished. Dreser found, on the contrary, 
the outflow to be uniformly much increased; the in- 
creased output of the ventricle and the prolonged sys- 
tole had more than counteracted the effect of the pro- 
longed diastole. This little experiment is of interest as 
it shows that the only experimental evidence we have 
agrees with the clinical evidence that digitalis is useful 
in aortic insufficiency. 

Members of the digitalis series are used for other pur- 
poses than as cardiac tonics, although the heart action 
probably plays a more important part here than is al- 
ways recognized. Thus the good results following the 
use of squills as an expectorant are almost certainly due 
in part to an improvement of the pulmonary circulation. 
Several of the series are used extensively as diuretics; the 
fact that as a rule they produce marked diuresis only 
when there is a diseased condition of the heart points to 
the effect upon the kidney being secondary to changes in 
the circulation. On the other hand some of these drugs 
produce diuresis in normal rabbits, and occasionally in 
healthy dogs and man, when there is no evidence that the 


Fig. 1144. 


Caffeine. 
teration caused by caffeine is acceleration. 
is mechanical. 


702 








Figs. 1144 anp 1145.—Tracing of the Ventricle of the Dog’s Heart; 1144, Normal; 1145, After 
The lever moves upward during systole, downward during diastole. 
The slightly larger excursion in diastole in 1145 
(Contrast tracings under digitalis: Figs. 1141 and 1142.) 





renal circulation is altered; this indicates that some of 
the series, especially squills and digitalis, have a direct 
action upon the renal epithelium, but comparatively little 
satisfactory work has been done upon this subject. There 
can be little doubt that the extraordinary diuresis pro- 
duced by digitalis in cases of cardiac dropsy is due largely 
to an improvement in the renal circulation; the blood is. 
removed from the veins and collected into the arteries, 
the congestion of the kidney relieved and a more uniform 
and active circulation established—a condition favorable 
for the secretion of the urine. 

Sparteine, the alkaloid of broom (Cytisus scoparius), has. 
been included by some in: the class of cardiac stimulants. 
It has been said to have an action similar to that of digi- 
talis; recent work (Cushny and Matthews, Archiv fir 
exper. Path. und Pharmakol., xxxv., p. 129, 1895) has. 
shown this resemblance to be entirely superficial and that. 
the drugs have 
little in common. 
Broom is used to: 
some extent as a 
diuretic in cardiac 
diseases; it is also 
said to make the 
heart beat more 
regularly, 

Cactus grandi- 
florus (cereus) has. 
been warmly rec- 
ommended by 
some clinicians as. 
a cardiac stimu- 
lant. Very little 
is known about. 
the chemistry of 
this drug or its. 
physiological ac- 
tion; there is cer- 
tainly no evidence 
that it belongs to: 
the digitalis series, 
as has been claim- 
ed by some. It is. 
said to accelerate 
the heart and to. 
cause a rise of blood pressure; the latter seems to be due 
in part to a stimulation of the vaso-motor centre. It is. 
sometimes combined with digitalis, but is said to be es- 
pecially useful in certain cases in which digitalis is con- 
traindicated. It is said to be valuable in cardiac weak- 
ness due to tea, coffee, alcohol, tobacco, etc. 

Caffeine.—Caffeine has a very characteristic action 
upon cardiac muscle which makes it a cardiac stimulant. 
of great value in some cases; it has also a stimulating 
action upon the vaso-motor and other medullary centres. 
The changes in the cardiac muscle have been most care- 
fully studied in the frog’s heart. When blood containing 
minute quantities of caffeine is perfused through a frog’s. 
heart placed in a William’s heart apparatus, the rate of 
the heart is slightly accelerated and the amount of blood 
expelled at each beat slightly increased, but the most. 
marked change is an increase in the force of the beat 
(Dreser, Archiv fir exper. Path. und Pharmakol., xxiv., 
p. 233, 1888). The heart is able to contract against a 
much greater aortic pressure than normally—that is, the 
“absolute power” of the cardiac muscle is increased. 
Dreser compares this action of caffeine to an increase in 
the cross section of the muscle fibres while their length 
remains the same. Caffeine has thus an action entirely 
different from that of digitalis; the effect of the latter is: 
the same as lengthening the muscle fibres while the cross. 
area remains the same; the extent of the contraction 
under digitalis is increased, while the absolute force is. 
scarcely altered. 

After larger quantities of the drug the heart, becomes. 
slower and its volume smaller; then the apex ceases to 
relax with the rest of the ventricle, but remains white and 
contracted, and eventually the whole heart passes into a. 


Fig. 1145. 


The only al- 
(From Cushny.) 


REFERENCE HANDBOOK ,OF THE MEDICAL SCIENCES. 


condition of rigor. In all these respects the action of 
caffeine upon the cardiac muscle is very similar to the 
remarkable effects the drug is known to have upon ordi- 
nary skeletal muscle. 

Upon the mammalian heart the chief effect of caffeine 
which has been described is an acceleration of the rate: 
this acceleration occurs when the heart is entirely isolated 
from the central nervous system (Bock, Archiv fiir exper. 
Path. und Pharmakol., xiiii., p. 367, 1900), and must 
therefore be attributed to a stimulation of the cardiac 
muscle. No observations seem to have been made upon 
the effect of caffeine on the absolute power of the mam- 
malian heart; that the extent of the contractions, and so 
the pulse volume, is not increased is shown by the accom- 
panying myocardiograms (Figs. 1144 and 1145). 

When caffeine is administered to a normal animal the 
effects upon the heart are somewhat obscured by the 
simultaneous action upon certain nerve centres. As a 
rule the heart is accelerated, but at times it is slightly 
slowed by a stimulation of the centre of the cardio-inhibi- 
tory nerves. On the other hand, stimulation of the vagi 
is usually less effective in slowing the heart after caffeine 
owing to the increased irritability of the cardiac muscle. 
That the cardiac acceleration is not due to a paralysis of 
the terminations of the vagi is shown by the fact that it 
occurs after these have been paralyzed by atropine; the 
acceleration must be attributed to a direct stimulation of 
the heart muscle. After larger doses the heart becomes 
weak, irregular, and arhythmic, resembling the condition 
seen in digitalis poisoning. The vaso-constrictor centre 
is stimulated by caffeine: this and the increased output 
of the heart due to the acceleration cause a rise of blood 
pressure. The most marked effects upon the circulation 
are seen in animals in which this has been depressed 
by such a drug as alcohol. Thus Binz found that the 
blood pressure of a dog deeply under the influence of 
alcohol rose from 84 to 120 mm. in ten minutes after 
the subcutaneous injection of caffeine; the pulse rate 
was doubled. The respiration was also greatly im- 
proved. 

Administered to a healthy man a moderate dose of 
caffeine causes the pulse to become full and hard; it is 
also moderately accelerated. Occasionally there is a 
slowing due to stimulation of the vagi. 

Theobromine has an action upon the heart very similar 
to that of caffeine; the peripheral vessels are not con- 
stricted, however, and so the rise of blood pressure is 
much less marked. 

The great diuretic power of caffeine has been attributed 
to the changes in the circulation, and it is probable that 
these do exert a favorable influence when the blood press- 
ure is very low. Under ordinary circumstances, how- 
ever, the constriction of the blood-vessels antagonizes the 
diuretic action, and the latter can often be obtained only 
when the caffeine is combined with such drugs as chloral 
hydrate or paraldehyde which dilate the vessels. It is 
now generally held that caffeine and theobromine pro- 
duce diuresis by a direct action upon the renal epithelium, 
aus entirely independent of their action upon the circu- 
ation. 

The experiments upon animals indicate the class of 
cases in which caffeine might be expected to give good 
results in therapeutics. It is chiefly in cases in which the 
heart is simply weak and in which there is no dilatation 
that caffeine is indicated; it causes the output of the 
heart to be increased and the blood pressure to rise. It 
is especially useful in cases of alcoholic and opium poi- 
soning, for not only is the cardiac muscle stimulated in 
these, but the vaso-motor and respiratory centres are also 
thrown into increased activity. Caffeine cannot be con- 
sidered a substitute for digitalis, for it has almost no 
effect upon dilatation of the heart in valvular lesions; 
it is often used in such cases, either alone or combined 
with digitalis, but the beneficial results seem to be due 
much more to its diuretic than to its cardiac action, 

Strychnine.—Strychnine has come into somewhat ex- 
tensive use in recent years as a cardiac stimulant; the 
good results following its use are probably to be at- 


, upon the heart. 


Cardiac Stimulants, 
Carlsbad, 


tributed to its action upon certain parts of the central 
nervous system (especially the vaso-motor centre) and: 
the nutrition generally, rather than to any special action 
At the same time there is some evidence 
that the frog’s heart is directly stimulated by small 
quantities of strychnine while larger amounts weaken 
and slow it. In the mammal strychnine causes a slight 
slowing of the heart due to stimulation of the vagus 
centre. If convulsions occur, the heart becomes acceler- 
ated just as it does in struggling from any cause. Few 
drugs have such a powerful action upon the vaso-con- 
strictor centre as has strychnine. Whether convulsions 
occur or not the arterioles are constricted to an extreme 
degree and the blood pressure rises enormously. The 
irritability of the subsidiary vaso-motor centres in the 
spinal cord is increased, so that a reflex rise of blood 
pressure may follow stimulation of a sensory nerve after 
the influence of the chief vaso-constrictor centre has been 
removed by section of the cervical cord. 

Strychnine, like iron, seems to be used rather as an ad- 
juvant to digitalis in the treatment of heart diseases; at 
the same time it is frequently recommended in those cases 
in which digitalis is contraindicated. It is also used in 
cardiac failure during typhoid and other fevers, shock, 
etc.; in these cases the action is probably mainly upon 
the vaso-motor centre. Reid Hunt. 


CARDIOGRAPHY. See Heart. 


CARLSBAD (Karlsbad) is one of the most important 
thermal stations of Europe; indeed, its reputation is 
world-wide. It is charmingly situated in the northwest- 
ern corner of Bohemia, some 70 miles from Prague, 
at an altitude of about 1,160 feet, lying in the narrow 
valley of the Tepel River among the pine- and fir- clad 
hills traversed by paths in all directions. There are many 
beautiful walks and drives in the woods covering the 
slopes of the valley, and attractive excursions in the en- 
virons. “The valley in which it lies is shielded from the 
south and east winds by the mountains, but is exposed 
to the winds from the north and west, and the climate is 
consequently somewhat trying and subject to sudden 
changes in temperature” (Stedman). The native popu- 
lation is about 12,000, and upward of 30,000 people 
visit the springs annually. 

These thermal waters are said to have been discovered 
in 13847, by the Emperor Charles IV., while hunting, 
but Carlsbad was known as a health resort a century 
earlier (Baedeker). “The springs issue from apertures in 
the rocky shell upon which most of the town is built, 
and are sixteen in number, all similar in their ingredi- 
ents, which are principally sulphate of sodium, carbonate 
of sodium, and common salt. They are chiefly taken in- 
ternally. They vary in temperature, the hottest having 
the least amount of carbonic acid gas. Some of the prin- 
cipal springs are the following (with their temperatures, 
Fahrenheit scale): 

“Sprudel, 162.5°—a steaming fountain leaping up at 
short intervals, and having a capacity of four hundred 
and fifty gallons per minute; Felsenquelle, 138°; Schloss- 
brunnen, 127°; Miihlbrunnen, 124.5°; Theresienbrunnen, 
122°: Marktbrunnen, 118°. These waters are classed 
among the sulphated alkaline waters.” The following 
is the composition of the Sprudel water, according to the 
analysis of Ragsky, as given by Stedman. “Each litre 
(1.76 pint) contains: 


Grams. Grains. 
PUI PHATE OL SOC «1 a%e016, 0.5/0 sisies se tie bud a\s's) sin. 2.3872 = 35.58 
Birlpnate Ole CACM os .cteutatie science asses eles « 168 = 2.44 
OHIOTIAE OL SOMEUML 7 eel cie csinro cle vials wis es)e is/are pe o/s 1.080 = 15.45 
CaTDONATEOL SOCTUMI ee ae cites ars cuamisie's eleels a- sie sie 1.361 = 20.41 
CATHONALE TOL GOIGMID os ere clelcialaceca tic sso nis nieiale state 297 = 4.45 
Carbonate Of MAGNESIUM .....ccccesesecceviue 124 = 1.86 
CAaPRONALE OL SErOUELUIN cece cclsce ie 8b tcdscisiee -0008 = 012 
Protoxide of iron N02= 5.08 
Protoxide of manganese .0006 = 009 
Fluoride of calcium 0038 = .045 
Phosphate of calcium .0002 = .003 
SiiGalatrela die Poee et ntas, ta'sielola ols.vieitceticie sia e’et so sre'e 0072 = .108 





Carbonic acid in one litre 210.59 ¢.c.’”’ (Stedman). 


Carmine, 
Cartilage. 





Although, as has been said, the waters are now used 
chiefly internally, there are seven bath houses with 
mineral, mud, vapor, hot air, and other baths, and with 
massage and Swedish movements. The Kaiserbad is 
said to be “one of the most magnificent bath houses of 
Europe.” The conditions for which the internal use of 
Carisbad water is beneficial are stated by Weber to be the 
following: 

In the first place, affections of the liver, including 
catarrhal jaundice, frequent attacks of biliary colic, early 
stages of alcoholic cirrhosis, enlargement of the liver 
in great eaters, etc. Secondly, habitual constipation, 
hemorrhoidal conditions in robust persons, some cases of 
chronic gastric and intestinal catarrh with or without 
diarrhea, some cases of dyspepsia, uric-acid diathesis, 
chronic glycosuria in fat people, and corpulence, which 
is often combined with a weak-acting heart. Enlarge- 
ment of the spleen is also said to be benefited by these 
waters, as are also periodic, frequently recurring head- 
aches connected with abdominal disorders. Disturbances 
of the female pelvic organs, chronic congestion and en- 
largement of the uterus, chronic affections of the conjunc- 
tiva and deeper structures of the eye, and chronic aural 
catarrh are all likely to be benefited or cured by the 
Carlsbad waters (Stedman). 

During the summer the usual time for drinking the 
waters is from half-past five to half-past eight in the 
morning, an interval of about a quarter of an hour being 
allowed after each glass (3 vi.), and the dose being from 
two to six glassfuls. 

In beginning a course of treatment the spa physician 
carefully considers each case, and regulates the habits and 
diet of the patient. Probably the regularity in daily life 
and diet has very much to do with the improvement of 
the patient. The average daily programme of the or- 
dinary Kurgiiste is outlined by Weber as follows: 

“Rise early to drink the water, and in the intervals 
promenade to the sound of the music; walk to some café, 
and take breakfast at about 9 A.m., consisting of coffee 
or tea, rolls, and perhaps boiled eggs or ham. At about 
one o’clock the chief meal of the day is taken; coffee 
and tea at about 4 P.mM., and a light supper in the even- 
ing.” Those who have been ordered a course of baths 
mostly take them in the forenoon, There are a fine Cur- 
haus and a good theatre; classical concerts are given 
regularly; there are covered walks; in brief, there is 
almost everything which will render the stay of the in- 
valid agreeable and pleasant. There are also good edu- 
cational facilities. 

The season lasts from the middle of April to the end of 
September or October, although one can take the waters 
at any season of the year. Besides the amount of water 
drunk at Carlsbad, it is said that about 8,000,000 bottles 
and 110,000 pounds of the salt are exported annually. 

An after-cure is always recommended subsequent to a 
course at Carlsbad. Instead of returning home immedi- 
ately, and at once resuming his or her usual mode of life, 
the patient should abstain from active work, adopt a 
simple diet, and live outdoors as much as possible for 
some weeks. 

Carlsbad is reached by various routes in about thirty- 
one hours (from London): by Cologne, Wiirzburg, and 
Niirmnberg or Bamberg; by Paris, Stuttgart, and Nirn- 
berg; or by Cologne, Leipsic, Dresden, and Kromotan. 

For the major part of the above account of Carlsbad, 
the writer is indebted to “Spas and Mineral Waters of 
Europe” (by Hermann and F,. Parkes Weber, London, 
1896), to which the reader is referred for much valuable 
information upon this subject. Edward O. Otis. 


CARMINE. 


CARGBA.—A name applied to the leaflets of several 
species of Jacaranda (fam. Bignoniacee), small trees of 
Brazil, especially of J. procera (Willd.) Spreng. and J. 
Caroba (Vell.) D. ©. They contain resinous and slightly 
aromatic constituents, and the crystalline, apparently in- 
sective body carobin, but nothing to which any special 


See Cochineal. 





704 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





medicinal properties can be assigned. The drug bears a 
high reputation and is largely used in Brazil as a remedy 
for syphilis and syphilitic disorders. This belief, which 
applies to so many plants of little or no activity, doubt- 
less results from the indefinite ideas which prevail regard- 
ing syphilis, all sorts of venereal diseases being included 
under this name. The drug is generally given in the form 
of the fluid extract, in doses of 1 to 4 ¢.c. (Mxv. to Ix.). 
Henry H. Rusby. 


CAROTA.—Carrot. The root of Daucus carota L. 
(fam. Umbellifere). This plant is a native of Europe, 
but freely naturalized in the United States (wild car- 
rot). The cultivated form is the common table carrot, 
grown everywhere. The fruits of wild carrot have been 
used as aromatic diuretics; the cultivated roots are made 
into pulp as poultices; but neither have any claim to med- 
ical notice. The coloring matter of carrot root is called 
carotin. The very small amount of volatile oil consists 
of pinene and probably cineol. W. P. Bolles. 


CARTHAGENE BARK. 
CARTHAMUS. Sce Safflower. 


See Cinchona. 


CARTILAGE.—Under this name is classified one of the 
important members of the group of connective tissues; 
it is characterized not so much by the structure and 
arrangement of its cells, as by the peculiar nature of its 
basement substance. Cartilage occurs in three tolerably 
distinct forms, the differences of which depend largely 
upon peculiarities in the structure of the basement 
substance. These formsare called hyaline cartilage, fibro- 
cartilage, and fibro-elastic cartilage. 

The most abundant and typical of these is hyaline car- 
tiluge. This, in the adult, is found covering the articular 
surfaces of bone, forming parts of the ribs and of the 
walls of the trachea and bronchi, and in less considerable 
masses in other parts of the body. Hyaline cartilage is 
translucent and of a bluish-white color, is firm in con- 
sistency, and elastic. Like other members of the con- 
nective-tissue group, it consists of cells and an intercellular 
or basement substance. The basement substance is for 
the most part quite homogeneous in the fresh condition, 
but it is occasionally very finely granular. By suitable 
treatment with chemical agents, it may be seen to con- 
tain, and almost to consist of, exceedingly minute and 
delicate fibrils, which under normal conditions are merged 
into a homogeneous mass. The basement substance is 
said by some observers to be penetrated by minute 
branching canals which Communicate with one another 
and with the spaces in which the cells lie. Mucin and 
gelatin, and arather indefinite substance called chondrin, 
have been obtained from the basement substance, but our 
knowledge of the chemical nature of these substances, 
and particularly of their existence in the cartilage in the 
natural condition before being exposed to chemical ma- 
nipulation, is still too indefinite to enable us to speak 
very positively of its chemical constitution. 

The cells of hyaline cartilage differ considerably in 
shape and arrangement in different cartilages and in dif- 
ferent partsof the same cartilage, depending, apparently, 
to a considerable degree, upon the conditions of pressure 
to which they are subject, as well as upon the intimate 
constitution of the basement substance and the influences 
under which its development transpires. The cells, except 
near free surfaces or where cartilage and fibrous tissue 
join, are in general spheroidal, ovoidal, ellipsoidal, or 
somewhat flattened at the sides, and lie unevenly dis- 
tributed in the basement substance. The cell body is 
finely granular, or in some animals contains delicate 
fibrils, and may enclose droplets of fat, and pigment 
particles, or may also contain glycogen. The nuclei— 
of which there may be one or more—are usually sphe- 
roidal, sharply outlined, and contain more or less well- 
marked networks of coarser and finer fibrils and nuclei, 
in which, during life, in some animals, slow oscillatory 
movements may be seen. The cartilage cells may lie 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Carmine, 
Cartilage. 











singly in the basement substance, but they are more fre- 
quently arranged in groups of two or four, or more, and 


the cells forming these groups are apt to be flattened on | 


the sides which abut on one another. Under normal 
conditions the cartilage cells completely fill the spaces in 
the basement substance in which they lie. But on ex- 
posure to the air, to water, to electric shocks of moderate 
intensity, to a variety of chemical agents, and under cer- 
tain pathological conditions, they separate from the walls 
of the spaces and shrink into irregular-shaped, coarsely 
granular masses, in which the nucleus may be partially 
or entirely concealed. This shrinkage may be only par- 
tial, some portion or points remaining adherent to the 
sides of the cavities, so that the shrunken cells may ap- 
pear irregularly stellate or have festooned edges. In 
this shrunken condition we usually see the cells of car- 
tilages which have been preserved in alcoholic fluids. In 
some parts of the articular, and also in the costal car- 
tilages, the cells lie in large groups, or in longer or 
shorter rows. At the free surfaces of cartilage, or where 
it comes in contact with the perichondrium, the cartilage 
cells are usually flattened, and just beneath the perichon- 
drium may merge imperceptibly into the ordinary flat- 
tened cells of the connective tissue. The basement sub- 
stance immediately about the cartilage cells may be seen, 
under favorable conditions, to be more transparent than 
the rest, the more transparent zone being sometimes very 
thin and sometimes of considerable thickness. This por- 
tion of the basement substance is called the capsule, and 
is believed to be that part which was last formed around 
the cartilage cell. Somewhat similar appearances may 
be seen not only around single cells, but around all 
groups which have apparently been derived from some 
single cell originally occupying their position in the 
basement substance. 

The basement substance of hyaline cartilage may, under 
a variety of conditions, become infiltrated with salts of 
lime, and thus assume to the naked eye a white, opaque 
appearance, and under the microscope appear crowded 
with larger and smaller distinct granules. Under patho- 
logical conditions the basement substance may become 
fibrillar as well as calcified. Cartilage is surrounded, 
except over the articular surfaces, by a vascular layer of 
fibrillar connective tissue called the perichondrium. The 
perichondrium contains a varying amount of elastic fibres. 
The fibrillated fibres of the perichondrium pass on into 
the hyaline basement substance of the cartilage, into 
which they become gradually merged. Although ves- 





eae 


Fig. 1146.—Hyaline Cartilage from the Head of the Femur of Frog. 
(xX 700 and reduced.) 


sels from the perichondrium sometimes penetrate for a 
short distance into the cartilage tissue, the latter is, in 
general, non-vascular. 

DEVELOPMENT OF HYALINE CARTILAGE.—At a very 
early period hyaline cartilage consists of a congeries of 


VODs LL —4p 





rounded cells closely packed together, with a small 
amount of intercellular substance around each cell. The 
intercellular substance gradually increases in amount, 
and the cells divide; 
new capsules, 7.¢., new 
portions of intercellu- 
lar substance, are form- 
ed around the new 
cells, while the old 
capsules are expanded 
and appear to coalesce 
with those of adjacent 
cell groups to form the 
homogeneous basement 
substance. In this way 
the cells become gradu- 
ally separated from one 
another, but may still 
retain a grouping 
which indicates their 
primitive relations. 
Schleicher has shown 
that in the division of 
cartilage cells, while 
the changes in the nu- 
cleus are in general 
those common to the 
indirect mode of cell 
division (see Cell), the 
separation of the body 
occurs, not by a grad- 
ually deepening con- 
striction as in cells 
which are surrounded 
by a fluid or yielding 
material, but by the 
formation of a partition 
out of the intracellular 
filaments. This parti- 
tion finally becomes 
continuous with the 
capsule around the 
new-formed cells, and F 
thickens with their sep- De aie 
aration from one an- 
other. The exact way 
in which the capsules 
and intercellular sub- 
stance originate, 
whether by a separa- 
tion of a portion of 
the periphery of the 
cells, or whether it is simply formed under their influ- 
ence, or entirely apart from them, is not certain. 
Frsro-CartTiLaGEe.—This variety of cartilage is found 
in the interarticular cartilages of some of the joints, such 
as the knee and jaw, between the vertebre, at the sym- 
physis pubis, around the tendons of certain muscles, and 
at points where tendons are inserted into hyaline cartilage, 
as at the junction of the ligamentum teres with the head 
of the femur. The cells are similar to those of hyaline 
cartilage, but the basement substance is fibrillated, the 
fibrille being arranged in dense bundles or interlacing in 
all directions. The cells are frequently arranged in rows 
between the bundles of intercellular fibres (see Fig. 1147), 
and are less uniformly distributed than are the cells of 
hyaline cartilage. This form of cartilage frequently 
merges, in structure, on the one hand into fibrillar con- 
nective tissue, and on the other into hyaline cartilage. 
FIBRO-ELASTIC CARTILAGE (yellow elastic or spongy 
cartilage).—This form of cartilage is not abundant in the 
body, being found in small masses in the external ear, 
Eustachian tube, epiglottis, and in some parts of the 
larynx. It is tough, opaque, and yellowish in appear- 
ance. The cells, which are irregularly distributed 
through the basement substance, are similar in appear- 
ance to those of hyaline cartilage. Around each cell isa 
narrow, strongly refractile, homogeneous zone of base- 





we Ree 


Fig. 1147.—White Fibro-Cartilage from 
the Ligamentum Teres at the Point 
where it is Inserted into the Head of 
Femur. X 650 diameters. (After 
Bohm and Davidoff.) a, Fibrous con- 
nective tissue; 5, fibro-cartilage; c¢, 
point of insertion of the ligamentum 
teres; d, hyaline cartilage. 


705 


Carvacrol, 
Cassia. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ment substance—the capsule. Outside of the capsule 
the basement substance is more or less densely filled with 
coarser and finer anastomosing. and interlacing elastic 
fibres (Fig. 1148). In addition to the elastic fibres the 
basement substance contains numerous large and small 









NN 


S 
ae 


ay 


>, 
TAS 
ea 


ESS 
oy 
ee 
ES 


SN 


Soe = 
YE 
LNES 
x 
MA) 
JAS 


MS 
550) 









. . 4 vy f 

G =H ( i 

re As ( ON 

DS es i s 

Fic. 1148.—Elastie Cartilage from the Human Ear. »X 760 diameters. 
(After BOhm and Davidoff.) Ata, in the immediate vicinity of the 
cartilage capsules, a network of elastic fibres with fine meshes: b, 
cartilage cell; ¢, elastic fibres. 


granules, consisting of a material similar in chemical and 
optical properties to that composing the elastic fibres— 
the so-called elastic granules. These elastic granules are 
unevenly distributed through the basement substance. 
Fibro-elastic cartilage is developed from a hyaline form of 
cartilage by the formation, in the basement substance, 
of the characteristic elastic fibres and granules. 


BIBLIOGRAPHY. 


For the methods of studying cartilage, see Ranvier’s Traité tech- 
nique d’Histologie, p. 270 et seq. For literature, see Index Catalogue 
of Library of Surgeon-General’s Office, U. S. Army, vol. ii.; also 
Quain’s Anatomy, tenth edition, vol. i., part ii., p. 244. 


T. Mitchell Prudden. 


CARVACROL.—Ozycymol. Cymophenol. (CeHs.CHs.- 
[CH,.CH».CH;|6H). This is one of the active constit- 
uents of oils of thyme and summer savory, and occurs 
also in some other plants. It is a thickish volatile liquid, 
with a specific gravity of about .981. It has a charac- 
teristic odor. Like thymol, with which it is associated, 
it is strongly antiseptic. It is very closely related to 
carvol, having the same composition. 

Henry H. Rusby. 


CASANTHROL isa thick and gelatinous emulsion of 
neutral reaction, composed of casein ointment and ten 
per cent. of lithanthracic extract. The latter consists of 
those constituents of coal tar which are soluble in benzol 
and ether. Casanthrol is soluble in water and when ap- 
plied to the skin dries like a coat of varnish. However, 
being pervious to water, it does not prevent, but rather, 
if anything, tends to increase, the perspiration. It is 
precipitated by mineral acids, acid salts, and calcium 
salts; no oil separates from it on warming, and it does 
not become rancid. Classing it among his water-soluble 
varnishes Unna considers it a valuable application in 
chronic eczema and other chronic conditions of the skin. 

8. Beck uses it in eczema and prurigo with no unpleas- 
ant secondary effects. It is the strongest coal-tar prepa- 
ration which can be employed in inflammatory conditions 
of the skin; and if desired it may be used as a vehicle 
for other drugs. W. A. Bastedo. 


CASCARA AMARGA.—Honduras Bark. The bark of 
Picrena Vellozii Engl. or of a related species, or, accord- 
ing to some authors, of an undetermined species of Zariri, 
syn. Picramnia (fam. Simarubacee). This bark comes 
from Central America, and is a very highly esteemed 


706 


vegetable bitter by those who are accustomed to it. 
There is, with its strongly bitter taste, a peculiar sweet 
and aromatic flavor not resembled by any other drug. It 
contains a small amount, about one-half per cent., of 
volatile oil and about three per cent. of the alkaloid 
picramnine. 'The latter has the peculiar sweet and bitter 
taste of the bark and is probably its principal active con- 
stituent. It, as well as its salts, is amorphous. It isa 
simple or slightly aromatic bitter of unusually pleasant 
flavor. Its use as an alterative in syphilis is common, 
but we have no evidence of any special properties in this 
direction. The dose is .3 to 1 gm. (gr. v.-xv.). 
Henry H. Rusby. 


CASCARA SAGRADA.—Riamnus Purshiana. Chittem 
Bark; Sacred Bark. “The bark of Rhamnus Purshiana 
DC. (fam. Rhamnacew)” (U.S. P.). To this definition 
should be added “collected at least a year before being 
used.” The genus Rhamnus and the nature of its species 
and their constituents have already been discussed under 
Buckthorn. The species here considered is a small tree 
growing very abundantly in our extreme Northwestern 
States and northward. It wasintroduced into the materia 
medica in 1878 and encountered a remarkable degree of 
prejudice and opposition, being practically boycotted by 
many of the most influential physicians. It, however, 
steadily increased in favor and is at present probably the 
most largely used in professional practice of any Ameri- 
can drug. During its early history, the bark of a related 
species, R. Californica Esch., growing abundantly in 
central and southern California, was frequently substi- 
tuted for it, but persistent exposure resulted in com- 
pletely stopping the fraudulent practice, so that adultera- 
tion and substitution are now almost entirely unknown. 
The bark is taken off in quills, but these are afterward 
broken up to save space in transportation. These quilled 
pieces are of variable thickness, up to nearly one-quarter 
of an inch. The outer surface is rarely fissured, but is 
more or less warty, the warts being low and broad. The 
surface is originally of a peculiar red-purple or purple- 
brown, but becomes more or less covered with gray 
lichens. These may grow so as to form a uniform gray 
covering or a series of gray patches of variable size. 
Pieces taken from the base or junction with the root, are 
frequently thrown into transverse wrinkles or semi-folds. 
The inner surface when fresh is light-yellow, but ex- 
posure turns it gradually darker until after two or three 
years it may be nearly black. The fracture is sharp and 
of a pale yellow. There isa slight odor and a peculiar 
bitter and somewhat aromatic taste. Preparations of the 
drug are apt to have a very disagreeable taste and nu- 
merous formule have been devised for avoiding this dis- 
agreeable feature. 

ComposiT1on.—The composition of cascara sagrada is 
very similar to that of buckthorn in its general nature, 
though certain differences are manifest. The frangulin- 
like body is not identical, and the percentage of emodin 
is muchsmaller. There is a much larger amount of resin 
and this is divisible into three distinct bodies. It is not. 
clear to which of these differences the more regular and 
less griping characters are due. Throughout the recent 
active discussion of the presence of emodin, or emodin- 
like substances (anthraquinones) as active constituents. 
of some of our most important cathartics, there has been 
shown a disposition to over-rate the effect of such pres- 
ence as determining similarity of action. It by no means. 
follows that other constituents are to be ignored in the 
laxative effects, merely because the anthraquinones are 
thus active; besides which, we have to reckon with minor 
differences in the anthraquinones themselves. The dis- 
tinctly bitter properties of cascara sagrada make it more 
effective in stimulating appetite and digestion. Like 
buckthorn, it is much more useful when given in small 
doses, for some time, to overcome habitual constipation, 
than when used asa cathartic. It has been at various times: 
claimed asa useful agent in the treatment of rheumatism, 
syphilis and similar diseases, and it is so by virtue of its 
depurative and eliminative properties, but not in any way” 


eee 


: REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Carvacrol, 
Cassia, 





as a specific. The actual physiological action of cascara 
sagrada has never yet been worked out, but it is evident 
that it in some way profoundly modifies the secretory 
and excretory functions. The fluid extract alone is offi- 
cial. The doseasa cathartic, taken at night, is 2 to4 c.c. 
(fl. 3 ss. to i.). Those few who find their rest thus dis- 
turbed may take it in the morning, or may take a smaller 
dose. Asan alterative or tonic laxative, the dose is 1 to 
2 ¢.c. (Mxv. to xxx.), preferably before meals. Licorice, 
alkalies, and carminative oils tend to disguise the bad 
taste. 

None of the extracted so-called active constituents of 
the drug are worthy to be compared to its preparations. 

Henry H. Rusby. 


CASCARILLA.—“ The bark of Croton Hleuteria Bennett 
(fam. Huphorbiacee)” (U.S. P.). This species of Croton 
is a large, widely branched shrub of the Bahama Islands. 

Cascarilla was imported into Europe about the middle 
of the seventeenth century, when it was considered a 
variety of cinchona. It has undoubtedly formerly been 
the produce of several species of Croton, but at present 
comes exclusively from the one above named. It is in 
quills or curved pieces, about one-twelfth of an inch 
(2 mm.) thick, having a somewhat fissured, easily 
detached, brown, corky layer, more or less gray from a 
covering of lichens, and the inner surface smooth. It 
breaks with a short fracture, having a resinous and 
radially striate appearance. \Vhen burned, it emits a 
strong, aromatic odor. Its taste is warm and very bitter. 

The active principles of this bark are cascarillin, a 
white crystalline, bitter substance, scarcely soluble in 
water, to which it owes its tonic properties, and an essen- 
tial oil, which latter it contains to the extent of some- 
thing more than one per cent. It also contains some 
resin and a little tannin. 

The composition just given indicates the use and value 
of cascarilla. It is a bright, rather pleasant, aromatic, 
bitter tonic, with no special qualities other than its taste, 
to distinguish it in medicinal value from other spicy 
bitters. It is used occasionally in pastils, and is said to 
be put into tobacco on account of its fragrance when 
burning. Alcohol extracts its virtues to the best advan- 
tage. Dose, asa tonic, lor2 gm. There is no official 
preparation. 

The section Hlewteria, of the enormous genus Croton, 
contains thirty or more plants, a number of which have 
barks possessing properties similar to those of cascarilla. 

W. P. Bolles. 


CASEATION. See Necrosis. 


CASEIN OINTMENT.—A thick, white emulsion, mis- 
cible with water and proposed by Unna as a vehicle for 
the application of drugs to the skin. Its formula is: 
Casein, 14; potassium and sodium hydroxides (1 to 4), 
.48; glycerin, 7; vaselin 21; salicylic acid or borax, 1; 
water, 56. As it dries it leaves a thin coating upon the 
skin. W. A. Bastedo. 


CASEOIODIN.—A substance of the nature of thyreo- 
iodin stated to have been used with good results in myx- 
cedema. The cedema subsided, the hair and skin be- 
came soft, the intelligence clearer, and the phlegmatic 
condition gave place to one of average activity. It is 
prepared from periodo-casein, and is a white powder 
containing 8.7 per cent. of iodine. The dose is gr. 4 once 
or twice a day, increased rapidiy up to gr.i.aday. In 
overdose it is capable of producing flushing, rapid, weak 
heart, and prostration. W. A. Bastedo. 


CASHEW (or Cajvu) NUTS. Anacardium. The ripened 
ovary, with contents, of Anacardium occidentale L. (fam. 
Anacardiacee), a large, widely sprawling shrub, or small 
tree, of tropical America, largely cultivated in all tropical 
countries for its fruit. The edible portion of this fruit 
consists of the fleshy enlarged pedicel, and is of the form 
and size of a medium pear, green or yellow with a red 





cheek. It is juicy to an extraordinary degree, and is 
consumed chiefly for its thirst-quenching properties. 
Unless thoroughly ripe, it is exceedingly astringent. 
When ripe, the juice is slightly sweetish and slightly 
acid. This fruit is also manufactured into a wine which 
is credited in Brazil with special properties as a hepatic 
stimulant. The ripened ovary, many times smaller than 
the fleshy portion, is partly hidden in the summit of the 
latter. It is kidney-shaped, about 3 cm. (1.25 in.) 
long, brownish-ash colored, and smooth externally. It 
contains a large, bland, oily, curved, edibleembryo. The 
pericarp, which is 2 or 8mm. ( in.), thick, is of cavernous 
structure, and contains when dry a thick or solid, black, 
extractiform, resinous substance, of exceedingly irritant 
propertics when applied to the skin. A bassorin-like 
gum exudes from the stem; an edible milky sap, which 
also is an indelible dye, flows from the trunk. 

The resinous extract consists of anacardic acid, and a 
yellow or brown oily liquid, cardol. This is an intense 
and dangerous irritant, causing often severe inflammation 
of the skin and blisters, and even the fumes, when it is 
burned, are said to have the same properties. It was 
formerly used as an irritant, and is still so used to some 
extent in the West Indies. It has no medicinal value 
here, and is only to be known as a poison. 

The East Indian anacardium is a smaller but similar 
product, from Semecarpus anacardium Linn. fil., in the 
same order. A milder cardol, “ Cardol pruriens,” is ob- 
tained from its fruit, and has been used also as an irri- 
tant, and as a basis of indelible ink. It is entirely out of 
use on account of the danger attending it. Poison ivy, 
Rhus toxicodendron L., and poison sumach, Rhus vene- 
natum, arein the same family, and, as well as some other 
species of Rhus, have a similar inflaming action upon the 
skin (see Potsonous Plants). W. P. Bolles. 


CASSIA, PURGING; CASSIA FISTULA.—* The fruit 
of Cassia Fistula L. (fam. Leguminose)” (U.S. P). The 
British Pharmacopeia improves upon ours in its definition 
of this article, under the title Cass¢@ Pulpa, as “The pulp 
obtained from the pods,” this pulp being the only portion 
of the fruit used. The drug has been undoubtedly in 
use for five or six hundred years, but its name is much 
older, having been transferred to this substance from 
some variety of cinnamon to which it properly belonged. 
The tree is a native of tropical Asia, but is extensively 
cultivated for its beauty, both in the Old World and in 
the New. It is of medium size and produces long, 
drooping racemes of beautiful, showy, sweet-scented 
flowers. 

The pods are nearly or quite straight, from 30 to 60 
cm. long by about 2.25 cm. in diameter (12 to 24 in. by 
1 in.), cylindrical, shortly stalked and blunt-pointed. 
The surface is dark purplish-brown, and although not 
very smooth it has a dull polish. The dorsal and ventral 
sutures are marked by broad, flat, longitudinally striated 
bands running the length of the pod. The position of 
the partitions is generally noticeable upon the surface 
by means of shallow, annular constrictions about 5 or 6 
mm. (+ to 4in.) apart. The exocarp (shell) is hard and 
brittle when dry. The cavity is divided by transverse 
septa into from twenty-five to one hundred chambers, 
each containing one brown, shining, flattened seed and 
further filled with pulp. This last, when the pods are 
fresh, is soft and fills the entire space; as they dry it 
hardens into a thick, black, extract-like mass which event- 
ually becomes hard and brittle and only covers the surfaces 
of the chambers, leaving the seed free and loose. When 
very dry, the quality is considered to be impaired. This 
pulp is removed for use by maceration. It has a sweetish, 
mawkish, mulberry-like taste and smell .and is slightly 
laxative, but, at least in the dry state in which the fruits 
reach us, it has very little value. Sugar, gum, and other 
common vegetable substances are all that have been 
observed init. Cassia Fistula is retained in the Pharma- 
copeia as a traditional ingredient of the Confection of 
Senna. In the south of Europe it is more used. Dose: 
of the pulp, from 4 to 12 gm. (3i to iij.) asa laxative; 


707 


Cassia, 
Castor Oil, 





as a cathartic, two or three times as much. The official 
confection contains 10 per cent. each of senna and 
tamarind, 7 per cent. of prune, 12 per cent. of fig, 16 per 
cent. of cassia fistula, and one-half per cent. of oil of 
coriander, the rest sugar. The dose is 4 to 8 gm. (3i to 
ij.). It is little used. Henry H. Rusby. 


CASSIA.—Cassra BARK, CasstA CINNAMON, and Cassra 
Bups. See Cinnamon. 


CASTALIAN MINERAL SPRINGS.—Inyo County, Cali- 
fornia. These springs are found near Owens Lake, and 
are thirteen in number, most of them being cold. One 
or two are sulphurous, and the others are alkaline and 
carbonated. The place is being developed as a resort. 
Some of the waters are also used commercially, and are 
recommended in cutaneous disease. The following an- 
alysis of one of the springs was made by Prof. Thomas 
Price, in 1880: 


ONE UNITED STATES GALLON CONTAINS: 


Solids. 
SOGUIMICATDOMABE! cieicsaieate sia! vislelaeieisiefalere/lsiela'ainiel e's siesta 








Sodium sul phsateieacacnverccls esse eisineiaietaye sisfetbieinis eleeeteete 1.02 
Sodium sulphate (?) . 
Sodium chloride ... g 
Potassium chloride 2 30 
AMO eaieeae meervaoye ‘ 
Magnesia .......... alate i 
SUG ai cae Fae Glace atorotereveeimterece clolatateleie’e Gielemts-ere eteiele steetelevstate 14.28 
BOvIC AGI Zigis sates core nisin CFR Sele a eistee levees sale Riatiannetc diate Trace. 
PHOSPHOTIE BCIOT ereyaiele acloihicteicrerepiaceleleistleteleie ele vinietaietercters Trace 
NOGUNGS cc ere viohteielos cle eins eiele ainieieletnie stnreletoieistericietireistetaine Trace 
BLOMING TS occccniicds en cuticce vosesitoraeecen isis Trace 
APOU bs clois cee: sla cis everutatMolaiossysvetelatacethrelereleteisia <ielate fice Tetaeierriciale Trace, 
CT MANTC WOAH ese ctaters cia elerelatelaidioieleaurataleteteravefelatelafersteiatete 13.48 
STOTT SOLAS seers aterancietetets savers elerstetelclereteter chars ersrereterelstetere 4,422.25 


Gases not determined. 


This is an exceedingly dense alkaline-saline water and 
cannot be used medicinally without dilution. There are 
other springs close by which are not so heavily impreg- 
nated. James K. Crook. 


CASTALIAN SPRINGS. Holmes County, Mississippi. 

Post-OFFIcE, Durant. Hotel. These springs are lo- 
cated three miles west of Durant, at the point of inter- 
section of the Canton, Aberdeen and Nashville and the 
main line of the Illinois Central Railroad, and about 250 
miles north of the Gulf Coast. There are from ten to 
twelve passenger trains arriving at and leaving Durant 
daily, all of which are met by the Castalian Springs 
stage line. 

The country around the springs is generally rolling, 
with some high hills and beautiful valleys, making a 
charming combination. The location of the springs is 
about 300 feet above the sea level. Notwithstand- 
ing the great rainfall in this section, there is very 
little gloomy or cloudy weather. The clouds roll up 
quickly, discharge their contents and disperse, leaving 
Old Sol to resume his sway. The temperature about the 
springs ranges, on an average, from 35° F. in winter to 
65° F. in summer. The greatest extremes ever noticed 
are 10° F. the lowest, to 90° F. the highest. The place 
is used as a resort both summer and winter. At present 
there are excellent accommodations for about 250 persons, 
but the resort is soon to be improved by the addition of 
a first-class new hotel with a capacity for 500 guests. 
The springs are situated in a pleasant little valley shaded 
by magnificent water-oaks, and surrounded by high hills 
with gradual slopes to the valley below. The hills are 
clad with evergreens of pine and some cedar. On the 
springs property which embraces some 3860 acres, there 
are about fifty springs and wells, only two of which, 
however, have been analyzed or used for medicinal pur- 
poses. We have been able to secure these analyses, one 
of which is only a qualitative determination of the 
mineral ingredients, while the second is a quantitative 
one. 


708 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


—_y vO O—LL_L_____————$— 


Sprine No. 1. 


(Examination by Prof. E. W. Hilgard, former State 
Geologist.) 


One United States gallon contains 138.5 grains of solid 
matter, made up of the following ingredients in the 
order of their quantities: 


Calcium sulphate. 
Aluminum sulphate. 
Magnesium sulphate. 
Iron sulphate. 


Tron carbonate. 
Potassium sulphate. 
Sodium chloride. - 
Silica. 

Sulphureted hydrogen gas, strongly charged. 

Carbonic acid gas, considerable quantities. 


Professor Hilgard states that the waters may be classed 
as sulphureted-chalybeate. They possess the astringent 
qualities of alum water, while at the same time they 
have laxative properties from the presence of the sul. 
phate of magnesium. 

This spring yields about 600 gallons of water per 
hour, having a temperature of 56° F. 


Sprine No. 2. 
(Prof. L. G. Patterson, present State Chemist, Analyst.) 
ONE UNITED STATES GALLON CONTAINS: 





Solids. ; Grains. 
Calcium: Sulphate :<e:0:5.0v/ac.+ee:sast 9.c.0-sinrere seine alate eel eee 37.23 
Magnesium gylphate oc cicicenc.cisccsicisemiletienta teeta 15.18 
Sodium sulphate 8.68 
BIMGA:., 5 07. s,s Ware atererel enleealharttareenttetetense 7.35 
Ferric and aluminum oxide 4.84 
Sodium chloride 2.47 
Potassium sulphate 1.29 

TOGA as. 0s.0is 40/4/0015 e:6inle ole e/siarti aici picie.ci ersfore erat ete Steet eet 77.04 
This spring flows about 300 gallons per hour. The 


water is used for bathing purposes, and is also sold by 
the barrel or case. It has long held a wide reputation 
in Mississippi for the treatment of the malarial cachexia 
and for liver, stomach, bowel, and skin affections. 

James K. Crook. 


CASTOR.—Castorewm. The dried preputial follicles 
with their contents, obtained from the Beaver, Castor 
Fiber Linn., and separated from the somewhat shorter 
and smaller oil sacs, which are frequently attached to 
them. The glands or reservoirs are usually connected 
in pairs by their excretory ducts, which open so near 
together as to be removed without dividing. They are 
oblong or pear-shaped, somewhat shrivelled, multilocular 
bags, of dark-brown color (when dry) and tenacious con- 
sistence. Thecastor itself is within these; it isan unctu- 
ous brown or reddish-brown substance of intense and 
disagreeable smell. It consists of volatile o7l, castorin, 
a resinotd substance, a peculiar fat, and other proximate 
principles, but like musk and others of its class the 
chemical composition is not especially instructive as to 
its qualities. There are two varieties of Castor, the 
Siberian, from the Siberian beaver, whose “pods” are 
longer (6 to 12 cm. = 24 to 5 in.) and larger, and whose 
contents are more fragrant; and the Canadian, from the 
American variety. The latter is naturally the most 
common here. 

This substance has been long used as a stimulant and 
antispasmodic in hysterical and other nervous conditions, 
but is now nearly obsolete as a medicine. It is no longer 
official either in this country or in Great Britain. There 
is some call for it as a basis of perfumes. Dose from .5 
to 2 gm. (gr. viij to xxx.). W. P. Bolles. 


CASTOR OIL.—O.LrEum Ricrnt. “A fixed oil ex- 
pressed from the seeds of Ricinus communis L. (fam. 
Euphorbiacee)” (U.S. P.). In temperate climates, this 
plant is an annual, often dying at the season’s close 
without ripening its fruit; or, where the season is long 
enough, as in the Middle States, it bears abundantly the 
first year, and is killed by the approach of winter; but 
below the frost line, as in the extreme south of Europe, in 


A. sn pl nat oa 


- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cassia, 
Castor Oil, 





Africa, and India, it becomes a shrubby or tree-like 
perennial, sometimes attaining, in the tropics, a height 
of forty feet. In the United States it usually attains a 
height of from three to twelve feet, with a round, very 
smooth, purple and glaucous, hollow, branching stem, 





Fig. 1149.—Castor-oil Plant. (Baillon.) 


and large, peltate or subpeltate, five- to eleven-lobed 
leaves. The flowers are borne in large, falsely axillary, 
paniculately branched spikes. The fruit is a short, 
blunt, prickly tricoccus capsule, containing three pendu- 
lous seeds. Castor-oil seeds vary considerably in size 
and markings; they are generally from 1 to 2 cm. (about 
4 in.) in length by about two-thirds as broad and 
half as thick, ovoid, blunt, and rounded at the ends. 
They are convex on the outer surface. The inner sur- 
face is usually flattened on each side of the middle by the 
pressure of the neighboring carpels, the two facets so 
formed uniting in a very blunt and rounded longitudinal 
angle. They have a good-sized caruncle at their upper 
end (or a scar if this has been broken off). The surface 
is very smooth and shining, usually of a gray color, 
marked with very pretty brown or blackish marblings. 
In color and markings, however, they may vary consider- 
ably. The nucleus consists of a soft, oily albumen, with 
a good-sized, straight, broad embryo in the middle. This 
plant is probably indigenous to India, but has been cul- 
tivated so long and extensively thatits original habitat is 
difficult to determine. It has been completely natural- 
ized, and grows with all the freedom of a native in other 
parts of Asia, as well as in many of the Mediterranean 
islands and coasts. It is cultivated exten- 
sively for its seeds in India, Southern 
Europe, and the Middle United States. It 
is a very variable species, and is divided 
into numerous varieties, mostly distin- 
guished by the size, shape, and color of 
capsules or seeds. 

The castor-oil plant was known to the Fie, 1150.—Seed 
ancient Egyptians and Greeks, and its oil ne ee 
was used for fuel, light, and medicine. It natural size. 
has even been suggested as the gourd that 
sheltered Jonah. After a long period of 
neglect, it was again brought into use, a hundred and 
twenty years ago, by Peter Canvane, a physician who 
had practised for many years in the West Indies, and 
who, in a treatise upon this oil, strongly recommended 
it as a gentle purgative (Pharmacographia). 

The oil is separated from the seeds by the usual methods 
employed with fatty substances, viz., by boiling in water 











and skimming it off; by extracting it by means of some 
solvent like alcohol or ether; or by expression. The 
latter is the method employed in the United States. The 
seeds are carefully cleared from dust and fragments of 
the capsules, and then warmed, by which means the oil 
becomes more liquid. The mass is then subjected to 
strong pressure, and the expressed oil further purified 
either by standing and decantation or by boiling with 
water. The yield is about forty or fifty per cent. The 
purer the oil is, the less active and griping it is. If ex- 
pressed cold from the peeled seeds, like the best Italian 
oils, it is very white and odorless, and almost tasteless. 

The higher the temperature employed in the process, 
the greater is the tendency toward the freeing of the 
irritating and griping ricinolete acid. The pulp left 
after expression contains a small amount of the albuminoid 
ricin, Which is a powerful irritant and convulsive poison. 
This substance renders the action of the seeds so violent 
as to unfit them for use as a medicine, though the prac- 
tice prevails in some countries of triturating one or two 
with a dose of the oil, to render the latter more effective. 

DescripTion.—The following is the official description: 
A pale yellowish or almost colorless, transparent, viscid 
liquid, having a faint, mild odor, and a bland, afterward 
slightly acrid, and generally offensive taste. 

Specific gravity: .950 to .970 at 15° C. (59° F.). 

Soluble in an equal volume of alcohol, and, in all pro- 
portions, in absolute alcohol, or in glacial acetic acid; 
also soluble, at 15° C. (59° F.), in three times its volume 
of a mixture of 19 volumes of alcohol and 1 volume of 
water (absence of more than about 5 per cent. of most 
other fixed oils). 

With an equal volume of benzin, it forms, at 15° C. 
(59° F.), a turbid mixture, but at 17° C. (62.6° F.) it 
yields a clear solution. 

When exposed to the air in a thin layer, it slowly dries 
to a varnish-like film. 

When cooled to 0° C. (82° F.) it becomes turbid, with 
the separation of crystalline flakes, and at about —18° 
C. (—0.4° F.) it congeals to a yellowish mass. 

If 3 c.c. of the oil be shaken for a few minutes with 3 
c.c. of carbon disulphide and 1 ¢c.c. of sulphuric acid, the 
mixture should not acquire a blackish-brown color 
(absence of many foreign oils). 

Castor oil consists almost wholly of a compound of 


1 pteinolete acid (C1;Hs2{0H]COOH) which is irritant and 


purgative when set free by saponification in the intestine. 

Castor oil is a cathartic of very reliable character, more 
uniform and painless in its action, and more susceptible 
of gradation, than almost any other. The full dose 
clears the bowels with great certainty, producing numer- 
ous and copious discharges of their contents, with but 
little irritation of their surfaces; indeed, when these are 
inflamed it appears to have a decidedly healing or sooth- 
ing effect upon them. On these accounts, when the de- 
sire is simply to relieve the entire intestinal tract, either 
from the accumulated feeces or from the irritating secre- 
tions of dysentery or enteritis, castor oil is the safest and 
surest means at the command of the physician. For at- 
tacks, also, of acute indigestion, and for the constipation 
following childbirth, it has long been almost universally 
used. It is nota hydragogue, nor is it very well adapted 
for continuous use in habitual constipation, although for 
“weak” and sensitive conditions of the bowels, when 
they are easily disturbed, now a little constipated, now 
a little loose, with frequent slight colics and flatulent 
tenderness, small daily doses of this medicine may be 
useful. Daily doses of ™xx. to xl., before breakfast, 
are recommended by high authority for overcoming 
chronic constipation. It is one of the ingredients of 
flexible collodion (Collodium flexile, U. 8. P.), to which it 
gives softness and flexibility. 

ADMINISTRATION.—There. is scarcely a medicine in use 
which is generally taken with so much repugnance as 
this. When it can be taken clear this is the best way, or 
it may be mixed with syrup or glycerin, or floated upon 
the surface of some aromatic water, or in the froth of 
soda-water containing some aromatic syrup; or a regular 


709 


Castration. 
Castration. 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





emulsion may be made with it, such as is made with cod- 
liver oil, by means of mucilage or other emulsifying 
agent. But the taste of the oil usually outlives that of 
the flavor, and these agents are, therefore, only partly suc- 
cessful. Another good way is to rinse the mouth with 
clear whiskey or other spirit, or lemon juice, then immedi- 
ately to swallow the oil, and follow it with another rins- 
ing with the liquor. If thoroughly emulsified, with the 
addition of orange juice, a confection is formed which is 
almost unobjectionable. Finally, it is put in elastic cap- 
sules, which for small doses, in the case of patients who 
will learn to swallow them, completely cover the taste. 
All these means, however, are more adapted to grown 
persons than children; for these the emulsion is probably 
the best, or it may be covered with a little lemon juice 
or glycerin. Another useful way to give ¢astor oil, in 
certain cases, is by injection; in this way it acts prin- 
cipally locally and mechanically as a lubricant, but a cer- 
tain quantity must be absorbed, as there is often more 
result from it than would be explained in this way. A 
good method is to give, for an adult, from 60 to 120 gm. 
(Zij. to iv.) clear, to leave it for from one-quarter to 
three-quarters of an hour in the bowel, and then to follow 
with a full enema of soap and water. Very free empty- 
ing of the lower bowel usually follows. 

Castor oil is absorbed to a slight extent by the skin, 
but the method has no practical value. 

Dose by the mouth, as a laxative, from 5 to 10 gm. 
(3i. toiij.); asa purgative, from 15 to 30 gm. Children 
require large proportionate doses. A baby a week old 
can easily bear from 3 to 5 gm., and a child of five or six 
years, 10 or 15 gm. Henry H, Rusby. 


CASTRATION.—The removal of the testicles or ovaries. 


I. Historica SKETCH OF CASTRATION IN MEN. 


Castration is a very ancient practice. 
sequence of the system of polygamy. The word eunuch 
means literally having charge of the bed-chamber. The 
Hebrew ‘word means mutilated, and the first royal cham- 
berlains were probably castrated men. Later the term 
eunuch was applied to men in all sorts of offices and it 
lost its original meaning. In some of the Eastern courts 
the eunuchs often played an important réle and became 
so prominent in affairs of state that the word eunuch 
came practically to be the name of a great state officer, 
the chamberlain. 

Eunuchs are represented on the bas-reliefs found dur- 
ing the excavations at Nineveh. “Here and there along 
the sculptured procession, in strong contrast to the 
bearded men, the eunuchs stand out with their smooth, 
beardless faces, fat cheeks and bald double chins. The 
artists adopted these features as a conventional mode of 
representing them.” * 

Herodotus relates that the castration of slaves was an 
industry among the Greeks. These slaves brought a 
high price in the markets of Ephesus. They were re- 
garded as the most faithful and most capable servants. 
In Rome also there were numerous eunuchs. Castration 
has been a feature in certain religious doctrines, one at 
least of which taught that it was necessary for salvation. 
The beautiful soprano voices possessed. by some of the 
eunuchs made them a prominent feature in the musical 
portions of religious services. We are indebted to Kor- 
sakow,+ physician to the Russian Embassy, for interest- 
ing data concerning the eunuchs in China. Early records 
of castration in China date back to 1100 8B.c. Next to 
beheading it was at one time the most severe form of 
punishment. The eunuchsare used as slaves in the royal 
household at the present time. Some are forcibly cas- 
trated, others submit voluntarily as a result of poverty, 
and others are sold into slavery as children by their 
parents. 

In China the operation is usually performed in child- 


* Andrews, “The Oriental Eunuchs.”’ 
Medical Association, xxx., 173-177, 1898. 

+ Korsakow, ‘“Eunuchen in Pekin’’ (abstract). 
Wochenschr., xxiv., 3388-340, 1898. 


710 


It was a con- 


Journal of the American 


Deutsch. med. 


hood. The trade is hereditary in certain families. The 
fee is about ten dollars. If the victim has no money the 
amputated genitalia are retained by the operator as 
surety. The operation is performed in the following 
manner. The genitalia are first completely anesthetized. 
The specialists are said to possess a secret method of local 
anesthesia. The external genitalia are then removed 
with one stroke of the knife. Crude methods of stopping 
the hemorrhage are employed. They have no notion of 
surgical asepsis. Dissection is forbidden by law and as 
a result they have no surgery. Retention and fatal sepsis 
area common sequence. Incontinence may follow reten- 
tion. In this case it is said that the approach of the pa- 
tient may be recognized at a considerable distance on 
account of the strong odor of ammonia. Later the 
aperture of. the urethra tends to contract and a wooden 
dilator is introduced and at first is worn constantly ex- 
cept during micturition. Even with these precautions 
retention follows in most cases as a result of cicatriza- 
tion. With this are associated cystitis and the formation 
of vesical calculi. 

The classical type is seldom seenin Pekin. The middle- 
aged eunuch differs little from other Chinamen. Those 
castrated in youth attain full stature. The timbre of 
the voice is like that of a woman. Those castrated after 
the age of twenty rapidly lose their hair and their voices 
become harsh and unpleasant. They age rapidly and 
at forty they give the impression of a person of sixty. 

Lortet * says that in most of the large cities of Egypt 
one meets in the streets many eunuchs, attached to rich 
families as trusted servants, especially as servants and 
guards in the harems. The methods of operating among 
the Egyptians are barbarous and the mortality is great. 

Many of the eunuchs castrated early in life were said to 
preserve the pure, clear timbre and high pitch of the 
boy’s voice, adding to this the power of the grown man’s 
lungs. In the Italian opera many of them attained 
prominence as really great singers. 

“Reputable authors assert that,” in Australia, “the 
wild natives limit the increase of families by crushing 
the testicles of the father after his first child is born.” * 


II. Errects oF CASTRATION ON MALE ANIMALS. 


Domestic animals are ordinarily castrated because they 
grow and fatten more quickly and are more valuable for 
working purposes. The effects of castration on animals 
are summarized by Andrews.+ He gives an interesting 
account of the effect upon the elk as observed in two cases 
by the late Judge Caton, of Ottawa, Ill. “The course of 
horn growth in the uncastrated buck is this. Their so- 
called horns are not composed of real horny material but 


‘of true bone, and are developed into antlers of immense 


size. They are shed annually, as in all the deer tribe. 
During the spring and summer they grow rapidly. They 
are then covered with skin, hair, and connective tissue, 
and are supplied with numerous large arteries and veins 
running between the boneand the skin. This is the stage 
called ‘the velvet.” Toward autumn a narrow, knobby 
ridge or ring of bone, like a narrow provisional callus, 
begins to, develop around the base of each horn; the ridge 
pushes out and presses hard against the nutrient vessels 
supplying the horn, and in some weeks obliterates them. 
The velvety skin and connective tissue covering the 
antlers are cut off from nutrition and die. The bony 
horn itself also dies later and the dead skin dries and be- 
comes loose, and the animal rubs it off among the trees 
and bushes, leaving the superb antlers in their perfected 
condition. The antlers now have no nutrition except a 
little derived from the small interior vessels of the can- 
cellated tissue, which are soon obliterated. They are 
now two immense necrosed bones and in the course of the 
winter undergo a separation, like any other necrosed bone, 
and drop off. In the spring a new pair sprouts and de- 
velops, like their predecessors. Judge Caton found that 


* Lortet, ** Allongement des membres inférieurs du 4 la castration.” 
Arch. d’Anthrop. Crim., xi., 861-864, 1896. 
+ Andrews, Op. cit. 


eae 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





if while the young horns were in the velvet the buck be 
castrated, the pair of horns then developing would go on, 
finish their growth, and be shed the following winter as 
usual; but the next pair were never shed. The effect of 
the castration is to prevent the formation of the bony 


ring at the base. Consequently the blood-vessels are. 


not obliterated, the horns continue in the velvet, they do 
not die, and are not shed. In our climate, however, the 
severity of the winter freezes the antlers and kills them 
down to a point, perhaps, eight inches from the skull. 
The frozen parts ultimately drop off and in the spring 
numerous small horns, like fingers, sprout up from the 
stumps. Thenext winter these are partly frozen,-and so 
on until a pair of large knobby bunchesof bone stand up 
on top of the head. 

“So far as I know, no one has tried protecting these 
horns from the winter’s cold to see what they would 
grow to. They would probably attain an immense 
size.” 

The ox is larger than the bull but relatively the neck 
and forequarters are thinner. The cerebellum is said to 
be larger. The horns are greater in length and diameter. 
In the adult bull the voice in lowing is an octave higher 
than that of the ox. This is in contrast to the effect of 
castration upon the human voice. 

The wool of the wether is said to contain less lanolin 
than that of the ram. This is of importance commer- 
cially. Castrated cats are excellent mousers. They are 
considerably larger than normal cats. 

It is stated that among certain species of squirrels, the 
males, in fighting, castrate each other. There seems to 
be no doubt that many of those captured by hunters 
have been castrated in some way; but exactly how it 
occurs does not seem to be settled. The capon or castrated 
chicken is fifty per cent. heavier than the cock. The 
flesh is more delicate and more tender. “Their spurs 
remain undeveloped, the colored comb and wattles about 
the head remain very small, and the gay ornamental 
plumage of the cock is mostly wanting.” 


Til. Errects oF CASTRATION ON THE HUMAN MALE. 


Castration in early life exerts profound developmental 
influences. The secondary sexual characters of the male 
are expressed in part by his greater size and strength and 
deeper, rougher voice. The origin of these characteristics 
is probably due to nervous or chemical influences origi 
nating in the testicles. Experimentally the invigorating 
effects of the injection of testicular extracts have been 
shown. Zoth* showed that daily injection for one week 
increased by fifty per cent. the working power of a man’s 
neuro-muscular system. At the same time there were 
less susceptibility to fatigue and greater power of re- 
covery. ‘These nervous or chemical influences are not 
essential to health as in the case of the thyroid. 

At puberty there occur acceleration of growth, changes 
in proportion, and the growth of the beard. The pitch 
of the voice may fall permanently an octave and for the 
time being may become rough, broken, and uncontroll- 
able. This is due to a general sudden enlargement of the 
laryngeal cartilages, and a lengthening of the vocal 
cords. In the eunuch the size, shape, and consistency 
of the larynx correspond more to the condition in the boy 
than to that inthe female. Calcification of the cartilages 
in old age does not occur. The timbre of the voice is 
boyish and the pitch is soprano. 

Apparently no accurate observations have been made 
concerning the changes produced by castration in early 
youth. The results of the operation as performed in 
some of the Oriental countries can hardly be considered 
cases of uncomplicated castration. The forms of opera- 
tion differ widely. In many cases the entire external 
genitaliaare removed. Complications arising from sepsis 
and other conditions must also be considered. No gen- 
eral statement concerning the changes in general appear- 


* Zoth, Quoted by Lee, ‘‘ Reproduction,” in ‘‘ American Text-book 
of Physiology,”’ 878, 1896. 





Castration, 
Castration, 





ance and nourishment can be made. There is probably a 
general tendency to adipositas, in late life at least. 

Statements as to the condition of the musculature vary. 
Hair does not develop on the chest, in the axille or on 
the pudenda, and no beard grows on the face. 

The thyroid in Gruber’s* case was very small. 

The internal genital organs are small and undeveloped. 
This is the case with the penis also. 

In animals an arrest of development in certain parts of 
the brain has been described. Statements concerning 
peculiarities of character and the mental capacity of 
Oriental eunuchs have been made, but they differ so 
widely that no general conclusions may be drawn. Some 
are described as weak and of a jealous, intriguing char- 
acter. Others are said to possess great energy and 
ability. It is probable that the moral atmosphere in 
which they lived has considerable influence in determin- 
ing these characteristics. 

Effect on the Serual Life.—Sturgis,+ after giving an his- 
torical review, calls attention to the forensic importance 
of this subject. He concludes that in animals, for a 
varying period after complete castration, normal sperma- 
tozoa are found in the contents of the seminal vesicles. 
This period varies in different animals, being six days 
for the dog, seven for the cat, and fourteen days for the 
guinea-pig. In man clinical cases are recorded in which 
fecundation of the female has occurred after coitus with 
the male who has been completely castrated. The diffi- 
culty of controlling all the circumstances, however, is 
obvious. Still pursuing the analogy in man as in the 
dog and cat, a complete castrate may be capable of pro- 
creation provided the coitus occur within the first seven 
days after the castration. 

The impossibility of drawing general conclusions from 
a small number of cases brings up the question of ac- 
cessory testes. Apparently a few indubitable cases have 
been recorded in which the accessory testis has been re- 
moved and examined microscopically. Turner t reports 
a case in which two testicles were found on the right 
side during an operation for hydrocele. One was situated 
above the other, the cords of the two apparently uniting. 
He also quotes a similar case reported by Lane. * “ Micro- 
scopical examination of the supernumerary testis showed 
well-formed tubules with spermatogenesis proceding.” 
In neither of these cases, however, does there seem to 
have been a microscopical examination of what was con- 
sidered to be the normal testis. It seems quite possible 
that in some cases of apparently complete castration 
normal functionating testes may be situated even intra- 
abdominally. 

This is important also in connection with the question 
of the effect of castration on the sexual passion. It is 
said that sexual desire may persist after castration in 
manhood and may develop occasionally even when the 
operation has been performed in childhood. The ox and 
the gelding do not completely lose the sexual passion. 

Castration for Enlarged Prostate.—The physiological 
relations existing between the testesand the prostate, the 
faulty development of the prostate after castration in 
early years, and the conception of an analogy existing 
between the hypertrophied prostate and myomata of the 
uterus, led to the performance of castration as a thera- 
peutic measure in cases of prostatic hypertrophy. 

From a developmental point of view the analogy be- 
tween the hypertrophied prostate and uterine myomata 
is not well founded. Only the sinus, pocularis, a remnant 
of the Milerian duct, corresponds to the uterus. Ana- 
tomically and histologically the similarity to uterine 
myomata of the so-called myomatous form of hyper- 
trophy is only superficial. 

The faulty development and small size of the prostate 
after castration in childhood and the retrogressive changes 





* Gruber quoted by Becker, ‘*‘ Ueber das Knochensystem eines Cas- 
traten.’? Arch. f. Anat. u. Entwickelungsgesch., 83-112, Leipsic, 1899. 
+ Sturgis, ‘‘ Are Complete Castrates Capable of Procreation?’’ Med. 
News, Ixxiii., 449, 1898. 
a Turner, “‘A Case of Supernumerary Testis.’? The Lancet, ii., 174, 


711 


Castration, 
Castration, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





following the operation in early manhood, indicate only 
the effects upon a normal organ. Here, however, we are 
dealing with an hypertrophic and pathologically altered 
land. 

. Following castration in animals there ‘is an atrophy of 
the glandular portions of the prostate. In most cases of 
hypertrophy there is an increase in the volume of the 
fibro-muscular stroma. The pure glandular forms are 
relatively uncommon. An atrophy of the glandular 
portions alone would have little influence in reducing the 
size of the organ. 

Retarded development of the prostate in congenital 
malformation and malposition (cryptorchismus) of the 
testes has been described. Apparently there have been 
a few cases of hypertrophy after castration in youth. 

The danger of the operation in old patients has led to 
modifications of various kinds. Among these may be 
mentioned unilateral castration, division of the cord, liga- 
tion of the cord, division or resection of the vasa defer- 
entia, division of Cooper’s nerves, angio-neurectomy, 
and sclerogenous injection. These do not appear to be 
as effective as the original operation. 

Many good results of the operation have been reported 
by trustworthy observers. Many very experienced sur- 
geons report only bad results. 

Although the sexual operations for prostatic hyper- 
trophy have often been performed, and there is no lack 
of experimental evidence of the effect of castration on 
the normal gland, yet one cannot say that the relations 
of this operation have as yet been entirely cleared up. The 
indications have not yet been adequately determined, 
and one-cannot say in any case what the result will be. 
The method in which castration brings about the result 
is still rather obscure, and the changes which the hyper- 
trophied prostate undergoes have been little observed at 
autopsy or studied histologically. The observations have 
yielded no noteworthy results. In almost all cases an 
atrophy could not be demonstrated. 

Important considerations are the effect on the cen- 
tral nervous system and the general effects. In old pa- 
tients there is often rapid exhaustion of strength. Cases 
of acute “mania have been reported. These effects may 
be due to the loss of an internal secretion. Frisch* has 
given up the sexual operations entirely. Three of his 
patients who were cheerful and strong before operation 
and had no evidence of involvement of the kidneys or 
other internal organs died within fourteen days after re- 
section, as a result of a loss of strength amounting almost 
to cachexia. 

The greater part of the publications on the subject are 
incomplete. A cure involves a condition in which the 
patient spontaneously completely empties the bladder 
within the normal interval. This fact is often lost sight 
of. Reports of a decrease in the size of the prostate are 
seldom based on accurate measurements. Cidema caused 
by retention is probably relieved, but the same result is 
attained by catheterization. Some of the reported cases 
have been operated on during the first period of reten- 
tion. 

There are a few apparently reliable cases in which the 
results were very satisfactory. Spontaneous micturition 
developed gradually and later a decrease in the size of 
the prostate could be demonstrated and was permanent. 
There was a decrease of residual urine and a disappear- 
ance of the obstruction and the cystitis. The contractil- 
ity of the bladder returned after years of catheteriza- 
tion or the patients were more readily catheterized. The 
soft forms of hypertrophy are most influenced. Fatal 
results are frequently due to secondary changes in the 
kidneys. 

The results of nursing, rest, and treatment of the cys- 
titis are apt to complicate the observations, and cases 
given simply symptomatic treatment often yield equally 
good results. 

It has not been decided what relation enlargement of 


* Frisch, ‘* Die Krankheiten der Prostata,” in Nothnagel’s ‘‘Specielle 
Path. u. Therapie,”’ xix., 


712 


the prostate bears to difficult micturition. There may 
be symptoms without much enlargement, and many old 
men with large prostates have no symptoms. The 
severity of the symptoms does not depend entirely upon 
the degree of hypertrophy. The hypertrophy is not 
physiological, but is caused by proliferation of a typical 
tissue and the result is much like that due to the presence 
of a neoplasm. There is possibly an embryological An- 
lage* for the condition. 

Most of the reported brilliant results have followed 
within a few days after the operation. They have pos- 
sibly been a result of depletion of the venous networks, 
with which the prostate and the neck and walls of the 
bladder are supplied. These vessels communicate freely. 
Their congestion probably has a great influence on caus- 
ing thesymptoms. <A distended bladder probably causes 
passive congestion in these vessels. In a short time this 
results in swelling and cedema of the neck of the bladder 
and of the prostate, and consequent closure of the orifice 
of the bladder. Castration possibly relieves this conges- 
tion by vaso-motor or other influences. 

The late publications of some of the best observers in- 
dicate that the operation is at present employed only to 
a slight extent. Mikulicz+ would limit the indications 
for the operation markedly. Frisch’st opinion, as ex- 
pressed at the Thirteenth International Medical Congress, 
is as follows: “Of all the various operations for hyper- 
trophy of the prostate only those which have for their 
object the complete removal of that portion of the pros- 
tate which .prevents the free flow of urine offer any 
chance of lasting success.” Under this head he does not 
include any of the operations involving the testicles. 

The conclusions of Lequeu § are reported as follows, 
from the same meeting: “As regards the remote results 
of double castration they are not so good as the early 
observations, which did not take a long enough space of 
time into consideration, would lead one to believe. The 
prostate certainly shrunk, but the patient improved to 
a far greater degree than could be accounted for by the 
diminution observed. The attacks of pain were less fre- 
quent and the contractility of the bladder improved so 
that the residual urine was less in quantity. But, after 
all, there was only amelioration and not permanent cure, 
and comparing the results of castration with those of 
other methods it was doubtful whether the advantages 
of it were worth the sacrifice.” 

The mental state of the patient, resulting from the 
change in his relations to society, must also be considered. 

Eiffects of Castration on the Osseous System.—Becker |} 
has made some very interesting observations upon the 
effects of castration on the osseous system. His material 
consisted of the skeleton of a colored eunuch and the 
pelvic bones of another. These he compared with the 
skeletons of two colored males upon whom the operation 
had not been performed. 

The general structure of the skeleton is slender as in 
the young negro. Ossification is delayed. This is true 
of the skull, the vertebrae, and the extremities, with the 
shoulderand pelvic girdles. Thesutures and epiphyseal 
lines are very clearly retained and present the condition 
found in very young individuals. In Gruber’s § case the 
normal ossification of the hyoid bone was absent. The 
bones in general are very long, making the skeleton very 
tall. The same thing is observed in the ox and the geld- 
ing, both of which have long extremities and high 
withers. The relations of the lower to the upper ex- 
tremities are analogous to those found in the young indi- 
vidual. The same is true of the relations of the forearm 


* The German word Anlage is variously rendered rudiment, origin, 
beginning, basis, foundation, fundament. 

+ Hoffman, ‘‘ Beitraige zur operativen Behandlung der Prostata- 
hypertrophie.”’ Beitrage zur klinischen Chirurgie, xix., 541, 1897. 

+ Frisch, ‘‘ The Remote Effects of Operative Treatment in Hyper- 
trophy of the Prostate.’’ Thirteenth Internat. Med. Congress, August, 
1900. Reported by Phil. Med. Journ., vi., 825, 1900. 

§ Lequeu, Ibid., 326. ' 

| Becker, ‘‘Ueber das Knochensysten eines Castraten.”’ Arch. f. 
Anat. u. Entwickelungsgesch. 83-112, . 

Gruber, quoted by Becker, Ibid. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Castration, 
Castration, 





to the arm and of the legs to the thigh. In the pelvis no 
characteristic changes are found. 

These results confirm those of Lortet.* He performed 
an autopsy on an Egyptian eunuch about twenty-five 
years old. The length of the long bones was consider- 
ably increased. This was especially marked in the lower 
extremities. 
hind legs of the castrated rabbit are abnormally long. 
In the capon the foot is elongated. It is especially the 
hind legs of the ox that are elongated. As a result the 
line of the back is horizontal instead of descending as in 
the bull. 

Effect of Castration on Sociological Conditions.—Castra- 
tion has been employed in some countries as a method 
for the punishment of crime. Asexualization for the 
limitation of disease and the prevention and punishment 
of crime has been urged to some extent at the present 
time. It has been maintained that the castration of 
chronic criminals, sexual perverts, and hereditary defec- 
tives would benefit society and elevate the human race. 
It has been proposed as a substitute for capital punish- 
ment and asa means of preventing the propagation of 
criminals. “The pleading of Brower,+ that asexualiza- 
tion is the most promising means of reducing crime, has 
been put on a practical basis by the suggestion of Mc- 
Cassey that criminals, especially those imprisoned for 
rape, should be offered their liberty at any time on con- 
dition of submitting to castration previous to discharge.” 

The editor of the Philadelphia Medical Journal t appar- 
ently favors legislation along this line, as may be judged 
from the following: 

“As we ascend in the social scale, with the present 
state of society, especially in the large cities, the number 
constituting a family becomes smaller and smaller. It 
requires no mathematician to discover that the shiftless, 
the thriftless, the indigent poor—the class which pro- 
duces, relatively, the greatest number of criminals and 
paupers, if not of the mentally deficient—are increasing 
out of all proportion to the thrifty, the well-to-do, the 
class which produces relatively few of the paupers and 
criminals.” 

Two causes for this may be assigned. The growing 
dislike on the part of parents of the upper and middle 
classes to be burdened with numerous children and the 
lavish free treatment by hospitals, dispensaries, and lying- 
in institutions to all who apply. “Never was such 
organized or persistent effort put forth to save the weak- 
ling, the physically incompetent, those who with less 
care would perish in the battle for life. 

“This effort at saving life is well, it is our duty; but 
it has its evil consequences. Parents relieved from much 
that is onerous in child-rearing are encouraged to beget 
others of their kind. Thus is beginning a multiplication 
of the indigent population which threatens serious con- 
sequences for the future. 

“Tf the confirmed criminal, the pauper, the degenerate, 
those who have ceased to have a regard for law and the 
consequences of their own acts, must be supported by 
the state, then society certainly has the right to say that 
such at least shall not propagate their kind. It is stated 
that Michigan has legalized asexualization for certain of 
these unfortunates. Other States and countries will in 
time follow her example. 

“ Asexualization will be held by some to be a harsh 
measure, but it becomes incumbent upon those who 
would discourage it to offer something better, for the 
future willcompel us to act. Regulation of the marriage 
law would be ineffectual,- because these lower classes 
have ceased to have respect for the law and the conse- 
quences of their own acts. 

“If society by her philanthropic efforts is forced to 
annul the law of the survival of the fittest, then self- 
interest, nay self-preservation, will compel her to adopt 


*Lortet, “ Allongement des membres inférieurs du a la castration.” 
Arch. d’Anthrop. Crim., xi., 361-364, 

+ Johnston, Am. Year-Book of Med., 519, 1900. 

$* serine, Pauperism, and Mental Deficiency. st 
vi., 


Phil. Med. Journ., 


It has been shown experimentally that the’ 





measures that will prevent the multiplication of those 
who at best can only add degeneracy to the race.” 


IVY. EFFECTS OF CASTRATION IN WOMEN. 


Advances in gynecological pathology have made cas- 
tration a much less common operation than it has been 
inthe past. Many conditions formerly considered patho- 
logical are now recognized as normal. Regeneration and 
restoration of function follow more conservative opera- 
tions in large classes of cases in which radical procedures 
were formerly considered necessary. 

It is difficult to get accurate data concerning many of 
the remote effects of castration “because women are 
naturally reticent about matters of sex.” Many of the 
patients are ignorant and unable to give intelligent ac- 
counts of their condition. 

The classification of the effects of castration here 
adopted is that of Pfister.* Many of the ingenious ap- 
plications of Pfliiger’s theory also are his 

Influence on Menstruation.—Before considering the 
effects of castration upon menstruation a brief considera- 
tion of some of the theories of menstruation is necessary. 
According to Pfliiger’s theory menstruation is the result 
of ovulation. The ovarian nerve endings are stimulated 
by the enlargement of the Graafian follicles in the ovary. 
The nerve supply of the ovary is very abundant, and the 
presence of ganglion cells has been described. The 
ovarian nerves have their centre in the lumbar region of 
the spinal cord. In this centre a summation of these 
stimuli takes place. The enlargement and bursting of 
the Graafian follicles is a continuous process. When the 
summation has reached a certain degree the stimuli are 
reflected to the vaso-motor apparatus of the uterus and 
ovaries. Meanwhile changes have been going on in the 
uterus. There has been formed the decidua menstrualis. 
This consists of a loose, succulent, and very vascular 
tissue. When the stimuli are reflected to the vaso-motor 
apparatus of the uterus a state of marked hyperemia is 
brought about. Under the influence of this hyperemia 
the capillaries burst and the menstrual flow is established. 

The stimulus caused by the enlargement of the follicles 
has been replaced experimentally by artificial means. 
The injection of sterile gelatin into the ovaries of bitches 
is said to have caused an immediate onset of the symp- 
toms of rut. 

In addition to its function of ovulation the ovary 
probably furnishes also an internal secretion, to which 
the cause of menstruation has been attributed. Of the 
existence of this secretion, however, there is no absolute 
demonstration, such as, for instance, the internal secre- 
tion of glycogen in the case of the liver. The assump- 
tion that it possesses this function rests upon the striking 
anatomical and physiological homologies existing be- 
tween the ovary and the internal secretive glands, and 
upon the disastrous results which follow its removal dur- 
ing the period of its functional activity. It may be that. 
the function ceases also at the menopause, and that many 
of the associated symptomsare due to its discontinuance. 

More tangible evidence of the internal secretive func- 
tion of the ovary is furnished by the experiments of 
Curatulo.t After castration he found the phosphates 
(P.O;) in the urine greatly and permanently reduced in 
quantity. These results have been confirmed in man. 

The beneficial effects of castration in cases of osteo- 
malacia appear to be explained by these experiments. 
By the removal of the ovaries the excretion of the phos- 
phates, which so largely constitute the inorganic, rigid 
portions of bone, is diminished. In this disease, however, 
no constant gross or histological changes in the ovaries. 
have been described. 

To what is to be attributed the periodicity of menstrua- 
tion? Pfliiger’s theory offers an answer to this question 
also. If a ripe follicle chances to be present when the 


* Pfister, ‘‘ Die Wirkung der Castration puE den weiblichen Organis- 
mus.”’ Archiy f. Gynikologie, lvi., 853, 

+Curatulo, ‘‘ Influence of Removal of Gate on Metabolism in 
Connection with Osteomalacia.”” Obst. Trans., London, xxxix., 58, 1897. 


713 


Castration, 
Castration, 





reflex hyperemia of the ovary occurs, its bursting is 
hastened. This explains the cases in which ovulation is 
coincident with menstruation. If no ripe follicle is pres- 
ent, however, ovulation does not occur. In lower ani- 
mals the rutting season and ovulation are synchronous. 
The periodicity of menstruation, then, is independent of 
ovulation. Pfliger’s theory assigns the cause to the 
periodic formation of the decidua menstrualis. The re- 
flex hyperemia does not cause menstruation unless the 
decidua menstrualis has been completely formed. 

If Pfliiger’s theory or the theory of internal secretion 
is correct, menstruation should cease after castration. 
Cases are repeatedly found in the literature in which it is 
said to have continued after the operation. In such cases 
it is probable that a portion of the ovarian tissue has 
escaped the operator and remained in place. In some 
cases this may have been in the form of accessory ovaries. 
These have been found at autopsy in such a relation that 
they might readily escape removalat operation. It seems 
that only a small amount of ovarian tissue is sufficient to 
continue the functions of the ovaries. A case has been 
reported in which a multilocular cyst developed after pan- 
hysterectomy. Pfister,* Clark,+ and Kelly ¢ believe that 
complete castration always results in absolute and per- 
manent cessation of the catamenial flow. 

Following the operation of castration, it has been ob- 
served in some cases that the succeeding menstrual period 
has occurred, but has begun earlier than usual. Accord- 
ing to Pfliiger’s theory, there should have been no suc- 
ceeding period. Pfister regards it as a result of the 
severe mechanical stimulation of the ovarian nerves that 
necessarily takes place during the operation. This takes 
the place of the stimulation normally produced by the 
enlargement of the Graafian follicles. 

The normal periodical flow has continued for a time 
after castration in some cases, and has then ceased at an 
earlier stage of life than normally. Here the operation 
has undoubtedly been incomplete. The early cessation 
is to be explained by the exhaustion of the remaining 
ovarian tissue. The number of Graafian follicles is limited 
and the supply gives out at an earlier period than nor- 
mally. 

Still another anomaly may be explained by Pfliiger’s 
theory. Menstruation may cease for a time after castra- 
tion, and then may be re-established. In these cases the 
remaining ovarian tissue contains possibly only very 
young follicles. It isconceivable that these develop only 
very slowly at first. Later, when they become more 
mature, their growth is sufficiently rapid to bring about 
the necessary stimulation of the ovarian nerve endings. 

It is significant that most cases in which menstruation 
persists after castration present technical difficulties at 
operation. These are often of such a character as to 
render it practically impossible to remove all of the 
ovarian tissue. They often take the form of dense adhe- 
sions to surrounding structures. Pfister reports two 
cases of unicornate uterus. Menstruation persisted after 
unilateral castrations. He believes thatthe “ Anlage” and 
development of the ovary were bilateral, and that the 
anatomical relations of one organ were so atypical that it 
could not be discovered at operation, and consequently 
remained to continue its functions. 

Following castration there are sometimes so-called 
vicarious hemorrhages. In a series of 116 cases Pfister 
noted their presence in 12. Two of these, in which 
periodical bleeding from the intestine occurred, he re- 
gards as genuine. In the other 10 cases the patients com- 
plained of periodical nose-bleed continuing for from one 
to two years. 

The effects of the operation upon leucorrhcea are usu- 
ally beneficial, and the condition improves or disappears. 
The change is not noted at first, but develops gradually 
with the retrogressive changes in the genitalia. In cases 
in which myomata are present the diminution is not 


* Op. cit. 

+ Clark, ‘‘Infiuence of Castration upon the Female Constitution.” 
Progressive Medicine, ii., 141, 5 

t Kelly, ‘‘ Operative Gynecology,”’ ii., 163, New York, 1898. 


714 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


so marked as in other cases. This is probably to be ex- 
plained by the presence of submucous myomata, which 
possibly mechanically continue the process which leads 
to the exudation. In the case of submucous myomata 
there are usually increased blood supply and hypertrophy 
of the endometrium. Castration results in a decreased 
blood supply and atrophy of the mucosa. The improve- 
ment after the operation suggests that leucorrheea is a 
result of this increased blood supply and hypertrophy. 

Molimina Menstrualia.—This term designates the un- 
pleasant sensations which often take the place of men- 
struation after castration, The etiology is possibly asso- 
ciated with a continuance of the periodical formation of 
the decidua menstrualis. The absence of stimulation 
from the ovary, however, prevents menstruation. With 
the gradual atrophy of the uterus the decidua menstrualis 
is no longer formed, and the symptoms disappear. Clark * 
believes that the decidua menstrualis is not formed at all 
after castration. According to the theory of internal 
secretion the symptoms are to be explained by a discon- 
tinuance of this function. The view that auto-intoxica- 
tion is responsible for the molimina has also been ad- 
vanced. Hippocrates believed that menstruation was a 
cleansing process for the purpose of ridding the system 
of impurities. The Hebrews + considered their women to 
be unclean during and for seven days following menstru- 
ation, and imposed severe penalties in cases of sexual 
congress during this period. 

The sensations are local and general. They are vari- 
ously described by the patients. There are sensations of 
heat, chilly sensations, dizziness, meteorism, pain in the 
back, pain in the abdomen, drawing pains, especially at 
the sides of the uterus, pain in the abdomen which not 
infrequently radiates to neighboring parts, sensations as 
of blood rushing toward the pelvic organs associated with 
feelings of fulness, weight, and dragging. Pfister noted 
their presence in thirty per cent. of the cases of his series. 
They were most pronounced shortly after the operation, 
persisting in some cases as long as two years. 

Eiffect on the Seaual Life.—The normal physiological 
phenomena of the sexual life may be expressed in terms 
of Pfliger’stheory. The tension of the Graafian follicles 
stimulates the endings of the ovarian nerves. This 
brings about a state of increased irritability of centres in 
the lumbar region of the spinal cord. Under these cir- 
cumstances the patient is very susceptible to sexual 
stimuli. Cutaneous and other stimuli may now arouse 
the sexual passion. At other times much greater stimuli 
may be necessary to bring about the result. In coitus 
the erotic sensations are produced by the mechanical 
irritation of the glans clitoridis. The gians contains a 
rich network of nerve fibres. These end in peculiar 
structures known as Krause’s tactile corpuscles. The 
mechanical stimulation probably brings about the erotic 
sensations in the lumbar region of the spinal cord. The 
irritability of these centres is probably increased by the 
stimuli from the ovaries passing through the ovarian 
nerves. This increased irritability is expressed by an in- 
crease in the intensity of the erotic sensations, 

According to Pfliiger’s theory, then, castration results 
in complete extinction of the sexual passion leading to 
sexual impulses, and of erotic sensations during coitus. 
Pfister found that in forty-three per cent. of his cases the 
sexual passion no longer existed, and that in fifty-two 
per cent. there was a cessation of the erotic sensations. 
He notes also that Gliiveke and Liesau arrived at similar 
conclusions. In the case of young individuals, he finds 
that the theory always holds good. He also quotes 
Beimler as having a similar experience. He offers an in- 
teresting explanation of the discrepancy. In the older 
individuals the sexual function has been active for a 
greater or lesser period of time. This has led to the de- 
velopment of a new factor. There have been formed in | 
the central nervous system memory pictures of previous 
experiences—the libido centralis. These serve to awaken 


and maintain the sexual passion independently of the 


* Op. cit. 


+ Leviticus xy., 19. 


“REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Castration, 
Castration, 





libido sexualis, which has for its basis the centres in the 
lumbar cord. The sexual life loses then the character of 
a purely physiological function. It comes to be par- 
tially dependent upon psychical influences. In support 
of this view he quotes Beimler’s experiments upon dogs. 
Some of the dogs were castrated after one or more preg 
nancies, and others were castrated before any pregnancy 
had occurred.. The former showed symptoms of heat 
after the operation, while the latter had no such symp- 
toms. He offers a similar explanation from Keppler’s 
case also. This was the case of a prostitute upon whom 
the operation of castration had been performed. She 
afterward continued her vocation. When her chosen 
lover was indifferent to her she submitted herself to him 
passively. When he was capable of arousing her inter- 
est, however, the sexual passion was aroused. Clark* 
reports the case of a variety actress who had suffered 
from gonorrhea for a number of years. The sexual 
passion had been almost abolished by constant suffering. 
Double pyosalpinx and severe pelvic peritonitis finally 
necessitated a double salpingo-o6phorectomy. Two or 
three years after operation, with renewed health, the 
sexual passion had returned with almost double force. 
In the same way may be explained the persistence of the 
sexual passion in some normal individuals until after the 

sixth decade. 
’ Certain general considerations also have a bearing upon 
this point. In the male sex the degree of sexual inclina- 
tion is fairly uniform. In the female, however, the de- 
gree varies greatly. “Concerning this point Prof. von 
Rosthorn, of Prague, made the startling statement to me, 
in a conversation upon this subject, that of all the women 
who consulted him at least seventy per cent., he felt con- 
vinced, had been indifferent to the sexual approaches of 
their husbands or lovers, even while they were yet in 
perfect health. In view of such statements it at once be- 
comes evident that the post-operative side of this ques- 
tion cannot be determined definitely without control 
records of the sexual proclivities of the patients before 
they became ill.”+ Asarule the sexual passion decreases 
with the approach of the climacterium. In many cases 
the post-operative state may be a result, not so much of 
the operation, as of the approaching menopause. In 
other cases it is possible that an inflammatory process 
may vicariously take the function of the ovary in stimu- 
lating the ovarian nerves. The sexual impulses and the 
erotic sensations are usually affected to an equal extent. 

The Effect upon the Genital Organs.—In the normal 
climacterium there is an increase of the connective tissue 
in the ovary, associated with the disappearance of the 
follicles. The other genital organs, especially the uterus, 
become atrophied. A similar result follows castration. 
The epithelium of the endometrium loses its cilia and 
becomes cubical, and the interglandular tissue becomes 
atrophic and cirrhotic. If myomata are present they 
take part in the general atrophy. The atrophy of the 
vagina, of the clitoris, and of the labia majora is less 
constant, but in some cases corresponds to that of the 
climacterium. This relation of the vagina and the ex- 
ternal genitalia is especially interesting when considered 
in connection with the effect of castration upon the sexual 
passion and the erotic sensation. The origin and per- 
sistence of sexual inclination and the trophic relations of 
the vagina and external genitalia are not so dependent 
upon the function of the ovary as are the uterus and 
menstruation. Cases in which this general atrophy does 
not occur must be regarded as instances of incomplete 
castration. Occasionally, as a result of atrophic changes 
in the vagina, sexual intercourse becomes very painful, 
or even impossible. Clark +t reports such a condition in 
a woman who was previously neurotic. The dyspareunia 
resulted in abandonment of the woman by her husband. 
In young animals the uterus does not develop after cas- 
tration, This is probably a result of the absence of reflex 
hyperzemia from the ovaries. 

There is a tendency of the breasts to take part in the 

* Op. cit. 


+ Op. cit. + Op. cit. 











general atrophy. Mistakes may arise, however, as a 
result of a general increase of subcutaneous fat. 

General Hifects.—At the time of the natural menopause 
the female organization undergoes considerable changes. 
There is an alteration of the general form of the body. 
This is, to a certain extent, a result of the general in- 
crease of the adipose tissue. The changes in the face are 
conspicuous. The cheeks and the lower part of the chin 
become broader and more massive. There is an increase 
in the general contour of the body. The trunk and 
especially the hips and gluteal regions become thicker 
and wider. It is largely the distribution of the sub- 
cutaneous adipose tissue which lends to the youthful 
female form its peculiar charm. After the menopause 
the condition is changed. The connective tissue which 
separates and supports the fat lobules becomes loose. 
Asa result the skin and subcutaneous tissue hang more 
loosely. The hair tends to lose its pigment. Chloasmata 
frequently develop in the skin of the face and scattered 
bristle-like hairs often make their appearance. There is 
a general increase of fat in the breasts, in the abdominal 
region, and in the extremities. Many of these changes 
contribute toward bringing about the characteristic ma- 
tronly appearance. 

After castration one might expect similar changes. A 
decided tendency toward greater deposition of fat is 
present. In a few cases this reaches an extraordinary 
degree. It must be remembered however, that the gen- 
eral health of most of the patients before operation is 
very poor. Convalescence, then, may be, to a certain 
extent, responsible for the result in some cases. The dis- 
tribution of fat, however, is somewhat different. Ex- 
cept in the case of the patients who are at the age when 
the organism is preparing itself for the natural climax, 
the matronly appearance does not develop. The dis- 
tribution of the fat is more like that of the youthful 
form. The patients appear brighter and more youthful. 
The complexion is clearer, the pigmentation of the skin 
is less marked and more uniform. The hair does not 
often turn gray early, pre-existing chloasmata often dis- 
appear. 

The breasts are not dependent. The nipple is often 
atrophic, and its areola frequently loses its brownish pig- 
mentation and becomes pink. The growth of hair upon 
the face does not take place. 

As in the natural climacterium these changes require a 
number of years for their accomplishment. 

Effect on the Nervous System and the Psychical Effects. — 
The effects of castration upon the nervous system vary 
greatly incharacter. Flushes in various parts are among 
the most commonsymptoms. Often, however, they have 
been present before operation, suggesting a tendency 
toward hysteria. They are described as sensations of 
heat passing from the pelvis toward the heart and lungs, 
even to the head. With these may be associated palpi- 
tation, dizziness, and tinnitus aurium. 'Theskin becomes 
hyperemic and even while the face, for example, is 
flushed and feels hot, the patients complain of sudden 
chilly sensations, especially in the back, passing up along 
the spine. Sweating occasionally occurs. The flushes 
are most marked shortly after operation, commonly with 
exacerbations corresponding to the menstrual periods. 
Varying much in intensity in the different cases, they 
usually sooner or later disappear. 

Headache is often complained of. Where it has existed 
before operation, the patients frequently assert that the 
intensity is increased. 

Occasionally nausea, vomiting, neuralgia, especially in 
the lumbar plexus, palpitation, sleeplessness, convulsive 
coughing, or chronic hoarseness supervene. 

The nervous symptoms are more pronounced than in 
the normal menopause. This is probably a result of the 
sudden and complete removal of the’ ovarian tissue, in 
place of its gradual exhaustion by normal processes. 
Often the patients have been in poor health, possibly for 
years, before operation, and no doubt the long-continued 
suffering has effected a permanent injury to the nervous 
system. 


715 


Catalepsy. 
Catalepsy. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Especially in the consideration of the psychical effects 


the previous state must be taken into account. Often the 
suffering has been so intense and long continued, and the 
general environment has been so depressing, that the pa- 
tients are eager to submit themselves to a dangerous 
operation that offers any prospect of relief. The im- 
mediate rise in spirits may be simply aresult of convales- 
cence. As a rule the improvement develops only 
gradually as in the natural menopause, which is often 
introduced and accompanied by mental depression. 

A weakening of the memory is frequently complained 
of. This may be simply a momentary forgetfulness of 
immediate occupation or an increase in the difficulty of 
recalling past events and experiences. 

Severe nervous disturbances may result from the re- 
moval of the ovaries even in the forties. 

Insanity does not follow castration any more frequently 
than it does other surgical operations. 

Therapeutic Results.—In most cases the results are 
good, and in a few caseseven ideal. The large majority 
of the patients lead an endurable life after years of suf- 
fering. Most of them are able to work after being in a 
state of partial or complete disability. As a rule they 
are satisfied with the results of the operation and often 
express their gratitude for their restoration. 

The results of course differ with the indications for 
operation. The least complicated results follow in cases 
in which castration has been performed for inoperable 
myomata. Almost without exception atrophy of these 
tumors takes place and they may even entirely disappear. 
Myomata are poorly vascularized and their disappear- 
ance is no doubt due to the decreased blood supply. The 
results are equally beneficial in cases of ovarian or me- 
chanical dysmenorrheea caused by displacements of the 
uterus and atrophy of the vagina. 

Hysteria appears to be practically unaffected, even 
when the organic disease is relieved. The same is true 
of hystero-epilepsy. 

The death rate from the uncomplicated operation is 
practically nil. The pathological conditions which neces- 
sitate castration are so frequently complicated, however, 
that the mortality is raised somewhat. The death rate 
then becomes that of the complication. 

Kelly,* in making aplea for conservatism in gyneco- 
logical operations, speaks of the effect of unilateral 
ovariotomy. He presents an analysis by Dr. J. H. 
Durkee, of 228 cases of unilateral castration, in women 
under 40 years of age, and draws the following conclu- 
sions: “The comparison of the advantage and disad- 
vantage of leaving in an apparently sound ovary is—in 
each case the average chance of having one child as 
contrasted with the risks of a recurrence of the disease 
in 2.6 per cent. of the cases. If the mortality of ovari- 
otomy is 5 per cent. then the risk of death is thirteen to 
one against it even if the disease recur.” 

“Ovulation and pregnancy under suitable conditions, 
are, to a degree unappreciable to the male mind, essential 
elements of woman’s happiness. To dwell upon this 
point would be but to reiterate what any attentive sur- 
geon may gather from his daily experience in the con- 
sulting-room, and to rehearse well-known facts in the 
history of womankind. 

“©. Schroeder stated that one of his reasons for the 
preservation of part of an ovary was to preserve the 
function of ovulation, even tf it were accompanied by but 
a theoretical possibility of conception.” 

After unilateral castration pregnancy may occur if 
only the tube of the opposite side is present. 

As in the case of other bilaterally symmetrical organs, 
the removal of one ovary results, in the rabbit at least, 
in a compensatory hypertrophy of the opposite organ. 

Interesting experiments in ovarian transplantation 
have been reported by a number of investigators. 
Normal pregnancies are said to have followed the opera- 
tion performed on castrated animals. It has not been 
shown whether all of the functions of the ovary are per- 


* Op. cit. 


716 


formed under these abnormal conditions. Schultz * per- 
formed transplantation experiments upon guinea-pigs. 
Corpora lutea were formed in the ovaries under the new 
conditions. He showed that the female organization is 
not necessary for the growth of the ovary, but that 
ovaries transplanted to the male animal will adapt them- 
selves to their new habitat. He found no evidence of 
the formation of corpora lutea, however. 

Many reports of the beneficial results of organotherapy 
after castration have appeared in the literature, but no. 
such brilliant results as in the case of athyria have been 
obtained. Favorable influences upon almost all of the 
unpleasant symptoms have been claimed, but reports 
vary considerably. Ovarian and thyroid extracts have 
been used. 

The beneficial effects of castration in cases of osteo- 
malacia have been referred to above. 

The question has also a sociological aspect. “My own 
continued experience only serves to confirm my opinion 
that the castration of women is often a direct cause of 
domestic unhappiness and that it has been repeatedly 
used by men as a good reason for breaking off engage- 
ments, and for the violation of marriage vows, and the 
abandonment of wife and children.”+ Many of the effects 
upon society in general are readily conceived. 

H. 8S. Steensland. 


CATALEPSY.—The cataleptic state, or one analogous 
to it, has been observed in a number of living beings in 
ascending the’ scale of evolution from the Drochocephale 
Virginiana toman. Owing to the protean forms assumed 
by catalepsy, and the presence of frequent complications, 
not to mention the strange theories advanced by ancient. 
authors, and the comments thereon, it is difficult to define 
the malady with clearness and precision. But among the 
more important writers of the present age, whose ten- 
dency is to substitute the scientific interpretation of mor- 
bid phenomena for the sciolistic rendering of apocryphal 
knowledge, the cataleptic condition is understood to mean 
a remittent neurosis of the cerebro-spinal system, unac- 
companied by fever, and characterized by attacks of vari- 
able duration, during which there is almost always sus- 
pension or perversion of consciousness and of sensibility, 
and always interruption of voluntary motion, with general 
or partial tension of the muscular system, and aptitude 
of animal life to receive and to keep different degrees of 
contraction impressed by extrinsic force or assistance. 

GENERAL CHARACTERS.—Much of the present obscur- 
ity concerning this curious neuro-muscular trouble is 
owing to the theories of a mythical pathology when the 
study of hysteria was but little advanced or the diagnosis 
of the neuroses was vague and only depended upon the 
stigmata described by the school of Salpétriére. Some 
regard catalepsy as a malady, others as a symptom, 
while still others deny its existence outside of alienation. 
Since the time of Galen, who appears to have been the 
first to recognize its coexistence with mental troubles 
(Comm. ii., in Hipp. Preed. edit. Kuhn, t. xvi., pp. 682- 
684), three successive theories relative thereto may be 
noted: 1. A neurosis that may complicate certain mental 
maladies. 2. A simple symptom that may supervene in 
all mental diseases. 3. One of the principal motor troubles 
of tension characteristic of a special disease, as katatonia 
or stuporous melancholia. 

Idiopathic catalepsy, as wonderful as it is rare, is an 
apyretic brain malady manifested by remittent attacks 
separated by intervals of health. Its special physiog- 
nomy is owing to the waxy position and plasticity of the 
limbs, and it is the only neurosis in which muscular con- 
tractions are possessed with abolition of the will. Either 
sex may be attacked, and the disease may occur in child- 
hood or occasionally in advanced age, a case being noted 
in a man of seventy-five years; but women are more sub- 
ject than men, and it occurs mostly about puberty or be- 
tween the twentieth and thirtieth years, generally in per- 


* Schultz, Centralblatt f. allgem. Path. u. path. Anat., xi., 200, 1900. 
+ Kelly, Op. cit. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Catalepsy. 
Catalepsy. 





sons of dull minds and sluggish physical organization. 
Cataleptic paroxysms may be spoken of as atypical. 
The fantastic characters of the cataleptic state render all 
clinical description absolutely obscure; so that the actual 
observance of a single case, or the study of a series of 
well-reported histories, will do more to throw light on 
the question than all the symptomatic enumerations that 
form the basis of these descriptions. 
Symptoms.—Systematic observance of cataleptic symp- 
toms relates chiefly to the three orders of pathological 
phenomena of the mind, sensation, and motion. An at- 
tack coming on in a nervous or melancholic individual 
may be sudden and all the functions of the life of relation 
appear entirely abolished. There is complete suspension 
of mental action, with cutaneous anesthesia, loss of ther- 
mic sensibility, and rigidity and inertness of the limbs, 
which retain the position given to them. This rigidity 
is described by the old Latin authors in such picturesque 
locutions as stipitis or trunct instar, and mortut ritujacens. 
In some cases the attack may have such precursory symp- 
toms as headache, insomnia, vertigo, hiccough, epigastric 
pain, a feeling of constriction in the throat, trembling of 
individual muscles, an undefined sense of discomfort, and 
different hysteriform nervous troubles. When suddenly 
attacked the patient remains motionless in the attitude 
had at the moment when struck. Patients have become 
cataleptic while drinking tea, playing cards, ascending a 
ladder, during attitudes of devotion, and the like, and 
have retained the position held at the time of attack. 
The various positions a cataleptic may be made to as- 
sume have been compared to those of a manikin, toa 
statue with springs or with limbs of soft wax, which 
preserve any constrained position or inflexion given to 
them for a comparatively long period. The muscles of 
the breast and the inspiratory muscles are unaffected 
during a cataleptic seizure; and it is probable that the 
digestive functions go on regularly, although the phe- 
nomena of absorption and nutrition operate with extreme 
slowness. The secretions and excretions are lessened, 
and even suspended, cataleptics having been known to 
go for twenty-five days without a voluntary evacuation 
and to undergo long abstinences, leaving them in the 
condition of hibernating animals. Consciousness, though 
mostly abolished, is not so in all cases, the suspension of 
sensorial function being more apparent than real. With 
the general disturbance of the vital processes there is al- 
most entire abolition of the functions of special sense. 
The mucous membrane of the nose, however, retains its 
sensitiveness slightly, and the act of swallowing may be 
performed when the substance to be ingested is placed 
deeply in the pharynx. Reflex irritability is sometimes 
lost, but the electric contractility of the muscles remains. 
Respiration is slow and tranquil; the pulse normal in 
rhythm, though sluggish and at times almost impercepti- 
ble. The pupils are dilated, and the fundus of the eye 
shows paleness of the choroids, with straight and attenu- 
ated retinal vessels. The temperature being lowered two 
to four degrees below the normal, the patient becomes 
icy cold, deadly pale, and expressionless—a condition 
that may easily be mistaken for death. In fact the an- 
nals of medicine record illustrative cases of apparent 
death from this cause, in which the victim has narrowly 
escaped burial alive. The old schoolman, Duns Scotus, 
is an instance of a resuscitated cataleptic. A case often 
quoted is that of a woman who was placed in a family 
vault, presumably dead, and having regained conscious- 
ness during the night, and fortunately finding the vault 
unlocked, returned home to her husband, and after this 
strange episode lived to bear a large family of sons and 
daughters. The event is commemorated by a monument 
and an inscription in the Lutheran cathedral at Magde- 
burg; and it is suggested that the possibility of such oc- 
currences may account for the custom that obtains in 
some parts of Germany of placing a bell above the public 
receptacles for the dead, and fastening the hand of the 
ostensible corpse to the rope, that it may be rung in the 
event of consciousness being regained. An instance is 
related in France of a cataleptic who was on two occa- 





sions the chance victim of hastily rendered funeral honors. 
Now and then one reads in newspapers of women being 
taken away for burial while in a cataleptic trance, and 
only recovering consciousness when being lowered into 
the grave. A woman in a trance having been buried 
alive in Naples, the court sentenced both the doctor who 
signed the certificate and the mayor who authorized the 
interment to three months’ imprisonment for “involun- 
tary manslaughter.” Such mistakes could hardly hap- 
pen nowadays, provided ordinary precautionary measures 
are taken to discriminate real from apparent death, such 
as the auscultatory signs, the indications furnished by 
the thermometer, the electric contractility of the muscles, 
and the ligature of a finger or a toe. 

The attack over, the patient suddenly regains con- 
sciousness, sometimes after epistaxis or the appearance 
of the menses, and there is usually no recollection of what 
has happened during the attack. Headache and general 
lassitude generally follow for a short time. The attack 
may disappear and be transferred into another neurosis 
or into a vesania. There is great variability in the num- 
ber and duration of the attacks, which may last for min- 
utes or hours, or entire months. The malady has been 
known to disappear after one attack; while in another 
patient as many as seven hundred paroxysms have been 
counted. The attacks may, moreover, be very irregular 
in manner, or they may be periodic, and even occur during 
sleep. There is no mental disorder in the intervals of 
simple catalepsy; but when the catalepsy is a symptom 
of profound nervous disease it may be associated with 
ecstasy and somnambulism, or the occurrence of hysteri- 
cal convulsions, delirium, maniacal attacks, and halluci- 
nations. For this reason it is generally held that catalep- 
tics are responsible for their acts during intervals, except 
when there is a complication. 

The condition represented by the picture outlined in 
the foregoing remarks is often modified or softened down 
into the incomplete form, which, though not having all 
the symptoms of what may be called ideal catalepsy, ex- 
hibits nevertheless, in a different degree, the motor and 
sensory disorders, and electrical reactions characteristic 
of the disease in question. 

CoMPLICATIONS.—Catalepsy may be associated with 
another nervous affection, such as hysteria, ecstasy, som- 
nambulism, tetanus, mania, hypochondria, and _ lype- 
mania; or with a disorder of an entirely different nature, 
aS pneumonia, typhoid fever, meningitis, rheumatism, 
intermittent fever, etc. It is complicated and mixed in 
hystero-catalepsy. Without doubt hysteria developed in- 
dependently of mental alienation is the neurosis with 
which catalepsy affects the most frequent relations and 
narrowest affinities. As one and the same morbid state 
they proceed from a common origin, and doubtless are 
closely related. Muscular rigidity in this form varies as 
to the degree, not being in positive relation with cutane- 
ous anesthesia, but almost always proportional to the 
depth of lethargy and to the volume of the muscles con- 
cerned in the movements of the articulations. Persist- 
ence of muscular tension, with absence of sensibility and 
fatigue, are spoken of in connection with this state asa 
new variety of perturbation of voluntary motility. Sys- 
tematic writers describe hystero-catalepsy as general or 
partial, complete or incomplete, and transitory or per- 
manent. In rare cases it is unilateral. 

Kestatic catalepsy has been often observed in ecstatic 
women and in priests. The records of sorcery and demo- 
nography abound in instances, historic and modern, of 
women becoming cataleptic during certain religious ob- 
servances, of priests who become so at certain stages of 
the mass, and of monks who throw themselves into pro- 
longed cataleptic ecstasies. No less a writer than Balzac 
speaks of profound meditation and fine ecstasy as cata- 
lepsy in the bud. Doubtless many ofthe queer sects 
mentioned by Dr. Hepworth Dixon, in “ New America,” 
are made up of individuals whose mental condition is 
more or less influenced by this disordered state. Anthro- 
pologically and pathologically speaking, the same remark 
would apply to various so-called religious ceremonies that 


717 


Catalepsy. 
Cataract, 





have obtained among all races in the times of all the 
prophets, from Moses to the Latter-Day Saints of Salt 
Lake City, and in the worship of all the gods from Jupi- 
ter to the latest theosophic misconception; and however 
much we may respect the courage implied in the expres- 
sion of a sincere opinion, it is impossible not to detect 
the further existence of this disordered state as shown in 
numerous sciolistic writings, notably those of Dale Owen, 
Swedenborg, and the theosophists. Moreover, it needs 
but little observation to trace the prevalence of the same 
morbid influence among clairvoyants, spiritualists, and 
even the ardent admirers of Madame Blavatsky. 

Catalepsy with somnambulism is a complication in which 
the phenomena of catalepsy and the symptom of som- 
nambulism are bound one to the other, and succeed in a 
regular order in such a manner as to forma single attack. 
They are sometimes distinct, independent of each other, 
and separated often by long intervals. 

The disease may occur with other accessories, as cata- 
lepsy with tetanus, catalepsy with epilepsy, and with 
chorea, the chorea happening in the daytime and the cata- 
lepsy at night during sleep. Catalepsy may also exist 
with permanent contraction of the feet and hands; with 
delirium and melancholy, with acute and chronic mania, 
and with dementia and idiotism. It isa frequent com- 
plication of paranoia, and is sometimes, though rarely, 
associated with hypochondria. We may occasionally see 
in the subject hysteria, catalepsy, ecstasy, and somnam- 
bulism succeed, turn by turn, and mix one with the 
other, with a frequency entirely out of the regular order 
of things and an intensity unheard of. This extraordi- 
nary mixture of cerebral neuroses was met with in its 
highest degree in the great convulsive epidemics of the 
Middle A ges, during the sixteenth, seventeenth, and eigh- 
teenth centuries; and their occurrence having become a 
matter of history and common hackneyed observation 
with writers on kindred subjects, it suffices to give them 
merely a passing mention. Catalepsy is met with in 
acute dementia, stupidity, and other non-determined cere- 
bral affections. The cataleptic states may still be mani- 
fested in the greater part of the neuroses, and in diverse 
affections of the brain, and with such acute diseases as 
pneumonia, typhoid fever, acute articular rheumatism, 
intermittent fever, and worms. Verminous catalepsy 
has been noted and commented upon by various writers. 

Epidemic catalepsy, like many of the neuroses, may 
become contagious by imitation under mesological cir- 
cumstances favorable to its propagation. Such circum- 
stances exist when the disease occurs in an assemblage 
of impressionable subjects, as a school or a convent, a 
camp-meeting, or a spiritualistic gathering, where a two- 
fold predisposition is to be found in the nervous temper- 
ament and in certain questionable hygienic and moral 
conditions. In former epidemics, the disease seen in its 
most startling and complete expression exhibited a ter- 
rible spectacle and mixture of all the neuroses and all the 
vesanias. It was common for celibate and ascetic per- 
sons to show the strangest nervous symptoms; to fall 
cataleptic at mass or during other religious observances, 
and to exhibit the complex symptoms of hysteria, demo- 
nopathy, and catalepsy. 

Catalepsy and cataleptoid phenomena may be provoked 
artificially in hysterical or other predisposed, impres- 
sionable and nervous persons, through mental sugges- 
tion, or by intense light, the sonorous vibrations of a 
tuning-fork, and by pressure on the ovaries. These arti- 
ficially induced conditions have been studied by various 
persons, who think the condition should properly be 
called syggignostic. 

PaTHoLoGicAL ANATOMY.—The physiological cause of 
this and of allied conditions is presumed to be inhibitory 
arrest of activity of certain tracts of the ganglion cells of 
the brain cortex. It is, however, impossible to say in 
the present state of scientific observation whether inhibi- 
tory lesions exist or not in catalepsy; but it is probable 
that there is, in addition to muscular inhibition, a morbid 
element, the essential nature of which is unknown. 
Such superficial alterations as considerable development 


718 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of the Pacchionian bodies and injection of the meninges 
found after death from catalepsy are insufficient to ex- 
plain the symptoms during life; and the inflammatory 
exudation or alterations found in the central organs, with 
softening of the optic thalamus and corpus striatum, are: 
lesions rather to be associated with other diseases than 
with catalepsy, since they were present as complications 
in the observed cases; therefore, until something more 
complete is known of the morbid anatomy of catalepsy, 
it must be regarded asa violent excitement, a sort of ten- 
sion, a cerebral cramp, the result of a purely dynamic 
lesion of the cerebro-spinal nerve centres whose function 
is to preside at the determination and co-ordination of 
movement. 

CausaTion.—If the pathological nature of catalepsy is 
obscure and unknown, its causes are extremely numerous, 
and present a particular interest. Nervous exhaustion 
is the most common predisponent, and of all the etiolog- 
ical moments hysteria is the most prominent. Catalepsy 
and insanity usually march together. Many authorities 
declare that no catalepsy can exist unless accompanied or 
followed by a psychosis. Acquired or innate predisposi- 
tions are found in persons of great nervous susceptibility 
and unsteadiness, or in those of a nervous and melan- 
cholic temperament with a previous neurosis, and ren- 
dered more susceptible by chlorosis, masturbation, or 
progressive spinal paralysis. Tumors, tuberculous men- 
ingitis, and other chronic cerebral diseases, may also give 
rise to cataleptic manifestations. Atavistic influences 
seem to account for some cases of catalepsy. It does not 
appear that the disease is ever directly transmitted, al- 
though heredity. as a general cause seems to preside 
over its development in many observed cases. 

The causes that may provoke a cataleptic crisis are 
numerous and varied, and it often follows diverse cir- 
cumstances, as excess of work, religious excitement, vio- 
lent fright, deep chagrin, an attack of anger or indigna- 
tion, gastro-intestinal irritation, sudden cessation of the 
menses, unrequited love, and worms. It may result in 
a transitory form from diffused encephalitis, or as one of 
the sequels of typhus or malarial fever, of acute articular 
rheumatism, ursemia, the puerperal state, auto-intoxica- 
tion, and pneumonia. Partial catalepsy may also be in 
consequence of the narcotic inhalation of ether or chloro- 
form, of poisoning by lead or carbon dioxide, hashish, 
or alcohol, and it may result from being struck by light- 
ning. In fact, any toxic substance or any concomitant 
psychosis may put into activity the cataleptic state. 
The production of crises, by looking fixedly or for some 
time at a bright object, and vividly riveting the mind on 
the image is one of the proceedings of Braidism or Mes- 
merism. Among the hack observations of medical writers 
are those relating to the Franciscan friars, who became 
cataleptic at mass during the elevation of the host. It 
is known that the monks of Mount Athos go into a state 
of cataleptic ecstasy by looking fixedly at the umbilicus; 
Indian fakirs fall into catalepsy by looking a quarter of 
an hour at the end of their nose; Egyptian sorcerers pro- 
cure sleep and insensibility by similar details; Arab sor- 
cerers of Cairo, by looking steadfastly into the palm of 
the hand; and it is related of Cagliostro that he brought 
on somnambulic crises by similar means. Instances of 
psychic shock, like that of a woman who became cata- 
leptic every time she saw a certain man who had insulted 
her, or that of an indignant French judge, who suddenly 
became cataleptic when insulted in court, incline one to 
the opinion that such expressions as “ petrified with in- 
dignation,” “motionless with surprise,” and the like, 
though merely implied comparisons, are not always to 
be taken in the metaphorical sense. 

DraGcnosis.—The marks that constitute the essential 
and pathognomonic character of catalepsy, as complete 
or partial aptitude of the limbs to preserve during a rela- 
tively long time the position given to them, and the im- 
possibility of the patient to modify this attitude, along 
with unconsciousness, anesthesia, and analgesia, should 
make the matter of diagnosis easy. Embarrassment is 
most likely to occur in cases of simulation, or when it is. 


“REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Catalepsy. 
Cataract, 





a question of discriminating between hysteria, tetanus, 
ecstasy, coma, lethargy, syncope, congelation, and cadav- 
eric rigidity. In the matter of simulation it is only nec- 
essary to test the sensibility, the reflex irritability, and 
the electrical contractility of the muscles, and to try the 
influence of mental suggestion. In cases associated with 
hysteria the distinction is a matter of no therapeutic im- 
portance. It may be well to question whether the con- 
dition is from acerebral lesion or of toxic cause. The 
neuro-muscular system of animal life being alone affected 
during an attack, that of vegetative life is without loss, 
as isshown by the persistence of circulation and respira- 
tion, which distinguishes catalepsy from syncope or as- 
phyxia. The general history of the case should cause 
no confusion in diagnosticating catalepsy from the affec- 
tions with which it may be associated. 
PRoenosis.—Many regard catalepsy as the index of a 
predisposition carried to a high degree and by itself not 
dangerous to life, but a disease in which recoveries are 
rare. Some recent authorities think otherwise in regard 
to the prognosis, and Hammond pronounces it favorable 
even in severe cases, as all his patients recovered under 
treatment. In cases resulting from malarial infection the 
prognosis is better. The same may be said of acute at- 
tacks resulting from injury, from worms, or from mental 
shock in comparatively healthy persons. The retention 
of smell and taste is indicative of returning health. Cases 
complicated with hysteria or the psychoses are most grave. 
Death may be in consequence of anzmia or of inanition. 
TREATMENT.—To arrest an attack of catalepsy efforts 
may be made to arouse the patient by peripheral irrita- 
tion, as that caused by a pinch of snuff or the inhalation 
of a few drops of amyl nitrite. Quinine and morphine 
in combination are recommended in periodic cases of 
malarial origin, and vermicidal remedies are called for in 
catalepsy caused by intestinal parasites. Tonics, iron, 
ergot, and apomorphine hy podermically—gr. 34—have all 
been recommended. The most efficacious medical treat- 
ment yet reported consists in the administration of one 
of the bromides in combination with zinc oxide, and the 
simultaneous use of strychnine and other tonics. Acu- 
puncture, faradic electricity, hydro-therapeutics, and 
change of air are useful adjuncts to the treatment. In 
addition to meeting symptomatic indications, moral hy- 
giene of the most rigid kind should be enforced, and it is 
of prime importance that all emotional or religious excite- 
ment beavoided. The mind should be disciplined; home 
influences are to be broken up; and every effort should 
be made to establish the general conditions of health, 
which must prevail before the morbid action can really 
be effaced. Irving C. Rosse. 


CATALPA. See Poisonous Plants. 


CATAPHORESIS.—If two fluids of different density 
are separated by a membrane, the fluids diffuse through 
such membrane until they are of equal density. This 
process has been called osmosis. If the two electrodes of 
a galvanic battery are placed in two compartments of a 
fiuid separated from each other by a porous septum, the 
fluid particles pass in the direction from the positive pole 
to the negative pole, so that the fluid in the one vessel 
increases, while it decreases in the other. The amount of 
fluid thus conveyed ina unit of time is larger the stronger 
the current and the smaller the conducting power of the 
fluid. This phenomenon has received many names, 
among which electrical osmosis, electrical diffusion, and 
cataphoresis are the best known, but the last one bids fair 
to remain in general favor. Cataphoresis, as Billings 
tersely puts it, is the power of the galvanic current to 
induce osmosis from the positive to the negative pole. 

Cataphoresis, which, scientifically speaking, means 
merely the action of the galvanic current, has in medical 
language acquired the meaning of introducing medical 
substances into the body through the unbroken skin, and 
is now almost exclusively used in this sense. If a defi- 
nite quantity of medicine in solution is placed on a disc 
or sponge electrode at the positive pole of a battery, and 





applied to a certain spot of the body, while the negative 
pole is placed anywhere in contact with the body, a local 
anesthesia is produced around the positive pole if the 
substance experimented with is cocaine, while the en- 
trance of quinine, strychnine, and many other drugs into 
the body by this method can be demonstrated by their 
presence in the urine or the saliva. Mention of attempts 
made in this direction date back as far as 1747, but not 
until 1853 do we find scientific demonstrations of the fact. 
From that date until to-day the matter has been investi- 
gated by physicists, physiologists, and physicians, in 
both Europe and America. Electrodes have been in- 
vented suitable to the different purposes of administering 
the drugs, but while cataphoresis is beautifully simple in 
theory and to the physicist, its practical application to 
every-day medicine is almost exclusively confined to mem- 
bers of the dental profession, who use it most successfully 
to anesthetize sensitive dentine and gums with cocaine, 
and for the bleaching of teeth. 

In medical practice cataphoresis has found but scant 
favor. Neurologists have produced deep local anes- 
thesia with cocaine cataphoresis where before large 
doses of morphine were needed to produce the same 
effect. The substitution of the former drug for the 
latter has been advocated enthusiastically in cases in which 
a possible morphine habit loomed up threateningly; but 
whether a cocaine habit is preferable to a morpbine habit 
is a subject open for discussion. The discovery of co- 
caine and the ease with which local anesthesia can be 
produced by its hypodermic use have undoubtedly re- 
duced the importance of further investigations of cata- 
phoresis for such purposes, and to the busy general prac- 
titioner the subject remains more or less a medical 
curiosity. 

How far the action of the cataphoric current in itself 
can induce or produce nutritive changes in the living 
cells is a question which opens an unlimited field for re- 
search. The so-called Porret’s phenomenon shows that 
its action on living protoplasm closely resembles that on 
fluids outside of the body, for if applied to muscular 
fibres the current induces a streaming movement from 
the positive to the negative pole in they protoplasmic con- 
tents of the fibres, so ‘that they swell at the negative and 
decrease in sizeat the positive pole; and if the electrodes 
are changed, the action is reversed. Only a very arbi- 
trary opinion may be ventured in deciding whether such 
compulsory rearrangement of the protoplasm can be 
looked upon as beneficial or harmful, and until we have 
more definite knowledge of the subject, the application 
of the cataphoric current as a mere stimulus to any part 
of the human body, aside from its electrolytic action, 
must remain, from a scientific standpoint, mere guess- 
work. Whatever beneficial results are reported must be 
accepted as due to chance, or perhaps to the imagination 
of the patient. It is, however, safe to predict that when 
medicine becomes a science, and we know the specific 
medication necessary to stimulate or rebuild certain defi- 
nite organs or parts of organs, cataphoresis will receive 
its due share of attention and assume its proper place. 
Attempts to force iodine into goitres and lithium salts into 
gouty joints are crude experiments in the right direction. 
While we know that such medicine can be forced into a 
definite part by cataphoresis, we must wait until further 
investigations demonstrate that the cells of that part will 
and do assimilate the medicines driven into their sub- 
stance; for unless such assimilation and subsequent excre- 
tion do take place, which change the worn-out or dis- 
eased cells into healthy ones, the medical substances 
introduced will act as foreign bodies and produce irri- 
tation instead of improvement. Julius Pohiman. 


BIBLIOGRAPHY. 


Landois: Text-Book of Physiology. 
W. J. Morton: Cataphoresis, 1898. 


CATARACT is the morbid impairment of the trans- 


parency of the crystalline lens, or of its enclosing cap- 
sule, and is lenticular or capsular, according to its situa- 


719 


Cataract, 
Cataract, 


tion. A less important division is that into true and false 
cataract, the latter being caused by deposits on the cap- 
sule, the result of disease. 

Cataract may be stationary or progressive, partial or 
total. It may be cortical or nuclear, according as it 
affects the cortical substance or the nucleus of the lens. 
When confined to the vicinity of either pole it is denom- 
inated anterior polar or posterior polar, in conformity 
with its position. The old division into hard and soft is 
rarely used at the present day, the consistence of the cat- 
aract largely depending on the age of the individual. 
Cataracts are moreover divided, according to the stage of 
development in which they are encountered, into incipi- 
ent, mature, and hypermature. Finally, they may be 
classed as simple or complicated; as simple when depend- 
ent on or associated with no known disease, either local 
or general; as complicated when proceeding from an 
affection of the system at large, such as diabetes; or, 
from an impairment of the eye itself, like glaucoma or 
separation of the retina. 

DrIAGnosis.— Objective Symptoms.—The modern methods 
of investigation render the diagnosis of cataract a matter 
of certainty. By their aid the slightest opacity of the 
crystalline lens can be detected and correctly located, and 
they have wholly superseded the old “catoptric test,” 
which depended on the reflected images from the anterior 
and posterior capsules, and the disappearance of the lat- 
ter when an opaque substance intervened before it. Re- 
course is now had to the concentration of light on the eye 
by means of a convex lens, and to the illumination of its 
interior by means of the ophthalmoscopic mirror. In 
either case the pupil should ordinarily be dilated by the 
application of one of the usual mydriatics, duboisine, 
homatropine, or atropine. The first of these acts with 
the most rapidity, the second produces the most tempo- 
rary effect, while the third is the one most generally ac- 
cessible. Previous to using the mydriatic the tension of 
the eye should be carefully noted. Should it be found 
to be excessive, no attempt to dilate the pupil is admis- 
sible. 

The pupil being dilated, and the rays of a lamp, placed 
30 to 50 cm. from the patient’s head, concentrated oblique- 
ly on the crystalline by means of a convex lens of short 
focus, 18 D. to 15 D. (2 to 24 in. focal length), any cap- 
sular and many lenticular opacities are rendered plainly 
visible. A second lens, held before the observed eye, 
may be used to magnify their distinctness. But it is nec- 
essary to bear in mind that, with advancing years, the 
outlines of even a normal crystalline lens assume increased 
distinctness. Its anterior surface takes on a silky lustre, 
the fibrous structure becomes more and more visible, 
while age gives the nucleus additional density and a yel- 
lowish reflex that may often prove deceptive. No abso- 
lute diagnosis of cataract must be based on the appear- 
ance of a grayish cloudiness in the centre of the pupil 
until the ophthalmoscope has been brought to bear on 
the spot. In this method of examination the mirror is 
alone used, being held at about the reading distance of 
the observer from the patient’s eye. The vivid red of 
the illuminated pupil remains unbroken when the media 
are clear, and the returning light traverses a transparent 
crystalline. When, however, this is not the case, the 
smallest opacities are distinctly seen as dots, shadows, 
or stripes against the bright background. Their precise 
situation is made out when the observer moves his own 
head to one side, opacities situated in the front of the 
lens moving in the same, those at its back in a reverse 
direction. The differential diagnosis between lenticular 
and other opacities of the transparent media is easily 
made, corneal spots being distinguished by oblique iJlu- 
mination, floating bodies in the vitreous by their mobility. 

So great is the danger of mistaking the reflex from the 
pupil, due to advancing age, for cataract, when the ex- 
amination is made by day and with the unassisted eye, 
that a diagnosis should rarely be made until both meth- 
ods here described have been employed. 

Subjective -Symptoms.—When an individual who has 
passed middle life begins suddenly to grow near-sighted, 


720 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


to see distant objects better through a concave glass, and 
to lay aside his usual reading-glasses, or even to require 
a weak concave for this purpose, commencing cataract 
may be suspected, and this even when no opacity of the 
crystalline is as yet visible. This state of the refraction 
is by no means invariable, but happens with tolerable 
frequency, and explains some of the cases of “second 
sight,” or the returning vision of the aged, a popular be- 
lief in which is so widely spread. Much more general is 
the occurrence of multiple vision with a single eye. The 
patient sees several new moons in the sky instead of one, 
and the flames of the street lamps are no longer clearly 
defined, but seem to shoot out long rays in all directions, 
or else several lights are seen in the place of one. The 
lens, in these cases, seems to undergo a separation into 
sectors, possessing different powers of refraction, prior to 
becoming the seat of actual cataract. As the disease ad- 
vances the acuteness of vision fallsoff. At first near, and 
later distant, objects are distinguished with increasing 
difficulty. Points of light loom up as if seen through a 
fog. A characteristic symptom is the change produced 
in the appearance of objects by varying degrees of illu- 
mination. In the majority of cases the cataract patient 
sees best before sunrise, after sunset, when the sky is 
overcast, or ona dull day. He is confused and blinded 
by a sudden increase in the amount of light around him, 
such as would be caused by the sun emerging from be- 
hind a cloud. The use of a mydriatic renders him to 
some extent again independent, and atropine may thus 
often be employed with advantage to eke out and pro- 
long vision that is being reduced from this cause, and 
where the opacity of the lens will be found to be mainly 
central. In the rarer cases, in which obscuration com- 
mences at the periphery, enlargement of the pupil ex- 
poses the imperfect portions of the crystalline and causes 
a disturbance of sight. Such patients see best through 
a contracted pupil, and instinctively crave an excess of 
light. 

DiaGnosis oF Maturitry.—As the success of the oper- 
ation for cataract is always greatest in cases in which the 
disease is fully formed, the question of ripeness becomes 
an important one, and may easily be settled. Oblique 
illumination should show the lens to be opaque up to its 
front. No layer of transparent substance is to intervene 
immediately behind the pupil. When the cataract is 
mature the iris is seen to be in direct contact with the 
opaque lens, and the edge of the pupil throws no shadow 
when the source of illumination is moved a little more to 
one side. In addition to all this, however, it isimportant 
to ascertain that each anterior chamber is of equal depth, 
that the iris of the eye affected with cataract is not bulged 
forward beyond the plane occupied by its fellow. For 
such bulging indicates the lens to be in what is called the 
“period of swelling.” Just before the opacity of the cor- 
tical substance becomes entire, its fibres often appear to 
swell and separate, the lens grows apparently larger and 
presses forward, frequently restricting the motions of the 
pupil. In time this process recedes, the lens loses in 
volume, and its mass becomes more compact, thus offer- 
ing a more favorable opportunity for the operation of 
extraction. The period of swelling should therefore or- 
dinarily be allowed to subside. 

FUNCTIONAL EXAMINATION.—It is hardly necessary to 
dwell on the fallacy of the popular notion that, in a case 
of cataract, blindness must occur before the operation be- 
comes admissible. Many a patient, misled by this belief, 
has waited until the last perception of light had died 
away, and then presented himself to tbe surgeon for 
treatment, to be met with the announcement that the dis- 
ease was not a cataract, and that treatment had only been 
possible while some vision remained. An opaque lens 
merely interposes a screen, more or less translucent, to 
the passage of light, an appreciable amount of which still 
filters through. Where no perception of light remains, 
therefore, no restoration of sight is possible. The patient 
must be able to make out not only the presence, but the 
position, of a luminous object. Having ascertained, by 
covering the other eye, that the one affected hasa general 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


perception of light, that the pupil expands and contracts 
in accordance with the degree of illumination, and that 
the position of a window can be pointed out, it is well to 
test more carefully the sensitiveness of both the central 
and the lateral portions of the retina. The patient is 


taken into a dark room, the good eye carefully covered,. 


and the gaze of the other fixed ina givendirection. This 
may be brought about by desiring the patient to hold up 
one of his own hands, at arm’s length, on a level with 
his eyeand straight before him, and directing him to look 
persistently toward the spot where he knows this hand 
to be. <A lighted candle is first held as close as possible 
to the hand he is fixing, and then moved in the same 
plane up, down, and to either side successively; the pa- 
tient being required to indicate each new position of the 
candle, without removing his eye from the direction of 
his own hand. If he sees the light each time its position 
is changed, it is certain that the whole extent of the 
retina retains its normal sensitiveness; if he fails to ob- 
serve it in one direction, the powers of the retina are cor- 
respondingly impaired. When the light, on being moved 
upward, can no longer be located, the lower portion of 
the retina is destitute of perception,.and it must be borne 
in mind that here is the usual position of a retinal separa- 
tion. When he sees the light laterally, but not straight 
before him, the region of the macula lutea is generally 
diseased, and the power of reading is unlikely to be re- 
gained, even after a successful operation. 

CAUSATION OF CATARACT.—Our knowledge on this 
point is extremely limited. Becker’s! researches go to 
show that senile cataract originates in an interruption of 
the progressive sclerosis of the lens. Attacked with this 
disease it shows in the outset a decided contraction of 
volume. The cortical substance is thus, as it were, split 
up. The intervals thus left are at first filled with the 
normal fluid, the index of refraction of which subse- 
quently changes, thus making the divisions more plainly 
visible by transmitted light. Actual opacity now begins 
to occur, the fluid constituents of the lens increase, and 
its volume augments. The microscope shows changes in 
the fluid, molecular opacity, and swelling in the fibres; 
the places of which latter in the cortical are subsequently 
occupied by the products of degeneration.* 

But all this brings us no nearer the cause of cataract. 
It is broadly stated that it is due toan impaired nutrition 
of the lens. This merely gives the difficulty another 
name. How is this nutrition effected? The crystalline 
body possesses neither nerves nor vessels, is suspended 
between two fluids, the aqueous humor on one side and 
the vitreous on the other, each similarly devoid of vessels, 
and probably in some way receives its nourishment 
through them. That substances introduced into tbe gen- 
eral circulation may ultimately be detected in the lens 
has been shown by experiment, although a considerable 
interval must elapse before their arrival occurs. They 
are supplied to the aqueous and vitreous by the vessels 
of the surrounding parts, and through them to the lens 
itself. Impaired nutrition of these two humors may 
therefore indirectly be the cause of cataract. 

It is certain, on the one hand, that there must be some 
predisposition in the system at large, as senile cataract 
almost invariably attacks both eyes, although at different. 
periods. It is equally certain that there must exist some 
local, modifying factor, inasmuch as the most diseased 
eye is always first attacked. This statement is based on 
the well-known fact that the prognosis in the second eye 
is usually better than that in the first. 

VARIETIES OF CATARACT. — Congenital.— These are 
either partial or total, more generally the former, occur- 
ring in the shape of sharply defined opacities. It may 
in general be said of cataracts of this class that they are 
the result of defective formation, and are accompanied 
by a certain amount of amblyopia or imperfect percep- 
tion; which not only persists after the mechanical ob- 
struction to the entrance of Jight is removed, but is apt 
to increase with advancing years, if the eye be left alone, 
thus rendering advisable the early performance of the 
operation. Very different in this respect is senile cata- 


Vou. Il.—46 


Cataract, 
Cataract, 


ract, which may last without impairing the functions of 
the retina behind it. 

1. Zonular Cataract.—This may be either congenital or 
met with in the earliest years of life, and is, according to 
Graefe, the most frequent of all the forms occurring in 
childhood. A central zone or shell of the crystalline is 
affected, circular in shape, surrounding and surrounded 
by entirely transparent lens substance. Seen from the 
front, by oblique light, or through the ophthalmoscopic 
mirror, it appears like an opaque or partially opaque 
nucleus to an otherwise transparent lens; and closer ex- 
amination reveals its own centre to be transparent. Its 
diameter ordinarily varies between 5and 8mm. Some- 
times this layer is surrounded externally by a second, 
equally opaque; sometimes, instead of a complete layer, 
groups of opaque points or strix are irregularly distrib- 
uted, with large intervals of clear lens periphery between 
them. In many cases the whole volume of the lens has 
suffered diminution. Zonular cataract is invariably met 
with in both eyes. It is frequently found that the chil- 
dren in whom it occurs have been the subjects of convul- 
sions. They are, also, sometimes the victims of rachitis. 
This disease of the lens, when congenital, generally occu- 
pies a lesser area at birth than subsequently, and is hence 
often overlooked in very early life. Its subjects may be 
recognized by the way in which they shade their eyes to 
get the advantage of a dilated pupil, going into dark cor- 
ners to thread a needle or perform some task requiring 
more than usual eyesight. In this connection it is desir- 
able to refer to the proper treatment of zonular cataract. 
Its object being the admission of more light to the eye, 
two methods at once suggest themselves, the one being 
the formation of an artificial pupil opposite a clear space 
in the lens periphery, the other the removal of the lens 
itself, by discission in the young, by extraction in the 
case of one advanced in years. Each of these methods 
has its advantages and disadvantages. A successful iri- 
dectomy relieves the patient from the necessity of the 
life-long use of heavy lenses for all purposes, but is of 
no value if the cataract subsequently becomes total, as is 
sometimes the case. A full dilatation of the pupil is 
therefore to be brought about and the effect on vision 
noted. If much improvement follows iridectomy is in- 
dicated, particularly if the cataract has the appearance of 
being non-progressive and if the history of the case 
shows that vision has not materially changed for some 
time. But if vision does not improve under mydriasis, 
or if there is a history of diminishing vision, the lens 
should be removed. 

2. Punctated Cataract consists ina large number of ex- 
tremely small points of opacity, scattered throughout 
the lens. At the anterior and posterior poles they are 
often grouped into a triangular figure composed of short 
lines, meeting at an angle of 120°. The figure at the 
anterior pole has not the same direction as that at the 
posterior. Under strong illumination the opacity takes 
on a bluish tint. Examined under a high magnifying 
power, these opaque points present the appearance of 
small round or oval drops. Their form and position en- 
courage the belief that they are situated, not in the lens 
fibres, but in the interfibrillar substance. According to 
Liebreich,? from whom the above account is borrowed, 
this form of cataract is frequently, perhaps, indeed, gen- 
erally, overlooked. 

3. Anterior Polar Cataract.—A small, round, brilliant, 
white point, sometimes attaining a diameter of 2 to 2.5 
mm., may occupy the centre of the anterior pole of the 
lens. At times it projects forward into the anterior 
chamber, and is then known as pyramidal cataract. 
Often there is a faint central corneal opacity in these 
cases, and then, according to Arlt, the rationale of the 
formation of this kind of opacity becomes evident. An 
intra-uterine central ulcer of the cornea is followed by 
perforation, the aqueous escapes, the lens comes forward 
into contact with the cornea, and a portion of the exuda- 
tion, caused by the ulcer, adheres to the anterior capsule. 
When the ulcer heals and the anterior chamber is re- 
established, the lens recedes to its original position, car- 


721 


Cataract, 
Cataract, 





rying with it the acquired opacity. It is contended by 
some observers that simple corneal inflammation, unat- 
tended by perforation, may also act as a cause. 

4, Posterior Polar Cataract.—This is a stationary opac- 
ity, rarely as small as the smallest examples of the kind 
just described, situated at the posterior pole of the lens. 
Its outline may be round and defined; or it may send out 
strie of opacity in different directions. It will generally 
be found to be associated with a persisting hyaloid artery. 

5. Total Congenital Cataract.—This may differ in no 
respect from the soft cataract of the young, which is 
next to be described. But it is more frequently liquid, 
or else shrunken, and is very apt to be adherent to the 
iris. The capsule in such cases may be abnormally thick- 
ened. These cataracts are always double, and very fre- 
quently hereditary. 

Soft Cataract of the Young.—The nucleus of the lens is 
rarely defined before the thirtieth year. Between thirty 
and forty there is, in the majority of cases, a small nu- 
cleus. After forty it is seldom absent. Cataract occur- 
ring in a lens devoid of nucleus is always soft. It com- 
mences sometimes in the shape of a general grayish 
opacity, at other times in the form of points or long striz, 
in the external cortical layers, and advances with com- 
parative rapidity until the whole lens becomes clouded. 
It is in this form of cataract that the swelling of the crys- 
talline, already alluded to, is most marked; the iris during 
this stage being thrown well in advance of its normal 
plane, and the movements of the pupil becoming re- 
stricted in comparison with those of the other eye. An 
operation at this time is apt to be followed by iritis, and 
should hence be avoided. Entire liquefaction may sub- 
sequently take place, the whole of the lens taking on the 
color of milk, or of milk mixed with water. As has been 
said, soft cataract may develop very rapidly. It may, 
moreover, be confined to one eye, and depend on either a 
general or a local cause, the nature of which may readily 
be determined. An example of the first is the 

Diabetic Cataract.—As the soft cataract of early life is 
so often confined to one eye, the simultaneous affection 
of both lenses at this period would lead us to suspect a 
constitutional origin, particularly the existence of dia- 
betes meilitus, and to examine the urine for sugar. This 
form of cataract may occur at any age, and, in the case 
of the young, progress with great rapidity. It resembles 
other cases of soft cataract in all respects, except that, 
according to some observers, traces of sugar are to be 
found in the lens. The prognosis of the operation is, of 
course, somewhat modified by the presence of so serious 
a disease, but need not necessarily be regarded as unfa- 
vorable, many cases making a rapid and uncomplicated 
recovery of sight. ‘It has been claimed 4 that the use of 
the waters of Carlsbad has been observed to arrest dia- 
betic cataract, and even to cause its complete disappear- 
ance. 

Vataract Occurring in Connection with Separation of the 
Retina, Retinitis Pigmentosa, or Disease of the Choroid.— 
Here we have undoubtedly to do with a local impairment 
of nutrition; and, of all these causes, the former is the 
most frequent. The cataract exhibits no peculiarity of 
appearance. Itscause must be inferred from the fact that 
it is monocular, that the vision of this eye had been con- 
siderably impaired before its appearance, and from the 
functional examination which reveals a diminished or 
extinct perception of light in one part of the field, gener- 
ally the upper. In retinitis pigmentosa the opacity com- 
mences as a round spot at the posterior pole of the lens, 
from which radii shoot out toward the periphery. The 
anterior portion of the lens subsequently becomes simi- 
larly affected, but total opacity does not occur. 

Traumatic Cataract.—The transparency of the lens 
depends on the integrity of its investing capsule. This 
may be ruptured by a contusion of the eye, or wounded 
by the penetration of a foreign body or of a sharp instru- 
ment. The aqueous humor then comes into immediate 
contact with the iens, which imbibes it, swells, and be- 
comes opaque. When the capsular wound is very small 
it may again close, and the opacity remain confined to 


722 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the contiguous portion of the lens. But more frequently 
the swollen cortical substance protrudes from and itself 
widens the capsular wound, thus exposing fresh portions 
of the lens and ending in its general obscuration. As 
they protrude into the anterior chamber these masses may 
be absorbed, and finally the whole cataract thus be re- 
moved. But more generally, unless the pupil be at once 
artificially dilated, the pressure takes place against the 
iris, which inflames and renders necessary the operative 
removal of the opaque body. 

Senile Cataract.—Under this form we understand the 
opacity of the cortical substance of a lens, the nucleus of 
which: with advancing years has both separated and 
hardened. It is necessary to a proper understanding of 
the subject to bear in mind the probability that only the 
cortical layers become actually opaque, and that there is 
no essential difference, in the transparency of the nucleus, 
between the eye of an aged person who has always had 
good sight, and the eye of one who has become blind 
from senile cataract. No precise age can be assigned as 
that at which this form properly begins, so much varia- 
tion is there in different individuals as regards the sepa- 
ration and hardening of the nucleus. In general it may 
be stated that senile cataract is most apt to occur after 
the fiftieth year. Testing the transparency of the crys- 
talline, in people who have passed this age, the observer 
is often struck by the appearance of a series of short bi- 
furcating linear opacities, ranged around the periphery 
of the lens. They may be the most numerous in either 
the upper or the lower segment, or even extend around 
its entire periphery. The practical point concerning 
them is that, though their appearance is always to be re- 
garded as suspicious, they are not necessarily an indica- 
tion of advancing cataract. They may either remain 
unaltered for years, or they may increase at once in num- 
ber and extent. In the former case they are simply a 
senile change, analogous to the arcus senilis of the cor- 
nea; in the latter they justify the diagnosis of incipient . 
cataract. They must be carefully observed, and the pa- 
tient is not to be alarmed with a positive diagnosis of 
disease unless they are found to be increasing. 

Becker ® gives the résumé of the various stages of senile 
cataract and their proper nomenclature. As long as there 
are a few opaque striz discernible in the periphery only, 
or in exceptional cases before or behind the nucleus, we 
speak of incipient cataract. If the opacity of the cortical 
substance bas advanced, the expression unripe cataract 
is used. There is no absolute line to be drawn between 
these two, save that the cataract is to be regarded as in- 
cipient so long asthe greater part of the cortical substance 
is transparent; as unripe when opaque cortical substance 
prevails. When the opacity of the cortical is complete 
the cataract is designated ripe. Oblique illumination then 
reveals no transparent portion, and no red reflex appears. 
when the ophthalmoscopic mirror is used. The posterior 
portion of the lens is now, of course, invisible, but it. 
ordinarily keeps pace in these changes with the anterior, 
and may be assumed to be in the same state. 

Senile cataract generally affects both eyes, but is de- 
veloped later in one than in the other. The fact that the 
eye last affected furnishes the better result has already 
been alluded to. That the tendency to this disease is 
hereditary has been abundantly demonstrated. The 
popular notions that the left eye is more apt to be first. 
affected than the right, and that more men than women 
are the subjects of cataract, rest on no reliable founda- 
tion. 

Absolute maturity of the senile cataract is not always 
to be waited for, or indeed invariably expected. In cer- 
tain cases the complete affection of the cortical progresses. 
with extreme slowness; vision in each eye may have 
fallen off to such an extent that reading and writing are 
no longer practicable, and the patient even finds it im- 
possible to go about alone in strange localities, or those 
with which he is imperfectly familiar. Failure of sight 
continues to progress, but can be made out with cer- 
tainty only by comparing the vision at long intervals of 
time. Meanwhile age creeps on and the general health, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


affected, perhaps, by both moral and physical causes, 
commences to give way. In other cases progress in the 
formation of the cataract comes to an absolute standstill. 
The sclerosis of the nucleus may be complete, the corti- 
cal substance partially opaque, admitting a considerable 
red reflex, or perhaps even an imperfect view of the 
fundus to the ophthalmoscope, and months and perhaps 
years elapse without any change in this condition of 
things. Ripeness is here evidently not to be expected, 
and surgical interference, either directly or after the 
operative production of maturity, is wholly justifiable. 

Black Cataract.—This name is applied to those rare 
cases in which the scl-rosis of the nucleus goes on unin- 
terruptedly and extends up to the capsule. Although 
occupied by a ripe cataract, the pupil appears black, 
even when oblique illumination is used. Cortical sub- 
stance is completely wanting, and the whole lens is con- 
verted into one hypertrophied nucleus. This condition 
is of most infrequent occurrence. 

Capsular Cataract.—Deposits on the capsule from with- 
out have already been alluded to. Primary affections of 
the capsule itself, the formation of opacities in its proper 
substance, are extremely rare. Ascareful an observer as 
Fuchs states that all so-called capsular opacities are de- 
posits externally. Thecapsule itself invariably retaining 
its transparency, capsular cataract ordinarily occurs as 
one of the changes consequent on hypermaturity of an 
ordinary cataract. 

Final Changes in an Over-ripe Cataract.—Inflammation 
in the lens, caused by this state of things, may bring 
about the formation of capsular opacities. The cortical 
substance may undergo partial absorption, this producing 
some improvement in vision and leading to a diminution 
in size of the lens. It may become liquid, and the nu- 
cleus, no longer supported, may sink to the bottom of 
the intracapsular space. The capsule sometimes thick- 
ens and becomes studded with crystals of cholesterin. 
The whole cataract may become cretaceous, or, under 
very exceptional circumstances, even osseous. In the 
former case extensive adherences with the iris may 
exist. 

TREATMENT OF CatTaract.—WMedical Treatment.—In 
view of the great advances made in the diagnosis and 
treatment of diseases of the eye during the present gen- 
eration, as well as of the earnest efforts that are still being 
made in all directions to further ophthalmological science, 
it would indeed be hazardous to assume that no local ap- 
plication or general medication to affect the progress of 
cataract will ever be discovered. None the less must it 
be firmly asserted that, at the present day, we possess no 
means whatever of preventing the formation of the dis- 
ease. Numberless remedies have been tried in the past, 
but have all proved inefficacious, and at the present day 
none but charlatans assert their ability to cure cataract 
without an operation. Someadminister nostrums, others 
make topical applications, while others again extol the 
virtues of electricity; the result in every instance being 
the same. If the cases of reported cure be thoroughly 
sifted, it will be found that by far the larger proportion 
are based on a mistaken diagnosis; that in many in- 
stances the process has simply come toa standstill; while 
in a small number of eyes the lens has either undergone 
spontaneous dislocation, or else the swelling of the crys- 
talline has been so unusually great as to rupture its cap- 
sule and lead to total absorption. Opacities of the layer 
of intracapsular cells may wholly disappear, and trau- 
matic cloudiness of a portion of the lens may regain some 
degree of transparency. It isalsoa well-known fact that 
diabetic cataract may vary directly with the progress of 
the disease. 

2. Surgical Treatment.—This consists in reopening a 
path for the rays of light to reach the retina, either by 
the side of the existing obstruction (iridectomy) or by 
its absolute removal. The latter may be effected in one 
of three ways: The cataract may be left in the eye, but 
be pushed aside from the axis of vision (reclination, de- 
pression); it may be caused to undergo absorption by 
being brought in direct contact with the aqueous humor 


Cataract, 
Cataract, 


(discission); or it may be bodily removed from the eye 
through an opening made for the purpose (extraction). 

General Considerations.—The indication for an opera- 
tion for cataract is a probable improvement in vision, 
combined with safety to the general health of the indi- 
vidual. The two preliminary questions, therefore, to be 
settled are, first, as to whether a careful examination of 
the condition and functions of the eye renders it likely 
that the cataract can be successfully removed; and sec- 
ond, whether the general health is likely to be injuriously 
affected by the excitement attending the operation, or 
the subsequent confinement that may be necessary. 

As a rule it is undesirable to operate on a teething 
child, a pregnant woman, or one who is menstruating or 
about to do so. The general condition of the patient 
should be carefully inquired into and the prognosis modi- 
fied if any general disease like diabetes or Bright’s dis- 
ease be present, and it is yet deemed desirable to proceed 
with the operation. If the patient is fresh from a jour- 
ney, a day or two’s rest should be allowed. If the oper- 
ation takes place away from home, a sufficient time should 
be afforded the individual to familiarize himself with his 
new surroundings. On the continent of Europe there is 
quite a general agreement among ophthalmic surgeons 
that serious operations, like the extraction of cataract, 
which entail a lengthened convalescence, should be per- 
formed away from home; generally in the private rooms 
attached to the hospital with which the surgeon happens 
to be connected. An establishment especially arranged 
for the purpose offers advantages of light, ventilation, 
quiet, and skilled attendance, with which no ordinary 
private house can compete. There is, moreover, a free- 
dom from care and anxiety that can rarely be secured at 
home. For the first day or two, relations and friends 
being excluded, there can be no allusion to exciting 
topics or consultation on household cares. Distance from 
the latter is found to induce, with the head of a family, 
a feeling of repose that close proximity would go far to 
destroy. 

The long-received notion that the spring and fall are 
the best seasons for cataract operations was undoubtedly 
based on the fact that these were the times of year which 
the peripatetic oculists, who formerly infested the com- 
munity, found most convenient for t:avelling. In the 
United States the extreme heat that may prevail during 
the months of July, August, and September might exert 
an unfavorable effect on a protracted convalescence, and 
therefore renders these months less eligible than those in 
which the weather is generally cooler. 

Should one eye be operated on when the other is en- 
tirely normal? Assuming the cataract to have been suc- 
cessfully removed, there are certain undeniable advan- 
tages in the association of such an eye with a normal one. 
Although the lens is wanting and the refraction of the 
two eyes thus radically different, binocular vision is often 
enjoyed. When this is not possible, double vision does 
not necessarily arise, as the patient learns to abstract 
from the image furnished by the imperfect eye, and to 
rely on the sound one for accurate perception. Even 
then he has a larger visual field than if he had only one 
eye, a better estimation of distance, and appreciation of 
solidity. He is no longer blind on one side, and, when 
moving about, avoids accidents to which he would other- 
wise be liable. With the young, therefore, such an oper- 
ation is always to be encouraged, both for these reasons 
and, in the case of females, for those of a cosmetic nature. 
But with the aged different considerations must prevail. 
The operation, with them, is neither as simple nor as 
safe, and the after-treatment is much more prolonged. 
The interruption in the usual habits of an elderly person, 
the shutting him up in a dark room, changing his diet, 
and depriving him for a fortnight of the air and exer- 
cise on which he is dependent, may exert a serious 
influence on his health. While in youth it is, therefore, 
advisable to operate on a single eye, the maxim in age 
should be never to touch a cataract on one eye until the 
other begins to be affected, and then to delay as little 
as possible, bearing in mind the fact that the longer the 


723 


Cataract, 
Cataract, 





operation is deferred the older will be the patient, and the 
greater the depressing effect exerted on his morale by 
impending and advancing blindness. 

Patients are often encouraged by their home advisers 
to wait until both eyes are fully affected, in order that 
both may be operated on at the same time. While the 
simpler cataract operations may undoubtedly, under 
ordinary circumstances, be performed in the young on 
each eye at one time. without incurring unwarrantable 
risk, the extraction of senile cataract on both eyes simul- 
taneously is unjustifiable, save in the most exceptional 
cases. And this for the following reasons: If one eye 
only be operated on, the symptoms which follow, and 
the way and manner in which the eye rallies from or, in 
extreme cases, sinks under the violence inflicted on it, 
guide us materially in what we are to do for the other 
eye, and teach us to adopt such precautions, or so to 
modify our method, as to give the patient a better chance 
of sight, and to save him from the dangers to which our 
ignorance of his idiosyncrasies exposed him the first time. 
Again, a patient or his attendants, being little used to 
such delicate operations, may Se imprudent, transgress 
our positive directions, and consequently lose the eye. 
If both eyes have been operated on, his only chance is 
gone. If, however, one only has been touched, he will 
learn wisdom with experience, and insure success by 
being more careful the second time. 

It is true that the refusal of the surgeon to operate on 
both eyes at the same time often practically results in 
but a single operation being performed. After the con- 
finement of a fortnight in a darkened room the average 
patient may well shrink from a repetition of his experi- 
ence, or fear its effect on the general health. Many people 
have not the time to give to the second operation, or the 
means of meeting its attendant expense. These are, 
however, minor considerations, and are not to be weighed 
in the balance with those which have been brought for- 
ward to show the superior safety of operating on but one 
eye at a time, in all cases of senile cataract. 

The Result of the Operation for Cataract.—In the most 
favorable cases the obstruction may be entirely removed 
from the axis of vision and full sight acquired, its acute- 
ness being quite equal to the normal standard. Un- 
der such circumstances all the eye has lost is the power 
of accommodation, which must be met by the use of 
glasses of different strengths for different purposes, or 
by shifting the interval between the glass habitually 
worn and the eye. 

But not always is the result thus successful. Portions 
of the lens may remain behind in the intracapsular space, 
clots of blood may be imperfectly absorbed, or inflam- 
mation may cause a proliferation of opaque substance on 
the face of the capsule: the whole sometimes becoming 
more or less adherent to the edge of the pupil. This forms 
what is known as secondary cataract, and demands in its 
turn an appropriate operation, or the loss of the eye may 
be entire, the inflammation following the original opera- 
tive interference being so violent as to cause entire opac- 
ity of the cornea, or even wasting away of the eye itself. 
An irritable stump, thus left, may give rise to sympa- 
thetic ophthalmia of the remaining eye, a condition of 
things which may also be brought about by the antece- 
dent inflammation. This result is fortunately extremely 
rare, and may not once occur in the experience of a life- 
time. 

ANTISEPTIC MEASURES.—Before entering on the de- 
scription of the various operations for cataract, the ques- 
tion of antiseptic measures is naturally to be considered. 

Our attempts at sterilization apply to the patient, the 
operator, and the instruments, the latter being by far the 
most fertile sources of infection. The surgeon and his 
assistants should wear special outer garments. Those 
made of linen, freshly washed and ironed, answer a use- 
ful purpose. The hands are to be thoroughly washed in 
warm water and with soap, scrubbed with a nail brush 
and afterward dipped in a four-per-cent. carbolic solu- 
tion, or else in one of corrosive sublimate (1 to 2,000). As 
far as the patient is concerned the vicinity of the eye and 


724 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


the edges of the lids are to be carefully washed with soap 
and water, after which a sterilized pad, soaked in the 
same solution of corrosive, large enough to cover the eye 
and its immediate neighborhood, may be applied and left 
in place until the moment for operating arrives. After 
using the anesthetic the conjunctival sac may be washed 
out with sterilized water, or a weak solution of corrosive 
(1to 5,000). It seemsa matter of comparative indifference 
which of these methods is employed, as so momentary 
an application will have but little effect on any bacteria 
that may be present. Particular attention is to be paid 
to the state of the lachrymal sac, and its freedom trom 
infectious secretion is positively to be ascertained. 

It is in regard to the sterilization of the instruments 
and the manner of bringing this about that the greatest 
diversity of practice has perhaps obtained and the most 
different methods have been adopted. The delicate in- 
struments used in ophthalmic surgery must naturally be 
handled with greater care than many of those employed 
on other parts of the body. Immersion in solutions of 
corrosive sublimate corrodes metal and ruins the edge of 
the knife. A four-per-cent. solution of carbolic acid has 
been proved insuflicient to destroy the suppurative germs, 
To bring about this result with certainty, probably no 
agent is more efficacious than heat, in either the dry or 
the moist form. Yet each of these has its disadvantages. 
Steaming or boiling, the latter in simple water or in alka- 
line solution, is apt to be followed by rusting. Baking 
at a temperature of 150° C., continued for an hour or 
more, is absolutely certain. But all instruments sub- 
jected to this must be made with metal handles in place 
of ivory or bone, and it is doubtful whether the fine 
knives used for the corneal section would, after such 
baking, retain a perfect edge. Many operators, influ- 
enced by the above considerations, content themselves 
with immersing their instruments, previously thoroughly 
cleansed, in a bath of absolute alcohol before the opera- 
tion, and withdrawing them one by one as they are 
wanted for use. 

But experience shows that knives thus immersed 
suffer appreciably in their cutting properties. It is 
the custom of the writer to have a small vessel of boil- 
ing water brought to the bedside, just before the opera- 
tion is commenced, and to immerse the blade of the cat- 
aract knife and the point of the keratome in it for a few 
seconds. 

ANSTHESIA.—General anesthesia, brought about by 
ether or chloroform, has now, in the vast majority of 
cases, given place to the local anzsthesia induced by co- 
caine. Thisagent was introduced and its properties were 
explained by Koller in 1884, Its use has become general. 
Employed ordinarily in the form of the hydrochlorate, 
and in a solution varying from two to five per cent. in 
strength, its contact with the eye brings about anesthesia 
of the conjunctiva and cornea, coming on in from one to 
two minutes and lasting some ten minutes. In an opera- 
tion for the extraction of cataract it should be applied 
two or three times. It is well to remember that the sen- 
sitiveness of the iris is not materially affected by the 
cocaine, and to prepare the patient for a certain amount 
of pain in case an iridectomy forms part of the operation. 
Besides producing anesthesia of the surface of the eye- 
ball, cocaine brings about other changes. It contracts 
the blood-vessels of the iris, and thus gives rise to a tem- 
porary mydriasis; it empties also the conjunctival blood- 
vessels. On account of this double effect the annoying 
hemorrhage that sometimes so much embarrasses the 
performance of an extraction is much less likely to occur. 
There is also noticed a wider opening of the lids and a 
lessened tendency to wink. Finally, the intra-ocular 
pressure becomes slightly reduced. 

If the surgeon finds it impracticable to prepare a steril- 
ized solution of cocaine on the spot, he may use a 1 to 
5,000 solution of sublimate as a menstruum. It is 
best to prepare the patient fora slight smarting sensa- 
tion when the first application is made to the eye. This 
very rapidly disappears. 

A one-per-cent. solution of holocain gives a local an- 


~ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


sesthesia quite as effective as that produced by cocaine. 
It causes an even greater degree of insensibility of the 
iris. It gives rise to no constitutional symptoms, as is 
sometimes the case with cocaine. It has the advantage 
of being distinctly bactericidal in its action. But it does 
not arrest hemorrhage as does cocaine. The solution of 
holocain should be made in porcelain, never in glass, and 
keeps indefinitely. 

There are other local anesthetics, none of which seems 
to deserve comparison with the two above described. 

Discisston.—In this operation the removal of the cata- 
ract is sought to be effected by wounding the anterior 
capsule, and bringing the aqueous humor in direct con- 
tact with the lens; the object being to cause its complete 
absorption without impairing the transparency of its 
capsular envelope. The former object will not be at- 
tained if the consistence of the cataract be too great or its 
sclerosis too marked. The latter cannot be secured if the 
operation be followed by serious inflammation, due to 
the excessive effect produced by its performance, and 
which would follow a want of care in proportioning the 
size of the opening in the capsule to the amount of tolera- 
tion the eye is capable of exhibiting. 

The substance of the lens, brought into direct contact 
with the aqueous humor, imbibes it just as a sponge 
soaks up water. Like the sponge it swells, and then 
slowly crumbles away and dissolves. It is the tendency 
to swell, and thus exert mechanical pressure on the con- 
tiguous parts that constitutes the main danger of the 
operation; and it is the merit of von Graefe to have first 
insisted on the necessity of proportioning the opening in 
the capsule to the amount of lenticular swelling the eye 
can safely sustain. The rapidity of absorption depends 
on the age of the individual, being most active with the 
young. The amount of swelling varies according to the 
maturity of the cataract and the period at which it is 
attacked. 

The course of normal absorption is as follows: First 
the edges of the capsular wound retract; then the lens 
substance begins to swell and protrude into the anterior 
chamber. Oblique illumination brings it into relief as a 
grayish plug, blocking the opening left by the needle. 
In some cases the whole lens gradually swells and presses 
forward until the anterior chamber is completely blocked; 
in others the process ismore gradual, and each successive 
protrusion slowly undergoes absorption. It first grows 
larger, then more transparent, next its surface becomes 
irregular, is gradually eaten away, and the mass finally 
disappears. Sometimes small fragments are successively 

detached, fall down, and are dissolved. One mass suc- 
ceeds another, protrudes, and goes through the same 
process until the whole lens has been removed.’ It is 
evident that the aqueous humor that accomplishes this 
task is too insignificant in amount at any one time to do 
more than a small portion of it, and must hence be 
steadily undergoing both excretion and renewal. As will 
be seen later on, Arlt bases on this fact a recommendation 
to hasten absorption, in cases in which it is progressing 
with unusual slowness, by occasionally doing paracente- 
sis of the anterior chamber, and thus artificially removing 
the saturated aqueous. 

We have thus traced the course of an operation fol- 
lowed by normal absorption. But all cases do not pro- 
gress thus favorably. The lens may imbibe the aqueous 
humor too freely, and swell with a rapidity that causes 
destructive pressure to be inflicted on the surrounding 
parts. The pupil may then be seen to contract, the 
ciliary redness that naturally is present in some degree 
during so active a process as absorption becomes alarm- 
ingly great, and even conjunctival chemosis may ensue. 
The iris becomes discolored, the eye waters, intolerance 
of light is felt, local pain becomes severe, radiating in 
every direction, and finally, unless proper measures of 
relief are taken, vision may gradually be extinguished 
by the development of secondary glaucoma, the legiti- 
mate consequence of the great increase in pressure. As has 
been observed by von Graefe, these symptoms are almost 
exclusively met with in the young, the lens in elderly 





Cataract, 
Cataract, 





people rarely imbibing aqueous humor so rapidly or to 
such a dangerous extent. 

To avoid iritis caused by direct pressure of the swollen 
cortical mass on the iris itself, it is most necessary that 
the pupil be fully dilated before the operation, and kept 
so during the whole of the absorption. An important 
contraindication to the performance of simple discission 
is therefore the failure of the pupil to respond to the ac- 
tion of a mydriatic. Cases in which the pupil cannot be 
readily and largely dilated are not those in which the 
performance of a simple discission is at all admissible, 
and this test should always be employed before deciding 
on the character of the operation to be selected. 

This operation is admissible in all simple lenticular 
cataracts of early life, up to the twenty-fifth or thirtieth 
year. It is especially to be employed in the case of in- 
fants, both because the size of the opening in the eye is 
so trivial as to obviate the necessity of attention to the 
healing process, and because at this age absorption takes 
place with such rapidity that the pressure of the swollen 
cortical mass is but little to be dreaded. It is also advis- 
able to do discission in lamellar cataract that occupies so 
large an area as to render an iridectomy useless, and 
when the patient has not passed the age of twenty. In 
the traumatic cataract of early life, where the extent of 
the original injury has been so limited as to produce an 
effect but slowly progressive, this operation may be used 
to hasten ripeness of the cataract, and to promote rapid- 
ity of absorption. For nearly a generation it has been 
justly abandoned in all cases of senile cataract. 

Instruments ; Preparation of the Patient; Method of 
Operation.—The instruments needed for the performance 
of discission are the ordinary spring speculum, fixation 
forceps, and stop-needle. The latter (Fig. 
1151), the perfection of which we owe to the 
inventive genius of Sir William Bowman, 
ought to be extremely slender, with a cut- 
ting edge of not more than a millimetre in 
extent. Its shaft should so completely fill 
the wound made by its point as to prevent 
the escape of the aqueous humor by its side 
during the operation. This would cause the 
lens to fall forward against the cornea, and 
embarrass the use of the needle. Lower down 
the instrument is furnished with a shoulder, 
which renders its penetration into the eye, 
beyond a certain depth, impossible. 

The patient may sit in a chair, facing the 
operator, unless anesthesia be employed, 
when the recumbent position is of course 





preferable. The objections to the use of an- PIG. 15) 
esthetics during the extraction of cataract Needle. 


do not apply to the operation of discission. 

Although the pain is not excessive, the subjects are young 
and consequently nervous; and, as will be seen, it is im- 
portant that sudden spasmodic attempts to close the eye 
should not be made. WNarcosis is therefore generally de- 
sirable, and its practice renders an assistant, for the most 
part, unnecessary. The pupil, as has already been stated, 
should be fully under the influence of atropine. The 
lids being separated by the introduction of the speculum, 
the eye is grasped by the fixation forceps at a point op- 
posite to that selected for the introduction of the needle, 
generally over the insertion of the internal rectus. The 
point of the needle is now applied to the cornea midway 
between its centre and periphery, downward and out- 
ward, and made to transfix it in the direction of the pos- 
terior pole of the lens, and perpendicular to the corneal 
surface, so as not to penetrate it obliquely. As soon as 
the needle has passed in up to its neck the handle is 
lowered and the point carried forward until it touches 
the anterior capsule at a point outward from its centre, 
perhaps midway between that and its periphery. Rais- 
ing the handle, and now regarding the instrument as a 
lever, the fulcrum of which is where it passes through 
the cornea, the operator makes its point descend along 
the face of the capsule, and inflicts on this membrane a 
vertical wound, some 2 mm. in extent. Lowering the 


725 


Cataract, 
Cataract, 





handle now, and at the same time slightly withdrawing 
the needle so that its point is no longer in contact with 
the capsule, he again pushes it forward, directing this 
time toa point on the nasal side of the horizontal meridian 
of the capsule, midway between its centre and periphery, 
and then making it inflict on its face a horizontal wound, 
precisely similar to the vertical one already made. The 
needle is then gently and steadily withdrawn, being held 
in the same position as when it entered the eye. At the 
instant of withdrawal it is well for the operator, if mn- 
assisted, to release the fixation forceps and raise the 
speculum slightly from off the eye, with his left hand, 
so that no pressure may be made upon it. The aqueous 
humor is thus less likely to escape, and the pupil con- 
sequently remains dilated. For a similar reason the re- 
moval of the speculum must be conducted with great 
care, and without touching the eyeball. If ansesthesia 
remain profound no spasmodic closure of the lids will 
occur at this juncture, and no aqueous be lost. 

Great care must be taken not to bruise or crush the 
cornea by too forcible manipulation of the needle, and 
to this end it should be simply allowed to rest lightly on 
the cornea, at its point of passage through it. The in- 
cisions should be as nearly as possible at right angles 
with each other, and should not be extended as far as the 
equator of the lens, in order to avoid too rapid swelling, 
as well as adherences between capsule and iris (Arlt). 
Should the needle slip out of the eye before the operation 
is completed it may be reintroduced, unless the aqueous 
has escaped, in which latter case the operation must be 
desisted from until the aqueous has again collected. 

When a single operation proves sufficient the average 
time necessary for the absorption of the lens is ten weeks. 
But the process does not always go on uninterruptedly. 
A small capsular opening may be so blocked by the pro- 
truding fragment of lens as to cut off the access of aque- 
ous humor to the parts behind, and absorption of this 
fragment may be followed by closure of the wound. In 
such cases the operation must be repeated and larger in- 
cisions made. Occasional paracentesis of the anterior 
chamber greatly promotes absorption, but would be 
needed only in exceptional cases. 

After-Treatment.—A bandage is of doubtful utility. 
With very young children it encourages weeping, and 
its moral effect is atany age depressing. A shade, cover- 
ing both eyes, may be given, and the room be dimly 
lighted. The pupil must be kept permanently dilated 
with atropine, a half-per-cent. solution of which should 
be applied three or four times a day, except in the case 
of very young children, in whom there is danger that 
symptoms of intoxication may manifest themselves. 
The atropine is to be continued as long as the absorption 
is going on, though after the first it need not be applied 
so frequently. If symptoms of reaction occur, as in- 
dicated by watering, undue ciliary redness, and local 
pain, strict quiet is to be enjoined and cold compresses are 
to be applied to the eye. If they continue, one or more 
leeches may be applied on the temple, care being used 
to apply the leeches as far as possible from the eye itself. 
The bowels are to be kept open. If no relief is experi- 
enced, and the symptoms grow more pronounced; if 
tension increase, chemosis appear, and pain become more 
severe, it will probably be necessary to open the anterior 
chamber and evacuate the aqueous humor through an 
opening sufficiently large to allow any detached frag- 
ments of lens substance to escape at the same time. In 
extreme cases it may be necessary to practise linear ex- 
traction of the whole lens, with or without iridectomy. 

Modified Discission.—In cases in which the pupil fails 
to respond promptly or thoroughly to atropine, or in 
which other indications of a tendency to inflammation are 
present, the operation of discission is rendered much more 
likely to succeed by the performance of an iridectomy 
three or four weeks before the use of the needle is under- 
taken. The excision of iris should be done upward, and 
the piece removed be of good size, and extend up to the 
ciliary edge of this membrane. The increased area thus 
given to the pupil lessens the number of points of con- 


726 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





tact between the cortical substance and the iris, renders 
contraction of the pupil much less to be dreaded, and 
diminishes the danger of secondary glaucoma. This last 
complication is not infrequently the cause of the blind- 
ness that sometimes follows discission, and the likelihood 
of its occurrence varies directly with the advance in age 
of the individual. In the performance of this modified 
discission Wecker® advises that the capsule be opened 
principally within the area of the new pupil, thus limit- 
ing the precipitation of fragments of the crystalline into 
the anterior chamber, and regulating the advance of the 
absorption. When the upper portion of the lens has thus 
been removed, its lower part may more advantageously 
be attacked. 

With regard to the operation of discission in general, 
it may safely be stated that, allowing the cases to be 
properly selected, and due care used in its performance, 
it is the safest and surest method at ourcommand. Total 
loss of the eye is, under these circumstances, excessively 
rare. 

In former times yet another method was practised, 
having for its object the removal of the cataract from the 
axis of vision without taking it out of the eye, namely, 
the operation of veclination or depression. A needle 
specially adapted to the purpose was passed in through 
the sclerotic, and used to tear the opaque lens away from 
its attachments, and lay it at the bottom of the eye. 
False in principle, and often disastrous in result, leading 
to restoration of vision in but from fifty to sixty per cent. 
of the cases in which it was used, this operation has 
justly been abandoned, and is, therefore, no longer to be 
described among the methods in use at the present day. 
It is still, however, of interest from a historical point of 
view, and will be ailuded to at length in a subsequent 
portion of this article. For the present we proceed to 
the consideration of those operations which rest on the 
principle of the total removal of the cataract from the 
eye, and commence with the one involving the smallest 
solution of continuity, the method of 

Suction.—This may be considered the operation of 
aspiration applied to cataract. Throughout the series of 
operations that have for their object the extraction of 
the lens, one of the great dangers to be apprehended is 
that connected with the healing of the wound necessarily 
inflicted on the eye. The larger this is, the greater the 
danger of inflammatory and other complications. Such 
accidents are least to be dreaded after a discission, they 
are appreciable with a linear extraction, and, as will be 
seen, the risk becomes greatest of all in the case of flap 
extraction. A method which should bodily and entirely 
remove the cataract through the smallest possible open- 
ing avoids at once the dangers attendant on slow absorp- 
tion and the chance of the imperfect healing of a large 
wound. The operation of suction fulfils both these con- 
ditions. It is accomplished by means of an instrument 
formed from the glass barrel of an ordinary subcutaneous 
injection syringe, to one extremity of which is attached 
a piece of rubber tubing ending in a mouth-piece, while 
on the other end is a bent hollow needle of large size, 
open at its extremity. This needle is passed through a 
small opening in the cornea and anterior capsule, the air 
in the tube is then exhausted, and the soft cataract sub- 
stance flows in to take its place. 

This, in brief, is extraction by suction. It is a method 
of great antiquity. Evidence exists of its having been 
used in the East in the fourth century, and frequent 
subsequent references are made to it in ophthalmic litera- 
ture. In 1846 it was revived by Laugier, who made his 
opening in the sclera, and introduced the point of the 
suction needle through the posterior capsule. Teale, in 
1864, published a drawing of an improved instrument, 
and recommended a method of operating which is sub- 
stantially that in use at the present day. Since then most 
authors refer to the proceeding. Yet it cannot be said 
to have ever yet found its way into general favor, or to 
have met with the appreciation which, in a certain class 
of cases, it really deserves. 

It is probable that extraction by suction would have 


-REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


attained greater popularity had the indications for its 
performance been better understood and the class of 
cases to which alone it was applicable, more sharply de- 
fined. Authors, for example, report in- 
stances of subsequent inflammation and 
failure in lamellar cataract, a form to 
which this operation is wholly inappli- 
cable. It should never be employed 
save in cases of known soft or liquid 
cataract, and in the traumatic form of 
the disease occurring in persons under 
the age of thirty. And in the latter class 
some time should be allowed to intervene 
between the accident and the operation, 
several days, or even a week, being, if 
possible, suffered to elapse, in order that 
the whole of the lens substance may be- 
come thoroughly opaque. The instru- 
ments needed are a spring speculum, fix- 
ation forceps, bent broad needle, and the 
suction apparatus (Fig. 1152). To the 
form of this latter especial attention is 
directed, as the figure here given differs 
materially from the instrument described 
by Mr. Teale, and generally used abroad. 
Our barrel is shorter, and slightly less in 
diameter than the English; the neck of 
the hollow needle, at its lower end, ex- 
actly fits the opening made by the broad 
needle, and the opening is across the ex- 
tremity (Fig. 1153) instead of being on its front face. 
The rubber tube that connects with the mouth-piece 
has a coil of light wire running the entire length of its 
interior. Each of these modifications offers a corre- 
sponding advantage, as will be seen when the operation 
comes to be described; and the greater favor it has met 
with in America may with justice be attributed, at least 
in part, to the superiority of the native instrument.* 
Operation.—This is by no means devoid of pain, and 
an anesthetic may be used to advantage. The pupil 
should of course be fully dilated. The surgeon, sitting 
behind the patient’s head, fixes the eye with forceps, and 
makes, with a bent broad needle, an 
oblique incision through the cornea at a 
point outward from its centre and about 
three-fifths of the distance between that 
and the sclero-corneal junction; prefer- 
ably in the outer-upper quadrant on the 
right side, in the upper-inner on the left. 
The point of the needle is carried across 
the anterior chamber, made to penetrate 
the anterior capsule, and then withdrawn. 
If this be carefully done, all the aqueous 
humor may be retained. The suction in- 
strument is now introduced, its orifice 
being directed upward, and its point 
brought in contact with the lens sub- 
stance. This being done, the air is with- 
drawn by the mouth, the force applied 
being perhaps similar to that used in 
smoking a well-made cigar. The neck 
of the hollow needle exactly fitting the 
wound, the instrument may be rotated, 
advanced and in part withdrawn, with- 
out loss of aqueous; and the important 
advantage is thus gained of not com- 
ing in contact with and bruising the iris. 
After the lens matter has filled the in- 
strument it may be withdrawn, cleansed, 
and if necessary again inserted, though 
it will be better if this can be avoided. 
While the suction is going on the wire in the flexible tube 
prevents this from doubling on itself, and thus obstructing 
the draught of air. The shape of the aperture of the needle 
enables the surgeon to search for separate portions of lens 





Fig. 1152. —Suc- 
tion Apparatus. 
(Reduced in 
size.) 





Fig. 1153. — Mag- 
nified Picture of 
Point of Suction 
Instrument. 





* This instrument is the one in use at the Massachusetts Charitable 
Eye and Ear Infirmary, and the modifications here detailed are largely 
due to the late Dr. Robert Willard. 


Cataract, 
Cataract, 


matter, and apply the point directly to them, while they 
are drawn in with a muck greater facility than would be 
the case with an opening differently situated. The opera- 
tion completed, the instrument is withdrawn and a band- 
age applied. It is ordinarily unnecessary to keep the 
patient in bed more than twenty-four hours, or even to 
retain a bandage for a longer period. A shade may be 
worn over both eyes until all redness has disappeared, 
but the amount of reaction is often astonishingly slight. 
A fear has been expressed lest vitreous should be drawn 
into the tube. This seldom happens, especially with the 
instrument here described, the length having been cur- 
tailed and the calibre reduced in order to get less at- 
mospheric pressure and thus avoid the accident. 

As regards the results of the suction operation, the re- 
ports of the Massachusetts Charitable Eye and Ear In- 























Fig. 1154.—Straight Lance Knife. 


firmary for the last eleven years show the performance 
of one hundred and seven operations by suction. In 
some of the reports the results of that year are given, in 
others the number of operations is simply stated; no 
selection in either case having been made. In the 65 
recorded cases the results are as follows: full success, 46; 
partial, 18; loss, 1. In 5 of these cases vision was 
perfect, that is ten-tenths. 

SimpLE Linear ExtTraction.—In the operation just 
described the opaque lens substance was removed through 
a minute opening, by being made to flow into a vacuum. 
In that now under consideration the same thing is effected 





Fig. 1155.—Cystitome. 


through a larger opening and by pressure. It is used for 
the same class of cases, viz., liquid, soft, and traumatic 
cataracts, in those who have not yet passed the age of 
twenty-five; and is moreover applicable to shrunken or 
rudimentary cataracts, on which suction would have no 
effect. And it is to be borne in mind that, while extrac- 
tion by suction has never yet found universal favor, or 
been much practised out of England and America, linear 
extraction has long and generally been regarded as an 
operation both justifiable and valuable. 

The instruments used in its performance are a spring 
speculum, fixation forceps, straight lance knife, cysti- 





Fig. 1156.—Daviel Spoon. 


tome, and Daviel spoon (Figs. 1154, 1155, 1156). Iris 
forceps and fine scissors should be in readiness, in case it 
is found necessary to excise a prolapse. The forceps 
may also have to be used where a shrunken cataract is to 
be removed. 

The patient is to be in a recumbent position, and to 
have the pupil fully dilated. Anesthesia, either general 
or local, may advantageously be employed. Having 
grasped, with the fixation forceps, a fold of conjunctiva 
to the inside of the cornea, the operator makes an incision 
with the lance knife in the corneal substance, perpendicu- 
lar to the surface of this membrane, and at a point on its 
horizontal meridian either midway between its centre and 
outer edge or, if nearer the latter, at least 2 mm. removed 
from it. As soon as the point of the instrument has en- 
tered the anterior chamber its direction is changed, and 
the knife is pushed forward in a plane parallel to that of 
the iris. A wound of from6 to 8 mm. having been made, 
the lance knife is slowly and steadily withdrawn, care 


127 


Cataract, 
Cataract, 


being taken to keep it always in the same plane, and 
thus avoid the too rapid escape of the aqueous, an event 
which would be followed by the contraction of the pupil. 
Owing to the triangular shape of the knife it is evident 
that the inner wound must be smaller than the outer, and 
it is well to attempt to equalize the two by directing the 
point of the lance either a little upward or a little down- 
ward, as itis withdrawn. But it should never be rotated, 
and should exert as little pressure as possible. 

If the capsule is opaque, or if we are seeking to extract 
a shrunken cataract, a small sharp hook, or the iris for- 
ceps, may now be introduced through the wound, and 
the capsule or cataract seized and withdrawn. If, how- 
ever, we are dealing with an ordinary soft cataract, the 
next step is the opening of the capsule. The cystitome 
is passed through the wound by gently pressing it 
against the outer edge, its cutting edge being held par- 
allel with the face of the cornea. Once in the anterior 
chamber its flat is made to glide over the front of the 
cataract until the point at which it is desired to com- 
mence the capsular opening is reached. The handle of 
the instrument is then turned so as to have the edge face 
the capsule, on which a wound is inflicted by the with- 
drawal of the cystitome in its new position, care being 
taken that the handle is again rotated just before the 
edge of the pupil is reached, so as to avoid wounding the 
iris. If the cataract be very soft the cortical mass will 
now begin to escape and rapidly fill the anterior chamber. 
Many operators content themselves with this single open- 
ing, which is quite sufficient when a Graefe’s cystitome 
is used, as a triangular flap is thus torn from the capsule. 
(This is the instrument given in Fig. 1158.) Ifa straight 
cut be made in the capsule it must be supplemented by 
another running at a slightly different angle; a large 
capsular opening being essential to the entire removal of 
the cataract, as well as the prevention of secondary cap- 
sular opacity. Many of the cataracts removed by this 
operation are very thin, and care must be used not to 
sink the point of the cystitome so deeply in the mass as 
to wound the posterior capsule. 

The opaque lens is next to be removed by pressure. 
At this stage of the operation it is better to take out the 
spring speculum, and to raise the upper lid with the 
thumb of the left hand. The rounded back of the Daviel 
spoon is now to be applied to the portion of the cornea 
that remains between the opening and the periphery of 
this membrane, and the wound so made to gape slightly. 
Pressure thus judiciously applied, aided by a slight 
amount of rubbing in the same region, will often cause 
the expulsion of the lens substance. But if this takes 
place very slowly, or ceases altogether, counter pressure 
may be applied through the upper lid, at the opposite 
side of the cornea, by means of the thumb that is used to 
hold the lid in place. The pressure and counter pressure 
thus made must be used alternately, with a gentle rock- 
ing motion, until the last portion of the cataract has 
emerged and the pupil has taken on a uniformly black 
appearance. 

If the nucleus should turn out larger or more consist- 
ent than was expected, and hence refuse to pass through 
the wound, the Daviel spoon may be gently introduced 
and an attempt made to extract it, either whole or piece- 
meal. Care must be taken not to rupture the posterior 
capsule, as the escape of vitreous both complicates and 
retards convalescence, besides at once interrupting the 
operation if it occurs in its early stages. The fragments 
of the cataract are then often driven apart and away from 
the wound, and cannot in many cases be collected or re- 
moved without entailing a dangerous loss of the vitreous 
humor. Ifa prolapse of the iris takes place, it may be 
allowed to remain until the cataract has been removed, 
when it will often return spontaneously, or can be made 
to do so by gently rubbing through the closed lids. But 
if it obstinately retains its position, it must be at once 
excised. The healing of this into the wound might not 
only alter the corneal curve, but prove a source of irrita- 
tion by the traction it would exert, thus giving rise to 
serious trouble. It might also increase the density of the 


728 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


scar. The more peripheric the wound the greater the 
danger of prolapse. 

Fragments of the cataract remaining in the pupil im- 
bibe aqueous humor, swell, and may thus give rise to 
grave inflammatory symptoms; causing iritis, and delay- 
ing or preventing the healing of the wound. It may not: 
always be possible to effect a complete removal of these 
portions, owing to the size of the wound, the consistence 
of the cataract, or the lodgment of the smaller pieces in 
remote situations inaccessible to ordinary pressure. As 
Arlt, whose account of the operation has largely here 
been followed,® justly observes, simple linear extraction 
is by no means as universally applicable in cases of soft 
cataract as the first accounts of the operation, given by 
von Graefe, would lead one to suppose. 

After-Treatment.—After having instilled a drop of a 
solution of atropine, and ascertained that the lips of the 
wound are in proper coaptation, as well as that no re- 
mains of the cataract or coagulated blood are to be found 
in the conjunctival sac, the eye is closed, and a simple 
compressive bandage applied over each eye, thus secur- 
ing absolute repose. An elliptical piece of linen, soaked 
in the weak sublimate solution, 1 to 5,000, is first laid on 
each eye. The orbital cavity is then evenly filled with 
corrosive cotton applied in small tufts, as evenly dis- 
tributed as possible. These, as well as the bandage 
itself, should of course have been carefully sterilized. The 
hand, passed over the summit of the heap, should not 
distinguish the prominence of the eyeball. This process 
having been completed, the whole mass should be made 
to exert gentle pressure on the eye by means of a band- 
age, which may be either a simple cotton or flannel 
roller, or, still better, the so-called Liebreich bandage. 
The simplest form of this well-known appliance is a cotton 
band, about 30 cm. long and 6 wide, knit in small al- 
ternate squares, the threads in adjacent squares running 
at right angles to each other. Long tapes are attached 
to each of the four corners. The peculiar construction 
of this band insures a considerable degree of elasticity, 
and it is held in place over the eyes by securing the tapes. 
behind the head, the two upper being tied above, the two: 
lower below the crown. It is weil to remove the bandage 
some eight hours after the operation, gently sponge the 
outer surface of the lids, and apply a fresh dressing. If 
no pain, swelling, or excessive lachrymation be present, 
nothing will be gained by opening and examining the 
eye. At the end of twenty-four hours, during which 
time the patient has been kept in a recumbent position, 
it will be well to open the eye and instil a drop of a solu- 
tion of atropine. The bandage is now to be changed 
once a day for three or four days, when it may be re- 
moved altogether and a shade over both eyes substituted. 
After the first day the patient may leave his bed. As. 
the redness slowly disappears, more light may be ad- 
mitted and moderate use of the eyes allowed. It must. 
be remembered that the wound requires several days to. 
consolidate, and that during this time it is no difficult 
thing to separate its edges. 

Local pain, redness, and increasing photophobia are 
evidences of excessive reaction. The bandage may then 
be removed and cold compresses substituted, leeches ap- 
plied to the temple, and even subcutaneous injections of 
morphine made in the same region if the suffering is con- 
siderable. The bowels must be kept open. If none of 
these measures give relief, the aqueous humor is to be 
evacuated; better, according to Arlt, through a periph- 
eric puncture, than by reopening the original wound. 
In spite of all these precautions, iridocyclitis may ensue, 
and even give rise to sympathetic affection of the re- 
maining eye. Such cases are, happily, very infrequent. 

We now come to the consideration of one of the most 
important operations on the eye—that for the removal of 
senile cataract. It is proper to consider it immediately 
after linear extraction, just described, inasmuch as the 
most approved method now in use is that of peripheric 
linear extraction; a proceeding somewhat allied to the 
foregoing, and the general adoption of which has resulted. 
in the virtual abandonment of flap extraction, so univer- 


\ 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





sally practised less than a generation ago. Before, how- 
ever, commencing the discussion of this method, it is de- 
sirable to consider one or two plans that have been 
recently proposed for the artificial ripening of senile cata- 
racts, the formation of which proceeds with unusual 
slowness. This delay in the growth of cataract has been 
alluded to in an earlier portion of this article. In many 
cases, as was there stated, it proves a serious misfortune 
to the patient. All power of using either eye on near 
objects may be gone; it may even be difficult for the in- 
dividual to move about unattended, especially in strange 
places, and he may thus become a burden to his family. 
Meanwhile the cortical substance still retains a portion 
of its transparency. The best. years of life are passing 
away, or those dependent on the patient may be reduced 
to poverty in consequence of his inability to continue 
their support. Something ought, under such circum- 
stances, to be done; and the alternative to removing an 
unripe cataract is the artificial production of maturity. 

Two methods alone are regarded at the present day as 
offering ordinary chances of safety. The first is that 
proposed by Professor Férster, of Breslau, in 1881, and 
consists in the performance of an iridectomy upward, 
together with the rubbing of the cornea, over the face of 
the lens, with the angle of a strabismus hook. There 
being no anterior chamber, the pressure is directly applied 
to the lens through the intervening cornea. “The effect 
in ripening the cataract,” says Forster, “is frequently 
to interrupt the entire reflex from the fundus within six 
days. In from six toeight weeks at farthest the cataract 
entirely matures.” At the time of his bringing out this 
method he had practised it for five years and in about 
one hundred and fifty cases. He considered it chiefly 
applicable in cases of senile cataract with -hard nucleus, 
and partially opaque cortical; but advised that it be not 
employed in posterior polarcataract. He warned against 
using a pressure, on the one hand, so light as not to hasten 
the cortical opacity, and on the cther so extreme as to 
rupture the zonula. Recently Dr. Charles Bull, of New 
York, has given an analysis of thirty cases, in which he 
employed this method. In addition to the rupture of 
the zonula, which may be produced by too strong press- 
ure, he alludes to another consequence, “a striated or 
radiating opacity of the cornea, which seems to be con- 
fined to the anterior layers, frequently remains for a long 
period, and fades out but slowly.” He also recommends 
a rotatory rubbing or massage. Slight iritis has been 
observed to follow the operation by several observers, 
including the present writer. In Dr. Bull’s series, iritis 
occurred five times. All his cases were successful, vision 
ranging between 7% and -%%, in all but three, in which it 
was under 2°. ‘The average duration of the confine- 
ment, after the first operation, was five days. 

The second method of artificially ripening a cataract 
was alluded to by Férster when he brought forward the 
operation above described. It had been, he said, observed 
by Snellen that a simple iridectomy would sometimes 
hasten the progress of lenticular opacity. This he con- 
firmed from his ownexperience. In a recent publication 
Jakobson again calls attention to this fact. “It is well 
known,” he says, “that, up to within a short time, peo- 
ple half blind were obliged for months, and sometimes 
even for years, to rely on extraneous aid. -By the per- 
formance of an iridectomy we are now enabled to offer 
them a prospect of sight within three months.”!° He 
goes on to say that his experience with Férstey’s opera- 
tion has been unfortunate, iritis and inflammatory thick- 
ening of the anterior capsule having occurred in his 
practice. An iridectomy alone, in cases of unripe cata- 
ract, has been followed by inflammatory reaction, yield- 
ing, however, readily to atropine and fomentations. 

Of these two methods the second is undeniably safer, 
as offering less instrumental interference with the eye. 
It possesses the advantage of being in itself one of the 
steps in peripheric linear extraction, and its anterior per- 
formance leaves just so much less to be done when the 
cataract is finally removed. The practical objection to 
it is the fact that it subjects the patient to two operations 








Cataract, 
Cataract, 





on the eye, instead of one; two confinements with both 
eyes bandaged in a darkened chamber. The effect of all 
this on the general health and morale of the individual 
will vary in different cases: and therefore renders it im- 
possible to lay down any fixed rule with regard to the 
propriety of producing artificial maturity. All that can 
be said is, that in ordinary cases of slow growth, the per- 
formance of the additional operation would seem a lesser 
evil than weary months of waiting for natural ripening. 

A. few general remarks with regard to the extraction 
of senile cataract may fitly precede the descriptions of 
the various operations devised for this purpose. And 
first with regard to the induction of anzsthesia. On this 
point there has been much difference of opinion, its use 
having been comparatively general in this country, but 
far less frequent on the continent of Europe. The ex- 
perience of the present writer has convinced him that the 
state of aneesthesia throws appreciable obstacles in the 
way of a successful extraction, and that its regular em- 
ployment tends to diminish the number of favorable re- 
sults that would otherwise be obtained. This opinion is 
based on several grounds. The necessity of fasting be- 
fore the administration of the ether or chloroform, and 
the inability to retain nourishment for some time after- 
ward, have a depressing effect, especially on the aged 
and feeble. The amount of congestion induced in many 
by the inhalation of ether encourages hemorrhage and 
embarrasses the performance of the operation. The pa- 
tient’s ability to move his eye at will being lost during 
anesthesia, every needed motion has to be given to the 
eye by traction with the fixation forceps, inflicting a 
fresh bruise at every application, and sometimes leading 
to a loss of vitreous. The collapse due to anesthesia 
annuls tension and renders the removal of cortical frag- 
ments proportionally difficult. After the operation the 
patient is incapable of giving information with regard to 
the clearness of his acquired sight, and moreover loses 
the moral support of having once seen, a support well 
calculated to cheer the succeeding dark days of con- 
valescence. The surgeon, too, is thus deprived of im- 
portant knowledge with regard to the result of the efforts 
he has made to clear the pupil. Finally, the nausea that 
so often comes on as the effect of the ether passes off, the 
retching and vomiting, that sometimes endure for hours, 
can only have an injurious effect on an eye so recently 
laid open, besides rendering the patient unable to take 
nourishment and depressing his morale. To ascertain 
whether these objections were more than theoretical, two 
series of cases were operated on, a certain number with 
and an equal number without ether. Each series con- 
sisted of one hundred, and the great difference in the 
percentage of success was wholly in favor of the non- 
administration of the anesthetic. 

This discussion, however, becomes less important in 
view of the fact that, save in the most exceptional cases, 
local anesthesia amply suffices. It has already been 
described. 

A very important question next arises, as to whether 
the eye shall be prepared for the removal of the cataract 
by the dilatation of the pupil, as was formerly the usual 
custom. This practice was generally continued after 
the operation of flap extraction had given way to that in- 
troduced by von Graefe. The arguments for the instilla- 
tion of atropine before extraction were, in brief, that there 
would be more room for the knife in its passage across 
the anterior chamber; that its point would be less likely 
to catch in the iris, and a wound or dialysis would con- 
sequently more seldom follow: and that the secondary 
dilatation that ensues on the re-establishment of the an- 
terior chamber would tend to keep the edge of the iris 
clear of any fragments of cortical substance that might 
remain behind, and lessen the likelihood of a closed pupil 
and of a secondary cataract. It began, however, by de- 
grees to be found that, where mydriasis had not been in- 
duced, it was easier to replace the iris after extraction, 
and thus prevent its healing into the corners of the wound. 
To prevent this accident it was even advised to apply a 
solution of eserine, after the lens was removed.!! Acting 


729 


Cataract, 
Cataract, 





on this hint, the present writer has been in the habit of 
applying the eserine an hour before the operation. At 
the time of its performance there is then found a consider- 
able contraction of the pupil, which does not in the least 
interfere with extraction, and which yields when the an- 
terior chamber is re-established. It then exerts on the 
iris a degree of traction that reduces to a minimum the 
danger of its healing into the corners of the wound, and 
would even seem to render this complication less frequent 
than formerly. This contraction of the pupil readily 
yields to atropine, should it be found necessary: to employ 
it during the after-treatment. Eserin. salicylat., rubbed 
up with vaselinein the strength of one per cent., will be 
found a convenient preparation to use on account of its 
being less affected by time than the ordinary solution. 
The application of eserine is sometimes followed by slight 
temporary pain, and is hence contraindicated at the time 
of the operation. Its use has been objected to on the 
ground that the tendency to a loss of vitreous might be 
increased, but this theory has been proved unfounded. 
The advantages of operating on senile cataract in an 
establishment especially arranged for the purpose have 
already been al- 
| luded to. Should 
| this course be ad- 
opted, it is well to 
have the patient oc- 
cupy his room the 
night before the 
operation is per- 
formed. A certain 
amount of acquain- 
tance with the bed, 
the surroundings, 
and the attendants 
is thus acquired be- 
fore the bandage 
that prevents all use 
of the eyes for sev- 
eral days has been 
finally applied. 
Another advantage 
is that there may 
often be met, in the 






i) 
q | 
7 
















i 























same place, some 
Fig. 157. Fig. 1158. Fie. 1159. Fre. 1160, CONValescent who 
Graefe Cysti- Rubber Rubber has already passed 
Knife. tome. Spoon. Spatula. through the opera- 


tion, and who can 
be brought in contact with the intending patient. A few 
words of encouragement from such an individual will 
often do more to dispel apprehension and establish con- 
fidence than anything coming from the surgeon himself. 

If a trained and experienced nurse be present, the ser- 
vices of a professional assistant may readily be dispensed 
with. The patient awaits the surgeon in bed and un- 
dressed. As the bandage to be applied after the operation 
is monocular, the eye that is not to be touched is closed 
by several short strips of isinglass plaster, crossing each 
other. A short preliminary drill in turning the eye in 
any given direction, without any corresponding move- 
ment of the head, will be found of much use; the patient 
being directed to roll the eye up, down, or to either side 
at the request of the operator; being also cautioned, the 
while, to avoid straining, and to breathe easily and nat- 
urally. In the case of very deaf people it is well to 
arrange a little code of signals in advance, a tap on the 
forehead being understood to meana direction to look up, 
one on the chin to look down. Under ordinary circum- 
stances the duty of the nurse is confined to handing the 
iced sponges as they are needed, and supporting the head 
while the bandage is being applied. 

PERIPHERIC LINEAR ExTraction.—This is commonly 
known as the method of von Graefe. The instruments 
needed are a spring speculum, fixation forceps, elevator, 
Graefe extraction knife (Fig. 1158), cystitome and rubber 
spoon (Figs. 1158 and 1159), Daviel spoon, iris forceps and 
scissors, anda small, straight, flexible rubber spatula (Fig. 


730 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


- 


1160). A few soft compresses, floating in ice water, are 
also required, as well as corrosive cotton bandages, etc. 

The surgeon stands at the head of the bed, and should 
be able to operate on the right eye with the right hand, 
on the left with the left. Local 
anesthesia having been fully 
brought about, he introduces the 
spring speculum and locks it in 
place, being careful not to stretch 
the lids to a distressing extent. 
Requesting the patient to look 
up, he firmly grasps the eye with 
the fixation forceps, a little be- 
low tbe cornea. Holding the 
knife with its edge up, he now 
proceeds to make the cut. The 
accomplishment of this is not 
without its difficulties, and de- 
mands a careful description. It 
can best be understood by refer- 
ence to the following diagram 
(Fig. 1161), taken from Arlt.}? 
The knife is entered, with its 
blade up, at the point a, 1.5mm. 
from the corneal edge, and 2 mm. below a tangent to the 
upper corneal periphery on the temporal side, and direct- 
ed at first toward the point 0, situated downward and 
inward from the pupil. Having been carried steadily 
forward some 6 to 8 mm. in the direction of this point, 
the handle is lowered, the point of the knife directed to 
that of counter-puncture c, pushed forward, and made to 
emerge at this place. The wound to be inflicted will thus 
be some 12 mm. in length. It is better now to remove 
the fixation forceps, thus avoiding the danger of undue 
pressure, and to request the patient to look down. The 
wound is completed by a sawing movement of the knife, 
alternately advancing and withdrawing it a little, direct- 
ing its cutting edge toward the point at or just behind 
the upper corneal edge, where it is intended that it should 
emerge (Fig. 1162). No attempt should be made to divide 
the conjunctiva until the scleral cut is complete. The 
blade of the knife may then still be directed upward, but 
a little outward, and a conjunctival flap formed some 2 
or 3 mm. in height. Raising the handle of the knife 
abruptly, from the temple, is advised by Arlt as facilitat- 
ing this. It will be seen that this is not strictly a linear 
wound, as originally intended by von Graefe, so that the 
title of the operation is, to some extent, a misnomer. But 
the conjunctival flap can be formed only when the cut is 
made as above described, and the advantages of this flap 
as a protection to the scleral wound are at once evident. 

2 A curved cut is, more- 
over, longer than a 
linear one. The exter- 
nal cut being 
12 mm. in 
length the in- 
ner one would 
measure from 9 to 10 
mm., and as the diame- 
ter of the lens rarely 
exceeds 9 mm., there is 
sufficient room for its 
emergence. 

Should there be con- 
siderable hemorrhage 
from the conjunctival 
flap or the scleral 
wound, filling the an- 
terior chamber and ob- 
scuring the view of the iris, it is better temporarily to 
remove the speculum and hold soft iced compresses in 
gentle contact with the closed lids. , In a few minutes 
the bleeding will cease, the eye can be again opened, the 
speculum reinserted, and the coagulated blood removed 
with iris forceps. Ordinarily, however, we proceed di- 
rectly to the second step in the operation, the iridec- 
tomy. 





Fic. 1161.—Ideal Peripheric 
Linear Cut. (Corneal 
diameter 12 mm.) am.en, 
tangents to the horizontal 
diameter mn; d é, tan- 
gent to the vertical diam- 
eter; a, point of punct- 
ure; a, b, line of direction 
of back of knife at time of 
puncture; c, point of 
counter-puncture; a, d, 
h, e, €, course of conjune- 
tival wound; a, ¢, course 
of cornea-scleral wound 
on outer surface of sclera. 






Fi@. 1162.— (From Michel’s ‘“ Lehr- 
buch.’’) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


It is better to accomplish this without resuming fixa- 
tion. The iris scissors are taken in the right hand, the 
forceps in the left. The patient being directed to look 
down, the conjunctival flap is lifted with the forceps and 
laid backward over the cornea. The iris is now seized at 
its pupillary edge, the forceps being well carried over 


toward the end of the wound at the operator’s right, - 


withdrawn, lifted forward, and a straight cut, or rather 
split, made in its tissue from the pupillary to the ciliary 
edge; it is then drawn over toward the opposite corner 
of the wound, being divided as it is thus drawn by re- 
peated strokes of the scissors, and the piece finally com- 
pletely excised by passing the scissors on the other side 
of the forceps and repeating the first cut from the pupil- 
lary edge backward. A coloboma of from 4 to 8 mm. in 
extent is thus formed. Professor Arlt, whose method of 
executing the iridectomy is here closely followed, advises 
strongly against tearing the iris from its ciliary attach- 
ment, rather than cutting it as just described. By fol- 
lowing the latter course hemorrhage is far less likely to 
occur. Theedgesof the colobomaare to converge toward 
the pupil, and if considerable iris tissue is left in the 
corners of the wound it is to be separately excised. At 
this stage it is often advised to replace small prolapses of 
iris at the wound angles with the rubber spatula; but as 
the delivery of the lens is almost certain to be followed 
by their recurrence, it is better to wait until this has 
taken place and the pupil been cleared. Hemorrhage 
may now, if at all embarrassing, be controlled in the 
manner formerly described. 

Opening of the Capsule.—Careful watch should be kept 
over the amount of pressure which the spring speculum 
exerts on theeye. If thisorgan be unusually prominent, 
or the straining of the patient excessive, the speculum 
may be slightly lifted off by the unoccupied hand of the 
operator; or even removed altogether and an elevator 
substituted. Fixation, which has been dispensed with 
since the performance of the first step in the operation, is 
not again to be employed. 

A word, in passing, on this subject. Sufficient stress 
has hardly ever been laid on the injurious effect on the 
eye of prolonged fixation. Each grasp of so delicate and 
sensitive a member with this rude instrument (toothed or 
serrated forceps) causes ciliary injection and acts as a 
local bruise, the multiplication of which may well tend 
to complicate or retard the healing process. Becker’s 
remarks, in this connection, are most instructive. He 
says: “Seizure of the conjunctiva bulbi, either alone or 
with the addition of the tendon of the rectus inferior, is 
ordinarily looked upon with indifference. And yet an 
appreciable injury is only too often thus inflicted. 
Though the fixation forceps be used in the most careful 
manner, the point which they seize becomes for days the 
seat of a defined redness. If the teeth of the forceps are 
very sharp, the patient restless, and the conjunctiva 
fragile, as is often the case with the aged, bleeding fol- 
lows, and the tissue may even tear.” Speaking later of 
the wrenching given the cornea, ciliary body, and iris, by 
drawing down the eye after the cut has been completed, 
he observes: “The more or less perfect manner in which 
these secondary injuries are avoided goes very far to de- 
termine the varying success met with by operators of 
otherwise equal skill.” 18 

The cystitome is introduced flatwise, at one corner of 
the wound, pushed forward until its extremity comes 
opposite the lower edge of the pupil, then turned with 
its cutting edge toward the face of the capsule, and 
drawn gently upward to the edge of the wound. To 
secure a free opening it is better to introduce it a second 
time, apply it at a point on one side of that first selected, 
and again draw it upward ina line diverging from the 
previous one. Care should be taken to exert little or no 
pressure backward, for fear of causing dislocation of the 
lens. If the eye be deep-set, it will be necessary to bend 
the stem of the instrument at an angle some 7 mm. from 
its point. Should the anterior chamber be filled with 
blood that cannot be cleared away, the cystitome must 
still be used in the region of the supposed pupil; but it 


Cataract, 
Cataract, 





is well, under such circumstances; to restrict somewhat 
its excursions. 

Arlt prefers, to the ordinary cystitome of von Graefe, a 
sharp iris hook with a flexible stem. In cases in which 
the capsule is opaque there is no doubt but that this 
membrane may be better seized with such an instrument 
and brought to the edge of the wound, where it can be 
removed with scissors. The use of the hook demands, 
however, special dexterity on the part of the operator. 

Delivery of the Lens.—We come now to one of the most 
critical portions of the operation, during which the 
escape of vitreous is most to be dreaded. Should this 
accident happen in the shape of a sudden gush, it is de- 
sirable immediately to close the eye. The withdrawal of 
the spring speculum takes time, as it has to be first un- 
locked und then carefully removed from under the two 
lids separately, and without tilting over the cartilage of 
the upper lid, acommon occurrence. It has, therefore, 
long been the practice of the writer to remove the specu- 
lum before proceeding to the delivery of the lens, and 
either to raise the upper lid with the forefinger of the left 
hand or else to lift it by means of a simple elevator, which 
can be instantly slipped out if occasion demands. To 
effect the removal of the lens, the patient is first directed 
to look down and to keep his gaze fixed in this direction. 
Much difficulty is occasionally experienced in keeping 
this up, the eye exhibiting a tendency to roll upward. 
In such cases it may be found advantageous to place one 
of the patient’s hands outside the bedclothes and then 
request him to look persistently in its direction. It may 
serve to fix his attention if the nurse smartly taps the 
hand from time to time. By getting the patient to look 
down we are able to exert pressure against the eye 
through the lower lid, and thus to escape the necessity 
of bringing any instrument in direct contact with the 
eyeball. The convexity of the Daviel spoon or the back 
of a large hard-rubber spoon is laid against the outside 
of the lower lid; pressed gently, at first backward and 
then upward, and then, if the lens shows a tendency to 
emerge and the edge presents itself at the wound, used 
to assist its expulsion by gently rubbing upward. Should 
the eye roll up, the pressure must, of course, be applied 
directly to the eyeball. The moment half the lens has 
passed through the wound, pressure is to be lessened, 
but not omitted, until the entire crystalline has emerged. 
If, in spite of judicious pressure, the lens fails to pre- 
sent itself at the wound, or, having presented itself, to 
advance, the first thing to do is to repeat the opening of 
the capsule, a delicate and often difficult proceedure. 

The lens once removed, the lids may be suffered to 
close and the patient to restafew moments. Compresses 
dipped in cold water may be applied to the eye exter- 
nally and frequently changed. When the eye is again 
opened, the pupil is to be carefully examined. If lens 
fragments or coagula occupy its area, they may be ex- 
pelled by repeating the manceuvre for the removal of the 
lens, rubbing upward while the patient looks down. 
They should, however, first be collected in the centre of 
the pupil by closing the eye and rubbing gently over its 
convexity, in a circular direction, with the point of the 
forefinger. If the cloudiness is evidently due to an 
opaque capsule, it is better to leave it alone and trust for 
its removal to a secondary operation. Incising it with a 
cystitome or sharp hook, as is sometimes advised, would 
lead to an escape forward of vitreous, and might com- 
plicate recovery. When the pupil is apparently clear, 
vision must be tested. If the answersare unsatisfactory, 
if the patient cannot count or name the fingers held be- 
fore him, his head of course being turned away from the 
light, the rubbing must be renewed. No inspection of 
the pupil by the surgeon gives information comparable 
to the actual exercise of vision by the patient himself; 
nor should the bandage be applied until the sight seems 
reasonably good. If, indeed, there were no other reason 
for this course, the advantage of the moral effect pro- 
duced on the patient can scarcely be over-rated. 

The corners of the wound must now be carefully ex- 
amined to see whether iris tissue has become incarcerated 


731 


Cataract, 
Cataract, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. — . 


there. Should this be the case the flat rubber spatula 
may be used for its replacement, pushing it first out of 
the wound, and then gently patting or spreading it out 
in its proper position. The importance of thus clearing 
the wound, as well as the danger of allowing a prolapse 
of iris to heal into the cut, can scarcely be exaggerated. 
As soon as the anterior chamber has become re-established 
the influence of the eserine will again be asserted, and 
offer an additional safeguard against this accident. After 
the remains of the cataract and coagulated blood have 
been removed from about the wound and from the con- 
junctival sac, by means of the edge of a bit of soft linen 
or a similar fragment of sponge, the conjunctival flap is 
to be carefully lifted into place by the iris forceps and 
the eye closed; care being taken that the upper lid, in 
its descent, does not reverse the flap. 

Accidents during the Operation.—The most dreaded is 
the escape of vitreous. This may be due to a faulty 
position of the wound, to intra-ocular disease resulting 
in abnormal fluidity of this humor, or to the employment 
of undue pressure in expelling the cataract. While the 
moderate loss of vitreous may be simply followed by a 
lengthened and irritable convalescence, its escape in any 
considerable quantity is apt to entail retinal separation, 
choroidal disease, or even general inflammation of the 
eyeball. The accident is characterized by the appear- 
ance in the wound of a transparent viscid fluid. If it 
occurs immediately after the completion of the cut, the iris 
is to be quickly excised. The removal of the lens has 
now to be effected, with as little further escape of the 
humor as possible. Any pressure would, of course, in- 
crease this tendency. No attempt is to be made to open 
the capsule, and the lens is to be removed by traction 














Fig. 1163.—Critchett’s Scoop. 


with an appropriate instrument. For this purpose the 
writer hasalways employed Critchett’s scoop (Fig. 1168), 
an instrument that combines lightness with flexibility, 
and effects reliable traction; occupying the while com- 
paratively little space in the eye and distending the edge 
of the pupil but slightly. Its employment demands a 
quick eye and a steady hand. If the eye is deep-set the 
instrument is to be somewhat bent, and is then to be in- 
troduced with the patient looking down, and in such a 
direction that its edge slips behind the periphery of the 
lens. It is now quickly passed down until its lower rim 
is thought to be opposite the base of the lens, the handle 
is then to be sharply but gently inclined backward, and 
the instrument at the same time drawn up and out of the 
eye, bringing the lens with it. This manceuvre bears a 
distant resemblance to that by which a lever pries a stone 
out of the ground. A gush of vitreous generally occurs 
at the instant the lens emerges; the eye is, therefore, to 
be instantly closed and dressings are to be applied. The 
lens is thus extracted in its capsule, and subsequent vision 
is apt to be unusually clear and distinct in cases in which 
a good recovery is made. 

Where, after the operation, vitreous simply projects at 
the edge of the wound, separating its lips, some advise 
excision of the prolapsed portion with fine sharp scissors. 
It is better practice to leave it alone and trust to, the in- 
fluence of the pressure bandage to effect its subsidence. 
Should this prolapse occur after the nucleus has passed 
out, but before the pupil has been thoroughly freed from 
cortical substance, the operator finds himself between the 
two horns of adilemma. ‘The lesser evil is to close the 
eye at once and. trust to time for the absorption of the 
remaining cortical. Bleeding into the anterior chamber 
may occur during either of the several stages of the op- 
eration, and has already been alluded to. 

Bandages and After-Treatment.—An elliptical patch of 
soft linen is to be laid on the eye, and the orbital hollow 
filled with small tufts of corrosive cotton, as was de- 
scribed in connection with the after-treatment of linear 


732 


extraction. In the present case, however, one eye is 
already closed by strips of plaster, and the bandage is, 
therefore, to be monocular. Every surgeon has his 
favorite form; the writer prefers a flannel roller, 4.5 ° 
mm. in width, and long enough to encircle the head three 
times alternately with a similar number of rising turns 
over the eye, one fold overlapping the other, the whole 
affording moderate compression and support. If the 
weather be very warm, gauze may be advantageously 
substituted for flannel. The bandage once applied, the 
room is to be darkened and the patient left in quiet for 
afew hours. He is to avoid turning over on the side of 
the operated eye. Should he desire to vary his position 
by lying on the opposite side, he is to lift his head slightly 
from the pillow, so as to avoid dragging on the bandage. 
Should the operation have been performed in the morn- 
ing, the patient may be seen again in the course of the 
afternoon. At this, as well as subsequent visits, it is 
well to avoid letting in daylight, on account of the great 
change in illumination that may unexpectedly occur. 
The sudden emergence of the sun from behind a cloud 
may unexpectedly flood the room with light and distress 
an eye used to entire darkness. A single candle is the 
best and most easily managed source of illumination. By 
the time of this visit the pad next the eye will generally 
be found more or less stiff and uncomfortable, having 
become soaked with blood and tears. It should, there- 
fore, be changed. The outside of the lids may be gently 
bathed with a soft compress dipped in lukewarm water, 
but they are on no account to be separated unless some- 
thing unusual has occurred. To this end the patient is 
to be cautioned, before the bandage is removed, not to 
open his eye, but to keep it softly closed. The feeling 
of soreness and the sensation of a foreign body between 
the lids will by this time have probably died away. 
The dressing having been renewed a bed-chair may be 
brought in, and the patient allowed to rest. himself by 
sitting up in bed fora short time. Later in the evening 
a dose of chloral may be given. It is well to have a 
watcher in the room the first one or two nights. 

At the visit on the following day, if the case be pro- 
gressing favorably, the lids are again to be washed and the 
bandage is to be renewed, but the eye is not to be opened. 
From this time forth the bandage may be changed once 
in twenty-four hours. By the third day the plaster used 
to close the other eye will ordinarily be found to have 
become quite stiff, and its edges will have rolled in, 
causing some discomfort. It is therefore to be soaked 
off. A Liebreich bandage may now be used over both 
eyes, instead of the flannel roller. By this time, too, the 
patient may sit up in an easy chair and have his bed 
made. He is to spend an increasing portion of every day 
out of bed until he occupies the latter only at night. 
The diet is to be nutritious, but all chewing should be 
strictly avoided. The room should still be kept darkened. 

There is, among ophthalmic surgeons, a great divers- 
ity of opinion as to when the lids should first be separated 
and the eyeexamined. Arlt lays downno fixed rule, but 
intimates that this may occur at the second visit, twenty- 
four hours after the operation; and even sooner if neces- 
sary. The experience of the present writer has led him 
to adopt a different course. He gradually came to find 
that the eye did quite as well if the lids were allowed to 
remain closed two or even three days. As time went 
on, a new fact forced itself repeatedly on his notice; that 
in certain cases, in which the healing process was inter- 
rupted by inflammatory complications, the first pain, 
lachrymation, or discharge followed accurately on the 
first separation of the lids, however carefully managed 
and however hasty the examination. The case might 
have been doing perfectly well for three or four days; 
no swelling of the lids, lachrymation, or undue discharge 
being present, or the slightest pain experienced; the eye 
might then, for the first time, be opened and rapidly sur- 
veyed by a weak light, no lens being used and no trial of 
the vision made, and yet within a few hours pain would 
occur and marked symptoms of inflammation be present. 
This happened so frequently that it became impossible 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Cataract, 
Cataract, 





not to connect the examination and the inflammation as 
cause and effect. Acting on this belief he kept prolong- 
ing the time that he allowed the eye to remain unopened, 
and now he rarely makes the first examination before the 
morning of the eighth day. At this time it is often re- 
markable to see how little evidence of the operation is 


present, a trifling redness in the immediate vicinity of 


the wound being sometimes all there is to be seen. This 
redness, slight at first, will be observed for several days 
steadily to increase before it begins to disappear. 

The above course of treatment is applicable only to 
cases in which the healing process may be presumed to 
be progressing normally. The writer believes that the 
longer the examination is deferred the more likely the 
patient is to do well, and he bases this opinion simply on 
experience. Of course, numerous theoretical objections 
to such a method might be alleged. It could be argued 
that the secretions of the wound, and the blood left in the 
conjunctival sac, being unable to escape, might decom- 
pose and act as sources of infection. This and other ob- 
jections might be brought forward. To those urging 
them the writer simply suggests a fair trial of the plan 
itself, believing that they will in the end themselves 
find that the longer they leave the wound undisturbed, 
in contact with and guarded by the covering provided 
by nature, thus sealed and protected from any germs of 
contagion with which the atmosphere may be infected, 
and which the exposure of a single instant might attract, 
the more success they will meet with in the after-treat- 
ment of extraction. 

One caution must here be given. While, as a rule, 
both eyes should remain covered until the eighth day, it 
must be borne in mind that some aged and weak people 
are peculiarly sensitive to the combined effects of dark- 
ness and solitude, and may be attacked by a form of 
delirium which renders them difficult to control. If this 
occurs the sound eye may be sooner uncovered, perhaps 
on the fourth or fifth day. After the removal of the 
bandage from both eyes, light may gradually be admitted 
into the room, the patient wearing a shade, or a pair of 
blue or smoked protective glasses curved to cover the 
eve more effectually, the so-called “coquille” spec- 
tacles. Several days should still be suffered to elapse 
before the patient is discharged from the immediate 
supervision of the surgeon. During this time the pupil 
is to be carefully watched, and atropine used if it evinces 
a tendency to contract, or if its area is at all occupied by 
remains of blood or cortical substance. Fifteen days 
after the performance of the operation the patient may 
ordinarily go to his own home, but he is to wear the pro- 
tective glasses fora month or six weeks longer, and to 
avoid exposure to bright light, or any use of the eyes. 
When six weeks have elapsed after the removal of the 
cataract he may cautiously commence the use of the ap- 
propriate glasses. 

We have thus far considered a case of uncomplicated 
recovery, and must be prepared to deal with departures 
from this type, they being unfortunately not infrequent. 
Unusual duration of the pain connected with the opera- 
tion itself may often be relieved by removing the band- 
age and washing the outside of the eye with ice-water. 
If it still continues, the edges of the lids may be examined 
to see if any lashes have become inverted, and the under 
lid may be slightly drawn downward to allow the escape 
of any accumulation of tears. Cold compresses may be 
alternated with the compressive bandage, or even a mor- 
phine injection may be made in the temple. In extreme 
cases the linen pad next the eye may be thoroughly wet 
with atropine, although the use of a mydriatic should, if 
possible, be dispensed with for several days after the 
operation, on account of the danger of prolapse into the 
corners of the wound. If the pain continues, or even if, 
in the absence of pain, the lids swell and lachrymation 
or discharge be present, the eye must be opened and 
carefully examined by oblique light, the candle being 
held to one side and its rays concentrated on the eye by 
means of a convex lens of short focus. Iritis, if present, 
is to be treated by leeches to the temple, atropine, and 








the alternation of the bandage with warm, but not hot, 
fomentations. If there are signs of suppuration in the 
wound, the fomentations are to be even more regularly 
applied, twenty minutes at a time, every four hours, and 
the bandage is to be kept on in the interval, being ap- 
plied even more tightly. The eye may, moreover, be 
bathed with the following antiseptic solution: Salicylate 
of sodium, 1 gm.; boracic acid, 3 gm.; dissolve in warm 
water, 100 gm.; stir well, cool slowly, and strain. 

Compresses wet with this solution may be constantly 
kept on the eye; if the inflammatory process continues 
and no benefit is derived from the fomentations and the 
bandage, quinine should be given in large doses, and the . 
general health supported with generous diet and stimu- 
lants. The previous history and habits of every patient 
are to be well weighed by the surgeon; those addicted to 
the free use of stimulants would incur great danger of an 
unfavorable result if these were suddenly suppressed. 
Should any form of opium have been habitually indulged 
in, the customary ration must be allowed. 

If thirty-six or forty-eight hours pass without accident 
it is probable that the eve will be saved, and some meas- 
ure of sight retained. _Irvitis is still possible, but, if prop- 
erly treated, is unlikely to result in blindness. One great 
danger to be guarded against during convalescence is a 
sudden blow on the eye, inflicted by the patient himself 
during sleep or carelessly when awake. This may cause 
bleeding into the anterior chamber, or even rupture of 
the wound. The blood may be absorbed or the wound 
heal under a prolonged application of the bandage, and 
no ultimate ill effect be experienced; orastate of chronic 
irritation may follow, ending in closure of the pupil and 
necessitating the performance of a secondary operation. 
Or, at the worst, irido-cyclitis may ensue, the pupil clos- 
ing and the iris being drawn forward until the anterior 
chamber is obliterated, all perception of light disappear- 
ing after weeks of suffering. There are even instances 
on record of this condition of things causing sympathetic 
irritation and ultimate loss of the remaining eye. It 
would be well, therefore, to proceed to enucleation in the 
case of an eye in this condition, especially if tenderness 
on pressure exists. 

SECONDARY OPERATIONS.—After an ordinary extrac- 
tion the anterior capsule retracts and leaves the area of 
the pupil occupied, substantially, by the posterior cap- 
sule only, thus exposing any portions of cortical sub- 
stance that may remain behind to the full action of the 
aqueous humor. In cases, therefore, in which the cata- 
ract was not entirely mature, and in which lens substance 
as yet clear has escaped notice and been left behind after 
the operation, it may happen that a pupil which at first 
appeared clear and black is discovered, on removing the 
bandage, to be entirely blocked with opaque cortical 
masses, swollen and pressing forward. These may be 
absorbed quietly and vision be slowly gained. But they 
are more apt to give rise to inflammation of the iris, by 
the mechanical pressure which they exert upon it, and 
to cause this membrane to contract adhesions with them. 
After the inflammation subsides we may thus find a pupil 
contracted, drawn up, and filled with a dense membrane, 
a so-called secondary cataract. Another form of second- 
ary cataract is the opacity of the capsule or the deposit 
of opacities on the capsule that sometimes occurs long 
after the extraction, and that does not appear to be con- 
nected with any unusual feature, either of the operation 
itself or of subsequent convalescence. Patients often re- 
turn, years after the cataract has been removed, com- 
plaining that their vision, originally excellent, has gradu- 
ally undergone diminution. The power of reading any 
but the largest type may perhaps have entirely disap- 
peared. The capsular opacities in these cases are often 
apparently insignificant, hardly visible indeed by oblique 
illumination. But the ophthalmoscope shows the outline 
of the optic nerve to be indistinct and distorted; and the 
mirror alone, particularly that of the binocular instru- 
ment, plainly reveals a delicate web of opaque capsule 
stretched across the pupil, now distinct in one part and 
now inanother, as the handle of the instrument is slightlv 


733 


Cataract, 
Cataract, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





rotated, and the direction of the reflected light thus 
changed. 

To bring about a return of vision it is necessary to 
secure a permanent opening in this capsular screen. 
Numerous devices have been imagined for the accom- 
plishment of this. Discission with a single needle is 
rarely sufficient. The introduction of a hook, through a 
small opening made for this purpose at the edge of the 
cornea, enables us to tear away a piece of the capsule, 
but may give rise to a dangerous amount of traction, 
and thus result in irritation or inflammation of the ciliary 
body. To avoid this, Bowman devised the so-called 
“double-needle operation.” Two ordinary discission 
needles are used; one is taken in the left hand, is passed 
through the middle of the inner half of the cornea, and 
made to penetrate the thickened capsule; the other is 
held in the right hand, passed through a corresponding 
point in the middle of the outer half of the cornea, and 
introduced into the capsule by the side of the first. One 
needle is then held still while the other tears from it, or 
else each is made to tear the capsule in an opposite direc- 
tion. In either case a point @appui is gained, and the 
strain no longer comes on the ciliary body. Among 
other ingenious operations of this class is one devised by 
Dr. C. R. Agnew, of New York. Passing his first needle 
through cornea and capsule, as in Bowman’s operation, 
he makes an incision with a broad needle at the opposite 
corneal edge, being careful in withdrawing this needle to 
allow no escape of aqueous by its side. He then passes 
through the opening a sharp and flexible hook, engages 
its point in the capsule just where it is pierced by the 
stop-needle, and tears a hole from this needle which thus 
acts as a point of support. 

Where the pupil is drawn up and filled with tough 
membrane, or remnants of lens substance enclosed in 
opaque capsule; where the iris, tightly stretched and 
thickened by inflammation, obstructs all access of light 
to the retina, the operations above described are imprac- 
ticable. Simple iridectomy is rarely resorted to, owing 
to the difficulty experienced in grasping and withdraw- 
ing sufficient iris tissue. Iridotomy, incision of the iris 
itself, is here to be advised. Wecker’s scissors, some- 
times used for this purpose, are a pair of short and deli- 
cate blades, made to open and shut by the lateral move- 
ment of the two sides of the long forceps handle to which 
they are attached. A lance knife is first passed through 
cornea and iris, and the scissors are then introduced into 
the opening in the latter and used to give it increased 
length, one arm being inserted behind iris and thickened 
capsule, the other in front of them. If the wound thus 
made gapes, disclosing a clear black pupil, no further 
interference is necessary ; if not, asecond incision is made 
at an angle to the former one. The included flap may 
even be withdrawn with iris forceps and excised. Far 
simpler, and, in the writer’s opinion, safer, is the incision 
of the iris and capsule by means of a narrow Graefe knife 
passed obliquely through cornea and iris, and made to 
act as a lever, incising the latter by simply raising or de- 
pressing its handle, according as its edge looks up or 
down, the cornea in this case acting as the fulcrum. By 
introducing the knife in a new place a second incision 
may be made at an angle to the former one. Vitreous is 
much less likely to be lost when iridotomy is done in 
this manner. 

Simple Extraction or EHatraction without Iridectomy.— 
This operation is daily finding its way into more general 
use. It cannot be said to have supplanted the one just 
described, as each has its appropriate field. But extrac- 
tion without iridectomy has become the more popular 
method, while the old operation is beginning to be con- 
fined to a daily diminishing class of selected cases. It 
might be well to preface the description of the operation 
by a brief account of its advantages and disadvantages. 

The advantages of the non-performance of an iridec- 
tomy are simply and concisely stated by Professor Pflii- 
ger (Kl. Monatsblatter fiir Augenheilkunde, May, 1892, p. 
161). He considers the return to simple extraction to be 
the greatest improvement in the cataract operation that 


734 





has occurred for twenty-five years, and for the following 
reasons : 

The conservation of the normal pupil combines optical 
with antiseptic advantages, in regard to the first part it 
having been proved that the corneal refractive power is 
at its best in the centre of that membrane; moreover, 

(1) There is no wound of the iris, and hence far less 
likelihood of a depot for the collection of offensive, that. 
is, infectious material; 

(2) There is no bleeding into the anterior chamber, to 
obscure the subsequent steps of the operation; 

(8) The wound is protected by the intact iris from con- 
tact with fragments of capsule, the presence of which so 
often causes slow healing and secondary infection, lead- 
ing it may be to chronic irido-cyclitis and even to sym- 
pathetic affection of the other eye; 

(4) There is a certain amount of protection against loss 
of vitreous; 

(5) Pfliiger’s experience leads him to think, strange as. 
the fact may appear, that there is less danger of second- 
ary glaucoma in the case of a simple extraction. 

It is not asserted that the percentage of corneal sup- 
puration is affected by the performance or non-perform- 
ance of an iridectomy. Stress is laid on the claim that, 
after successful simple extraction, the excentric vision is. 
better and light better borne. On the other hand, it may 
be replied that the iridectomy need not be a large one, 
and that being made directly upward it is largely covered 
by the upper lid, thus insuring a considerable use of the 
centre of the cornea. 

Furthermore: 1. Considering the extent of the corneal 
wound, as well as the frequently large solution of con- 
tinuity of the conjunctiva itself, the additional terrain 
afforded by the iridectomy for the collection of infectious 
material would be a matter of small account. 

2. Bleeding is reduced to a minimum by the action of 
the cocaine, and frequently is entirely absent. 

3. If prolapse of the iris, or even dislocation of the 
pupil occurs, the capsular fragments may yet come in 
contact with the wound, and these capsular fragments, 
as well as cortical remains, can be both more perfectly 
detected and thoroughly removed where the area is laid 
bare by an iridectomy. 

4. That the statistics of simple extraction show a les- 
sened percentage of vitreous prolapse, as compared with 
the Graefe operation, is not as yet universally admitted. 

5. The same may be said in regard to the occurrence 
of glaucoma. The experience of individual operators. 
is here at variance. Dr. Knapp, in 1890, reported three 
cases of glaucoma as occurring among one hundred simple: 
extractions (Archives of Ophthalmology, vol. xix., p. 299). 

There are two serious drawbacks to simple extraction: 

The first is the difficulty in clearing the pupil of cortical 
and capsular remains, after the lens has been delivered. 
It is obvious that, with an iridectomy, there is a larger 
pupillary area in view and a wider aperture for the 
extrusion of whatever may occupy it. Moreover, the 
manceuvres we generally employ for the clearing of the 
pupil, the tilting and rubbing, tend to maintain, if not 
to produce, the presence of the iris between the lips of 
the wound, and to render its ultimate reposition more 
difficult. 

This leads directly up to the main objection to simple 
extraction, the liability to iris prolapse. This accident is 
met with in from seven to ten per cent. of all cases of 
this operation. Its disadvantages are the change thereby 
wrought in the corneal curve, the dislocation of the 
pupil, the lengthened convalescence entailed, and the 
tendency to cystoid cicatrization of the wound. It is. 
most likely to occur in consequence of a sudden motion 
or injudicious effort on the part of the patient within the 
first few days after the operation, and may be brought. 
about by the forcible contact of the hand with the eye 
during sleep. The wound being ruptured, the aqueous. 
humor escapes, and carries with it the iris, which remains. 
incarcerated between the lips of the wound. A sudden 
sharp pain is sometimes felt and arouses suspicion as to 
what may have occurred. But there are cases in which 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cataract, 
Cataract, 





no imprudent motion is known to have taken place, and 
no warning has been sounded, and yet in which the first 
inspection of the eye, several days after the operation, 
reveals an extensive iris displacement. 

The tendency of the eye to undergo this accident is 
well illustrated by the statistics of a third series of 100 
cataract extractions without iridectomy, published by 
Dr. Knapp (Archives of Ophthalmology, vol. xix., p. 280). 

In 7 of these cases iridectomy had to be performed 
during the operation. 

In 2 cases the iris folded itself over the knife and 
was excised. 

In 8 cases prolapse and incarceration of the iris occurred 
during the healing process. 

Highty-three of these patients therefore recovered with 
fair, round pupils, 15 either had iridectomy performed 
or would have been better off had this been done. Ina 
recent letter Dr. Knapp informs me that his confidence 
in simple extraction is undiminished, and that he em- 
ploys it in fully 90 per cent. of all his cases. 

PERFORMANCE OF SIMPLE ExTRACTION.—The long, 
narrow knife of von Graefe may be used for the corneal 
incision, the puncture and counter-puncture being made 
just above the horizontal meridian of the cornea, in the 
transparent periphery of this membrane, the apex of the 
cut alone encroaching on the limbus. This is the course 
taken by experienced operators like Knapp, who aim at 
the avoidance of the peripheric section of former years. 
The capsule opening is made by some at the same time, 
and with the same knife used in the incision; by others 
with a special cystitome, and may be central or periph- 
eric, either method having its advocates. Sometimes 
a piece of the anterior capsule is removed with forceps 
specially constructed for this purpose. To expel the 
lens pressure is made at the base of the cornea, through 
the lower lid, while the upper lip of the wound is at the 
same time slightly depressed by means of pressure made 
through the upper lid. After the delivery of the lens, 
the pupil, if still occupied by fragments of cortical or 
remains of capsule, may be freed by judicious manipula- 
tion, or irrigated with a sterilized solution of boric acid 
or common salt, either one-half or one per cent. in 
strength. These solutions should be slightly warmed 
and but little force used in their introduction. For this 
reason the syringe originally employed by McKeown will 
be found less manageable, as well as more difficult to 
sterilize, than the apparatus of Lippincott (Transactions 
American Ophthalmological Society, Twenty-seventh 
Meeting, p. 115), or the “undine” of Wicherkiewicz. 
The writer has modified the latter instrument by attach- 
ing to its large aperture a short rubber tube, ending in a 
glass mouthpiece. Both hands of the operator are thus 
left free; he holds the mouthpiece between his teeth, and 
is enabled at will to modify the pressure to any extent, 
or even to reverse it and withdraw masses of cortical by 
suction into the apparatus itself. Solutions of corrosive 
sublimate are no longer used for irrigation, on account of 
the corneal opacities they were found occasionally to in- 
duce. Care must be taken to keep the opening of the 
irrigator as far from the pupillary edge as possible, pro- 
lapse of the iris being readily encouraged by its too im- 
mediate contact with this region. It is at best a clumsy 
instrument and its use a choice of evils. 

After the clearing of the pupil and anterior chamber 
has been completed the iris must be carefully replaced, 
there being no better instrument for this purpose than a 
flat, narrow rubber spatula. If reduction be found im- 
possible, or the iris shows a tendency to fall back into the 
wound, a small iridectomy must be made on the spot. 
In any case a solution of eserine (one per cent.) or pilo- 
carpine (two per cent.) should be dropped into the eye 
before closing it. 

It has of late been seriously proposed by certain sur- 
geons that the non-operated eye be left unguarded, that 
only a light dressing be applied to the other, and that the 
patient be kept in an undarkened room and allowed much 
freedom of motion. Good results are claimed from such 
an absence of treatment. This, if true, would reverse 








our traditions and revolutionize our practice. But as yet 
the only evidence in its favor is that of vague assertion, 
unsupported by definite statistics. Its advocates are at 
present few. 

Iris prolapse being, as has been stated, often due to 
the sudden escape of the aqueous humor, consequent on 
a rupture of the corneal wound, an ingenious means of 
obviating this has been devised by Dr. H. B. Chandler, 
of Boston, and proposed by him as a modification of the 
operation. He makes a small opening in the iris in order 
to allow the free escape of the aqueous, which collects 
behind this membrane, and claims that this prevents 
prolapse. 

His description of the operation is as follows: “ After 
making a corneal cut, exactly at the cornea-scleral junc- 
tion, a very small piece of iris, about 1 or 2 mm. from 
the periphery, is caught up, either by means of a fine iris 
forceps, with teeth situated on the lower portion of the 
blade, as near the point as possible, or by means of a 
sharp hook, the bent portion being at right angles and 
about 1 mm. long, and gently drawn out, is cut horizon- 
tally as close to the gripping instrument as possible; this 
leaves a small round opening, not more than 1 to 2 mm. 
in diameter” (Boston Medical and Surgical Journal, 
October 16th, 1890, p. 366). 

For two or three days after a simple extraction greater 
quiet is necessary than is the case when iridectomy has 
been performed, the patient being cautioned to avoid 
straining and all sudden exertion. The occurrence of 
severe pain in the eye, or even a feeling of irritation, 
such as might proceed from the presence of a foreign 
body, should arouse suspicion of prolapse. If this comes 
on within two days after the operation, the eye must be 
opened and the protruding iris reduced or excised. 
Otherwise it is better to leave it alone until the wound is 
thoroughly consolidated. After a lapse of several weeks 
the prolapse, if it shows no signs of flattening, may be 
excised or cauterized. 

And now comes the practical question as to which of 
these two methods of extraction, the combined or the 
simple, is to be employed ina given case. In the pres- 
ent state of our knowledge the first thought of the sur- 
geon is undoubtedly a desire to remove the cataract 
without the mutilation of the eye which accompanies 
an iridectomy, provided this can be done with safety. It 
is therefore well to sum up the contraindications to the 
simple operation. Concerning these, opinions vary, yet 
it may fairly be conceded that extraction with iridectomy 
is a safer method when: 

(a) The patient is well advanced in years. 

(0) When he is very nervous or restless, impatient of 
restraint or devoid of self-control, prolapse of the iris 
being under such circumstances more to be dreaded. 

(c) When the diameter of the cornea is less than usual, 
or when the pupil fails to dilate properly under the in- 
fluence of a mydriatic. 

(d) When the presence of a tremulous lens, or antece- 
dent disease, gives reason for apprehending fluidity of the 
vitreous. 

(e) When posterior synechiz exist. 

(f) When prolapse of the iris, occurring during the 
operation itself, does not admit of reposition. 

The exclusive employment of one method of extract- 
ing cataract would seem unwise. Each case must be 
taken on its own merits; its history, the condition of the 
eye, and the disposition of the patient carefully consid- 
ered, and the operation selected that seems likely to be 
followed by the best results. Doubtless a successful 
simple extraction leaves the eye in a more normal condi- 
tion, and thus affords a more perfect result. To gain 
this result the operator requires a maximum of experi- 
ence and skill, while the patient must be prepared for a 
somewhat more burdensome convalescence, and must also 
be willing to incur a slightly increased risk of accident. 

It is impossible, in an article like the present, to review 
all the different operations for the extraction of senile 
cataract that have been proposed, even within the present 
generation. Those just described are the ones in general 


735 


Cataract, 
Cataract, 








use at the present day, and are considered to furnish, on 
the whole, a larger percentage of success than all others. 
There are, however, two methods that have attracted a 
good deal of attention and found influential advocates. 
They deserve at least a passing notice. Liebreich’s 
method of extraction is performed as follows, the knife 
used being similar to that in peripheric linear extraction, 
only somewhat narrower: The patient isin the recumbent 
position, the pupil under the influence of atropine. 
Supposing the right eye to be the one to be operated on, 
the surgeon stands behind the head of the patient. He 
raises the upper lid with the forefinger, and steadies the 
eye by pressing lightly against the sclera with the middle 
finger of the left hand. The right hand holds the knife, 
whose back is directed horizontally and backward, while 
the plane of its blade forms an angle of about forty-five 
degrees with the horizontal meridian of the eye. The 
point is made to enter the sclera about 1 mm. away from 
the edge of the cornea and 2 mm. below its horizontal 
diameter, and to emerge at a similar point on the opposite 
side. The knife is then made to cut its way out down- 
ward, forming a flap, the apex of which is 2 mm. above 
the lowest point of the cornea. The cut itself is formed 
with the least possible sawing motion, the knife being in 
the first instance thrust so far forward that the section 
can be completed as it is withdrawn; and at the last mo- 
ment the upper lid is suffered to fall. Next, the capsule 
is carefully opened. “For the third act of the opera- 
tion,” says Liebreich, “we lay the Daviel spoon gently 
against the lower edge of the cornea; while the left fore- 
finger, by which the upper lid is raised, exercises a slight 
pressure through the lid against the upper part of the 
cornea. The lens is thus slightly tilted, its lower edge 
presses against the posterior surface of the iris, folds it 
forward, glides over it to the edge of the pupil, over- 
comes the resistance of the sphincter, and engages itself 
in the wound, which contact with the Daviel spoon has 
already caused to open. The forefinger,of the left hand 
slightly presses the upper lid from above downward over 
the cornea, and thus completes the expulsion of the lens. 
A similar manceuvre with the lid is again employed to 
extrude the cortical substance which has been left be- 
hind, after a little rubbing has been done to drive it 
from behind the iris toward the centre of the pupil. If, 
after this is completed, the pupil does not appear round 
but seems drawn toward the wound, its natural shape 
may be restored by rubbing upward with the lower lid. 
If this does not prove effective the Daviel spoon may be 
introduced.” !4 

This operation commends itself by its simplicity, by 
the small number of instruments which its execution re- 
quires, and by its comparatively slight interference with 
the eye. No extended statistics of its results are accessi- 
ble. The dangers attending it are obvious—the possi- 
bility of the iris healing in the wound, and the produc- 
tion of astigmatism due to the position of the corneal cut. 

Lebrun’s operation much resembles that of Liebreich. 
The points of puncture and counter-puncture are, how- 
ever, at the edge of the cornea, 1 mm. below its horizontal 
diameter, while the cut is made upward, its apex reach- 
ing a point atthe junction of the upperand middle third 
of the vertical corneal meridian. During the cutting 
process the edge of the knife is gradually made to 
change its direction; starting from an angle of thirty de- 
grees with the basis of the cornea it ends at right angles 
to it. At the middle of the curve, therefore, the cornea 
is divided vertically (Arlt). The same objection may be 
made to this operation that was advanced against Lieb- 
reich’s, though its application here is even more forci- 
ble. The danger of anterior synechia is greater, that of 
astigmatism is imminent, and corneal opacity, from im- 
perfect or delayed healing of the wound, extremely likely 
to occur. In the opinion of the writer, and in view of 
the results that a careful collection of statistics has proved 
to attend the method of peripheric linear extraction, the 
operation of Lebrun is not to be advised at the present 
day. 

Flap Extraction.—No article on cataract would be 


736 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





complete without a description of this method, which for 
so many years stood at the head of all operations for 
senile cataract, and whose complete eclipse by the method 
of von Graefe and by simple extraction is due to their in- 
creased percentage of success. The instances in which 
its performance at the present day might be desirable are 
so exceptional that it is mainly of interest from an his. 
torical point of view. The rapidity with which it has 
been thrust into the background is illustrated by the fact 
that, within the memory of the older generation of 
ophthalmic surgeons now on the stage, it was the only 
recognized operation for senile cataract. 

It is not advisable to perform this operation without 
an assistant. Although the spring speculum may be 
used to separate the lids, the finger is far preferable, both 
on account of the ready closure which its withdrawal 
permits, and also owing to the diminished danger of 
pressure on the eyeball. The patient being in a recum- 
bent position, the operator sits on the edge of the bed in 
front of him, generally on his right side. The left hand 
is employed for operating on the right eye, the right on 
the left. The knife used is shown in Fig. 1164. If we 
assume that the left eye is to be operated on, the assist- 
ant takes his stand behind the patient’s head. He draws 
down the lower lid with his right forefinger, being care- 
ful not to evert it, and spreads his remaining fingers in 
such a way that they may interfere with the movements 
of the operator as little as possible. With the forefinger 
of the left hand he raises the upper lid, drawing it gently 
upward, parallel with, but not away ‘from, the eyeball, 
pressure being made against the edge of the orbit. The 
operator fixes the eyeball, below the cornea, with the 
ordinary fixation forceps. Holding the knife with its 
edge downward, he introduces the point in the horizontal 
meridian of the cornea, just at its transparent edge, and 
having penetrated into the anterior chamber, carries the 
blade “rapidly across it, keeping it parallel with the iris, 
until it emerges on the opposite side at a point correspond- 
ing to that at which it entered. The eyeball, being now 
held on the knife, is thus perfectly controlled, and the 
fixation forceps may be dispensed with. The handle of 
the knife is now slightly thrown back toward the temple, 
and the blade pushed gently but steadily forward, com- 
pleting the cut, if possible, without withdraw- 
ing the blade at all backward; great care being 
taken to inflict no unnecessary violence on the 
cornea by pulling or twisting. As the cut is 
completed the assistant allows the upper lid to 
escape from his finger and gently descend. 
The peculiar wedge shape of the knife used 
thus gives us a semicircular cut, extending 
around the entire periphery of the lower half 
of the cornea, the length of the wound being 
about 9 mm. and its capacity of opening in the 
vicinity of 4 mm., thus affording ample space 
for the passage of the largest cataracts. 

Great care must be taken not to draw back 
the knife before the counter-puncture has been 
made, and if possible before the completion of 
the cut; and the hand of the operator must be 
perfectly steady, in order to keep the blade 
always in the same plane. A neglect of either 
of these precautions might result in the prema- 
ture escape of the aqueous humor and the fold- 
ing of the iris over the edge of the knife. 
Should this latter accident happen, gentle 





pressure against the cornea with the middle ee 
finger will often cause the iris to recede. If Knife. 


it is impossible to effect this, the cut must be 
completed without regard to the slight deformity to the 
pupil that would result from the excision of a small 
piece of the iris substance. 

The cut just described can also be made upward with 
equally good result. This course offers no special ad- 
vantages; and the execution in this direction as in many 
cases, somewhat more difficult. 

The operator now himself assumes the raising of the 
upper lid, using for that purpose the thumb of the right 


_REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cataract, 
Cataract, 





hand. Directing the patient to look down, he lifts up 
the flap with the back of the cystitome, which is so held 
that its cutting edge looks downward, and whose shaft 
now occupies the anterior chamber, while its point re- 
mains external to the eyeball, projecting inward from 
the inner corneal edge. Drawing the instrument, in this 
position, from left to right, he causes its point to glide 
into the anterior chamber. Once opposite the face of the 
lens, he makes a half-revolution by slightly twirling the 
handle between the thumb and fingers until the cutting 
edge is in contact with the anterior capsule. . The knife 
being rapidly drawn along its face a horizontal opening 
is made. Another opening should be made at right 
angles to the first, the point of the cystitome having first 
been disengaged from the lens substance and passed up- 
ward to the spot at which the incision is to commence. 
‘The instrument is then laid over on its back and with- 
drawn from the eye, the process by which it entered 
being simply reversed. 

To effect the delivery of the lens the patient is directed 
to look up. The surgeon raises the upper lid with the 
thumb of one hand, while he places the forefinger of the 
other on the lower lid. Gentle pressure on the eye, made 
with the thumb through the upper lid, causes the lens to 
turn on its horizontal axis and its lower edge to enter 
the wound. By now making the upper lid descend over 
the cornea in a succession of sweeping movements, the 
lens is, as it were, coaxed out and escapes from the eye. 
After its greatest diameter has once entered the wound, 
the rest passes with very little persuasion. If it was al- 
ready dislocated into the anterior chamber, it will escape 
as soon as the cut is completed. After the removal of 
the lens the patient is allowed to take a brief rest. The 
eye must then be carefully inspected to see whether the 
pupil is free from cortical remains, whether the iris is 
well in place, and whether the edges of the wound are in 
proper apposition. Much information as to the state of 
the pupil may be gained by ascertaining whether fingers 
can be counted a short distance off. If there is a pro- 
lapse of the iris, it may often be made to recede by slightly 
rubbing the upper Jid against the cornea; but if this can- 
not be effected it must be excised. 

The after-treatment of flap extraction is similar to that 
already described under the head of Peripheric Linear 
Extraction, the dressings being identical. Less freedom, 
however, can be allowed the patient immediately after 
the operation, as sudden movements must be carefully 
guarded against, and the presence of a cough might be 
extremely prejudicial. In brief, the proper healing of 
the wound largely depends on the preservation of per- 
fect quiet, on the part of the patient, during the first 
twenty-four hours. Occasional change, for a few min- 
utes, from a recumbent to a sitting posture may be al- 
lowed. For several days the food should be liquid, or 
at least quite soft, and all chewing is to be avoided. 

Some very few cases still remain in which flap extrac- 
tion might with justice be preferred. Besides being 
applicable to dislocations of the lens into the anterior 
chamber, it is especially available when a foreign body 
is situated in the lens and requires to be extracted with it; 
also when a cicatricial condition of the upper part of the 
-cornea prevents peripheric linear extraction in this region. 

The description of a single remaining operation, wholly 
given up to-day in civilized communities, on account of 
the dangers to which it exposes the eye, but still in gen- 
eral use among the natives of India, will also be of inter- 
est in an historical point of view. 

RECLINATION.—This is the oldest method known, and 
is referred to by both Galen and Celsus. It consists, in 
brief, in the removal of the opaque lens from the axis of 
vision by pressing it downward, or downward and back- 
ward, with a suitably shaped needle, introduced for this 
purpose sometimes through the cornea, but more gener- 
ally through the sclerotic. 

According to Arlt, the operation would be performed 
in the following manner: The pupil is artificially dilated. 
‘The lids being separated by a spring speculum, and the 
eyeball seized with the fixation forceps, the needle (Fig. 


Vou. I1.—47 


1165), with its convexity directed upward, is made to 
penetrate the sclerotic somewhat below the horizontal 
meridian, and about 4 mm. from the corneal edge. One 
cutting edge of the needle is directed toward the anterior, 
tbe other toward the posterior pole, and the point toward 
the middle of the vitreous humor. “ After it 
has passed in up to its neck, the handle is 
turned on its axis(toward the thumb), so that 
the convexity, formerly upward, is now di- 
rected forward. The handle is now lowered 
toward the lobe of the ear, in order that the 
point may be pushed forward toward the 
edge of the lens, and farther, until it enters 
the posterior chamber. Steadily pushed for- 
ward, the needle now enters the pupil, where 
its metallic sheen is recognized, provided it 
emerges external to the capsule. When the 
point has once reached the opposite pupillary 
edge and passed behind it, the instrument is 
to be regarded as a lever, the fulcrum being 
situated in the sclerotic. The handle is now 
raised toward the nasal eminence, and the 
lens depressed downward and outward. The 
handle is to be raised no higher than is suffi- 
cient to form an angle of about one hundred 
and twenty degrees with the corneal basis. 





A brief pause with the needle in this position Fig. 1165.— 
is necessary in order that the vitreous may ps is 
settle down properly around the lens. The  Xeedie.” 


instrument, held thus, is withdrawn up to its 

neck, and then returned to the position which it occupied 
before its advance toward the edge of the lens. Ifasingle 
performance of the manceuvre results in the lens remain- 
ing fixed, a thing usual when the consistency of the vitre- 
ous humor is normal (always provided the lens has been 
attacked at its centre of gravity), the handle is to be 
twirled round in the opposite direction, away from the 
thumb, and withdrawn from the eye in the line of the 
original puncture. Should the lens rise before the with- 
drawal of the needle, a second and third effort at replace- 
ment may be made. Further attempts would hardly 
accomplish the object, and might easily do harm by 
breaking up the structure of the vitreous.” !® 

At the present day this operation for cataract is prob- 
ably more largely performed in India than in any other 
part of the world. The armamentarium of the native 
travelling oculist consists of a sharp knife, the blade of 
which is wound around with some material so as to leave 
only the point free, and a copper probe or spatula. With 
the former an incision is made through the sclerotic, 
while the latter is introduced through this opening and 
the lens depressed. The inability of these self-educated 
practitioners to do extraction is, of course, one reason 
why this method is so generally used. But, in addition 
to this, we are told that suppurative keratitis is exceed- 
ingly frequent among the poor, rice-fed Hindoos after 
flap extraction. Thirty per cent. of the operations for- 
merly performed in Calcutta are said to have failed in this 
way.'® The writer here quoted also states that hardly a 
week passes that he does not see, in the hospitals of Cal- 
cutta, patients on whom reclination has been done, suf 
fering from either inflammation of the choroid or from 
retino-choroiditis. 

When reclination is followed by success, the lens prob- 
ably becomes encapsuled in its new position. If, on 
the other hand, inflammation follows, it ordinarily in- 
volves the iris, choroid, or ciliary body, or may attack 
all three. The outcome is, of course, most serious. 
Secondary glaucoma may follow. But the lens, even 
when encapsuled, may subsequently act as a foreign 
body. For it is to be remembered that the complete ab- 
sorption of a hard cataract in this position is not to be 
reckoned on. Destructive inflammation may come on 
years later and all vision be destroyed. Sympathetic 
inflammationn of the other eye may even ensue. It is, 


| therefore, hardly possible to conceive of circumstances 


in which the operation of reclination may at the present 
day be regarded as justifiable. 


737 


Catarrh, (Urethra, 
Catheterism of the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





History oF Exrracrion.—lIt is uncertain whether the 
ancients were acquainted with this method; it is probable 
however, that they were, as passages in Galen and Pliny 
have been thought to refer to the removal of the cataract 
from the eye. At all events, if known, it fell into nearly 
complete disuse and oblivion; and not until the time of 
Daviel, in 1750, did it begin to be cultivated as a recog- 
nized procedure. This surgeon used numerous instru- 
ments, consisting of narrow sharp and blunt knives, and 
scissors; he made at first a small opening in the cornea, 
enlarged it afterward, and then removed the lens. His 
followers sought to improve his method by simplifying 
its application, and soon superseded the various instru- 
ments he had used by a single knife. This was subse- 
quently modified, especially by Beer, to whom we owe 
the form of knife used in flap extraction at the present 
day. Gradually more exact rules were laid down for the 
performance of this operation; the situation and size of 
the cut, the best method of opening the capsule and 
pressing out the lens were all perfected. Despite the 
utmost care, however, used in carrying out the various 
steps of the operation and in the after-treatment of the 
patient, there was an appreciable percentage of loss; 
owing largely to one of three causes—diffuse suppuration 
of the corneal flap, defined suppuration of the same, and 
iritis. To diminish the danger of the second of these, but 
more particularly to guard against the last, Mooren pro- 
posed, in 1862, that a preliminary iridectomy be per- 
formed some two weeks before the extraction. The re- 
sults which he obtained by pursuing this method were 
proved to be incontestably superior to those that had fol- 
lowed the simple operation. This was the first great step 
forward in the path now pursued. It allowed the lens 
to emerge more readily, and subjected the iris to less 
danger from pressure and bruising in the process. In 
1863 Jakobson proposed the following operation: He 
narcotized his patient and made a lower section in the 
sclero-corneal junction, practising a broad iridectomy 
downward after the removal of the lens. He thus gained 
the advantage of doing the whole operation at one time, 
but incurred the disturbing effect of an iridectomy down- 
ward. Previous to the bringing forward of either of 
these methods, Schuft (now Waldau) had invented, and 
in 1860 published, a series of spoons intended to remove 
the lens through a small wound at the edge of the cornea, 
These were, however, large and clumsy, did great vio- 
lence to the eye, and were, in 1865, superseded by others 
much more delicate, invented by Bowman and Critchett. 
Outspooning remained for a time a favorite method in 
England, but was afterward given up on account of the 
dangers which it involved. In 1865 von Graefe brought 
out the method that bears his name, and gave an account 
of it to the Heidelberg Society at its annual meeting. It 
quickly found its way into general favor, and, with the 
modification in the cut described in the course of this 
article, has remained the popular method up to the pres- 
ent day. 

Other modern procedures demand a brief notice. In 
1866 Alexander Pagenstecher described an operation for 
removing the lens in its capsule through a broad incision 
made with a lance knife, and by means of an iridectomy 
downward and outward. <A specially constructed scoop 
was employed. In 1867 Weber devised a lance-knife, 12 
mm. broad and somewhat concave on its back. With 
this he entered the anterior chamber at the lower or 
lower-inner edge of the cornea, in the plane of its basis, 
and made a wound 10 mm. in length. If he thought it 
best to remove any iris, he excised but a small piece, and 
that from the pupillary edge. The opening of the capsule 
and removal of the lens, which latter was effected by 
pressure, completed the operation. Kuechier, in 1868, 
proposed to remove the lens through the natural pupil, 
making an incision straight across the cornea in its hori- 
zontal meridian. Analogous to thisare the operations of 
Liebreich and Lebrun, already described. 

A consideration of the following figures will show why 
flap extraction has fallen into disuse, and why the periph- 
eric linear method has taken its place. 


738 





Graefe’s own statistics were as follows: Simple flap- 
extractions, 600—loss, 7 per cent.; flap extractions with 
iridectomy, 900—loss, 5 per cent.; linear extractions, 600- 
—loss, 2.8 per cent. Horner gives: Linear extractions, 
1,088—loss, 2.67 per cent. Noyes has collected from 
various sources: Flap extractions, 10,094—loss, 10.4 per 
cent. ; linear extractions, 10,661—loss, 5.8 per cent. 

The larger proportion of loss given, according to the: 
figures of Dr. Noyes, would naturally be connected with 
the large number and varying skill of the surgeons whose- 
results are thus grouped. Hasket Derby. 


BIBLIOGRAPHICAL REFERENCES. 


10Otto Becker: Zur Anatomie der gesunden und kranken Linse,. 
Wiesbaden, 1883. 
eee Monatsblatter fiir Augenheilkunde, June, 1884, pp. 199,. 


3 Nouveau dietionnaire de médecine et de chirurgie pratiques, vol. 
vi., p. 481. 4 Hufeland’s Journal, March, : 
5Q. Becker: Graefe-Saemisch, vol. v., p. 256. 6 Loc. cit., p. 209.- 
7 Becker: Graefe-Saemisch, vol. v., pp. 178, 179. 
® Traité théorique et pratique des maladies des yeux, t. ii., p. 171.. 
® Graefe-Saemisch, Vol. iii., p. 263. 
10 Archiv fiir Ophthal., 30, ii., S. 266. 
11 Wecker: Thérapeutique oculaire, p. 466. 
12 Graefe-Saemisch, vol. iii., p. 295. 
13 Graefe-Saemisch, Vol. v., pp. 341, 342. 
ae Eine neue Methode der Cataract-Extraction, pp. 12, 18, 14, Berlin,. 
15 Graefe-Saemisch, vol. iii., p. 254. 
16 Macnamara: Diseases of the Eye, p. 525. 
17 Archiv fiir Ophthalmologie, Jahrg. 30, Abth. 2. 


CATARRH, NASAL. See Nasal Cavities, ete. 


CATECHU.—Cutch; Black Catechu. “An extract pre- 
pared from the wood of Acacia Catechu (L.f.) Willd. (fam. 
Leguminose)” (U. 8. P.). Catechu is similarly obtained’ 
from the wood of A. Suma Kurz. That of the present 
edition of the British Pharmacopeceia is discussed under 
Gambir, This species of acacia is a crooked, straggling 
tree of thirty to forty feet in height, with a trunk about. 
a foot in diameter. It grows commonly in India and 
Burmah, and yields a very durable, hard timber and a 
tan bark. The sap wood is whitish, the heart wood of a 
very dark brown. It is said that both are extracted for- 
the catechu, the process being by boiling the chips. The 
decoction, more or less purified by straining, is evaporated 
by artificial heat and is then moulded into various forms. 
The moulds are commonly lined with leaves, the remains- 
of which adhere to the outer surface of the dried masses. 
The latter are of various forms and sizes, according to 
the custom of the locality or the convenience of the: 
maker. The best usually come in the form of slabs or 
blocks, of the size and form of an ordinary bread pan. 
In India a superior quality, of a light brown color, is. 
prepared chiefly for mastication by introducing sticks into- 
the thickened decoction, when the catechu collects upon 
them, after the form of crystals. Dymoch and Hooper 
(“ Pharmacographia Indica,” i., 558) describe a very high- 
priced sort which is collected from cavities in the trunk. 
This is called AKhersal or Khairsal, and is of a very pale- 
brown or yellow color. The official description of catechu. 
is as follows: 

In irregular masses, containing fragments of leaves, 
dark brown, brittle, somewhat porous and glossy, when: 
freshly broken. It isnearly inodorousand has a strongly 
astringent and sweetish taste. 

If 20 parts of catechu be digested with 200 parts of: 
alcohol and the liquid filtered, the undissolved matter, 
after being dried at 100° C. (212° F.), should not exceed: 
3 parts in weight. 

The tincture, diluted with 100 parts of water, acquires- 
a green color on the addition of ferric chloride T.S. 

If 2 parts of catechu be boiled with 20 parts of water, 
a brownish-red, turbid liquid will be obtained which. 
turns blue litmus paper red. 

Upon incineration, catechu should not leave more than: 
six per cent. of ash. d 

To this description it may be added that the color of 
some which is very good may be better characterized as. 
a brown-black, and that a microscopical examination re-- 


- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





veals the presence of a large quantity of minute crystals 
of catechin. Emphasis should be laid upon the fact that 
good catechu is nearly odorless. Much of what comes to 
our market possesses a vileodor. It is toughish, scarcely 
porous, and has a waxy or greasy looking surface instead 
of the lively, slightly sparkling lustre of that which is 
pure. Such is largely used for tanning and similar pur- 
poses, but is not fit for medicinal use. 

About one-third of catechu consists of catechin 
(Co: HO» + 5H20), and about one-half of catechu-tannic 
acid (Co,H,.O;). The latter can be obtained from cate- 
chin by heating, especially with the addition of water or 
alkalies. 

Catechu, as its composition would indicate, is a pure 
astringent, which may be generally used either exter- 
nally or internally, when this effect is desired. We have 
official a compound tincture, of ten-per-cent. strength, 
with diluted alcohol and one-half per cent. of cassia, the 
dose 2 to 8 c.c. (fl. 3ss. toij.). The official troches con- 
tain each 6 cgm. (about gr. i.) of catechu, with tragacanth 
and sugar. Henry H. Rusby. 


CATHARTICS. See Lazatives and Purgatives. 


CATHETERISM OF THE URETHRA.—The term 
catheterism, often erroneously written catheterization, 
is employed to designate the various methods used in 
exploring and relieving the many pathological conditions 
of the urethra and bladder. The term is especially used 
to designate the introduction of hollow instruments 
through the urethra into the bladder for the purposes of 
withdrawing the urine, evacuating blood clots, removing 
fragments of stone after litholapaxy, exploring, irrigat- 
ing the urethra and bladder; and the employment of solid 
instruments for the purposes of dilating stricture, of re- 
moving foreign bodies, and of crushing stone. 

The word catheter, derived from the Greek kafinuc, 
meaning a “thing to send down,” or “to let into,” con- 
veys no idea of the character of the instrument or of its 
use, nor whether it is solid or hollow, straight or curved, 
conical or cylindrical, large or small. But the derivation 
of the word may serve to explain why the term catheter- 
ism is employed to indicate the introduction of all varie- 
ties of urethral instruments for whatever purpose em- 
ployed. 

Throughout this article the term catheterism will be 
confined in its meaning to the introduction of hollow in- 
struments into the bladder, through the urethra, for the 
purposes of evacuating the urine; of examining the 
urethra and interior surface of the bladder; of introduc- 
ing various medicaments for the relief of pain or for the 
cure of diseases; of irrigating the urethra and bladder; 
of distending the last-named organ with either water or 
air as a preliminary to operative interference, and of es- 
tablishing continuous drainage in cases of cystitis after 
injuries or operations upon the urethra, prostate gland, 
or bladder. 

A catheter is a hollow instrument either open at both 
ends or terminating at one end in a solid point with an 
opening placed laterally or on the superior aspect of the 
instrument; this opening is known as “the eye.” Cath- 
eters vary in size from 2 to 30 mm. in circumference, and 
from thirteen to fifteen inchesin length. They are either 
flexible or rigid, straight or curved, cylindrical or conical. 
If the instrument is cylindrical, a uniform calibre is 
maintained throughout its entire length; if it is conical, 
it tapers toward the vesical end and terminates either in 
a fine point or in an olivary tip, becoming smaller in 
diameter as the end of the instrument is reached. 

The exact method of manufacturing the best grades of 
flexible catheter is a secret with the individuals by whom 
the instruments are made; especially is this true of the 
preparations employed for coating, as well as of the 
method of giving the high polish and satin finish which 
the better grades of instruments possess. 

Soft rubber, bevelled-eye catheters, the so-called “soft 
caoutchouc catheters,” are made from india rubber which 
has been vulcanized. There is also a more rigid form, 


Catarrh., (Urethra, 
Catheterism of the 


the cheaper grades of which are manufactured from 
either cotton or linen; these materials are employed as 
a framework, and are coated with either shellac or resin 
varnish. 

The objection to the cheaper forms of flexible catheter 
is the readiness with which they absorb water, making 
them liable to swell, as a result of which the coats crack 
and peel, the elasticity disappears, and the instrument is 
rendered stiff, brittle, and worthless. The use of anti- 





Fig. 1166.—Woven Eye of Catheter. 


septic solutions causes the instrument to become rough 
on its surface and so brittle as easily to be broken. 

The most expensive and reliable flexible catheters are 
made from either cotton, or Lisle, or silk thread woven in- 
toa web and usually coated witha gummy material. As 
soon as this material becomes dry it forms a translucent 
cover, takes ona high polish, and at the same time remains 
elastic and pliable. When properly coated the instru- 
ment should be able to withstand moist heat, steam, dry 
heat, or immersion in boiling water for at least five 
minutes, and should have the power to resist the action 
of ordinary antiseptic solutions, acid or alkaline urine, 
and pus. The frame should be perfectly smooth and 
free from irregularities, the end should be firmly stayed, 
and the whole instrument should possess the highest ten- 
sile strength. 

Interesting statistics are given by Gouley in an article 
on catheterism which appeared in the New York Medical 
Journal, November 4th, 1899, in which he says: “The 
tensile strength of different qualities of web catheters 
was ascertained to be as follows: That of an English 
commercial catheter was 42 pounds; that of an American 
commercial catheter 54 pounds; that of an American Lisle 
thread catheter 56 pounds; that of an American silken 
linen catheter 60 pounds, and that of an English silk web 
catheter 85 pounds. An American silk web catheter of 
the best quality was then tested to 115 pounds without 
breaking, but the varnish was stripped off at each end.” 

Theoretically these instruments are supposed to be as 
highly polished on the inside as on the outside, so that 
they may be more readily cleansed and sterilized, and 
the danger of infection thereby lessened. Unfortunately, 
it is wellnigh impossible to arrive at this condition of 
perfection. The nearest approach is to be found in the 
high grade of catheter, but at a greatly increased cost. 
The eye of all flexible web catheters should be woven, 





Fig. 1167.—Eye Cut with a Punch. 


strengthened, and stayed, whereby the continuity of the 
frame is left unimpaired. In the inferior grade of web 
catheters the eye is formed by cutting with a punch, 
which is most objectionable, as the catheter is very apt 
to fracture at that point. 

Flexible catheters made of silk web are by far the most 
serviceable and the best. They cost more than those 
made from other materials, but are cheaper in the end; 
for they are more durable, and, with proper care, can be 
made to last a long time. They are not so liable to 
crack or break as are the cheaper varieties; they are 
more easily sterilized, and hence are the safest of all the 
varieties of web instruments that can be employed. The 
danger of infection from their use is lessened. They do 
not become sticky, nor do they blister in warm weather; 


739 


Catheterism of the 
Urethra, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





they are not injured by contact with antiseptic solutions, 
tissue fluids, or the fatty materials with which they are 
anointed before use. 

In the shops is found a hard-rubber gum elastic catheter 
which is sold under the name of “the English catheter.” 
This instrument is very durable and is coated with a ma- 
terial which is highly polished; the shaft is re-enforced 
by a steel stilette. On being subjected to heat the in- 
strument becomes soft and pliable and may be made to 
assume an exaggerated curve, which being maintained 
by the stilette, will become permanent on cooling. This 
form of catheter may be bent to assume the prostatic 
curve; it is then passed into the urethra, as far as the 
membranous portion, when on gently removing the sti- 
lette the curve will become greatly expanded and will 
oftentimes pass over an enormously enlarged middle 
lobe of the prostrate gland when all other forms of 
catheters have failed. Gross states that in some cases 
it is of advantage “to bend back the shaft of the instru- 
ment so that it will resemble somewhat an italic S pro- 
cumbent.” Catheters of this description may be kept 
on an over-curved stilette, by which means the increased 
prostatic curve, desired in some cases of prostatic hyper- 
trophy, is maintained, the instrument being always ready 
for use in case of an emergency. The sphere of useful- 
ness of the English gum catheter is limited; in some con- 
ditions of prostatic hypertrophy it is invaluable. 

The india-rubber or soft vulcanized caoutchouc cath- 
eter, the most improved form of which is manufactured 
in the United States, is sold under the name of “ Nélaton,” 
or “ Jacques catheter,” so-called after its original Parisian 
maker. Many cheap and poor varieties of this instru- 
ment are sold. If an inferior quality of catheter is em- 
ployed, it will be found that after having been used fora 
short period the instrument has become swollen, soft, and 
flexible, and has increased in calibre as well as in length, 
so that its further use is impossible. Should the rubber 
contain an excess of vulcanizing material it soon becomes 
hard and brittle, and when catheterism is attempted the 
instrument may break and a portion be left in either the 
urethra or the bladder. In warm weather catheters are 
liable to become hard and brittle, notwithstanding the 
care expended on their preservation. They are injuri- 
ously acted on by fatty acids and by the materials em- 
ployed as lubricants. They withstand boiling but poorly, 
and are soon rendered useless by the action of the mate- 
rials applied to sterilize them. 

“The eye” is often badly constructed and is generally 
situated too far from the vesical end. The lumen is usu- 
ally too large, rendering the end of the catheter over- 
flexible, so that its passage through the urethra is ac- 
complished with difficulty; at the same time such an 
instrument is liable to double on itself, thereby injuring 
the urethra. The site at which “the eye” is located is 
in danger of being fractured. Another objection is that 
the instrument from the eye to the tip is hollow, whereas 
it should be solid so as to prevent the accumulation of 
foreign material, such as pus, blood, and microbes. When 
hollow it is very difficult to cleanse, and wellnigh im- 
possible to sterilize. In practice many cases are met with 
in which the use of an inferior variety of soft-rubber 
catheter has given rise to much trouble. In one instance, 
where the patient was practising auto-catheterism, the 
end of the instrument broke off, and was left in the 
bladder; owing to a hypertrophic condition of the pros- 
tate gland a perineal section was rendered necessary to 
remove the fragment. In another case part of the instru- 
ment was broken off in the urethra and was then forced 
into the bladder by the attendant in his efforts at removal; 
it was extracted by means of a lithotrite. 

Recently there has been put upon the market a new form 
of soft-rubber catheter which—so it is claimed—combines 
the qualities of the pliable soft-rubber catheter with the 
elastic spring of the firm, flexible instrument. This is ac- 
complished by having the anterior portion pliant and the 
posterior more rigid. By this device it is presumed that 
the pliant portion will apply itself to the curves of the 
urethra, while the firmness of the posterior part will per- 


740 


mit the operator readily to pass the instrument through 
an irritable, spasmodic urethra or through an obstructing 
lobe of the prostate gland into the bladder. The vesical 
end of the instrument terminates in either a cylindrical 
or an Olivary tip. This form of catheter is still on trial. 

The soft-rubber catheter is probably the one in most 
general use. It easily adjusts itself to the shape of the 
urethra; it is not liable to exert an injurious pressure 
on the canal, and there is no danger of producing a false 
passage. A properly constructed soft-rubber catheter 
should be at least thirteen inches long, should vary in cir- 
cumference from 10 to 30 mm., and should be perfectly 
pliable and highly polished. The eye should bea little less 
than one-quarter inch (5 mm.) from the vesical end, and its 
diameter should be the same as that of the lumen of the 
instrument. Usually the eye is placed laterally, but re- 
cently an improved form of soft-rubber catheter has been 
manufactured in which the lateral eye is omitted; the tip 
of the vesical end is left well rounded and open. In my 
experience this modification has proved most satisfactory. 
When the eye is placed laterally, the tip of the catheter, 
from the eye to the vesical end, should be solid, and not 
hollow, for reasons already given. The termination of 
the instrument may be either conical or cylindrical. The 
proximal end should be conical in shape and of a larger 
calibre than the shaft, so that the nozzle of the irrigating 
apparatus can be easily attached when required. 

The soft-rubber catheter is especially designed for evac- 
uating the urine; for irrigating the urethra and bladder 
with various medicated solutions; for introducing anes- 
thetic remedies for the production of local anesthesia; 
for distending the bladder with either water or air, when 
it is proposed to perform suprapubic cystotomy or Bot- 
tini’s operation on the prostate gland; for supplying 
continuous drainage for the relief of chronic cystitis and 
inflammatory diseases of the prostate gland, and for pre- 
venting urethral fever after operations on the urethra. It 
is sometimes employed as a means whereby to measure 
the increase in length of the urethra in cases of prostatic 
hypertrophy. It should be used, wherever possible, in 
preference to any other form of catheter. Its introduc- 
tion gives rise to but little pain except in those cases 
in which the urethra is very sensitive and spasmodic; 
then a more flexible instrument, such as the silk web 
catheter, will pass with greater ease and with less pain. 
In cases in which it is found difficult to pass the catheter, 
owing to urethral spasm, its firmness may be re-enforced 
by the introduction of either a filiform bougie or a wire 
stilette, which should extend to within a quarter of an 
inch of the eye of the instrument and should be re- 
moved as soon as the compressor urethre muscles are 
passed. The finest grade of soft-rubber catheter is not 
only very durable, but is more readily sterilized than any 
other grade of flexible instrument. It can be boiled for 


the space of five minutes without injury. It is always 








Fig. 1168.—Tips of Soft-Rubber Catheter. 


the instrument to be chosen for self-catheterism, wher- 
ever possible. Not only is its use attended with less 
pain, but it is almost impossible for the patient, unless 
the urethra and prostate gland be very much inflamed or 
congested, to injure himself, no matter how roughly it 
may be used. 

The soft, pliable instrument is to be selected, if pos- 
sible, when the establishment of continuous drainage is 
required. Occasionally it will be found necessary, owing 
to the condition of the urethra or the prostate gland, 
to make use of a flexible web or even a metal catheter. 
Continuous drainage by use of the latter instrument is 


- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Catheterism of the 
Urethra, 





always attended with more or less pain and danger of an 
abscess forming at the peno-scrotal junction. When it 
becomes necessary to leave a metal instrument in the 
urethra the patient should be carefully watched. 

Five years ago the writer read before the Philadelphia 
Academy of Surgery a paper in which he strongly advo- 
cated continuous drainage after injuries of, or after oper- 





Fig: 1169.—Continuous Catheterism, in the Recumbent Posture. 
(Horwitz.) 


ations upon, the urethra, prostate gland, or bladder; and 
also in chronic inflammatory diseases of these organs, espe- 
cially when associated with alkaline urine, pain, tenesmus, 
and frequency of micturition, and with chronic urethral 
fever. The ideas put forth were based upon large ex- 
perience. The subject elicited a heated discussion, every 
member of the society who was in attendance taking ex- 
ception to the method of treatment suggested. A radical 
change in the views of the profession on this subject has 
since taken place, doubtless owing to the investigations 
and writings of Guyon and Michan, who have strongly 
advocated in suitable cases the mode of treatment here 
described, and who fully verified all that was claimed 
for the benefit to be derived from this method; since 
which time its employment has become general. This 
treatment is to be followed in cases of chronic cystitis, 
especially when there is frequency of urination; in cases of 


pain attended with an ammoniacal urine which is loaded ° 


with pus; and also in cases in which the inflammation of 
the bladder depends on obstructive enlargement of the 
prostate gland. When retention of urine is due to the last- 
named cause, and a flexible catheter has been successfully 
passed, it should be allowed to remain in the urethra for at 
least four days. Ifthe instrument is removed immediately 
after the urine has been evacuated, ina few hours catheter- 
ism will again become necessary, and, as is frequently the 
case, it will be found impossible to reinsert the instru- 
ment; thus making either aspiration or some more radical 
operation necessary, which would have been avoided if 
the catheter had been allowed to remain én situ. When 
the catheter is permitted to remain in the urethra, a bene- 


ficial effect of continuous pressure on the inflamed and 
congested canal is produced, the tenesmus is relieved, and 
the bladder is put at rest. When the instrument is al- 
lowed to remain in the urethra for the period indicated, 
it will be found that on its removal not only can a much 


‘larger instrument be easily inserted, but usually no fur- 


ther difficulty from urination will be experienced. This 
method of draining the bladder is also indicated in wounds 
of, or after plastic operations upon, the urethra, and with 
proper care the catheter may be allowed to remain 77 
situ for a week, or longer if necessary. 

In over one hundred and fifty-eight cases of external 
perineal urethrotomy which have been performed by the 
writer, and in which the soft-rubber catheter was allowed 
to remain in the urethra until the new canal had entirely 
formed around it, in not a single instance did a perineal 
fistula follow, as is so commonly the result in the oid 
method of treatment. Whenever it was possible the 
wound was closed by means of interrupted sutures, union 
taking place by first intention, and the patient being thus 
saved several weeks of tedious convalescence. 

In cases in which internal and external urethrotomy 
combined has been performed, and it is then found to be 
difficult to pass a catheter in the usual manner, on account 
ot the rough and nodular condition of the urethra, the act 
can be readily accomplished by inserting a long pair of 
forceps, designed for the purpose of removing foreign 
bodies from the urethra through the meatus, and making 
the jaws of the instrument appear at the perineal wound. 
The proximal end of the catheter is then caught and 
drawn from behind forward until it protrudes an inch or 
so beyond the meatus. The vesical end is then passed 








Fae Be ak nba n 


Fig. 1170.— Intermittent Drainage; Continuous Catheterism. 


(Horwitz. ) 


along a steel gorget, through the membranous and pros- 
tatic portions of the urethra, into the bladder. In cases 
of hematuria in which the bleeding is due either to a vesi- 
cal growth or to some pathological condition of the pros- 
tate gland, continuous drainage is invaluable. In chronic 
cystitis associated with alkaline urine, polyuria, and fre- 
quency in passing water, especially if due to prostatic 


741 


Catheterism of the 
Urethra, 


hypertrophy, or when attempting to get the patient in 
proper condition for a capital operation on the urethra, 
prostate gland, or bladder, continuous drainage is always 
indicated as the preferable method of treatment. Ina few 
instances it will be found that the presence of a catheter 
in the urethra will give rise to urethritis. This is espe- 
cially true if the instrument has been previously ster- 
ilized with formalin and not thoroughly washed before 
its introduction. This condition, however, is harmless; 
it usually requires no treatment, and, as a rule, promptly 
disappears on removal of the instrument. When con- 
tinuous drainage is employed there is always danger of 
an abscess forming at the peno-scrotal junction, the result 
of pressure whilst the penis is in the pendant position. 
This complication is not liable to follow the use of a soft- 
rubber catheter, but may ensue when either a flexible ora 
metal instrument is employed; the latter being most liable 
to give rise to the trouble. If the surgeon, on the alert 
for this danger, watches the peno-scrotal junction for any 
suspicious redness, tenderness, or cedema (forerunners of 
an abscess and urinary fistula), the threatened condition 
can be averted by the prompt removal of the catheter. 

Singular as it may seem, the presence of a catheter 
placed permanently in the urethra, far from producing 
pain, is usually followed by relief, by assuaging strangury 
and by putting the bladder at rest and permitting the pa- 
tient to secure much-required sleep. For a few hours 
after the introduction of the catheter a feeling of weight 
in the perineum is usually complained of, but this soon 
subsides. 

Many methods have been suggested to insure the re- 
tention of the catheter within the canal and prevent its 
slipping from the urethra. After making trial of the vari- 
ous modes that have been devised, the writer has fixed 
upon the following as the most practicable: The patient 
is placed in bed; the catheter is inserted, and connected 
with a drainage tube, which conducts the urine into a 
vessel at the foot of the bed. The instrument is kept in 
place by means of a piece of tape, tied so that the knot is 
located on the under surface of the catheter. The two 
ends of the tape are carried to the middle of the body of 
the penis and then knotted once more; the ends are car- 
ried around the organ and another knot is tied on the 
dorsum of the penis; the extremities are then carried up 
and fastened to a band around the waist. The manner 
of securing the instrument is probably more clearly de- 
lineated in the accompanying figure (Fig. 1171.) 

If a soft-rubber catheter cannot be employed a good 
flexible web instrument should be used. The objection 
to these instruments is that their continued presence gives 
rise to irritation, and they are consequently not so well 
borne by the patient; the utensil in a short time becomes 
blistered, cracked, and worthless, especially if the urine 
be alkaline and contain an excess of phosphates. It is 
always well, no matter what variety of catheter is em- 
ployed, to change it at least every third day. The urethra 
and bladder should be irrigated daily with a normal saline 
or warm boric-acid solution. Care should be taken to 
prevent the eye of the catheter, which is just within the 
vesical sphincter, from becoming plugged with blood or 
pus. 

Various self-retaining catheters have been devised by 
surgeons, but they have not generally met with the ap- 
proval of the profession. They are usually unmanage- 
able, hard to introduce, frequently give rise to hemorrhage, 
and are difficult to sterilize: They possess no advantage 
over the method of retaining the catheter suggested by 
the writer. Theiremployment is notrecommended. An 
instrument of this description devised by Petzzer consists 
of a soft-rubber catheter the vesical end of which is made 
to project laterally well beyond the shaft of the instru- 
ment. This projecting portion, when stretched over a 
metal carrier, becomes obliterated. After the catheter 
has been introduced the stilette is removed, when the 
projection reappears and is held in place by coming in 
contact with the narrow vesical neck. A simple device 
is that suggested by Malécot; it consists of a soft-rubber 
catheter, with two pliable loops at the vesical end. When 


742 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


this instrument is passed through the urethra the loops 
are pressed against the shaft of the catheter, and then, 
owing to their elasticity, they return to their original 
position as soon as the catheter enters the bladder and the 
pressure exerted upon them by the walls of the urethra 
is removed. 

It is only in acute cases accompanied by fever, and 
after operations upon the urethra, prostate gland, and 
bladder, that it is necessary to keep the patient in bed 
whilst continuous drainage is made. In many cases of 
long-standing prostatic disease the writer has prolonged 
this method of treatment for the space of six weeks with 
great benefit, the patient being allowed to sit in a chair, 
to lie on a sofa, or to walk to a limited extent around his 
chamber. When it is desired to let the patient be up 





Fig. 1171.—Continuous Drainage, the Patient Being Allowed to be 
Up and to Walk About. (Horwitz.) 


and about and still maintain continuous drainage, the 
catheter is kept in place as shown in Fig. 1171, the end of 
the instrument draining into a six-ounce bottle, which is 
suspended by tapes to the harness around the patient’s 
waist, and which can be emptied whenever necessary. 

In cases of external perineal urethrotomy in which 
drainage is to. be maintained until the perineal wound is 
healed, the object being to prevent the urine from passing 
through the wound, it will be seen by Fig. 1170 that the 
catheter is kept in place in the manner already described, 
the proximal end being closed with a plug, to be removed 
whenever there is a desire for urination. 

Flexible web catheters should be at least thirteen inches 
in length and may vary in circumference from 2 to 25 mm, 
They should be thoroughly covered with the coating of 
gum employed for the purpose; the entire surface of the 
instrument should be perfectly smooth, highly polished, 
and capable of resisting heat, at a temperature of 212° F., 
for at least five minutes. Catheters of this description 
should possess firmness and elasticity, and at the same 
time they should be pliable, having the same dégree of 
stability from one end to the other. They should never 
be rigid, especially toward the vesical end. In order to 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Catheterism of the 
Urethra, 





‘accommodate the nozzle of the irrigating apparatus the 
proximal end should be funnel-shaped and of a larger 
calibre than the shaft of the instrument. Except in 
flexible catheters, designed for evacuating blood clots 
from the bladder, these instruments should possess but 





























Fic. 1172.—Flexible Woven Eye Cylindrical Catheter. 


a single eye, which should be at a distance of rather 
less than a quarter of an inch from the vesical end 
and located laterally. The lateral eye of straight web 
catheters is frequently omitted, the instrument being 
simply a tube open at both ends. In some forms of 
curved catheters, the so-called “elbow catheter,” it is 
found to be advantageous to have the eye on the superior 
aspect of the concavity of the point instead of being 
placed laterally. When catheters terminate with either 
an olivary tip ora long conical point, the eye must be situ- 
ated about one inch from the vesicalend. The eye should 
always be woven into the instrument, and from the eye to 
the vesical end the tip should be solid. The shape and 
curve given to the vesical end of the instrument will de- 
pend on the purpose for which the catheter is designed. 
Flexible catheters, being firmer and not so pliable as 
the soft-rubber instruments, possess the advantage of 
having a greater resistance along the shaft, are less apt 
to bend, and are more likely to pass along a urethra in 
which obstructions exist; besides, they are always under 
the control of the operator. The employment of flexi- 
ble catheters is indicated in cases in which there is an 





Fie. 1173.—Olivary Tip Catheter. 


irritable or spasmodic condition of the urethra, arising 
from either inflammation or hyperesthesia. The instru- 
ment usually employed when these conditions exist is a 
flexible woven-eye cylindrical catheter, shown in Fig. 
1172. 

In cases of stricture of the urethra of large calibre a 
flexible catheter, varying in calibre from 5 to 15 mm., 
may be employed; it must be cylindrical, or must termi- 
nate in an olivary or conical tip. This form of catheter 
is likewise made with asharp conical termination shaped 
somewhat like a rat’s tail; hence it is frequently spoken 
of as the “rat-tail catheter.” Instruments of this form 
are of special service in cases of retention of urine due to 
prostatic hypertrophy in which the obstruction results 
from enlargement of the lateral lobe, causing the urethra 
to deviate markedly to one side or the other. In such cases 
the long narrow projection at the vesical end readily fol- 
lows the lateral curve of the prostatic portion of the canal. 
When the retention of urine is due to enlargement of the 
middle lobe it is well to employ a flexible catheter which 
at about one-half inch from its vesical end is bent at a 
slight angle, or “elbowed” as it is called, so that the tip 
of the catheter glides along the anterior wall of the ure- 


YLMAUN BOD 






Fig. 1174.—Conical Tip (Rat-Tail) Catheter. 


thra and is readily guided over the obstructing lobe of 
the gland, passing through the urethra into the bladder. 
This instrument is known as “ Mercier’s coudé catheter,” 
more commonly spoken of as the “ prostatic catheter.” 
In order to facilitate the passage of the Mercier catheter 
in difficult cases, Guyon recommends that the instrument 
be constructed with beaks of different lengths, and that 
the angle formed by the junction of the beak and the 
shaft should be of different degrees. The angles that 











he suggests the catheter should have are 40, 35, 30, and 25 
degrees. 

Mercier’s catheter is frequently employed to determine 
the length of the urethra in cases of senile hypertrophy, 
When there is marked increase in the size of the prostatic 
gland, with lengthening of the urethra, a modification of 
the elbow catheter is employed, known as “ Mercier’s 
bicoudé catheter.” In this instrument tnere are two 
bends—one about half an inch from the vesical tip and 
a second one at a distance of a little over two inches 
from the first. 

Guyon has devised a catheter intended for the relief of 
retention of urine due to prostatic obstruction. In this 
instrument, which is constructed somewhat on the same 
principle as Mercier’s, the angle at the point is more acute 
and the instrument terminates in a conical tip, the eye 
being located on the superior, instead of the lateral, aspect 
of the catheter. 

In rare instances, where there is a very unusual en- 
largement of the middle lobe of the prostate gland, and 


































































































Fie. 1175.—Mercier’s Coudé Catheter. 


especially where there is marked increase in the length of 
the urethra, some surgeons prefer a catheter with a full 
semicircular curve, terminating in either a conical or 
an olivary point. 

Flexible catheters are never to be employed when a 
soft-rubber instrument will answer the purpose. When 
auto-catheterism becomes necessary, as in prostatic hy- 
pertrophy, the use of the flexible instrument should be 
reserved until the soft-rubber catheter can no longer be 
employed. 

Flexible double current catheters have been devised 
for the purpose of irrigating the bladder. They are 
quite rigid and possess no advantage over those made of 
metal. ‘Their use is not recommended. 

My experience has led me to infer that no benefit is 
derived from the employment of these double current 
instruments. There are many other varieties and forms 
of catheters which have been designed at different times 









Fia@. 1176.—Guyon’s Flexible Prostatic 
Catheter. 


for the relief of various conditions, but they have not 
met with the approbation of the profession and have but 
few advocates. 

“Evacuating catheterism ” is a term used to designate 
the use of the instrument when rendered necessary for the 
discharge of purulent urine, for the expelling of residual 
urine retained by stricture, by prostatic hypertrophy, or 
by blood clots, or for the removal of detritus following 
the crushing of stone. 

In some of these conditions the use of metal catheters 
is essential. But the great improvement effected in re- 
cent years in flexible instruments, which are now made 
of any desirable size or curve, has caused the profession 
generally to abandon the employment of metal instru- 
ments, except for the relief of retention of urine due to 
tight strictures, for the removal of blood clots or of frag- 
ments of stone after litholapaxy, and for making an en- 
doscopic examination. 

Metal catheters are made of either tin, steel, silver, or 
German silver, the latter being most commonly in use. 
These instruments should be ten inches in length, and 
should vary in diameter from 5 to 30 mm. They must be 
perfectly smooth, polished, and of light weight. Close to 


743 


Catheterism of the 
Urethra, 





the vesical end, on either side of the catheter, is placed an 
eye for the passage of urine. The tip should be closed, 
rounded off, and very nearly of the same calibre as the 
body of the instrument. The proximal end is open and 
usually provided on each side with a small ring to which 
pieces of tape may be fastened when it is necessary to 
secure the catheter in situ. It is important that a metal 
catheter should have the same curve as that assumed by 
the more fixed portion of the normal urethra; this curve 
is measured from the front of the triangular ligament to 
































REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








The great improvement in the manufacture of flexible 
catheters in the present day has caused the employment 
of those made of metal to be very seldom necessary. 
As Sir Henry Thompson has so well said: “The flexible 
instrument is capable of effecting all 
the good which can be accomplished 
by the metal instrument, and it does 
it with less pain and irritation to the 
patient. The difference between the 
two in most hands means a difference 
of bleeding and not bleeding, pain 
and very slight discomfort, freedom 
from subsequent irritation and an at- 
tack of chills and fever, and of course, 
as a sum of these differences, a safe, 





ZY easy, and rapid success in place of a 
G.TIEMANN & CO. _— Fy painful and protracted one.” 
= A The employment of the metal cath- 

















Fic. 1177.—Ordinary Metal Catheter with Thompson Curve. 


the neck of the bladder. It begins in the penile urethra, 
about one inch and a half from the bulb, and reaches 
its lowest point as it passes through the anterior layer 
of the triangular ligament; it then passes through the 
membranous and prostatic portions of the canal, upward 
and backward, toward the bladder. The normal urethral 
curve will vary under different conditions. It may bea 
good deal straightened by lateral pressure made on either 
side of the root of the penis. It is lengthened when the 
bladder is distended with urine, or in cases of prostatic 
hypertrophy. The curve is more acute in children, and, 
according to Gross, “in adults where general develop- 
ment is below the average”; hence the curve of the cath- 
eter, both in adults of this type and in children generally, 
“should be increased, or should describe an are 
of a smaller circle.” 

Change in the curve may result from abscess, 
from infiltration of urine into the perineal tissues, 






Fic. 1178.—Over-Curyed Silver Prostatic Catheter. 


from tumors in the vicinity of the rectum or scrotum, 
such as hernia, hydrocele, and hematocele, or from tu- 
mors of the testicle. In corpulent persons the curve of the 
urethra is diminished, and consequently a catheter with 
a segment of a larger circle is required; on the other 
hand, in spare men the curve is more acute. The trac- 
tion exerted by the abdominal muscles on the suspensory 
ligament renders the curve more abrupt, and it is for this 
reason that when a catheter is to be passed the patient 
should be placed in the recumbent posture with the 
shoulders elevated. 

Mr. Briggs first demonstrated that the fixed curve of 
the urethra is the are of a circle three and one-quarter 
inches in diameter; or of a circle described by a radius 
one and five-eighth inches in length, the chord of the are 
of which measures two and three-quarter inches. This 
statement was corroborated by a series of investigations 
made by Sir. Henry Thompson, who pointed out that the 
curve of the metal catheter 
should always be fashioned 
according to the rule just 
given; since which time in- 
struments so constructed 
are spoken of as having 
the “Thompson curve.” 

The axis of the point of the instrument should form a 
right angle with the axis of the shaft. The curve of the 
urethra can be temporarily obliterated by means of a 
straight instrument. 


744 


Mimi ——_é,l: 


eter may be advantageous when the 
urethra is irritable and spasmodic 
and when the instrument, if it is to 
be passed successfully, must possess a certain degree of 
rigidity. Its use is also indicated when the stricture 
is irritable, nodular, and tortuous; for the relief of re- 
tention of urine caused by blood clot; and in some 
cases of hypertrophy of the prostate gland. A metal 
instrument should not be employed for continuous 
drainage if it can possibly be avoided. If, however, its 
employment for this purpose should become necessary it 
should not be allowed to remain in the urethra for a 
longer period than four days, as its presence is liable to 
give rise to the formation of abscesses at the peno-scrotal 
junction. Flexible instruments are preferable to those 
made of metal when it is desired to irrigate the urethra or 
bladder. The double-current irrigating metal catheter is 
an unnecessary instrument. It possesses no advantage 
over the soft catheter; if the irrigating fluid is allowed to 
flow through the double-current instrument only a small 
portion of the diseased mucous membrane of the blad- 
der is reached by the medicament. 
Should the outflow be checked, 
whereby the viscus is distended, no 
advantage is gained over the em- 
ployment of the ordinary single tube 
soft-rubber catheter. 

In very old men, with an inordinate 
enlargement of the prostate gland, 
especially in its longitudinal direc- 
tion, an over-curved silver catheter, 
the so-called “ prostatic catheter,” is often of great service 
in relieving retention of urine. The instrument should 
be at least twelve inches in length, the curve of which 
should form an are equal to one-third the circumference 
of a circle five and a half inches in diameter. This instru- 
ment has the high commendation of Sir Benjamin Brodie, 
and was rendered extremely popular in this country by the 
teaching of the elder Gross. Its use is restricted to excep- 
tional cases and it should not be employed until other in- 
struments have failed. It is very dangerous in the hands 
of those inexperienced in the manipulation of urethral im- 
plements. Ifimproperly or roughly used it is very liable to 
lacerate the urethra or wound tbe prostate gland. Some 
genito-urinary surgeons absolutely condemn its employ- 
ment; this, 1am confident, isa mistake. On several occa- 
sions I have been called in consultation to attend patients 
suffering from retention of urine due to a prostatic hyper- 
trophy on whom all the various forms of catheters had 















Fiqa. 1179.—S. W. Gross’ Spiral Prostatic Catheter. 


been unsuccessfully employed, when I was enabled to 
pass the over-curved prostatic catheter without mjury or 
difficulty, hence preventing the necessity for aspirating 
the bladder or performing a more serious operation. The 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Catheterism of the 
Urethra, 





catheter should be passed with great gentleness; no force 
should ever be exerted; and in some instances where the 
beak of the instrument is prevented from entering the 
bladder by the enlargement of the middle lobe of the 
prostate gland, its onward progress may be facilitated and 
often successfully accomplished by inserting the index 





Fic. 1180.—Agnew’s Mucus Catheter. 


finger of the left hand, which has been well lubricated 
with sweet oil, into the rectum and pressing the instru- 
ment gently upward toward the pubes, whilst at the 
same time by means of the right hand, which holds the 
proximal end of the instrument, the handle should be 
depressed between the thighs and gently urged onward. 
To those who have had experience in the use of urethral 
instruments the prostatic catheter is of great value, but 
when employed by a novice it is not free from danger. 

The spiral silver catheter with a Mercier coudé curve 
was devised by the late S. W. Gross. It is but seldom 
employed in civil practice, well-made flexible instruments 
being more serviceable. In the equipment of surgical 
cases for the army and navy this form of catheter is in- 
valuable, being readily sterilized, durable, and not af- 
fected by climatic changes. 

In 1850 the elder Gross devised a special form of 
catheter for the relief of retention of urine due to blood 
clot. He recommended it highly, and I have on several 
occasions found it very serviceable. It is of the same 
size and curve as the ordinary metal instrument; it has no 
eye, and the orifice at the vesical end is closed by means 
of an obturator. It is passed in the usual manner into 
the bladder, and by depressing the handle well between 
the thighs the point is passed through the blood clot 
lying at the base of the organ until it reaches the super- 
natant liquid, where by means of the mechanism con- 
nected with the handle the little button which closes the 
vesical end is made to project, leaving an orifice through 
which the urine can flow into the catheter. When the 
blood has been but recently effused Gross advised “that 
from six to eight hours be allowed to elapse so that the 
blood may subside and clot in the bottom of the bladder 
before the instrument is used.” When active hemor- 
rhage exists, with a tendency to the formation of ob- 








Fig. 1181.—S. D. Gross’ Blood-Clot Catheter. 


structive clots, attempts are to be made to prevent this 
condition by means of irrigation with hot hemostatic 
agents and the establishment of continuous drainage. It 
is in cases of vesical tumor attended with a constant and 
free hemorrhage followed by rapid formation of clots, 
that this instrument finds its greatest use. 

When retention is due to a tortuous stricture of small 
calibre, bougies about the thickness of a broom straw, 
called from their size “ filiform bougies,” are employed. 
They are made of catgut, rubber, or whale-bone. Those 
manufactured from the last-named material are the most 
durable and in most general use. 

The filiform bougie should be eighteen inches in length, 
well rounded, perfectly smooth, and polished. If it be 
rough, chipped, or fractured it should not be employed, 
but discarded as worthless. Irregularities on the surface 
are not only apt to arrest the progress of the tunnelled 
instrument, which is passed over the bougie as a guide to 
the opening of the stricture, but, by the sudden arrest of 
the instrument at the point of obstruction, it is apt to 
cut the filiform, leaving a portion of the latter in the 
urethra, which may prove very difficult to remove. I 
have met in consultation with two cases in which this ac- 
cident occurred. In one instance a portion of the filiform 











was broken off in the urethra. It could not be removed 
at the time with the instruments at hand and the patient 
was kept at rest until the proper utensil could be pro- 
cured. In the mean time in attempting to pass water the 
fragment of the filiform 
was voided. In the second 
case the filiform was broken 
off in the clasp of a tight 
stricture; the patient was 
etherized and the stricture 
rapidly dilated in the hope 
of securing the broken por- 
tion. In performing this op- 
eration the piece of broken 
filiform was pushed into the bladder. It apparently 
gave rise to no pain or inconvenience and the individual 
was opposed to any further efforts toward its removal, 
The stricture was kept well dilated by 
means of steel bougies, and threé weeks 
later the fragment was passed during 
the act of urination. Filiform bougies 
are generally straight, and they are then 
made to terminate in an olivary tip 
with a narrow, well-rounded neck. In 
order to facilitate the passage of the 
instrument through very tortuous 
strictures, the end of the beak is some- 
times slightly angled or twisted, as is 
shown in Fig. 1182. 
After the filiform has been success- 
fully passed an effort should be made 
to slip over it a tun- 
nelled catheter con- 
structed for the pur- 
pose ; the bougie is then 
to be used as a guide. 
If this can be accom- 
plished the urine can 
be evacuated, the cath- 
eter removed, and an 
attempt made to dilate 
the stricture by the 
passage of a tunnelled 
catheter of larger size. 
In some 
cases it will 
be impossi- 
ble to pass 
the catheter 
through the 
stricture; 
the filiform 
may then 
be fastened 
in situ and the patient 
given a hot bath; after 
which he should be 
wrapped in blankets, 
and a hot lemonade, 
containing half an 
ounce of whiskey, to- 
gether with one-quar- 
ter grain of morphine 
and ten grains of quin- 
ine, should be admin- 
istered. He should be 
encouraged to sweat 
freely. In the major- 
ity of cases it will be 
found that in a short 
time the urine will be- 
gin to drop from the 
end of the filiform by Fic. 1182.—Filiform Bougies, Olivary, 
a Angled and Twisted. 
capillary attraction, 
and gradually the 
pressing symptoms will be relieved. Should the blad- 
der be greatly distended, and the symptoms urgent, and 
should it be found impossible to pass the tunnelled 


745 





Catheterism of the 
Urethra, 


catheter over the filiform, through the stricture, into the 


bladder, the bougie may be fastened in the urethra and 
either the bladder aspirated, or an external perineal ure- 





G.7T/EMANN &CO, 







throtomy or a suprapubic cystotomy per- 
formed. As to the best course to pursue, 
the surgeon must be guided in each case by 
the cause of the retention, by the age as 
well as the condition of the patient, by the 
symptoms, and by the length of time that the 
retention has existed. 

The utensil which is passed over the filiform 
bougie as a guide is known as the “Gouley tun- 
nelled catheter.” These instruments vary in size 
from No. 8 up to No. 18, French scale, and con- 
sist of a catheter with a. Thompson curve but 
short beak. The eye of the instrument is oc- 
cluded by an obturator, which can be removed after the 
catheter has been introduced, allowing the urine to flow. 
At the vesical end is a short tunnel which 
terminates in a groove passing along the back 
of the catheter. The loop at the end, which 
is the beginning of the tunnel, is threaded over 

















Fig. 1184.—Mercier’s Invaginated Catheter. 


the filiform which serves to guide the implement directly 
to the opening in the stricture. These catheters are used 
not only for the relief of retention of urine, but in the 
treatment of stricture of the urethra by gradual dilatation. 

A very useful and practical instrument, 
which has been wellnigh lost sight of by the 


Fic. 1183.—Gouley’s Tunnel Catheter, Threaded Over the Filiform. 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


which tilts the beak upward and allows it to pass for- 
ward, along the urethra, into the bladder. After the 
water is drawn the gum catheter is first removed; the 
metal instrument is to be 
withdrawn, or, if continu- 
ous drainage is desired, the 
male catheter may be gently 
removed, leaving the gum 
instrument in place. In 
some cases it will be found that after the gum catheter 
has been passed into the bladder the urine will not flow. 
This is usually due to the eye of the instrument being 
blocked up by a small clot of blood, which can easily be 
removed by the injection into the catheter of a syringe- 
ful of warm distilled water. Blood clots and 
fragments of stone after crushing operations 
are removed by the large metal catheter of 




















Fic. 1187.—Evacuating Catheter (Curved). 


the Bigelow ‘evacuating apparatus. Gentleness and a 
thorough practical knowledge of the anatomy of the 
urethra are necessary in the employment of these instru- 
ments, especially when the attempt is made to introduce 
a perfectly straight tube. 

The direct visual examination of the urethra, by the 
insertion of hollow tubes constructed for the 
purpose, by means of which the canal can be 
illuminated either by reflected light or directly 
by means of a small electric lamp affixed to the 
end of the tube, is called “endoscopy ”; while 
the instrument employed for the purpose is 
known as an “endoscope.” Endoscopes are straight, 
cylindrical tubes varying in calibre and length to suit 
the size and portion of the urethra that 

it is desired to examine. They are made 

















profession, was devised in 1850 by Mercier 











for the purpose of relieving retention of urine 
in cases of prostatic hypertrophy in which 
a false passage exists. It is known as Mer- 
cier’s invaginated catheter. It consists of two 
catheters, one made of metal and the other of gum. The 
one made of metal, usually spoken of as the “ male cath- 
eter,” should be eleven inches long, slightly curved, with 
an oval eye near to the vesical extremity. From the eye 
to the tip the instrument is made to slant with the object 
of tilting the end of the gum catheter forward when it is 
passed through the metal tube. The gum catheter is 


eighteen inches in length and is known as the “ female 
It should be smaller in circumference than 


catheter.” 





Fig. 1188.—Klotz’s Endoscopic Tube. 


either of hard rubber or of various metals. Those manu- 
factured from rubber are not recommended. They are 
injured by caustic applications, absorb a 
great deal of light, and cannot be readily 
sterilized by heat, as they are apt to 
become warped and bent. The most 
serviceable are those made of highly 
polished silver. This metal permits the 
walls of the tube to be thin, thereby in- 











Fig. 1185.—Gouley’s Tunnel Catheter, with the Stylet in Place. 


the male and when passed into the male instrument should 
fit loosely. The gum catheter should have an eye one- 
eighth inch from its end. The 
method of employing these instru- 
ments consists in first passing the 


creasing the bore of the instrument and serving to make 
it of light weight. These instruments are easily steril- 











gum tube into the male until the 
former almost reaches the eye of the 
latter. The male catheter is then 
passed into the urethra until its tip 
becomes inserted in the false passage, thereby blocking 
it up and preventing the further progress of the instru- 
ment. The gum catheter is now gently pushed onward 
until its tip emerges from the eye of the male catheter, 








Fig. 1189.—Oberlaender’s Endoscopic Tube. 


ized and but slightly acted upon by caustics and acids. 
The most improved endoscope carries a light at the end 
of the tube. The most satisfactory instru- 
ment of this kind yet devised is that of 
Valentine, with Koch’s tubes, in which the 
entrance of light is so arranged as not to in- 









































Fig. 1186.—Evacuating Catheter (Straight). 


terfere with the application of medicaments 
to any portion of the urethra. An endoscope 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Catheterism of the 
Urethra, 








exposes to view only a small portion of mucous mem- 
brane which appears at the vesical orifice of the instru- 
ment, but by moving it forward and backward the entire 
canal can be gradually inspected from the posterior ure- 
thra to the meatus. Endoscopic tubes are provided with 
obturators by means of which the vesical orifice is closed, 
thus facilitating the introduction of the tube into the ure- 
thra. The obturator may consist of a solid plug, made of 
hard rubber, or of a strong wire rod on the end of which 
is an olivary bulb of sufficient size to close the end of the 
tube. The bulb should have a deep slit corresponding 
with a similar one on the handle, so that the air may be 
allowed to enter the tube, thereby rendering the removal 
of the obturator easy and avoiding the danger of injury 
to the mucous membrane of the canal by suction. 

The endoscope is manipulated on exactly the same 
principle as is the straight evacuating catheter of the 
Bigelow apparatus. 

To perform catheterism skilfully it is essential that the 
operator should have a good practical knowledge of the 
anatomy of the urethra, as well as of its relations to the 
adjacent urinary organs. 

When an attempt is made to insert an instrument of 
any kind into the urethra the utmost gentleness should 
be observed. It should be passed slowly, so that if an 
unexpected obstruction is encountered, the danger of in- 
juring the canal may be avoided; force should never be 
exerted unless the operator is a surgeon of large experience 
in urethral instrumentation. Even in the most proficient 
hands injury may be inflicted by the employment of too 
much violence. It should be borne in mind that an in- 
strument can be gently guided through the urethra when 
an obstruction exists, but it cannot be forced through 
without danger. When a novice first attempts catheter- 
ism, if it is found that an obstruction exists which pre- 
vents the easy introduction of instruments, it is wiser to 
seek the assistance of one who has had extensive experi- 
ence in urethral surgery, rather than to persist in fruit: 
less efforts to pass through the impediment; an attempt 
of this kind frequently results in traumatism, accom- 
panied by hemorrhage, irritability, congestion of the mu- 
cous membrane, and a spasmodic condition of the urethra. 
The physician should always bear in mind, when dealing 
with urethral cases, that if he cannot benefit his patient 
he must at least be careful not to inflict unnecessary in- 
jury, as is unfortunately often done. 

The elder Gross, in his “System of Surgery,” has em- 
phasized the fact that but few physicians pass a catheter 
skilfully when he says: “The introduction of a catheter, 
although apparently very simple, is one of the most 
delicate operations in surgery. It requires skill of the 
highest order, as well as an intimate knowledge of the 
anatomy of the urinary organs. My conviction is that few 
men do it well.” 

In practised hands the sense of touch becomes so 
greatly developed that the surgeon knows with certainty 
exactly what portion of the urethra is being traversed as 
the instrument passes aiong; consequently he is enabled 
to decide by the touch alone whether the catheter should 
be advanced or withdrawn, raised or depressed, or if it 
should be allowed to remain 7m s¢tw until the muscular 
spasm has relaxed. 

The urethra is a canal which extends from the meatus 
urinarius to the bladder. Its walls are in contact, ex- 
cept when separated for the passage of urine, or for the 
emission of semen, or distended by the introduction of 
instruments or other foreign bodies. 

In the flaccid penis the urethra forms two curves, one 
in the penile portion, which is obliterated when erection 
takes place or when traction is exerted upon the penis by 
stretching it upward toward the middle line of the ab- 
domen. This part of the urethra is freely movable; it 
is distensible, yields to pressure, and readily changes its 
course, without injury, when instruments are inserted. 
It is only by gross negligence that a false passage can be 
established in this section of the canal. The more fixed 
division of the urethra describes a curve, which is fully 
explained on page 748; it yields very slightly to the ad- 














vancing tip of the urethral instrument, and consequently 
here false passages are not uncommon. 

Anatomically the urethra is divided into three parts: 
the penile, the membranous, and the prostatic. For clini- 
cal purposes it has been divided into two, the anterior and 
posterior. The former extends from the meatus to the 
anterior layer of the triangular ligament. The latter is 
the portion beyond the ligament and includes the mem- 
branous and prostatic urethra. The length of the urethra 
varies in different individuals; it measures from eight to 
nine inches. The average length is eight and one-half 
inches. Asarule an obstruction met with over seven 
inches from the meatus may be regarded as arising from 
an affection of the prostate gland, usually an enlarge- 
ment of the organ. 

The penile urethra is generally six and one-half inches 
in length. It is lined with a delicate mucous membrane, 
on the roof and floor of which are the openings of numer- 
ous ducts leading to the urethral glands; these are 
known as the glands of Littré. The urethra, in the 
spongy portion, is surrounded by involuntary, longi- 
tudinal, and circular muscular fibres, as well as by erectile 
tissue. The penile urethra has an expansion at either 
end. The dilatation back of the meatus is called the 
fossa navicularis, on the roof of which is a reduplication 
of the mucous membrane. It is valve-like in form and 
is called the lacunamagna. This fold, or pocket, is from 
one-half to three-fourths of an inch from the meatus, 
the distance varying in different individuals. It is the 
first point which is apt to catch the beak of an instrument 
and arrest its progress after passing through the meatus, 
It is for this reason that, when an attempt is made to in- 
sert a catheter, the tip of the instrument should be kept 
in contact with the inferior wall until the lacunz are 
passed. 

The bulbous portion, or the corpus spongiosum, is the 
termination of the penile urethra. It lies directly in 
front of the anterior layer of the triangular ligament. 
Here the spongy urethra terminates and the membranous 
portion begins, forming what is known as the bulbo- 
membranous junction; a very common site for an or- 
ganic stricture of small calibre, and for the formation of 
false passages by urethral instrumentation. 

The membranous portion of the canal joins the bulb 
at its upper rather than at its lower part, forming a dilata- 
tion on the inferior wall like a pouch or pocket. As 
men advance in years, especially if they have practised 
auto-catheterism for some time, this pouch becomes 
dilated, particularly on the floor of the urethra; it fre- 
quently acts as an obstruction and gives rise to a good 
deal of difficulty when one attempts to make an instru- 
ment glide past the spot. Occasionally small depressions, 
surrounded by folds of mucous membrane, are found on 
the floor of the bulbous urethra. When inflammatory 
conditions exist these folds become cedematous and in- 
crease the difficulty of instrumentation. These obstacles 
can generally be overcome by keeping the penis on the 
stretch and maintaining the beak of the instrument in 
contact with the superior wall of the urethra. 

In old men in whom an obstruction at the bulbous 
urethra exists, and who are required to perform catheter- 
ism daily, an irritation is produced which is frequently 
attended by a low grade of chronic urethritis. As a re- 
sult, a stricture forms, and this, in conjunction with the 
abnormal dilatation at the bulbous portion, renders cath- 
eterism extremely difficult. 

The bulbo-membranous junction of the urethra is in 
contact with the anterior layer of the deep perineal fascia. 
When catheterism with a metal instrument is attempted, 
the beak touches the point of junction, the handle being 
well depressed between the thighs. The layer of fascia 
acts as a fulcrum and turns the point upward toward the 
opening of the membranous urethra, thereby assisting its 
onward passage toward the bladder. When the bulb is 
unusually enlarged, the fascia, instead of being an assist- 
ance to the passage of an instrument, acts as an obstruc- 
tion, preventing its further transit and favoring the 
formation of a false passage if undue force is exerted. 


747 


Catheterism of the 
Urethra, 





Especially is this true if a stricture of small calibre is also 
present. 

When a false passage is produced, the operator will be- 
come aware of the fact by the sudden interruption to the 
further progress of the instrument, together with the 
great local pain that immediately ensues. In addition 
the proximal end of the instrument will deviate from the 
median line. If a false passage has been made in the 
posterior urethra it can readily be detected by a rectal 
examination. Asa rule, hemorrhage does not make its 
appearance until after the instrument has been with- 
drawn. It will vary in quantity from a few drops toa 
continuous flow, depending on the portion of the peri- 
urethral structures which has been injured. 

Catheterism of the urethra in which a false passage 
exists generally requires an instrument with a large curve 
in order to reach the bladder. 

The membranous urethra is usually three-fourths of 
an inch in length. It lies between the anterior and pos- 
terior layers of the triangular. ligament, which serves to 
hold it firmly in place. This portion of the canal, to- 
gether with the prostatic urethra, is frequently spoken 
of as “the deep” or “fixed urethra.” It is composed of 
a mucous coat, submucous tissue, a few involuntary 
muscular fibres, and a thin layer of vascular tissue, which 
bleeds freely when injured. ‘The membranous urethra is 
less movable than the prostatic portion; it is surrounded 
by a band of strong muscular fibres called the compressor 
urethre, The filaments of this muscle pass over, under, 
and around the urethra; they aid not only in retaining 
the urine when the bladder is distended, but also in pro- 
tecting the entrance of the posterior urethra from the in- 
vasion of foreign bodies and urethrai instruments which 
are being roughly manipulated. 

It is a voluntary muscle, being under the control of the 
will. It is markedly influenced by reflex action, giving 
rise to spasm, which accounts for the retention of urine 
which is observed occasionally in acute urethritis and 
after the use of strong injections, and which sometimes 
follows operations on the abdominal cavity, rectum, 
genital organs, and lower limbs. 

The passage of either a catheter or a bougie is rendered 
difficult when resistance is offered by the firm contraction 
of the muscular fibres, when hyperesthesia of the pos- 
terior urethra exists in nervous, impressionable individ- 
uals, or when rough instrumentation is used. It is usu- 
ally at the bulbo-membranous junction that the most 
difficulty is experienced when catheterism is attempted. 
Strictures of the membranous portion of the urethra are 
usually of traumatic origin. The prostatic urethra is 
about one inch and a quarter in length; it is somewhat 
longer in cases of prostatic hypertrophy. It is more moy- 
able than the membranous portion. It is frequently the 
site of traumatism and false passages made by the ignor- 
ant and by rough use of urethral instruments. The pros- 
tatic urethra passes downward and forward and becomes 
the membranous urethra on reaching the posterior layer 
of the triangular ligament. The interior wall shows va- 
rious deep depressions. In rare instances the mouth of 
the ejaculatory ducts are widely dilated and offer an ob- 
struction to catheterism when attempted. While an in- 
strument is passing through the prostatic urethra the tip 
should be kept in contact with the superior wall. 

From what has been said it will be understood that the 
urethra is not a tube of uniform calibre, but consists of 
a series of physiological dilatations and contractions. This 
is well illustrated in the following classification given by 
Taylor, showing the calibre of the different portions of 
the canal: 


Millimetres. Calibre. 
MECBLUS \Sreis.cle sie scapaics bine sieretmntainnmie cetaticrs.¢ 7-9 21-28 F. 
HOSS NAVICULBTISNT +2 ete ws acs eters 10-11 30-33 
Middle of pendulous portion........... 9-10 27-30 
BUD, sro uet eter dye certs serve mralicchataia orttvinrersiniors erase 11-12 33-36 
Membranous urethra ......cesscccvenes 9 27 
Apex of prostate.\.. S25) 3c tat ates ease 10 30 
Middle \of:iprostates; «cue sinew esc enieaters 15 45 
Vesical end of prostate.........ceccesss 11 33 


An examination of the anatomical construction shows 


748 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


that one is dealing with a tube which presents two 
marked constrictions and three dilatations, as well as a 
movable and a fixed curve; the constrictions being found 
at the meatus and internal vesical sphincter, the dilata- 
tions at the fossa navicularis, bulb, and middle portion of 
the prostatic urethra. The fixed curve begins one-half 
inch in front of the bulb. These facts should be borne 
in mind by the operator. 

The difference between the superior and the inferior wall 
of the urethra is an anatomical point of great importance. 
The superior wall is smoother, less vascular, not so in- 
timately connected with the important structures, is more 
constant in formand regular than the inferior wall, which 
presents a series of broken lines due to depressions. The 
curve of the urethra remains regular only on the superior 
wall, which is the shortest route to the bladder. The 
dilatations of the urethra take place at the expense of 
the inferior wall, and they assist in causing its irregular- 
ities. The greater the curve of the urethra the greater 
its length, in consequence of which the depressions in 
the bulbous and prostatic portions of the canal will be 
more marked. 

In selecting the size of the catheter or bougie to be 
employed the operator may be guided by a law first 
enunciated by Otis in 1883, in which he demonstrated 
that the calibre of the urethra bears a constant rela- 
tionship to the circumference of the flaccid penis. He 
gives a scale exhibiting the relative proportion between 
the circumference of the penis and the calibre of the 
urethra. In my opinion the ratio laid down by Dr. Otis 
is too large; that suggested by White in Morrow’s 
“System of Genito-Urinary Diseases” is more reliable 
(loc. cit.). It is as follows:— 

“Circumference of penis, middle of spongy portion, 3 
inches; calibre of urethra, 26-28 mm. Circumference of. 
penis, 34 inches; calibre of urethra, 28-830 mm. Circum- 
ference of penis, 34 inches; calibre of urethra, 30-32 mm. 
Circumference of penis, 33 inches; calibre of urethra, 382- 
34 mm. Circumference of penis, 4 inches; calibre of 
urethra, 34-86 mm. It is seldom necessary to go beyond 
this last size.” 

Phimosis, either congenital or acquired, may contract 
the orifice of the prepuce to such a degree that it will be 
impossible to locate the meatus. When this condition 
exists the foreskin may be divided on the dorsum suffi- 
ciently to render the opening visible, or if necessary cir- 
cumcision may be performed. 

In some instances an cedematous condition of the fore- 
skin, due to inflammation, may render it impossible to 
find the meatus. The obstruction is due in part to an 
elongation of the prepuce, and also in part to the fact 
that the preputial orifice is contracted. If, after the fore- 
skin has been retracted as far as possible, the meatus can- 
not be found, an attempt should be made to lessen the 
amount of serous effusion in the organ by pressure. This 
may be effected by grasping the penis firmly with the left 
hand, retracting the prepuce as far as possible, and mak- 
ing continuous pressure on the organ. Some surgeons 
advise the application of a broad elastic band. When 
pressure applied in the manner indicated fails, the skin 
of the penis should be sterilized and multiple punctures 
should be made in the vicinity of the prepuce with an 
aseptic tenotome, which allows the serum to escape. 
After this operation the foreskin can be retracted to such 
an extent that it will be possible to locate the meatus. 
When the glans penis is covered with papillomatous 
growths difficulty in finding the meatus may be experi- 
enced; usually under these circumstances the meatus can 
be detected by means of a probe. 

Catheterism should always be performed with the pa- 
tient lying in the recumbent posture. Unexpected and 
serious symptoms sometimes arise suddenly from ure- 
thral instrumentation despite the utmost gentleness and 
care. Individuals liable to be so affected are usually 
of a neurasthenic type, but these symptoms may arise in 
strong, robust men in whom no cause for their appear- 
ance can be found. Shock more or less severe, epi- 
leptiform convulsions, and even death have been known 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





to follow the introduction of an instrument into the 
urethra, 

It isalways well to have the shoulders slightly elevated, 
whereby the abdominal muscles are relaxed and the ten- 
sion on the suspensory ligamentis relieved. Flexing the 
thighs also aids in relaxing the abdominal muscles. The 
patient should be instructed to open the mouth widely 
and to take full, quick inspirations, which will relax the 
diaphragm and subdue muscular tension, in addition to 
occupying the 
mind, so that at- 
tention is diverted 
from the affected 
parts. 

The method to 
be employed when 
one undertakes to 
carry out urethro- 
vesical catheter- 
ism will depend 
on the character 
of the instrument 
to be used, wheth- 
er it be soft, flexi- 
ble, metal, straight 
or curved. It has 
already been 
shown that the 
calibre of the 
urethra is a vari- 
able one; that it 
consists of a series 
of physiological 
contractions and 
dilatations; that 
the  dilatability 
possesses a_ rela: 
tion to the circum. 
ference of the flac- 
cid penis. As a 
rule, the external 
meatus is the most 
contracted por- 
tion of the canal. 
It will frequently 
be found to vary 
in size; in some 
instances being unusually large and in others abnor- 
mally contracted. It is a safe rule to regard an instru- 
ment to be of a proper calibre when it can be readily 
inserted through a normal meatus and passed through 
the entire canal without encountering any abnormal ob- 
struction. A normal meatus may, therefore, be taken as 
a guide for the size of the catheter to be employed. When 
the urinary outlet is abnormally contracted meatotomy 
should be performed. 

Regarding the size of the catheter, every patient is a 
law unto himself, as no two individuals have a urethra 
of exactly the same calibre. All genito-urinary surgeons 
agree that a catheter should be neither too large nor too 
small; that the urethra should be moderately filled, but 
not dilated. The catheter which fulfils this indication 
can be inserted far more readily, will give rise to less dis- 
comfort and pain, and will involve less danger of pro- 
ducing a false passage or of causing attacks of urethritis 
and orchitis than will the use of very small catheters, 
which are so frequently employed by patients under the 
impression that they give less pain and are more free 
from danger. The calibre of the catheter suitable for 
the average individual is about 15 French. 

Both soft and flexible catheters are passed in the same 
manner. The instrument having been sterilized and 
anointed with an antiseptic lubricant, and the patient 
having placed himself in the recumbent posture, the sur- 
geon should stand on the left side and grasp the penis 
between the middle and ring fingers of the left hand, 
just behind the corona glandis, leaving the index finger 
and thumb free to retract the prepuce and separate the 


Penile Urethra 
Length 634 in. 


Membranous 
Urethra 
Length % in. 


Prostatic Urethra 
Length 134 in. 


Total length of 
- Urethra 814 in. 









Bladder 


Fig. 1190.—Showing Normal Physiological Constrictions and Dilatations of Various Portions 
of the Urethra, with the Calibre and Length of Each. 





Catheterism of the 
Urethra, 


meatus. The penis should be stretched upward toward 
the middle line of the abdomen. The end of the catheter 
is then to be inserted and slowly and gently propelled 
forward with a uniform motion, introducing about a 
quarter of an inch of the instrument at each movement. 
This is to be continued until the bladder is reached. If 
any obstruction is met with the further progress of the 
instrument should be immediately arrested. It should 
be gently retracted for a short distance and then an effort 
should be made to 
reinsert it. After 
the instrument 
has been passed 
through the ure- 
thra and the urine 
evacuated, the 
proximal end of 
the instrument 
should be closed 
either by pinch- 
ing the end of the 
instrument or by 
closing the orifice 
with the index 
finger, which pre- 
vents the urine 
that remains in 
the catheter from 
escaping when the 
eye of the catheter 
emerges from the 
meatus. When 
employing a cath- 
eter with a coudé 
curve, it should 
be recollected that 
the instrument is 


_Fossa Navicularis 
Calibre 30-33 F 


Calibre Anterior 


Urethra 














Calibre 
33 to 36 F 


Posterior 


Calibre 27 F 
rental Urethra 


External Vesical 


Calibre 45 F in contact with the 

' two opposite walls 
Calibre 35 Fg fee Vasical of the urethra, so 
eehinciar that when the bul- 

P bous portion of 


the canal is reach- 
ed it should be 
more rapidly low- 
ered toward the 
thighs than is the 
custom in employing other forms of catheter. If this 
advice be followed the instrument will pass readily into 
the membranous urethra. 

Daily catheterism frequently gives rise to a low grade of 
chronic urethritis attended by a spasmodic condition of 
the urethra, rendering the operation painful. This con- 
dition is relieved by daily irrigation with a warm boric- 
acid solution, and by passing a conical bougie every third 
day. The spasm may be overcome by the administra- 
tion of: 


(Horwitz.) 


He bine pelladonnseace cies stories 3 ss. 
SOG DOM prpereiaeies wietsalete laisse) Ziv 
Gi CRP OUASSUe Pr teielsteosietaeferetelele ox Sule 
BU LAO DEIES iis) ais pax ootbldys sfsiors 3 iij. 
A Quire, Gestils se. rte ie ale tteilee ise, < ad % vi. 


M. Sig: Tablespoonful in water three times daily. 


Gouley highly recommends gr. 54, of hyoscyamus sul- 
phate, to be given three times daily. He advises that the 
remedy should not be administered over three days in 
succession, when an interval of four days should be ai- 
lowed to intervene before its administration is resumed. 

Relapsing orchitis in old patients practising auto- 
catheterism is due either to the use of infected instru- 
ments or to a too frequent use of the catheter. When 


this condition exists, the urethritis may be treated in 


the usual manner and continuous catheterism employed. 
In the aged, whose sexual powers have long been sus- 
pended, double vasectomy may be resorted. to; for this 
not only prevents any further development of orchitis, 


749 


Catheterism of the 
Urethra, 





but is oftentimes beneficial in causing atrophy of the 
hypertrophied prostate gland. 

Patients suffering from the effects of residual urine 
due to prostatic hypertrophy should not employ a cathe- 
ter too frequently. A number of individuals have come 
under my cognizance who were affected with urethro- 
cystitis complicating an obstructive prostate gland, and 
who were in the habit of inserting the catheter at least 





Fig. 1191.—Showing Passage of a Curved Instrument through the 
Anterior Urethra. (Englisch.) 


once an hour. The too frequent use of the catheter un- 
doubtedly increases the inflammation of the urethra and 
bladder. When the desire for urination is frequent and 
urgent, rendering the repeated introduction of a catheter 
necessary, the individual should be put to bed and con- 
tinuous catheterism instituted until the inflammation at 
the neck of the bladder has subsided, after which some 
permanent relief should be afforded by an appropriate 
operation. In cases in which the urine is sterile the fre- 
quency with which catheterism may be resorted to is 
well formulated by White, who says: “ When the urine 
is sterile it is rarely necessary to catheterize more than 
once in four hours. The frequency should be in propor- 
tion to the amount and character of the residual urine, a 
very good working rule being the use of the catheter once 
a day, preferably at bedtime, for three ounces, twice for 
six ounces, and then once more for every additional two 
ounces.” 

A curved metal instrument, whether catbeter or bougie, 
is to be passed through the urethra on precisely the same 
principles as those which have already been stated. The 
patient is to be placed in the position which was recom- 
mended when I described the manner of introducing a 
rubber catheter. The surgeon stands on the left side, 
grasps the penis in the manner already described, and 
stretches it gently upward toward the middle line of the 
abdominal wall, thus obliterating the curve of the penile 
urethra and lessening the dilatability of the bulb. The 
proximal end of the catheter is held lightly in the right 
hand, with the handle well over the left thigh. The 
vesical end is then inserted into the meatus, and kept in 
contact with the floor of the urethra until the lacuna 
magna is passed and the curve of the instrument is fairly 
in the canal. The handle of the instrument is moved to 
the middle line of the abdomen, and the right hand gently, 
but firmly, and with uniform force, pushes the catheter 
into the urethra, at the same time stretching the penis 
gently on the shaft of the instrument until the right and 
left hands are about three inches apart. 

The catheter continues to glide along the urethra until 


750 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


its onward progress is slightly retarded; which means. 
that the beak has reached the sinus of the bulb, is in con- 
tact with the anterior layer of the triangular ligament, 
and is ready to pass through the fixed curve of the canal. 
The operator now takes hold of the instrument with the 
left hand and slowly and gently changes it from the 
horizontal to the vertical position, bringing it down be- 
tween the thighs, when the catheter will pass through 
the membranous and prostatic portions of the urethra. 
The changing of the instrument from a horizontal to a 
vertical position brings the curved portion directly under 
the pubic arch, which is opposite the opening of the 
membranous urethra, behind the triangular ligament. 
Should any obstruction be met -with at this point, no at- 
tempt should be made to carry the instrument onward 
until the temporary contraction of the compressor urethree 
muscles has relaxed. If the retraction: be due to the im- 
pinging of the tip of the instrument on the triangular 
ligament, it should be slightly withdrawn, the handle of 
the instrument well depressed between the thighs, bring- 
ing the tip of the instrument in contact with the superior 
wall of the urethra, when, by gentle pressure made in the 
axis of the body, it can be readily passed into the bladder. 

Occasionally it happens that the dilated mouths of the 
ducts leading to Cowper’s glands will be sufficient cause 
for the arrest of the progress of an instrument. When 
this occurs it will be found that the point of the instru- 
ment has deviated either to the right or to the left of the 
median line and that it is impossible to urge it onward. 
By slightly withdrawing the instrument and keeping the 
tip in contact with the anterior wall of the urethra, the 
obstacle will be overcome. 

Should the instrument be arrested at the bulb, the 
right hand should be passed back of the scrotum and 
with it the shaft of the instrument raised, whereby its 
onward progress will be greatly facilitated. When the 
arrest is due to a prostatic hypertrophy, the index finger 
of the right hand may be inserted into the rectum and the 
catheter gently lifted upward, when it will advance 
without further trouble. 

Englisch describes a rare form of obstruction which 
when present gives rise toa good deal of trouble. Owing 
to an unusually firm attachment of the penis to the sym- 
physis pubis, by means of the suspensory ligament, a 
band is formed, and with it is associated a dilatation or 
pocket of the superior wall of the urethra, which is apt to 
catch the tip of the instrument and prevent its further 
progress. It is on lowering the beak of the catheter, in 
order to pass the obstruction, that a false passage is apt. 





Fig. 1192.—Showing the Passage of a Curved Instrument through the 
Posterior Urethra. (Englisch.) 


to be produced. When failure to pass a catheter is due 
to this cause, the right hand should be placed on the body 
of the penis, just in front of the symphysis, and the 
organ gently pressed downward; at the same time the 
instrument should be withdrawn about half an inch by 
means of the left hand; the handle of the catheter is then 
slightly elevated in order to place the tip of the instru- 
ment on the floor of the canal, after which it should be 
slowly pushed onward until the obstruction is passed. 


-REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Catheterism of the 
Urethra, 





The dilated mouths of the ejaculatory ducts will in 
rare instances impede the passage of acatheter. Should 
this condition exist, the tip of the instrument must be 
kept in contact with the roof of the prostatic urethra. 
But it must be borne in mind that the superior surface 
of the prostatic urethra, especially in the posterior por- 
tion, is quite thin and can be easily punctured. It must 
always be recollected that perineal and scrotal tumors, 
as well as prostatic hypertrophy, change very materially 
the fixed urethral curve. When any of these conditions 
exists catheters with a curve suitable for the altered con- 
dition must be selected. 

In most instances when the catheter reaches the blad- 
der the urine begins to flow; after the instrument has en- 
tered the cavity, it will be found that it is freely movable 
along its axis, and that the beak can be readily turned in 
all directions. 

When there is an enlargement of the middle lobe of the 
prostate gland, the urethra is elongated to a marked de- 
gree, and the operator may fail to draw off the urine 
owing to the fact that the catheter has not been intro- 
duced sufficiently far, or that it is too short to reach the 
distended organ. 

Occasionally it will be found that after the catheter 
has entered the bladder the urine will not be expelled. 
This may be owing to many reasons. The most common 
cause is the blocking up of the eye of the instrument 
with either pus or blood. These obstacles may be over- 
come by passing through the catheter a warm five-per- 
cent. solution of boric acid. The failure to evacuate may 
be due to an atonied condition of the bladder, owing to a 
lack of proper muscular contractility of the walls of 
theorgan. This difficulty may be surmounted by placing 
a hand on the abdomen just above the pubesand making 
gentle pressure over the distended viscus. 

The eye of the instrument may be obstructed by com- 
ing incontact with the mucous membrane of the bladder. 
This condition may be readily obviated by giving the 
wrist a slight twist, or by moving the catheter back and 
forth. When the bladder is distended this impediment 
cannot arise. In rare instances the urine is lodged in a 
diverticulum. When this occurs the fluid cannot be 
reached by a catheter. 

Suppression of the urine may be mistaken for reten- 
tion. When suppression exists the characteristic symp- 
toms of retention are absent; there is no pain, spasm, or 
sense of weight in the pelvic region. A constant desire 
to urinate, associated with tension, is present. There may 
be dribbling of the urine, or but a few drops are passed 
at a time, but there is never a full stream. There will 
be absence of the characteristic, hard, pyriform tumor, 
which is fluctuating, but not affected by change of pos- 
sture, and which is always situated in the median line. 
The absence of these well-marked symptoms of retention 
should prevent any difficulty in making a differential 
diagnosis. 

When residual urine is associated with an excessive 
enlargement of the prostate gland, the beak of thecatheter, 
on entering the bladder, is liable to be high above the 
level of the fluid lying in the pocket at its base. When 
this condition exists, it is recommended that the individ- 
ual be instructed to lie on his side, or to assume the “ knee- 
chest position”; an attitude exceedingly unpleasant to 
many patients. The resort to such expedients shows 
that the time for operative interference has arrived. 

In nervous patients, or in those in whom the urethra is 
inflamed orirritable, a urethral injection of one drachm of 
a two-per-cent. solution of cocaine should be. administered, 
and it should be kept in contact with the irritated surface 
for the space of five minutes before instrumentation is 
attempted. An excellent local anzesthetic has been sug- 
gested by Lydston, who claims that “it is absolutely 
safe, free from constitutional effects; distinctly lessening 
the hemorrhage both before and after operation; and 
causing less disturbance of nutrition of the wounded tis- 
sues.” It consists of a ten-per-cent. solution of antipyrin 
in one per-cent. solution of carbolic acid. The solution 
should be fresh and allowed to remain in the urethra for 











ten minutes. I have employed this frequently as a sub- 
stitute for cocaine with most satisfactory results. 

The passage of straight tubes through the urethra into 
the bladder requires a slightly different manipulation, 
and more skill than is needed for the introduction of 
curved instruments. The procedure is also attended by 
greater danger of traumatism. At the start a straight in- 
strument is inserted into the urethra in the same manner 
as an ordinary catheter, except that it is entered parallel 
with the middle line of the abdomen and slowly passed 
into the urethra toward the rectum until it cannot be ad- 
vanced any farther in that direction; it is then slowly 
brought from the vertical to the horizontal position, 
pressure being made at the same time with the right 
hand on the body of the penis directly in front of the 
symphysis pubis; which not only assists to relax the sus- 
pensory ligament, but helps to straighten the curve of 
the urethra. In order to be sure that the point of the 
instrument is not caught in the dilatation at the bulb it 
should be slightly withdrawn, the handle of the instru- 
ment being brought well down between the thighs, and 
then pushed gently upward in the axis of the body. In 
old men with a dilated bulbous urethra or a prostatic 
hypertrophy the passage of a straight catheter is often 
impossible. 

In attempting to pass filiform bougies it is well first to 
distend the canal by gently injecting a syringeful of 
liquid aseptic cosmoline. The filiform is then intro- 
duced into the meatus and passed slowly down to the 
obstruction, the patient’s face meanwhile being carefully 
watched for the slightest expression of pain; should this 
arise the onward passage of the filiform must cease. The 
least impediment to the passage of the bougie should warn 
the operator that he has introduced the instrument as far 
as is justifiable. A second filiform should then be intro- 
duced in the same manner, and the process repeated until 
six or eight whalebones have been inserted, when the 
operator gently tries each in turn to see if the opening in 
the stricture can be found. This manceuvre requires care 
and patience. Under no circumstances is force to be 
employed. The opening in the stricture may be situated 
above or below, or at the right or left of the centre. 
When the attempt is made to pass a filiform bougie the 
tendency is for the operator to work toward himself; con- 
sequently if the opening is on the right side, and if, after 
a fair trial, he finds that the attempt to insert the instru- 
ment whilst standing on the left of the patient fails, he 
should change his position to the other side of the patient. 
Upon renewing the attempt in this new position he will 
often find that the instrument will readily pass through 
the stricture. 

In eccentric stricture the opening will probably be 
found by this manipulation. When the instrument 
glides through the contraction with little or no pain, and 
without force being required, it will pass into the bladder 
and be freely movable in the urethra. These instruments 
are frequently made with a spiral twist or angle at the 
end, on the supposition that the physician can more 
readily pass such a one should the stricture be eccentric. 
Asa rule, the straight instrument is all that is required. 

The failure on the part of many practitioners to use 
successfully filiform bougies is owing to several reasons: 
The instruments sold in the shops are more often than 
otherwise worthless; they are too stiff, not well rounded, 
do not terminate in a proper neck, and are generally too 
large to serve as guides to small-sized tunnelled catheters 
which are designed to pass over them. The surgeon 
should make his own filiform bougies; a dozen properly 
constructed will, with ordinary care, last through several 
years of active practice. An important rule to follow is 
to employ the filiform before a bougie, catheter, or any 
other instrument has been passed into the urethra. If 
an instrument has been previously used it will generally 
be useless to attempt the passage of the filiform; failure 
being the usual result. The operator must not be spar- 
ing of his time in these cases; infinite veep is a neces- 
sary element of success. 

To introduce a tunnelled catheter successfully over the 


751 


Catheterism of the 
Urethra, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





filiform and through the stricture the instrument should 
be gently passed down to the obstruction, then transferred 
from the right to the left hand, and whilst the hand hold- 
ing the penis puts it on the stretch the filiform is slightly 
withdrawn about a quarter of an inch, and then both 
filiform and tunnelled catheter are to be carried together 
through the stricture. This procedure prevents the 
catheter from cutting the filiform in two and assists in 
guiding the instrument through the obstruction. 
Catheterism in children must be very gently performed, 
as the urethra at the bulbo-membranous junction is very 
easily torn. Keegan has pointed out that the capacity 
of the urethra varies in children of the same age much 
more than does that of the adult. Litholapaxy in children 
has proven that the dilatability of the urethra is far greater 
than was formerly supposed. Freyer reports a success- 
ful case of litholapaxy in a child eighteen months old. 
Catheterism in children is to be conducted on the same 
principles as those which guide us in performing the 
operation in the case of an adult; the utensil used must 
be of a size suitable to the calibre of the urethra. When 
curved instruments are employed, the arc should be in- 
creased over that of the ordinary normal bend of the ure- 
thra and should describe the arc ofa smaller circle. 
Catheterism in women, as a rule, is easily accomplished 
by touch, without the assistance of the eye. It is diffi- 
cult to locate the meatus in old women, especially if they 
have borne many children, the landmarks being obliter- 
ated, and the meatus being removed farther back than is 
normal. The dilatation of the mouths of the ducts lead- 
ing to the glands situated in the vicinity of the urethra; 
an anteflexed uterus; hypertrophy and cysts of the labia; 
papillomatous growths or cicatrices in the vicinity of the 
meatus-—all these may render it very difficult or even 
impossible to locate the urinary opening by the sense of 
touch. When any of these conditions arises I am averse 
to catheterism being performed by touch. It is fraught 
with danger to the patient; infection of the badder being 
very apt to ensue. I have seen many cases of cystitis 
in women thus produced. Before the catheter is used 
the external genitalia should be carefully sterilized and 
if practicable a vaginal douche should be administered. 
Especially is this to be done after childbirth, and fol- 
lowing operations on the uterus, vagina, and external 
genitalia, or when the patient is suffering from some 
specific inflammatory condition. When attempts are 
made to pass the catheter by the sense of touch, the 
operator is unable to determine whether the pathologi- 
cal secretions have been removed and the parts prop- 
erly cleansed before he inserts the instrument. There 
is always more or less uncertainty in at once locating the 
meatus; the instrument is apt to be thrust in different 
directions before the opening is located. If the vulva 
and vagina have not been properly sterilized an infected 
catheter will assuredly be inserted into the bladder; hence 
it should be insisted on in every case that female pa- 
tients be catheterized by aid of the eye rather than by 
touch. To pass the catheter by touch, the woman lies on 
her back with the thighs slightly flexed and the knees 
elevated. The thumb and index finger of the left hand 
separate the labia. The middle finger is then inserted 








Fic, 1193.—Sims’ Female Catheter. 


into the vagina and passed backward and upward until 
the superior wall is reached; it is then to be brought for- 
ward until the depression in which the meatus is situated 
is felt. This spot having been determined, the finger is 
passed a little backward and held firmly in place while 
the catheter, which is in the surgeon’s right hand, is 
passed over the finger, which is in contact with the upper 
wall of the vagina, and serves to guide the instrument 
into the urethra. After it has entered the meatus the in- 


T52 





strument should be carried backward, upward, and then 
directly backward. When the instrument is to be passed 
by sight, the patient is brought to the edge of the bed, 
the legs are flexed, and the feet allowed to rest on the 
side of the bed. The genitals are cleansed and sterilized 
and the labia well separated by the index finger and 
thumb of the left hand. If the genital organs are in 
normal condition the meatus comes at once into view, 
when the catheter can be readily inserted. Female 

















Fig. 1194.—Ordinary Pattern of Metal Female Catheter. 


catheters are straight tubes made of either glass, silver, 
or German silver, the former being preferable. They 
should be six and one-half inches in length and 14 F. in 
circumference. They are always to be sterilized by boil- 
ing. Whenabnormal conditions exist, it may be necessary 
to employ either a male soft rubber ora flexible woven 
catheter. 

The durability and usefulness of rubber urethral in- 
struments depend on the care taken to preserve them. 
In order to employ catheterism with safety to the pa- 
tient, it is essential that the surgeon should be thoroughly 
familiar with the modern methods in vogue for the pres- 
ervation and sterilization of instruments, and for the 
proper sterilization of the urethra and hands of the oper- 
ator. Like all other surgical procedures, aseptic cathe- 
terism requires that the hands of the operator, the instru- 
ments employed, as well as the preputial fold, glans 
penis, and urethra, should be rendered as nearly sterile as 
possible. 

Unfortunately the urethra is the normal habitat of a 
variety of micro-organisms, some of which are harmless, 
while others become virulent when the physiological re- 
sisting power of the urethra is lowered by injury or dis- 
ease. It is probable that when the urethra is in a patho- 
logical condition, the intra-urethral microbic life increases 
in activity, and also that the micro-organisms that were 
apparently harmless in the normal condition become vir- 
ulent. The introduction, into the canal, of infected in- 
struments producing slight traumatism from careless 
handling, or an abrasion of the mucous membrane from 
friction, may cause not only constitutional infection, 
giving rise tosome of the various forms of urethral fever, 
but also secondary infection of some of the adjacent uri- 
nary organs which are connected with the urethra. I.ust- 
garten, Mannaberg, Melchior, Legroin, and others have 
conclusively demonstrated that the urethra normally con- 
tains, among other forms of micro-organisms, staphy- 
lococci and streptococci, which in all probability be- 
come active when infected instruments are inserted into 
the healthy urethra. Dirty instruments, especially if they 
injure the mucous membrane at the same time, both give 
rise to a suitable soil for the nidus and growth of these 
microbes, and at the same time introduce into the urethra 
pathogenic micro-organisms which were not present pre- 
vious to the passage of the catheter. 

Many persons have contracted virulent gonorrhoea in 
this manner. In one instance, which I saw in consulta- 
tion, violent infection followed the insertion of a steel 
bougie; it produced cellulitis, gangrene, and sloughing 
of the under portion of the corpus spongiosum, with ex- 
tensive hypospadias—conditions which rendered neces- 
sary several plastic operations before the cure of the case 
was completed. Besides the micro-organisms enumerated 
a bacillus is found so closely resembling the tubercle bacil- 
lus that it is nearly impossible to distinguish between 
them. It is probably a smegma bacillus. Its presence 
is frequently the cause of a mistaken diagnosis of tuber- 
culosis of the genito-urinary tract. There are also several 
varieties of diplococci which so closely resemble those of 
Neisser in every respect that in some forms of chronic 
urethritis they cannot be distinguished from the gonococci. 
From what has been said it is evident that it is impossible 
to render the urethra aseptic; therefore the term “aseptic 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


catheterism” is a misnomer. A catheter may be made 
aseptic, but efforts made to sterilize the urethral tract are 
abortive. Unfortunately, antiseptic remedies of sufficient 
strength to render the urethra sterile cannot be employed. 
When the urine is alkaline and purulent, much may be 
accomplished by the internal administration of such 
remedies as have a tendency to sterilize the urine. At 
the same time irrigation with any weak antiseptic solu- 
tion should be employed, and the instruments and the 
surgeon’s hands should be thoroughly cleaned and steri- 
lized. 

Since the introduction of antiseptic methods of catheter- 
ism, not only has the mortality of urethral operations 
materially diminished, but patients make a more rapid 
convalescence; in most instances they escape urethral fever 
and such complications as urethritis, prostatitis, cystitis, 
orchitis, and infection of the kidney. Evacuating cathe- 
terism can be performed with less danger to the patient, 
cystitis and orchitis being infrequent complications under 
these circumstances. 

When the urine is alkaline, containing pus or blood, 
especially if the microscope reveals the presence of the 
bacillus coli communis, the employment internally of 
such remedies as quinine, boric acid, salol, eucalyptus oil, 
and urotropine is indicated; the latter remedy is the most 
efficient. When the gonococci are present, methylene 
blue, given separately or in combination with cubebs, 
copaiba, or sandalwood, is frequently of service. The 
hands of the surgeon should be carefully washed and 
scrubbed with soap and water, especial attention being 
given to the subungual spaces. Afterward they should 
be rubbed with a piece of sterilized gauze saturated 
with alcohol, with a view to dissolving the fatty matter 
of the skin, thereby removing the material which serves 
to shelter microbic life. In order to perform catheterism 
with the least danger of infection, it is essential that the 
hands should be as clean as soap and water can make 
them; it is not necessary to complete the sterilization 
by immersing them in a solution of the bichloride of 
mercury, unless some more formal operation is to be 
performed. 

As microbic life swarms in the vicinity of the foreskin, 
preputial folds, and glans penis, the parts should be 
thoroughly washed with soap and water, and then bathed 
with a solution of bichloride of mercury of a strength 
not greater than 1 to 5,000. Care should be observed not 
to allow the solution to be introduced into the urethra; 
severe urethritis might be produced. Antiseptic solu- 
tions which are employed to irrigate the urethra should 
be very weak. A corrosive sublimate solution should 
never be stronger than 1 to 20,000. Irrigation with a solu- 
tion of the strength advised is indicated before an opera- 
tion on the urethra, prostate gland, or bladder is com- 
menced. It is sometimes beneficial in tuberculous lesions 
of the genito-urinary tract. It should not be employed 
as a daily irrigation by patients who practise auto-cathe- 
terism, as its continuous use is apt to give rise to ure- 
thritis. Permanganate of potassium solution may be em- 
ployed in varying strength, from 1 to 5,000 to 1 to 2,000. 
In a solution not stronger than here indicated it can be 
used daily with great benefit, rarely giving rise to irrita- 
tion. Nitrate of silver solution of a strength of 1 to 10,000 
is sometimes employed, especially when chronic inflam- 
matory conditions of the urethra and bladder exist. 

One of the least irritating and most satisfactory cleans- 
ing solutions, when the catheter is being used daily, is a 
warm five-per-cent. solution of boric acid. If there is no 
infection of the urethra nothing is more serviceable, pre- 
vious to catheterism, than an irrigation with a warm nor- 
mal salt solution. 

Beck, in the Medical News for January, 1900, has sug- 
gested the prophylactic injection of a five-per-cent. 
emulsion of iodoform and glycerin before the introduction 
of an instrument into the urethra. He claims that “if an 
abrasion is caused the iodoform will come in contact with 
the wound at the very moment when it is made and with 
the wound serum at the stadium nascendi. Iodine is set 
free and during this chemical process bacteria are de- 


Vou. IIl.—48 


Catheterism of the 
Urethra, 





stroyed or the development at least is arrested.” This is 
an,excellent suggestion, and I have often employed the 
remedy, but patients frequently object to its use on ac- 
count of the disagreeable smell of the iodoform. 

It is useless to expect the patient to sterilize the external 
genitals and urethra whenever the catheter is to be in- 
serted; nor is this absolutely essential. If the individual 
can be impressed with the danger of neglecting the ordi- 
nary methods of cleanliness, there will be but little diffi- 
culty in getting him to wash and cleanse the parts at 
least once or twice a day and to use only sterilized un- 
damaged catheters. In cases in which the patient is able 
to pass his urine, but in which catheterism is necessary, 
it is well to instruct him first to urinate, thereby “ flush- 
ing” the urethra before the canal is irrigated preparatory 
to the introduction of the instrument. In cases of retention 
of urine the urethra in front of the obstruction should al- 
ways be irrigated with either the salt or the boric-acid 
solution previous to instrumentation. Inretention due to 
acute urethritis the canal should be irrigated with a solu- 
tion of permanganate of potassium not stronger than 1 
to 8,000 before attempting catheterism. A catheter which 
has been employed in a case of retention of urine due to 
acute gonorrhea should immediately be sterilized by 
boiling after using, when it may be laid aside until it is 
determined whether its employment is again necessary. 
It should be used on but one individual. 

The preservation and durability of soft-rubber and 
web catheters depend on the manner in which they are 
cared for. Rubberor gum-coated catheters should never 
be coiled; they should be kept at full length, perfectly 
straight; means being taken to prevent them from com- 
ing in contact with each other. As soft-rubber catheters 
when exposed to the air undergo oxidation, it is essential 
after they have been sterilized that they should be 
wrapped in moist steril- 
ized gauze and secured 
in tightly closed glass 
tubes. Englisch states 
“that vulcanized caout- 
chouc catheters are best 
preserved in asbestos.” 

Web catheters are 
stored in the same man- 
ner. Coiling these in- 
struments causes their 
gum coatings to crack, 
thus rendering steriliza- 
tion impossible and in- 
creasing the chances of 
their injuring the ure- 
thral mucous mem- 
brane. If a soft-rubber 
instrument has become 
hard and_ brittle, or if 
it is greatly lengthened 
and softened by the use 
of the lubricants em- 
ployed, it should be dis- 
carded. Flexible instru- 
ments should not be 
employed when the coat- 
ing is not perfectly 
smooth or if they show 
the least abrasion, fis- 
sure, or crack. 

Soft-rubber catheters 
may be sterilized by 
boiling for five minutes; 
they are not injured by 
the process. The finest 
grade of web catheter will withstand boiling without 
injury unless it be repeated too frequently or continued 
for too long a time, when the coating is liable to be- 
come blistered and the instrument rendered worthless. 
After a rubber or web catheter has been employed it 
should be thoroughly washed with soap and water and 
a full stream of water allowed to flow through it. It is 










































































Fig. 1195.—Hermetically Sealed Glass 
Tubes for Storing Sterilized Cathe- 
ters, with Convenient Form of Stand. 


753 


Cathetcrism of the 
Caustics, [Urethra, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








then placed in the glass cylinder known as a “ cathetero- 
stat,” which serves for both a sterilizing and a storing jar. 
It was devised by Frank and Dufaux. It consists of a 
glass cylinder sixteen inches long, having on the inside 
near the rim a shelf on which rests a perforated metal 
plate for holding the rubber instruments. In the bottom 
of the jar is placed a dozen tablets of trioxymethylene, 
which is a derivative of formal. It has been demon- 
strated by the experiments of Janet and Guyon that this 
antiseptic is the least harmful and the most efficient that 
can be employed for catheters of ordinary calibre. An 
- exposure to the fumes of these tablets for twenty-four 
hours is sufficient, unless the instruments be of very small 
calibre, when they should be allowed to remain ex posed to 
the sterilizing fumes for at least three days. These ex- 
halations are given off at a temperature above 56° F.; 
below this point vaporization does not take place, The 
apparatus should, therefore, be kept in a warm room. 
The tablets preserve their efficiency for a long time and 
waste imperceptibly. 

A metal box for the purpose of sterilizing rubber ure- 
thral instruments has been devised by Janet. It is of 
two sizes. The larger is for hospital use; the smaller for 
patients who have recourse to auto-catheterism. The 
box is seventeen inches long, three inches high, and three 
inches wide, and rests on four metal feet. It is closed at 
both ends, one extremity having a tightly fitting metal 
cap attached which can be removed when access to the 
interior is desired. The interior is furnished with two 
shelves which are perforated by holes; on these shelves 
the catheters are to be placed. In addition there is, 
at the bottom, a shelf covered with a perforated metal 
screen on which can be placed trioxymethylene tab- 
lets; or it may be covered with flannel which can be 
moistened with liquid paraform or covered with a pow- 
der of formal. 

Patients who require the use of a catheter four times 
daily should have eight catheters, four to be placed on 
the upper and four on the lower shelf of the apparatus. 
At the end of twenty-four hours the instruments are ready 
for use. During the day the four catheters on the upper 
shelf are to be used, washed, and put aside; at the end 
of the day they are replaced on the empty shelf. On the 
following day the instruments on the lower shelf are to 
be employed, thereby allowing an- opportunity for the 
catheters on the upper shelf to be resterilized and ren- 
dered ready for service when needed. If the catheters 
are not to be frequently used the instruments should be 
allowed to remain in either the closed catheterostat or in 
the metal box until thoroughly antisepticized, when they 
should be removed, wrapped in sterilized gauze, and 
placed in tightly corked glass tubes ready for use. By 
this means the surgeon has his rubber urethral instru- 
ments always prepared for any emergency that may 
arise. Before using the urethral instruments that have 
been sterilized by formalin or its derivatives, they should 
be either thoroughly washed with a five-per-cent. boric- 
acid solution or placed in a tin cup containing boiling 
water for at least five minutes: as in many instances 
the formalin deposited on the catheter proves irritating 
to the mucous membrane of the urethra. This is espe- 
cially necessary in the case of those who require daily 
catheterism and in whom frequent introduction of the 
instrument is necessary. For patients whose duties ne- 
cessitate their absence from home and who cannot have 
access to sterilized catheters, a papier-maché pocket case 
has been devised which is light and can be conveniently 
carried; the instruments in this case are kept in an aseptic 
condition. It holds four instruments which are curved, 
but not bent; it is supplied with a pocket in which three 
formaline tablets may be placed together with a small 
tube containing an antiseptic catheter paste suggested 
by Guyon and Frank. 

Under no circumstances should the surgeon sanc- 
tion the patient’s carrying the catheter in his pocket 
or lining of his hat, as is frequently done. If the in- 
dividual objects to employing the contrivance just 
described, he may use an inexpensive case made of 


754 


German silver which is large enough to carry two 
catheters. 

An ingenious apparatus for the sterilization of cathe- . 
ters by means of steam has been devised by Kuttner. In 
this apparatus the catheters are so arranged that the 
steam passes down through the instruments, emerges at 
the eye, then passes back outside and escapes at the up- 
per end of the apparatus. 

Filiform bougies which have been used should be 
washed with soap and water, dried, and sterilized in the 
same manner as the rubber instrument by the formalin 
process; or after thorough washing they may be immersed 
in a warm solution of the bichloride of mercury of a 
strength of 1 to 1,000, after which they should be rinsed in 
sterilized water and dried. These instruments if exposed 
to the air become hard and brittle and are destroyed by a 
parasite which attacks them. Consequently they should 
be preserved from contact with the air by either being 
kept in a metal case or by being wrapped in flannel 
smeared with mercurial ointment. Before using a metal 
instrument it should be examined to ascertain if it be 
smooth and polished. If any roughness or flaw can be 
detected it should be discarded. 

Metal urethral instruments are readily sterilized by 
heat. After being used they should be thoroughly 
washed with hot water saturated with Johnston’s ethereal 
soap (an admirable preparation, as the ether which it 
contains removes all the adherent fatty matter); they 
should then be boiled for ten minutes in a two-per-cent. 
solution of sodium carbonate, which prevents rusting; 
after which they should be either wrapped in sterilized 
gauze or placed in a rack made for the purpose. Before. 
being again employed they should be placed in boiling 
water for five minutes, thoroughly dried on a sterilized 
towel, and dipped as far as the handle into a jar contain- 
ing alcohol; after withdrawing the instrument, the ad- 
herent alcohol should be ignited. When the alcohol is 
consumed, the instrument is ready for use. 

In cleansing the Gouley tunnelled catheter the same 
procedure is to be carried out; care being taken to ob- 
serve whether the tunnel at the end of the instrument is 
clear and clean and whether the obturator works smooth- 
ly. This rule likewise applies to endoscopic tubes. Care 
should be taken to have the interior of the tube thorough- 
ly dried after cleansing. This may be accomplished by 
passing a bit of absorbent cotton through the catheter. 
The most satisfactory mode of drying urethral instruments 
in order to prevent rusting is by placing them for a few 
minutes in a hot oven. 

A very important matter connected with the use of 
urethral instruments relates to the question of the proper 
lubricant to be employed; it must be both aseptic and 
antiseptic. One of the best and by far the most satisfactory 
is petroleol (fluid cosmoline). It isa fixed oil from which 
all the volatile and offensive properties have been sepa- 
rated. It is not affected by climate and is not influenced 
by temperature; it contains no foreign ingredients. On 
exposure to the air it does not decompose nor turn rancid. 
Its reaction is neutral and it can be applied to the most 
sensitive urethra without producing irritation. Itshould 
be kept in a tall, wide-mouthed jar which can be tightly 
corked when not in use. It is easily rendered sterile by 
placing the jar containing the liquid in a sterilizer for 
a few minutes daily. I have used liquid cosmoline as 
a lubricant for many years with the most satisfactory 
results, and. I can recommend it to the profession as 
one of the best of its class. The jar should be kept 
tightly corked and no instrument should be introduced 
into it until it has been sterilized. There is no lubricant 
that lessens the amount of friction as satisfactorily as 
oil. Guyon has suggested the use of a thick paste 
composed of: 


Rie Luly saponin ae ecm eeeet ere Ziv 
IA. Cid.Carbol Pee eee oe emcees 31. 
Glycerini, 
tA CUS Eee see nee alelueternete aa Ziv. 


M. Sig: Lubricant for urethral instruments. 


. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Or— 
ee LU Vcc SEL OMS iaiers walt eroa vie esre a « BV 
FROSOTGI Hr Matar s aclalt ee iaisia Sagas « 3 iij. 
Glycerini, 
PAGE BRR AS Cae cotn aera aa Ziv. 


M. Sig: Lubricant for urethral instruments. 


These preparations have the advantage of being easily 
removed from the instrument. Unfortunately, in some 
cases their use is attended with a good deal of irritation. 
In the September number of the Jowrnal of Cutaneous and 
Genito- Urinary Diseases, Dr. E. Wood Ruggles suggested 
a lubricant which I have found to be most efficacious, It 
contains: 


PG uM AP ACanths acc. ee. sete e-e sere gr. xlviij. 
Acid. carbol. (95-per-cent. sol.)... Mi. 
SVEPCRTIND: Sic tenie er sda det eed: ene 3 iij. 
PAQUICE Etat epee eats era alee oral ad iv. 


“Mix the three last constituents, pour the resulting 
liquid on the gum tragacanth in a mortar, and allow the 
compound to stand over night. Then triturate with 
pestle until a homogeneous mass is formed. It can then 
be used from an ordinary ointment jar or put into paint 
tubes if thought more desirable.” 

Bangs highly recommends a preparation which he has 
named “lubrichondrin”; it is especially useful in lubri- 
cating metal instruments protected by a rubber coat, such 
as the dilators of Oberlaender, and Kollmann, and the Otis’ 
urethrometer. It consists of Irish moss (chondrus crispus) 
to which oil of eucalyptus (1 to 1,000) and formaldehyde 
(1 to 500) have been added. It is sold in closed tubes 
which may be boiled, thereby sterilizing the material be- 
fore it is used. White and Martin have suggested a iubri- 


cant that I can also recommend. It is: 
Ree SOLO PLY CERIGE 1s ys, Se vs slid dws Satie 
Mistilledswateroves oeid westse seks % ix, 


M. Sig: Use as lubricant for sounds. 


It is not always necessary thoroughly to anoint metal 
instruments before they are inserted into the urethra. In 
many cases it will be found sufficient to lubricate well the 
meatus urinarius, by which means the instrument will be 
sufficiently lubricated to enable it to pass through the 
canal without difficulty. Should the slightest friction 
be experienced, the instrument should be at once removed 
and well anointed with whatever lubricant the surgeon 
may prefer. 

The negligence of many physicians in permitting their 
patients to make use of rancid oil, lard, and even saliva 
for the lubrication of their urethral instruments cannot 
be too strongly condemned. When patients are taken to 
task for their carelessness they invariably reply that they 
were not aware of the danger they incurred, that their 
doctor had said nothing to them on the subject. 

Patients who enter upon “catheter life ” should always 
be warned of this danger, and of the pain and discomfort 
which may ensue from infection if proper cleanliness be 
not observed and if the instruments be not carefully 
sterilized. Orville Horwitz. 


CATNIP.—Cataria. Catmint. The leaves and flow- 
ering tops %f Nepeta cataria L. (fam. Labiate). This 
large and showy herb of Europe and Asia is very abun- 
dantly naturalized in the United States. It grows about 
deserted houses, barns, and in similar waste places. It 
becomes four or five feet high, and almost as broad, and, 
branching from the base, forms a pyramid of inflores- 
cence, the flowers very small but very pretty. It is 
peculiarly aromatic and derives its name from the fond- 
ness of cats for it, which incites them to the most curious 
demonstrations. They not only eat it, but roll in it, and 
evince the utmost joy, and apparently affection, in its 
presence. Larger animals of the cat tribe, such as lions 
and tigers, act similarly, and great excitement may be 
caused at the “zoo” by introducing it into the cages. 


Catheterism of the 
Caustics,. [Urethra, 





With a small amount of volatile oil and an amaroid, it is 
a very mild aromatic bitter. It is usually given in de- 
coction, in large doses, the warm water aiding its dia- 
phoretic action. Henry H. Rusby, 


CATOOSA SPRINGS.—Catoosa County, Georgia. 

Post-OFFICE.—Catoosa Springs. Hotel and cottages. 

Accrss.—From Atlanta and Chattanooga via the 
Western and Atlantic Railroad. Distance north from 
Atlanta, 115 miles; east from Chattanooga, 26 miles. 
From railroad, 2 miles. 

This resort is nestled among the mountains of North 
Georgia at an elevation of 945 feet above the sea level. 
The aspect of the country is quite rugged, the Sandstone 
Mountain, about a mile distant, reaching an altitude of 
1,800 feet above the tide water. From the summit of 
this mountain may be seen Mission Ridge, the historic 
Lookout Mountain, and many other points of lesser in- 
terest. The hotel and cottages at the springs have room 
for six hundred guests, and are supplied with all modern 
conveniences. The climate is bracing and invigorating, 
even in the summer months; in winter it is temperate, 
and the weather is not subject to sudden changes of 
temperature. The springs are fifty-two in number, 
situated within an area of two acres. It is not unusual 
to find quite different properties even among springs only 
a few feet apart. Most of them are quite strongly min- 
eralized. The ten principal ones are as follows: The 
“ All-healing,” the “Red Sweet,” the “Cosmetic,” the 
“Chalybeate,” the “Magnesia,” the “Congress,” the 
“Alum,” the “Black Sulphur,” the “ White Sulphur,” 
and the “Buffalo.” They range in mineral ingredients 
from about 84 to 104 grains to the United States gallon. 
Following are analyses of three of the springs by Prof. 
W. J. Land, of Atlanta: 


























; Ne. 4,or | N.9, |. No. 10, 
One United States gallon | Chalybeate Me Buffalo 
contains. Solids. Spring. Pa Hee Spring 
Grains. Gate Grains 
Calcium sulphate .............. 41.56 44.81 45.00 
Magnesium sulphate........... 27.90 2.01 33.02 
Strontium sulphate ............ .20 21 29 
SOdiImM) Sulphate... eccceccnars 1.59 1.67 1.67 
Potassium sulphate ............ 2.30 2.32 2.31 
Aluminum sulphate............ 67 2.47 2.39 
Calcium carbonate ............. 3.75 3.85 3.86 
Magnesium carbonate.......... 7.48 8.40 8.70 
WVON CATDONBIG sane cane sere cee be) 19 28 28 
Lithium carbonate .........000 Trace Trace. Trace 
Manganese carbonate.......... 01 .02 12 
Strontium carbonate ........... 04 04 .04 
Potassium carbonate ........... ett ai 6.01 
Sodium carbonate.............. 26 26 .08 
Calcium Nitrate vijceccs vvecct sas of 82 .08 
Ammonium nitrate ............ ll 10 91 
GHC ULOMIGEH See's ce acces 26 15 15 
Magnesium bromide ........... .30 31 3] 
Galen MVOTIGe!: <5 ctv ws « cle slerv. ere .02 .02 01 
Sodium chloride ...........000. 14 14 Ai 
Crenic and apocrenic acids..... 02 OL OL 
Free sulphuric acid .....ccccc0. 01 6.13 13 
Free carbonic acid ........+.e0: 4.31 4.51 4,62 
Hydrosulphuric acid ........... ; 2 Trace 
Total ingredients .......... 91.60 108.16 110.02 














Total residue upon evaporation at 212° F. is 100.11. 


All of these springs boil up through the hard black 
slate of the mountain side. They are perennial, the most 
severe and persistent droughts causing no perceptible 
difference in the rate of their flow. The waters are 
recommended for stomach, kidney, and bowel disorders, 
and for debility. The “All-healing” Spring is used for 
local troubles. The waters are shipped on order in 
bottles or barrels to any part of the country. 

» James K. Crook. 


CAULOPHYLLUM. See Cohosh Blue. 


CAUSTICS.—Previous to the introduction of anes- 
thetics, caustics formed a very important part of the 


155 


Caustics, 
Caustics, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





surgeon’s armamentarium: The dread of the knife was 
put natural, and the sufferer eagerly seized upon any 
means that would render it unnecessary. At that period 
the advantage of the knife was not so marked as it is 
with modern aseptic surgery. After the use of this in- 
strument gangrene and septic absorption were of very 
common occurrence, whilst the destructive action of 
caustics rendered the ‘wound aseptic, and these undesirable 
complications rarely followed. 

One of the principal uses of caustics was in the removal 
of gangrenous tissue from unhealthy wounds, whether 
traumatic or surgical. The unhealthy granulations and 
necrosed tissue were thus destroyed, and as the sloughs 
were detached a healthy healing surface appeared. An- 
other important use was in the removal of tumors and 
new growths. If they were small, one or two applica- 
tions would prove suflicient; if they were of great size, 
the growth would be destroyed in segments by the in- 
sertion of small pieces of caustic into its substance and 
then by removing the resulting slough. In certain in- 
stances a method adopted by M. Maisonneuve in 1858, 
known as cauterization en fleches, was followed. The 
idea was to surround the base of the tumor with small 
points of chloride of zine which would separate the dis- 

eased tissue from the healthy as thoroughly as if a knife 
had been employed. ‘The growth could then be enucle- 
ated and a healthy granulating surface would remain. 
Caustics were also of use in opening deep abscesses, as 
they slowly penetrated into the collection of pus and left 
a channel for its exit. For the treatment of sinuses and 
fistulee, strands of thread were saturated with the caustic 
and drawn through the passages. 

At the present day the usefulness of caustics is very 
limited, but when judiciously employed, there are sev- 
eral conditions in which they prove of much service. 
Their value is recognized as an application to the surface 
of unhealthy ulcers, as a means of destroying the poison 
in septic wounds, for the removal of small growths upon 
the surface and upon the mucous membrane of the oral, 
nasal, and vaginal cavities, and for the destruction of 
superficial malignant growths. 

The treatment of indolent ulcers and other granulating 
surfaces with nitrate of silver, sulphate of copper, and 
other mild caustics is of daily occurrence and of unques- 
tioned utility. The caustic coagulates the granulating 
surface, forming a thin covering which in a short time 
becomes detached, leaving a healthy surface. To de- 
stroy the poison of chancres, specific ulcers, wounds 
produced by venomous animals, and septic wounds, the 
stronger caustics are required. The part must be acted 
upon thoroughly and rapidly to prevent the absorption 
of the poison, and for this purpose fuming nitric acid, 
chloride of zinc, and chromic acid are some of the proper 
caustics to be selected. The destruction of warts, papil- 
lomata, etc., by the aid of caustics is common, and 
whether the frequent application of mild caustics is de- 
cided upon, or their rapid removal by the stronger caus- 
tics is adopted, the result is the removal of the growth 
with very little, if any, deformity. The employment of 
caustics in the treatment of malignant diseases of the 
skin is a question of much greater importance and one 
that has provoked much discussion; the surgeons adher- 
ing tothe use of the knife, whilst the dermatologists hold 
strongly to the superiority of caustics. Those opposed 
to the use of caustics point out that they destroy only 
the localized disease and leave untouched the surround- 
ing lymphatics and glands that may be infected; that an 
unsightly scar remains; and that the procedure is much 
more painful than when the part is excised and the 
wound made to heal by first intention. On the other 
hand, it is claimed that patients will submit earlier to the 
application of a paste, and that by these means the dis- 
ease is really more thoroughly removed. It is thought 
that the inflammation excited in the surrounding parts 
will destroy the pathological cells that may exist, as their 
vitality is much lower than that of the normal cells, and 
when arsenic is used it is claimed by many that it exerts 
a special toxic action upon such cells. This action is not 


756 








only exerted upon the structure of the tumor to which 
it is applied, but is thought to extend in all directions 
throughout the inflamed area and to exert a selective ac- 
tion upon the pathological tissue. 

With modern surgical technique, there can be no ques- 
tion as to the advantage of the knife in the great major- 
ity of cases, but certain conditions arise in which the 
preference will be given to the treatment by caustics. In 
many cutaneous cancers, lupus, nevi, etc., especially 
such as are of slow growth and extend superficially rather 
than deeply, the employment of caustics will generally 
be more successful than excision. A consideration that 
counts in favor of the caustic, especially in the aged, is 
the avoidance of the necessity to administer an anesthetic. 
The resulting scar is hardly to be considered, as, when the 
subcutaneous parts are not deeply involved, it is smooth 
and white, and not disfiguring. 

Caustics should not be employed if any glands are in- 
volved, nor for any extensive disease upon mucous sur- 
faces. They should beavoided when the skin approaches 
closely to the underlying bone, or over eminences. Upon 
the soft elastic tissue of the scrotum and similar tissues 
they must be used with great care, as the softness of the 
tissue renders it more difficult to control their action. 
Pain is not an objection to the use of caustics as it may 
be controlled by the admixture of morphine or by the 
application of cocaine to the part. 

Caustics are difficult to manipulate successfully. To 
become proficient requires a great deal of experience, 
which is acquited only by the frequent and careful use 
of these agents. When applied they should be kept 
under observation and carefully removed when the proper 
degree of destruction has been secured. If they are left 
too long in contact with the parts there will be an un- 
necessary destruction of tissue; if for too short a time, 
the effect will be inadequate and often unfavorable, as 
the mild degree of inflammation excited by the caustic 
may add to the activity of the disease. 

The after-treatment is that of ordinary surgical wounds. 


. The necrosed tissue is not to be forcibly detached, but 


cut off in portions as it separates. If the destruction 
of the part is extensive, granulations should be favored, 
to reproduce as much tissue as possible; and, if it should 
be found necessary, the repair may be completed by 
skin-grafting. 

Very many substances possess a caustic action, but ex- 
perience has limited the number to a few which have 
proved most serviceable. Of these the principal ones are 
the corrosive acids, alkalies, arsenic, chloride of zinc, and 
chromic acid. Nitrate of silver is the type of the milder 
caustics, which are really little more than strong astrin- 
gents. (For the actual cautery see article on Cauterization.) 

Acrps.—WNitrie acid has proved the most serviceable of 
all the corrosive acids and is the one most employed. It 
acts rapidly, destroying the integument and the tissue 
beneath, the depth depending upon the quantity applied. 
Nitric acid is not so hygroscopic as sulphuric acid, but 
acts in a similar manner. It abstracts moisture from the 
tissues and combines with the albuminous constituents, 
producing a dry, yellow slough, which separates in about 
ten days, leaving a healthy granulating surface. It is 
not as painful. as the alkalies or some of the less active 
caustics, on account of the rapidity of its action. One 
objection to its use is its tendency to diffuse itself on the 
surface. To overcome this the acid has beén combined 
with saffron, asbestos, and sulphur to the consistence of 
a paste, which renders it more manageable. Its action 
may also be limited by covering the surrounding skin 
with gutta-percha or some greasy substance. Previous 
to the introduction of curetting, nitric acid was very ex- 
tensively used as an intra-uterine application in various 
forms of endometritis. Curetting, however, has dis- 
placed the caustic and its use is now restricted to erosions 
and specific ulcerations. It is also employed with much 
success in all chancres, condylomata, etc. In the bites 
of rabid animals and poisonous insects and in septic 
wounds, its penetrating properties make it a very useful 
caustic. The acid is applied by means of a glass rod 


_ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





dipped into the acid, or of a small piece of cotton wool 
wrapped around the end of a probe ora splinter of wood. 
The part should be closely watched during the operation, 
and when it is sufficiently cauterized it should be washed 
with water or with an alkaline solution. 

The Acid Nitrate of Mercury was a favorite caustic 
among French surgeons, but it is not much used at the 
present day. Its action is due to the nitric acid which it 
contains. In addition, the mercurial salt was supposed 
to supply an alterative effect. Its destructive power is 
not so great as that of the pure acid, and yet it is more 
liable to set up inflammatory action in the adjoining 
healthy tissues. It forms a dry, grayish-white eschar 
which falls off in from ten to twelve days. Its too free 
application has given rise to salivation. 

Sulphuric Acid is the most powerful of the acid caustics 
and was formerly muchemployed. It has a very marked 
affinity for the water in the tissues, in consequence of 
which they are rapidly dehydrated. It destroys all the 
structures with which it comes in contact, and combines 
with the albumen and fibrin, forming a tough, structure- 
less, black slough. Thisis very slowly detached and may 
remain adherent until cicatrization is complete. As with 
all fluid caustics it is extremely diffusible. This is lessened 
by mixing it with other substances to the consistence of a 
paste. Richard’s paste was made with charcoal; Michel’s 
consisted of asbestos, one part to three of acid. Syme 
used sawdust with the acid in equal parts. 

Hydrochloric Acid has never been much employed as a 
eaustic. Itis milder than nitric or sulphuric acid and 
its slough is whitish and soft. Its local application in 
combination with its internal administration, in diph- 
theria, was advocated by Bretonneau. 

Acetic Acid is a very mild caustic. It is chiefly em- 
ployed in the treatment of warts, corns, and similar 
superficial growths. 'The pure glacial acetic acid only 
should be used, and care should be taken not to employ 
any that has been exposed to the air, as the acid rapidly 
absorbs moisture and is thereby reduced in strength. 

Trichloracetic Acid is a very valuable caustic and one 
that will probably be more used in the future. Its ad- 
vantages are, that it does not penetrate deeply and does 
not produce much inflammatory reaction. It has been 
particularly recommended in the treatment of nevi, and 
it is also used in venereal warts and in superficial cutane- 
ous growths. A crystal is placed on the part to be 
cauterized and there is rapidly formed a dry, white, 
adherent eschar which is superficial, and leaves a very 
slight scar which is hardly noticeable. 

Arsenous Acid.—This is the caustic most employed 
at the present day for the destruction of cancerous and 
other growths, when they are suitable for treatment by 
caustics. When applied to a raw or ulcerating surface, 
it produces an intense inflammatory reaction which 
terminates in gangrene and death of the part. The in- 
flammation extends into the surrounding tissues, in all 
directions, lessening as it advances. 

Arsenic does not exercise its caustic action upon the 
epidermis, and when the disease is not superficial it is 
necessary to remove the skin by curetting or by the ap- 
plication of an acid or an alkali. When required for use 
it is diluted to the extent of one half or two thirds with 
gum arabic and moistened to form a paste. ‘There are a 
number of pastes which have acquired much celebrity. 
Marsden’s paste was formed of 2 parts of arsenic with 1 
of gum acacia. In Dupuytren’s paste the arsenic was 
mixed with calomel in the proportion of 1 part to 10 or 
15. Hsmarch’s paste consists of 1 part of arsenic, 1 part 
of morphine sulphate, 8 parts of calomel, and 48 of gum 
arabic. Sir Astley Cooper’s ointment contains: Arsenic, 
1 part; sulphur, 1 part; and spermaceti ointment, 8 
parts. The arsenical paste of Frere Cémo contains 10 
grains of arsenic, 2 scruples of red sulphite of mercury, 
and 10 grains of charcoal. Piunket’s caustic contains: 
Ranunculus acris and ranunculus flammula, of each 1 
ounce; arsenic, 1 drachm; and sulphur, 5 scruples— 
to be beaten together into a paste. 

The length of time during which a paste is to be kept 











Caustics, 
Caustics. 


applied depends upon its strength. The extent of the 
cauterization may be estimated by the inflammatory 
areola in the surrounding tissues. This should not be 
allowed to advance too far, as a necrosis of the part 
will follow. On the other hand, if the redness is not 
well marked, the caustic action is deficient. When the 
arsenic is diluted one-half, the destruction of the part is 
likely to require from sixteen to eighteen hours; with 
Marsden’s paste this will probably be accomplished in 
from ten to twelve hours. After the removal of the 
‘caustic the part is to be poulticed, and when the slough 
is detached, if the disease is not wholly removed, the ap- 
plication is to be repeated. The resulting scars are white 
and as a rule they are not disfiguring, unless the destruc- 
tion of tissue has been great. 

There is a possibility of poisoning from the absorption 
of arsenic, and as a precaution it isadvised that not more 
than one square inch of surface should be covered at one 
time. The danger, however, is not very great, as the 
diseased surface is destroyed so rapidly that the poison 
is “walled off” from the absorbents and blood-vessels. 
Absorption really takes place more readily when a dilute 
solution is employed. 

Recently it has been recommended that a solution of 
arsenic, in equal parts of alcohol and water, should be 
employed in preference to the pastes. The treatment is 
commenced with a solution of 1 to 150, and then the 
strength is increased to 1 to 80. The surface is prepared 
by washing and rubbing until the blood is made to ap- 
pear; it is then allowed to dry and the solution is ap- 
plied daily until the slough separates and the disease is 
destroyed. The treatment is continued for a period vary- 
ing from one or two weeks to two or three months, 
according to the extent of the disease. 

Chromic Acid.—Although slow in its action this isa 
very powerful and a very diffusive caustic. The pure 
crystals are employed or an aqueous solution of about 
one part in four. It produces great pain. When ap- 
plied it immediately coagulates albumen, and, absorbing 
moisture, forms a fluid caustic, which dissolves the tissues. 
It gradually forms a dry, hard, dark eschar. It is par- 
ticularly recommended in bites of venomous snakes, and 
is used to destroy superficial and mucous growths and 
syphilitic ulceration. 

Carbolie Acid is also a mild caustic. It is not used to 
cause any destruction of tissue, but is employed in the 
treatment of poisoned wounds, syphilitic ulcerations, 
and hemorrhoids. It unites with albumen, producing a 
dry, white, and very superficial slough. It acts rapidly 
and painlessly, producing an anesthesia of the spot. 

ALKALIES.—The caustic alkalies have all been employed 
to a greater or less extent, but potash is the most active 
and has been most used. Their action differs from that 
of the acids in that they unite with the water of the 
tissues and, becoming fluid, destroy the underlying parts. 
They produce soft, gelatinous sloughs, which separate 
quickly and leave a slowly granulating surface. They 
penetrate deeply and, unless carefully applied, may 
cause much unnecessary destruction of tissue. 

Potassa occurs as small, irregularly shaped masses, or 
in small cylindrical sticks, in which latter form it has 
been prepared for convenience of use. It is a very deli- 
quescent salt and, unless carefully preserved, is difficult 
to use. The addition of lime lessens its affinity for water, 
and the official Potassa ewm Calce is the most satisfactory 
preparation for caustic purposes. It is prepared by mix- 
ing equal parts of potassa and lime, and when moistened 
with a little alcohol this mixture forms the well-known 
Vienna paste. The mixture may also be fused and run 
into small cylindrical moulds. The greater the degree 
of heat employed the harder are the sticks. This caustic 
is kept applied to the parts for ten or fifteen minutes, and 
when the paste is used the area of its action may be 
limited by protecting the surrounding skin with adhesive 
plaster. The depth of cauterization depends upon the 
quantity of caustic applied and the length of time it is 
allowed to remain. When morphine is added in the pro- 
portion of one part to three it is said to form a painless 


157 





Cauterization. 
Cedar Keys. 








caustic. Caustic potash and gutta-percha may be melted 
together in equal parts to form a paste which is very 
convenient for use, as it may be moulded into any shape. 

Soda resembles caustic potash in appearance. It occurs 
in masses and in cylindrical sticks. Its caustic properties 
are milder than those of potash. It is not so deliquescent 
and possesses the advantage of being less diffusible. 
London paste is prepared by mixing together, in a warm 
mortar, equal parts of soda and unslacked lime, and 
moistening the mixture with water when it is wanted 
for use. 

Sodium Ethylate.—This salt was introduced as a caustic 
in 1870 by Benjamin Ward Richardson. It is a white 
powder which, when brought in contact with moist 
tissue, is decomposed into alcohol and caustic soda. It 
is used as the Liq. Sodii Ethylatis which is official in the 
British Pharmacopeia. This is a solution of the salt in 
absolute alcohol. It is a syrupy, colorless liquid, and 
has been recommended as a very effective and manage- 
able caustic. It is applied by means of a glass rod, for 
two or three successive days, and the resulting dry 
eschar should not be removed until it becomes detached. 
It has been successfully employed in the treatment of 
nevi, lupus, and superficial growths. 

ZINC CHLORIDE shares with arsenous acid the greatest 
popularity as a caustic in the treatment of cancerous 
ulceration. When applied to the surface, the skin is de- 
stroyed.,but the pain is so severe that the corrosive acids 
are often applied first. When the zinc is then applied 
to the diseased tissue the pain is much lesssevere. Chlo- 
ride of zinc acts rapidly, and, being deliquescent, it may 
—unless its action is controlled—effect a more extensive 
destruction of tissue than is desired. It coagulates the 
albuminous tissues and in a few hours forms a dry, 
firm, whitish slough, which separates in about one 
week. Chloride of zinc is mixed with wheat flour and 
formed into cakes, or with plaster of Paris, which very 
completely limits the extent of its action. Another 
method is to saturate lint with the deliquescent sait and 
then to cut off a portion of the required shape and size. 

The chloride of zinc pastes are innumerable, as the 
fact that it has no toxic action has made it a favorite 
caustic with many. Canquoin’s pastes are made in four 
strengths with wheat flour and water in the proportion 
of one part to two, three, four, or. five parts of flour. 
Mayet’s paste contains 8 parts of zinc chloride, 1 of 
zine oxide, and 7 of flour; Rodiquet’s, equal parts of zinc 
chloride and flour, with gutta-percha added to form a 
firm mass. In Landolphi’s caustic, the zinc chloride is 
combined with equal parts of chloride of gold, chloride 
of antimony, and chloride of bromine. What is known 
as Bougard’s paste, which is being highly advocated, is 
composed of wheat flour, 60 gm.; starch, 60 gm.; ar- 
senic, 1 gm.; cinnabar, 5 gm.; sal ammoniac, 5 gm.; 
corrosive sublimate, .50 cgm.; and solution of chloride 
of zinc at 52° C., 245 gm. 

SILveR Nirrate is a much weaker caustic than any 
of the foregoing. It has no effect upon the surface, but 
upon mucous membranes or denuded and granulating 
surfaces it causes a coagulation of albumen which results 
ina superficial slough. This is at first grayish white, 
but becomes dark owing to the reduction of the silver. 
It is dry and dense. This reagent acts rapidly, without 
pain, and does not excite any inflammatory action in the 
surrounding skin. It is used in the removal of warts, 
condylomata, etc., but is not of any service in the treat- 
ment of cancerous disease. It is chiefly employed in the 
management of unhealthy granulating surfaces, which 
it rapidly replaces with healthy healing granulations. 
The pure salt, fused into sticks for convenience of use, is 
generally employed. Some prefer the mitigated caustic, 
prepared by fusing the nitrate with two parts of nitrate 
of potassium. A very convenient method is to cover the 
end of a silver probe by fusing the nitrate and placing 
the probe in the liquid caustic, the adhering fluid being 
allowed to crystallize by exposure. For the destruction 
of chancres and syphilitic sores the nitrate of silver is not 
to be depended upon. 


758 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Other mild caustics which resemble the nitrate are sul- 
phate of copper, sulphate of zinc, and sulphate of 
alumina. Beaumont Smal. 


CAUTERIZATION.—The term cauterization is as cor- 
rectly applied to the use of the potential cautery or caus- 
tic as to the actual cautery. The term, however, is so 
generally associated with the latter that it is almost re- 
stricted to the use of that form of cautery. Before the 
actual cautery was brought to its present state of perfec- 
tion, it was much less employed than the caustics, but 
now their relative position is reversed and the actual 
cautery is the one generally employed. It is easy to ap- 
ply, its action is more rapid, the heat is readily controlled, 
and the extent of cauterization may easily be defined. 
A great advantage of the actual cautery lies in the many 
devices to facilitate its use, as seen in the numerous 
burners or points, which range from the broad flat ham- 
mers to the finest needles, and include wire, scissors, 
knives, ete. 

From the earliest days of medicine to the middle of the 
present century very little advance was made in the de- 
velopment of the actual cautery. The application of 
heated metals appears always to have been adopted, and 
the irons employed for this purpose remained much the 
same through all the centuries, and even at the present 
day they may be found in the possession of many. Such 
changes as were made were in the shape and number of 
the irons, or in the handles which were common to the 
several irons. -A very crude method which retained its 
popularity until recent years was the application of 
heated coals, and the ignition of substances on the sur- 
face to be destroyed. The latter were known as moza 
and were prepared by saturating cotton wool with nitrate 
of potassium and allowing it to dry; after which it was 
placed in a metallic tube with a handle, ignited, and al- 
lowed to burn down to the skin. With the introduction 
of illuminating gas, efforts were made to utilize it asa 
cautery, and instruments were made by which the jet of 
gas was brought in contact with the part to be cauterized. 

In 1876 Paquelin introduced the thermo-cautery which 
bears his name, and it remains a favorite cautery on ac- 
count of its portability and the ease with which it may be 
kept ready for use (Fig. 1196). The principles of this 





Fig. 1196.—Paquelin’s Thermo-Cautery Ready for Use. It consists of 
bulbs of Richardson’s spray apparatus, a glass receptacle for fluid, 
iin movable platinum burner in a ron-conducting wooden 

andle. 


well-known appliance lie in the metal selected for the 
burners—these being made of platinum, a metal that be- 
comes incandescent at a comparatively low temperature 
—and in the ingenious manner in which a light benzene 
gas is supplied to the heated point. As long as the gas 
is supplied the point remains heated, the degree of heat 
depending upon the quantity of gas, which is easily con- 
trolled by the india-rubber bulb (Fig. 1197). Many other 
cauteries, based upon the same principle, have been made, 
but none has hitherto supplanted that of Paquelin. The 
electrical cautery, however, is destined to be the cautery 
of the future, its advantages being very marked, especial- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ly in surgery of the cavities of the nose and throat. The 
electricity is supplied by wet or dry cell batteries, or 
may be drawn directly from the domestic supply with 
the intervention of a transformer. The expensiveness of 
these instruments has been an obstacle to their general 
use, but this is now no longer a fact, and excellent gal- 
vano-cauteries are within the reach of all. ’ 
There isa marked difference between the burners of the 
thermo-cauteries and those of the galvano-cauteries. As 














Fig. 1197.—Modification of Paquelin’s Thermo-Cautery. 


insufflation. 


a current of electricity requires to pass through the burn- 
ers of the latter, they are either in the form of a wire loop, 
or are formed of porcelain around which the wire is 
wound. Inthe latter forms the porcelain readily becomes 
incandescent when the current is passed through the wire. 
‘The ease with which the point can be heated or cooled 
is a great advantage of the galvano-cauteries. Thus, for 
example, the burners may be placed in position before 
being heated and not removed until they become cool. 

Three degrees of heat are found desirable in the use 
of the actual cautery: a white heat, a red heat, and one 
in which the metal has not become candescent. The 
white heat is the most intense and the most destructive 
of tissue. It is also the least painful, as the terminals 
of the nerves are destroyed too rapidly to allow them to 
convey the impression of pain. The black heat is not 
used for cauterizing purposes, but almost solely for that of 
counter-irritation. As a hemostatic red heat is superior 
to white. 

The depth and extent of tissue destroyed depend upon 
the degree of heat and the length of time during which 
it isapplied. It chars and destroysall tissues, and leaves 
athin, dry, hard eschar, which does not become detached 
for several days. Ordinary hemorrhage is immediately 
controlled, but in the removal of pedunculated tumors, 
when the supplying vessels are large, it should not be 
depended upon. The actual cautery is employed for the 
removal of small tumors, hemorrhoids, and superfluous 
hairs, in the destruction of cancerous and unhealthy sur- 
faces, in poisoned wounds, and in all conditions in which 
a caustic is desired. In the treatment of affections of the 
nose and throat, and in gynecological work, it is of par- 
ticular service. 

As a hemostatic, the actual cautery has always been 
of much service. In former times it was the principal 
means of controlling hemorrhage, and at the present day 
all operating rooms are provided with a cautery to check 
ae: bleeding from vascular tissues and from oozing sur- 

aces. 





A metallic vessel lined 
with sponge receives the benzene, and is provided with a stopcock to control the 


Cauterization, 
Cedar Keys, 





As a counter-irritant the actual cautery has occupied a 
foremost position and has proved of much service. (See 
also Caustics and Counter-Irritation.) 

Beaumont Smail. 


CEANOTHUS.—WNew Jersey Tea. Redroot. The root 
of Ceanothus Americanus L. (fam. Rhamnacee), a low, 
much and densely branched shrub of Eastern and Central 
North America, represented in the far West by numerous 
other species with the same properties. Its 
fruits much resemble those of the tea plant, 
which fact is said to have led to the use 
of its leaves as a substitute for tea during 
the revolutionary embargo. The root has 
enjoyed domestic and a slight professional 
use as an astringent. It is stout, much and 
crookedly branched, of a bright reddish 
color, which soon fades on keeping; hard 
and woody. The red color pervades the 
wood. It contains six to nine per cent. of 
tannin, the bark containing more than the 
wood. The leaves contain an equal amount. 
One-fifth per cent. of ceanothine, an alka- 
loid, has been reported, but nothing is 
known of its properties. Owing to the 
close resemblance, in appearance and prop- 
erties, of this root to Peruvian rhatany, it 
has been used as a substitute and adulter- 
ant of the latter. 

The dose of ceanothus is 4 gm. (3 i). 

Henry H, Rusby. 


CEDAR KEYS.—A small town of about 
2,000 inhabitants, situated upon the gulf 
side of Florida, 155 miles southwest from 
Fernandina, with which it is connected by 
railroad. As will be seen from the accom- 
panying climatic chart, the climate is a 
mild, equable marine one, with a large 
number of clear and fair days: 


CLIMATE OF CEDAR KEYS, FLA. LATITUDE, 29.8; LONGITUDE, 83.2; 
PERIOD OF OBSERVATION, FOUR YEARS. 














Ele ee 1B 2 
Data. 25 Ez Ss Gi) PS 
Solas ee les ihe s 
5 = > 
Temperature (Fahr.)— 
Average or normal ,.... 59.5° 59.8° 62.0° 63.9° 71.3° 
Average daily range....| 12.1 2.1 12.2 12.5 
Mean of warmest....... 65.6 64.4 68.8 (fie 
Mean of coldest......... 53.5 52.3 56.6 58.5 
Highest or maximum...| 7 {7 7 82 
Lowest or minimum....| 22 32 35 40 
Humidity— 
Average relative........ 80.8% | 81% 75.4% | 71.5% | 75.4% 
Precipitation— 
Average. rainfall in 
TNGHOSS chracctcate tov cise 2.73 5.31 2.98 3.58 58.02 
Wind— 
Prevailing direction ....| N.E. N.E. N.E. S.W. N.E. 
Average hourly velocity 
in Miles Pisces es eee 8.5 9 9.6 Eek: 9.2 
Weather— 
Average number of clear 
GRYRS ccadtacence tees 14 8:5 13.8 14 158.4 
Average number of fair 
Bice donee ieisiesiecds 11.4 14.7 9.2 12.2 149.4 
Average number of clear 
and fair days......... 25.4 23.2 23 26.2 | 307.8 








The winter climate is said to be milder than that 
found upon the east, or Atlantic, coast of Florida. The 
facilities for bathing, boating, fishing, and hunting are 
also said to be good. So faras climatic conditions are con- 
cerned, Cedar Keys differs but little from Tampa, about 
100 miles farther south on the same coast, but the former 
has not become a “resort” like the latter, and has no 
such accommodations as exist at Tampa. The drainage 
and water supply are also said to be questionable. A1- 
though Cedar Keys is reputed to be “extremely health- 
ful,” one would hardly care to send an invalid there un- 


159 


Cedar Springs. 
Cell, 


less he were sure of obtaining adequate accommodations 
and favorable hygienic conditions. These latter are quite 
as essential as a favorable climate in the selection of a 
health resort. Edward O. Otis. 


CEDAR SPRINGS.—Preble County, Ohio. 

Post-OFFicE.—New Paris. Hotel. 

Accress.—Take Pittsburg, Cincinnati, and St. Louis 
Railroad to New Paris, 35 miles west from Dayton; 
thence take carriage one mile to springs. 

These springs are situated in a rolling section of coun- 
try, about 1,000 feet above the sea level. The surround- 
ings are very pleasant and attractive. There are said 
to be not less than one hundred springs within an area 
of two square miles. Several are used for medicinal 






purposes. We presentan analysis of one of them by Dr. 
A. Fennel: 
WASHINGTON SPRING. 
ONE UNITED STATES GALLON CONTAINS: 

Solids. Grains 
SOdMM CATDOMATE Frat cis sew cdeleetetastlaces sa eis sisigie siatsne 2.26 
Magnesium Carbonate ’iai scisisis crvleis’s ois asleoisielelelos! Cewisieria 5.82 
TYOT! CALDONIATO Rs ctenteiine ook Caio bisiclel cratule evaistaye eiiecnistins 1.32 
Calelumicarbonate so. ented Sects eek ect stats cidsennen sasiele 3.96 
Calcium) sulphate archer ceiices caaieiscec htAslecisivcice sures ao 1.24 
Sodium SuIPHAte cesresceriiecoc ecto betetietieis ooislw sais Bais or pielorase 18 
Caleiiim PMOSsSpHea tee resis ciete steiete arerstelels otstsia’oosieisisyeieiniom gitar 2.13 
Sodium chloride....... alate ec dae bias du dletele sists Si aieiese neste 98 
FA LUT INIA, 55, Siers poet ct rate sels a's. wise Yobebatelabans ayejeiateee dleseueinceca tents 22 
TOGA Fare avarater eta stars, cle bAreeaheeue sap aleve a riniael aiciaraiecgt sitet okater ste 18.11 


The waters resemble those of the Bethesda Spring at 
Waukesha, Wis., but contain more iron. It is claimed 
that they are especially valuable in catarrh of the blad- 
der, in renal diseases, and in dyspepsia. 

James K. Crook. 


CEDRON SEEDS.—The seeds of Simaba Cedron(R. Br.) 
Planch. (fam. Simarubacee). The plant is a small tree of 
Northern South America, and is considerably cultivated 
in the tropics. It yields an edible fruit about the size 
of, and somewhat resembling, a large peach. The soli- 
tary seed is similar to a Brazil nut in both form and 
size. In their home, the seeds have a high repute as 
an antiperiodic, and trials with them here have largely 
supported these claims. Their use as an alternative of 
the cinchona products appears well justified. The white 
or whitish crystalline volatile amaroid cedrin appears to 
be the active constituent, though the presence of an alka- 
loid has been claimed. Cedrin is soluble in both water 
and alcohol. Cedron seed is commonly given in the form 
of the fluid extract, the dose of which is .06 to .5 c.c. (Mi. 
to viij.). Henry H. Rusby. 


CELANDINE. CHELIDONIUM.—“ The entire plant, 
Chelidonium majus L. (fam. Papaveracee)” (U. 8. P.). 
In some _ phar- 
macopeeias the 
root only has 
been recognized, 
but the composi- 
tion and prop- 
erties are the 
same through- 
out. The drug 
is little used and 
will probably be 
dropped from 
the Pharmaco- 
peia at its next 
revision. This, 
the only species 
of the genus, is 
a perennial herb, 
with slender 
branching stem, bright yellow delicate flowers, and an 
acrid, irritating, disagreeable-smelling yellow juice. 
The plant is sufficiently described by the Pharmacopeia 
in its description of the dried herb. “ Root several-headed, 
branching, red-brown; stem about twenty inches (50 






me). 2 ot 
Se 
Fig. 1198.—Celandine, Slightly Reduced. Seed 
enlarged about four times. (Baillon.) 


760 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





cm.) long, light green, hairy; leaves about six inches 
(15 em.) long, petiolate, the upper ones smaller and 
sessile, light green, on the lower side glaucous, lyrate- 
pinnatifid, the pinnez ovate-oblong, obtuse, coarsely 
crenate or incised and the terminal one often three-lobed ; 
flowers in small, long-peduncled umbels with two sepals 
and four yellow petals. Capsule linear, two-valved and 
many-seeded. The fresh plant contains a saffron-colored 
milk-juice and has an unpleasant odor and acrid taste.” 
Celandine is a native of Europe, but has been abun- 
dantly naturalized in the United States, where it affects 
rich, shaded dooryards. It isan old country medicine, and 
has been used to dissipate warts and as a dressing for 
ulcers. Its general composition is very similar to that 
of bloodroot, but the important alkaloid is chelerythrine, 
associated with chelidonine, a and 8B homochelidonines and 
protopine. Thereare also chelidonic and chelidoninic acids. 
Chelerythrine acts in a markedly different way from its 
close relative, sanguinarine, lacking entirely the irritating 
properties of the latter upon the motor centres, which it 
depresses or paralyzes from the first. It also depresses 
the muscles. The ends of the sensory nerves are first 
irritated and then depressed. Chelidonine tends to coun- 
teract this primary sensory stimulation. The homocheli- 
donines and protopine are in very small amounts. Their 
effects are also in the general direction of both sensory 
and motor depression. Hence the effects of celandine 
are not violently irritating like those of bloodroot, and 
are finally soothing and depressing. There is, however, 
enough sanguinarine, in connection with the primary 
sensory irritation of the chelerythrine, to make the drug 
strongly irritating in the first stage of action. It acts as 
a laxative or a purgative, and has always been regarded 
as an active cholagogue. Large doses may cause emesis, 
but the tendency of this drug is purgative, as that of san- 
guinarine is emetic. There is no official preparation. The 
dose is 1 to 4 gm. (gr. xv. to lx.), The extract is mostly 
used, in doses of .5 to 1 gm. (gr. viij. to xv.). The 
drug has been a favorite domestic basis for poultices, and 
the juice is a counter-irritant, similar to bloodroot. 
Henry H. Rusby. 


CELASTRUS. See Bittersweet, False Climbing. 


CELERY.—This well-known succulent vegetable, 
Apium graveolens L. (fam. Umbellifere), is distilled in the 
fresh state for a delicious volatile oil which is used for 
flavoring. The fruit, however, is the important part 
from the standpoint of materia medica. It is similar to: 
the other cremocarps of the family, but is very small, 
only one-twenty-fifth inch in ilength, broadly ovate, dark 
brown, hard, smooth, and:generally contains twelve oil 
tubes. It is largely used in its own form for flavoring 
purposes and as a carminative, similarly to its relatives, 
and in doses of grams ij. to iv. (3 ss. toi.). Its volatile 
oil, containing limonene, is also largely used for the same 
purposes. Henry H. Rusby. 


CELL.—A cell is one of the elementary forms of organ- 
ized substances of animals and plants. It is irreducible 
into more simple parts except by mechanical or chemical 
means; it is therefore the histological element. 

HisToricaL.—It is to the botanists that the credit of 
the discovery of the minute structure of living matter is 
due. At the end of the seventeenth century Malpighi 
and Grew demonstrated the fact that plant tissue was 
made up of small spaces with firm walls, and that these 
spaces were filled with fluid. They called these spaces. 
cells, from the Latin “cella,” a little cavity or space. 
Further investigation showed that this plant cell con- 
tained, in addition to the fluid, a somewhat granular sub- 
stance and that this granular mass contained a darker 
spot, which spot we now know to be the nucleus. 

Investigation of animal tissue by Purkinje, Valentin, 
Miller, and Henle (1880-40) showed that it was com- 
posed of elements similar to those of plant tissue. In 
1838 Schwann, as the result of his investigations, an- 
nounced the fact that animal and plant tissues were 
made up of similar elements, and he defined these ele- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ments, the cells, as “small vesicles, with firm walls, en- 
closing fluid contents.” 

As the investigation of the plant cell advanced it was 
found that in many instances it was completely filled by 
this granular substance, and it was named protoplasm 
by Mohl. Further investigation of the animal cell 
showed that the cell wall was absent in many cases, and 
the question was raised as to whether these bodies could 





C, Centrosome; F’, foreign body; H, 
hyaloplasm ; J, intranuclear network or reticulum; K, karyosome 
or false nucleolus; LL, linin; M, nuclear membrane; JV, nucleus: 
Nu, nucleolus; S, spongioplasm; V, vacuole. 


Fie. 1199.—Diagram of a Cell. 


be classified as cells. It wasalso found that these bodies 
were identical in structure with the protoplasm of Mohl, 
and the term protoplasmic bodies was applied to them 
by Remak. 

In 1860 Max Schultze announced his protoplasmic 
theory of the structure of animal cells. He demonstrated 
that the cell wall or membrane of the earlier investigators 
was not an essential part of either the animal or the plant 
cell; that, as a general rule, the plant protoplasm hada 
firm wall, but under certain conditions it became divested 
of it and then assumed the same characteristics as those 
of the animal protoplasm. Having determined that the 
element was not a cellor little space filled with fluid, but 
a formed material, he still retained the term cell of the 
earlier investigators. We still continue to use the same 
term, as it has become a fixture in biological nomencla- 
ture. Schultze defined a cell “as a little mass of pro- 
toplasm endowed with the attributes of life.” 

As the investigation of the cell proceeded it was found 
that this mass of protoplasm was of a much more intri- 
cate structure than was at first supposed, and that the dark 
spot, the nucleus, was an important part. This necessi- 
tated a revision of Max Schultze’s definition, and the fol- 
lowing was formulated: “A cell is a little mass of proto- 
plasm, which contains in its interior a specially formed 
portion, the nucleus.” 

During the last decade a vast amount of information 
in regard to the structure of the cell has accumulated. 
This is especially so in regard to the nucleus and the 
part it plays in the process of cell division. These dis- 
coveries will be considered in the discussion of the struc- 
ture of the cell. 


STRUCTURE OF THE CELL. 


Cell body, a. Spongioplasm or cytoreticulum, 
1. + Protoplasm, or + >. Hyaloplasm, 
Cytoplasm, c. Microsomes. 
(a. Nuclear membrane, 
b. Intranuclear net- § @. Chromatin. 
work, 6. Linin. 
ec. Karyolymph or nuclear sap, 
d. Nucleoli. 


9 Levent or 
* ) Karyoplasm. 


8. Centrosome. 
4. Cell membrane. 





‘of the cell. 


Cedar Springs. 
Cell. 





Cytoplasm (cell body, protoplasm).—Under the ordi- 
nary powers of the microscope the cytoplasm has a 
granular, in some instances a homogeneous appearance; 
but upon analysis with the highest powers it is found to 
be composed of two distinct substances: the spongioplasm 
or cytoreticulum (Fig. 1199, 8), which forms a network 
or reticulum the spaces of which are filled with what is 
believed to be a fluid substance, and the Ayaloplasm (Fig. 
1199, H). The proportion of these two elements varies. 
In young cells the hyaloplasm predominates, but as the 
cells grow it decreases relatively, and the spongioplasm 
increases. The amount of the spongioplasm, the thick- 
ness of its threads, and the size of its meshes also vary 
in different cells. Embedded in the cytoplasm are mi- 
nute granules, the mzcrosomes ; these, together with the 
nodal points of the spongioplasm, give the granular ap- 
pearance to the cell-body. The distribution of the mi- 
crosomes is not uniform; usually the periphery of the cell 
is entirely free from them, and then in some cells they are 
grouped in masses or they may be distributed irregularly. 
If they are numerous and coarse in character, the cyto- 
plasm has a dark look; if they are fine and less numer- 
ous it has a lighter or nearly clear appearance. In addi- 
tion to the microsomes other objects are sometimes found 
in the cytoplasm, viz.,pigment or fat granules and clear, 
spherical-shaped cavities—vacuoles (Fig. 1199, V). 

In 1892 Butsehli published the results of his observa- 
tions on the minute structure of cytoplasm. He claimed 
that the reticular appearance was due to the fact that it 
was a foum or emulsion, being made up of numerous 
microscopic vacuoles, the walls of which were in close 
apposition, so that the microscope showed them only in 
optical section and not their surfaces. In order to con- 
firm this theory he made numerous experiments and 
finally succeeded in producing what he called “artificial 
cytoplasm,” which when viewed with the microscope 
had nearly the same appearance as the spongioplasm of 
acell. This artificial cytoplasm was made by rubbing 
up olive oil with cane sugar or potassium hydrate. A 
drop of this mixture was placed on a slide, a small drop 
of water was added, and the whole was covered with 
cover glass, the weight of which spread it out in a thin 
layer. From these experiments he concluded that cyto- 
plasm was a mixture of fluids of different densities, the 
heavier forming the walls of the vacuoles, while the 
lighter collected in their cavities. 

At present we have two theories as to the structure of 
cytoplasm: the reticular, which is supported by the ma- 
jority of investigators, and the foam or emulsion theory, 
which is advocated by Butschli and his school. 

Nucleus.—The nucleus or karyoplasm (Fig. 1199, 1) is 
now known to be the important part of the cell, being 
the centre of all its activity. It is generally embedded 
in the cytoplasm, but in a few cells it projects above the 
surface. It stains, or, more properly speaking, some of 
its elements stain, with certain dyes, such as carmine, 
hematoxylin, etc. 

It may be spherical, oval, rod-like, or irregular in its 
shape, and its size is generally in proportion to the size 
In a few instances it is nearly as large as 
the cell itself (lymphocytes). Every cell, as arule, has 
at least one nucleus, sometimes two or more, and in the 
large giant cells one hundred or more have been found. 
A few cells—red blood cells, the surface cells of the epi- 
dermis, and the respiratory cells of the terminal air pas- 
sages of the lungs—are without nuclei. 

These cells did at some previous time have a nucleus, 
but in the process of differentiation the nucleus disap- 
peared. 

In the resting state the nucleus is surrounded by a 
membrane, the nuclear membrane (Fig. 1199, I), which 
encloses the nuclear contents or karyoplasm. This mem- 
brane is divided into two layers, an inner or chromatic, 
and an outer or achromatic. By some investigators it is 
considered as a special condensation of the cytoreticulum. 
The karyoplasm is made up of a formed material, the 
intranuclear network or reticulum (Fig. 1199, 7), and of 
what is believed to be a fluid substance, the karyolymph or 


761 


Cell, 
Cell, 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





nuclear sap, which fills the spaces formed by the reticu- 
lum. The intranuclear network is composed of two ele- 
ments: chromatin, which stains with the nuclear dyes, 
and linin (Fig. 1199, Z), which does not stain. The 
chromatin occurs in the form of irregular anastomosing 
threads, which are supported by the linin. These chro- 
matin threads vary in their thickness and arrangement. 
In some nuclei they appear in the form of a thick or thin 
convoluted thread; in others as rounded or irregularly 
shaped granules. Some investigators believe that the 
chromatin occurs in the form of short, rod-like masses and 
that these masses are embedded in the linin. The linin 
is a transparent, unstainable substance, only to be dem- 
onstrated by special methods of preparation. 

The Nucleoli are of two kinds: the true nucleoli or plas- 
mosomes (Fig. 1199, Nw), and the net knots or karyosomes 
(Fig. 1199, A). The true nucleoli are spherical in shape 
and they stain intensely with the nuclear dyes. They 
may lie free in the nuclear sap or they may be attached 
to the threads of the intranuclear network. The karyo- 
somes or false nucleoli are thickened nodal points of the 
reticulum. The function of the true nucleoli is un- 
known. 

Centrosome.—This is a minute spherical-shaped body 
(Fig. 1199, C) found within the nucleus in the resting 
state. It is the special organ controlling the process of 
cell division. In the earlier stages of this process it 
passes into the cytoplasm, remaining near the nucleus, 
and is surrounded by a zone of fine, radiating fibrils, the 
attraction sphere or archoplasm. In some few cells no 
centrosome has been discovered as yet, but this is be- 
lieved to be on account of its minute size and difficulty 
of demonstration. 

Cell Membrane.—The cell membrane is now believed to 
be an unimportant part of the animal cell. It is present 
in but a few instances—fat cells and the ovum being 
exceptions. In the ovum it is well developed and has 
structural differences ; in other cells, however, it is gen- 
erally of a homogeneous appearance and is considered by 
many to be a condensation of the cytoplasm. 

Cells differ greatly in shape. They may be oval or 
spherical—the form of all young cells; discoid, as in the 
case of the red blood cells; flat, as in some forms of epi- 
thelium; cylindrical or columnar, as in the epithelium of 
the intestine; or, finally, irregular, as in the connective- 
tissue cells and nerve cells. The element of pressure is 
an important factor in the modification of the shape of 
cells, and is well exemplified in the various forms of 
stratified epithelium. 

VITAL PROPERTIES OF CELLS.—Under this heading are 
grouped the phenomena of movement, irritability, metab- 
olism, and reproduction. 

Cells exhibit the phenomena of movement under three 
forms: protoplasmic, ameboid, and ciliary. 

Protoplasmic movement is difficult of observation on 
account of the slowness of the process. It has been de- 
monstrated in a few animal cells, and in plant cells it is 
easily observed, the streaming of the cytoplasm being an 
example. All animal cells are believed to possess it to 
a greater or less degree. It is made manifest by the 
changes in the form of the cytoplasm, by the movements 
of the microsomes, and by the changes in the position of 
the nucleus. 

Ameeboid movement is similar to that exhibited by the 
unicellular organism, the amceba. Nearly all animal cells 
possess it tosome extent, it being well marked ina special 
few, viz., the leucocytes, lymph cells, and wandering con- 
nective-tissue cells. Ifaliving leucocyte be studied under 
the microscope, it will be seen to change continually its 
form (Fig. 1200). Gradually a bud-like mass of the 
cytoplasm will push out from some point, or several may 
start from different points. These pseudopodia may re- 
tract, or one may be extended for a considerable dis- 
tance, the remainder of the cytoplasm flowing into it. 
Other pseudopodia are given off and the above process 
is repeated. By this means the cell will gradually crawl 
through the field of the microscope. It is by means of 
this amceboid movement that the leucocytes pass through 


762 


the walls of the capillaries and wander through the spaces 
of the tissues and organs or between other cells. 
Ciliary movement is the power possessed by the hair- 
like appendages of certain cells (see Hpitheliwm). 
Irritability is the property that cells have of respond- 
ing to external stimuli. These stimuli, taough almost 





Fic. 1200.—Amceboid Movement. (After Verworn.) 


innumerable, may, ina general manner, be grouped as me- 
chanical, electrical, and chemical in their nature, or as 
due to heat and light. 

All cells do not react in the same manner to the same 
stimulus, nor do all stimuli cause the same reaction in an 
individual cell. The response of a cell to a specific 
stimulus depends upon its structure. Some, those of 
the organs of vision, for example, respond to light only ; 
while others may respond to one or more stimuli. 

Under mechanical stimuli are classed pressure, violent 
shaking, and crushing, any one of which causes cells to 
react in some manner. 

While heat is a necessary condition for the vital activ- 
ity of cells, it must be confined within rather fixed limits; 
these varying considerably, however, for different cells. 
If the temperature be raised to 40° C. the vitality of the 
cell is destroyed, but, on the other hand, the temperature 
may be lowered to a considerable extent without the 
cel] being killed. An increase of heat above that at 
which a cell normally exists causes a marked increase 
in its vital processes, until the heat-rigor point (40° C.) is 
reached, when a coagulation takes place and the cell is 
killed. Lowering of the temperature below the normal 
produces a gradual diminution of activity until the cold- 
rigor (0° C.) point is.reached, when the cell passes into a 
“narcotic” state. Apparently cells can remain in this 
state for a considerable length of time without their 
vitality being destroyed, for if they be gradually warmed 
up to their normal temperature their vital functions are 
resumed. 

Light, in the higher order of animals, is believed to be 
a stimulus to the cells of the organs of vision only. In 
some of the lower animals, other tissue cells, especially 
those of the skin, respond to its stimulation. 

Electrical stimuli, when applied in the form of weak 
currents, cause an increase, strong currents a decrease, in 
cell activity. If the latter are continued for a consider- 
able length of time they cause the death of the cell. 

Chemical stimuli are almost numberless, and at 
present their manner of action is not thoroughly under- 
stood. Some cause contraction, some increased move- 
ment, others increased secretive activity, etc. <A strik- 
ing example of the effect of chemical stimuli is that 
known as chemotaais. This is the property possessed 
by certain cells of responding to the stimulation of 
chemical substances introduced into or formed in the 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cell, 
Cell, 





body. Some substances cause the cells to approach 
them—~positive chemotaxis ; others repel them—negative 
chemotaxis. The leucocytes respond quickly to this 
form of stimulation. 

Metabolism is the property which cells possess of ab- 
sorbing and of giving off materials. The former process 
is termed constructive metabolism or anadolism, the latter 
destructive metabolism or katabolism. The anabolic 
products are retained in part by the cell for its nutrition 
and the remainder are given off as its specific secretion. 
Katabolic products are mostly thrown off as excretions. 

REPRODUCTION. —AII of the multitude of cells entering 
into the formation of the various tissues and organs of the 


adult animal body are derived from one original cell, the 
ovum. Every cell is the result of the division of a pre- 
existing cell (mother cell) into two cells (daughter cells). 
This process is known as cell division. 

Two chief forms of cell division are now recognized: 
indirect cell division (karyokinesis, karyomitosis, or 


mitosis) and direct cell division (amitos?s). 
Indirect cell division, or mitosis, is the process by which 
the vast majority of the cells of the animal body divide. 
In this form of division the intranuclear network under- 
goes a series of complicated changes; the nucleus divides, 
and finally the cell body itself, into two equal portions. 
The process is divided into four stages: 


the first 





Fig. 1201.—Diagram of Indirect Cell Division or Mitosis. (After Béhm and von Davidoff.) A, Cell with resting nucleus; B, prophases; 
nucleus showing thickened convoluted thread of chromatin, daughter centrosomes, and early stage of the formation of the achromatie 
spindle; C, prophases, formation of the chromosomes ; D, prophases, achromatic spindle in long axis of the nucleus, chromosomes dividing ; 
E, anaphases, chromosomes moving toward the centrosomes; F’, anaphases, chromosomes collected at the poles of the nucleus forming the 
diaster ; commencing constriction of the cell body; G, telophases, further constriction of the cell body, daughter nuclei returning to the 
resting state; H, telophases, deeper constriction of the cell body, daughter nuclei showing monaster and convoluted thread of chromatin ; 
TI, telophases, complete division of the cell body forming daughter cells the nuclei of which have returned to the resting state. 


763 


Centaury. 
Cephalhzematoma, 





stage, prophases, in which the nucleus undergoes a series 
of preparatory changes; the second stage, metaphases, 
in which the first steps in the division of the nucleus 
take place; the third stage, anaphases, in which the 
nuclear material is distributed to the new-forming nuclei; 
finally the fourth stage, telophases, in which the complete 
division of the nucleus and cell body takes place, with 
the formation of daughter cells. 

Prophases.—The resting nucleus enlarges and the cen- 
trosome passes into the cytoplasm, where it divides in 
such a manner as to form daughter centrosomes. The 
daughter centrosomes lie near the nucleus, separated by 
quite an interval, each being surrounded by the radiating 
fibrils of the archoplasm, some fibrils of which, stretching 
between the centrosomes, form the achromatic spindle 
(Fig. 1201, B). The intranuclear network becomes con- 
verted into a fine convoluted thread, which in some 
cases is continuous; in others it is broken up into sey- 
eral threads. The thread or threads next shorten and 
become thicker, the convolutions being reduced in num- 
ber. At this stage the chromatin stains intensely and 
resists the action of decolorizing agents. The chromatin 
next becomes arranged ina series of connecting loops, 
forming the wreath. The nuclear membrane and the 
nucleolus disappear. In some cases it appears that the 
nucleolus is thrown out into the cytoplasm and there 
degenerates. The wreath breaks up into V-shaped seg- 
ments, the chromosomes (Fig. 1201, (). These chromo- 
somes are always of an equal number, varying from 
two to thirty-six, and each species of animal has a char- 
acteristic number, which in man is sixteen. 

The centrosomes migrate to the poles of the nucleus, 
and the achromatic spindle appears in its long axis, being 
formed by some of the fibrils of the archoplasm stretch- 
ing between them (Fig. 1201, D). The chromosomes, 
which have become much shorter and thicker, collect 
around the axis of the nucleus at its equator, the equa- 
torial plane, their closed ends being directed toward the 
centre, forming the monaster (Fig. 1201, D). 

Metaphases.—This stage is the commencement of the 
actual division of the nucleus. The chromosomes of the 
monaster split lengthwise into halves, which at first lie 
close together, but gradually draw away from each other 
(Fig. 1201, D) and form daughter chromosomes, the 
original chromatin being divided into equal portions. 

Anaphases.—The nuclear material is, in this stage, 
equally distributed to the now forming daughter nuclei. 
The chromosomes separate into two equal groups, and 
each group gradually moves toward one of the centro- 
somes (Fig. 1201, #), where they collect in a form similar 
to that of the monaster; this is termed the déaster (Fig. 
1201, #). Toward the close of this stage the cyto- 
plasm becomes slightly constricted at the equatorial 
plane. 

Telophases.—The constriction of the cytoplasm noticed 
in the previous stage continues to deepen until the cell- 
body is divided into equal halves, forming daughter cells, 
each of which receives one of the groups of chromosomes, 
one-half of the remaining nuclear material, and one 
centrosome. The nuclear membrane and the nucleolus 
reappear and the daughter nuclei return to the resting 
state (Fig. 1201, G, H, J). 

Direct Cell Division or Amitosis.—This form of cell 
division is now believed to be confined to the lymph 
cells and leucocytes. The nucleus in this form of cell 
division divides without the intranuclear network under- 
going the same complicated changes as in the indirect 
form. 

The nucleus first becomes constricted (Fig. 1202, A); 
this constriction gradually increases and finally cuts the 
nucleus into two parts, forming daughter nuclei; these 
daughter nuclei draw away from each other by amceboid 
movement (Fig. 1202, £). At times the complete divi- 
sion is delayed and the nuclei remain connected, for some 
time, by a narrow thread of the nuclear material (Fig. 
1202, C). Division of the cytoplasm take splace by the 
development, at first, of a constriction between the nuclei, 
and then finally by the entire separation of the daughter 


764 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


cells thus formed. Like the nucleus, the cytoplasm may 
in some instances remain connected (Fig. 1202, D), or 
its division may be delayed while the nuclei go on 
dividing, the result being an accumulation of nuclei and 
the formation of multinucleated cells. 

The innumerable cells found in the adult organism, 
though derived from a common parent, the ovum, lose 





a 


Fig. 1202.—Direct Cell Division or Amitosis. 


(After Arnold.) 
Constriction of the nucleus; B, complete division of the nucleus, 
commencing constriction of the cell body; C, daughter nuclei still 
connected by a thread of nuclear material; D, daughter cells still 
connected by a narrow band of cytoplasm. 


in many respects all resemblance to that cell. They as- 
sume new forms and functions, these being brought 
about by a process of cell differentiation. 

After the fertilization of the ovum it divides by mitosis 
and at first the daughter cells resemble the mother cells. 
Soon changes make their appearance in the cells and they 
can be grouped into two forms. These two forms con- 
tinue to multiply and finally they become arranged into 
three distinct layers—the layers of the blastoderm. From 
these layers of the blastoderm all of the tissues of the 
body are derived, each layer furnishing certain specific 
tissues. 

For more minute details of the structure and function 
of cells consult “The Cell in Development and Inheri- 
tance,” E. B. Wilson, and “General Physiology,” Max 
Verworn, translated from the German by Frederic S8. 
Lee, M.D. George C. Freeborn. 


CENTAURY, AMERICAN. See Gentianacee. 
CEPHAELINE. See Jpecac. 


CEPHALHAMATOMA.—The name given by Naegele 
is from the Greek, kegaA7y, the head, alua, blood, and dua, 
morbid condition. A morbid condition of the head char- 
acterized by an effusion of blood. Latin Cranii tumor 
sanguineus ; French, Céphalématome, or Tumeur sanguine 
de la téte; Italian, Cefalhematoma; German, Kephala- 
matom, or Kopf blutgeschwulst. First described by Mi- 
chaelis. 

Synonyms. — Cephalematoma; ecchymoma capitis; 
ecchymoma capitis recens natorum; thrombus neona- 
torum; abscessus capitis sanguineus neonatorum; tumor 
capitis sanguineus neonatorum; cephalophyma; cranio- 
heematoncus. 

Drrrnirion.—An effusion of blood upon or within the 
crania of newly born infants. 

VARIETIES.—Subaponeurotic, fhe simplest, but not the 
most common form—a bloody effusion immediately un- 
derneath the cranial muscles. 

Subpericranial, situated between the pericranium and 
cranial bone—the most common form. 

Diploic, situated within the diploé—a rare form, and 
differing from others in that it continues to bleed when 
laid open. (This is explained by the abundant supply 
of arteries and veins in the reticulated structure of the 
diploé.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Centaury. 
Cephalhzmatoma, 





Subcranial, generally situated between the skull and 
dura mater, and sometimes in the cavity of the arachnoid. 
A case of triple cephalhzematoma is reported by Oui; it 
appeared after an easy spontaneous accouchement; spon- 
taneous suppuration and opening of the occipital tumor; 


puncture of the left parietal tumor (the larger one of the. 


two parietal tumors), followed by rapid recovery; non- 
intervention with the right parietal tumor, which very 
slowly underwent resolution, 

PatrHOLOGIcAL ANATOMY.—The scalp generally retains 
its natural aspect. Exceptionally its appearance be- 
comes red and livid. Its substance remains uninjured, 
and the pericranium preserves its transparency. The 
effused blood is contained in a sac of fine membrane, 
having all the characteristics of condensed cellular tissue. 
It rests on the bone, from which it can be easily detached, 
and underneath the pericranium, to which it adheres 
more firmly. Points of ossification can be observed on 
the under surface of thismembrane. The earlier writers 
thought that the outer table of the skull was necrosed, 
carious, and destroyed, and that the ruptured vessels of 
the diploé gave rise to the hemorrhage. A bony ring 
forms in the majority of cases. It begins as soon as the 
separation of the pericranium is arrested, which is about 
the secondday. ‘This has been said to be only a delusion 
of the sense of touch, but its presence has been demon- 
‘ strated by numerous autopsies. It is not, however, 

always present, being absent in tumors situated near a 
suture. There are many theories as to its causation, 
The following, by Virchow, is probably not only the 
most beautiful, but also the most plausible: The healthy 
cranium grows by proliferation of the inner layers of the 
periosteum. If, then, the pericranium, through the blood 
which is poured out, is held apart from the cranium, the 
bone-forming layers of the periosteum being still thrown 
off, they cannot reach that part of the bone for which 
they are intended, on account of the presence of the 
blood. Eager, however, to fulfil their office, they join 
themselves to the bone at the border of the tumor where 
the bone is still attached. Bland Sutton reports a case 
which had occurred in a monkey. Autopsy showed the 
bony ring. Similar formations of bone are observed in 
rabbits subjected to experimental elevation of the peri- 
cranium. 

ErroLocGy.—The etiology has occasioned much dis- 
cussion. The reception of some injury by the child dur- 
ing parturition was long thought to be the cause. A 
number of observers failed to note that it succeeded diffi- 
cult labors. The tumor occurred on parts not liable to 
pressure. Cases are reported after breech presentations, 
after Cesarean section, and after painless labor, and it 
has been observed that a narrow pelvis in the mother is 
an infrequent accompaniment. It occurs in premature 
births. These tumors form on children of advanced age 
and on adults; sixty-six and two-thirds per cent. of the 
cases are males. While it is very easy to imagine how 
pressure during parturition might cause the tumors, yet 

_it is very evident that in a large proportion this is not the 
cause but that it must be some fault of the blood-vessels. 
Intracranial hemorrhage is in reality a form of apoplexy, 
and it is quite probable that the tendency is inherited. 
One case is on record in which the same mother gave 
birth to three children successively who had cephal- 
hematoma. Inacase reported by the author, the mother 
said: “Three of my other children died of convulsions, 
and I gave this one up as soon as they came on.” These 
other children, too, might have had cephalhematomas, 
and there might have been an inherited tendency; or an 
unusual friability or thinness of the vessels, or incom- 
plete development of the outer layer of the skull, might 
have been the cause. If cephalhzematomas are caused 
by pressure in breech presentations, this must be clue to 
the action of the cervix on the cord or neck of the child. 
Pressure during delivery undoubtedly has something to 
do with the causation of a considerable number of these 
tumors, yet there are many others which must result 
from a diseased condition of the blood-vessels, inherited 
or acquired. Heydecker reports a case which was due, 


in his opinion, to imperfect ossification of the cranial 
bones. 

FREQUENCY.—The average, so far as it can be learned 
from the statements of authors, is 1 in every 235 children 
born. 

Location.—It is most frequently situated on the right 
parietal bone, then on the left, occasionally on the frontal, 
more rarely on the occipital and in the temporal regions. 

Draenosis.—It is a disease of the newly born. Ex- 
ceptions: One case has been reported in a child of six 
months, another in one of twelve months, a third ina 
man of twenty-six years, a fourth in one of thirty-six, 
and a fifth ina woman of forty-nine. These, however, 
are anomalies. One notices a tumefaction, usually one, 
two, or three days after birth. It develops gradually; 
it is of fluid character. It pulsates forcibly at the begin- 
ning, if connected with an artery; it loses this later, but 
fluctuation is always present. In size the tumor ranges 
from that of a hazelnut to that of a mass involving the 
whole surface of the parietal bone. The tumor is limited 


_by the sutures in the three varieties situated between the 


pericranium and the dura mater; in the subaponeurotic 
and arachnoid varieties this is not so. The scalp is nat- 
ural in appearance in the subaponeurotic variety. The 
bony ring is almost pathognomonic in the subpericranial 
variety, but is not so often present in those situated be- 
tween the cranium and dura mater; in the other varieties 
it is absent. The diagnosis of internal cephalhematoma 
must be made from the symptoms of brain pressure, 
twitchings, convulsions, stupor, or paralysis which it 
may produce. The caput succedaneum occurs in the 
first twelve to thirty-six hours. Cephalhzematoma is at 
birth either absent or scarcely noticeable, grows from day 
to day until, on the eighth day, it attains its full size, and 
then, perhaps, the bony ring can be felt. The caput 
succedaneum pits on pressure, while the cephalheematoma 
does not. From hernia cerebri congenita it may be dis- 
tinguished by the fact that this pulsates, while cephal- 
hematoma simply fluctuates; hernia cerebri, further- 
more, is not found on the parietal bones, but on the 
sutures and fontanels; it protrudes during the acts of 
coughing and crying, is partly reducible, and then causes 
slight convulsions. Therim of bone resembles somewhat 
the elevated ring, but pressure of the finger on the tumor 
does not find a bony floor as in cephalhematoma. The 
skin over hernia cerebri is thin and hairless, in cephal- 
hematoma it is normal. Fungus of the dura mater does 
not contain fluid, does not fluctuate nor feel doughy, has 
no bony ring, and the overlying skin is thick and blue. 
This form of tumor becomes smaller under pressure, and, 
besides, it seldom occurs in children. Atheroma and 
fatty tumors occur rarely at such a tender age. They 
can be differentiated by the trocar, but one must be care- 
ful to exclude hernia cerebri before using this instru- 
ment. There is no danger of confounding cephalhema- 
toma with hydrocephalus externus, and the osseous circle 
will distinguish the former from aqueous cysts. Telan- 
gioma occupies the favorite seat of hematoma, but is not 
covered with hair, pulsates weakly, and is somewhat 
diminished in size by pressure. 

Proenosis.—For the extracranial tumors the prognosis 
is good, for the intracranial it is bad. Death takes place 
mostly from exhaustion, brain pressure, and secondary 
hemorrhage; from rupture of the tumor; from necrosis 
or caries of the bone leading to perforation; from throm- 
bosis of the cerebral sinus; from extension of the inflam- 
mation into the meninges and brain itself; from absorp- 
tion of ichorous discharge, and from pyemia. Arthritis, 
phlebitis umbilicalis, pleuritis, scleroderma, intestinal 
hemorrhage, caries of the skull, and, in the internal 
variety, idiocy are among the results which may follow 
cephalhzematoma. 

TREATMENT.—Authors are divided; some follow the 
expectant, others the active plan. Some of those who 
use the knife wait till the eighth to twelfth day; a few 
make the incision earlier. The artificial evacuation of 
the blood is usually unnecessary, and may do harm; asa 
rule, non-interference is best. If pus forms it should be 


765 


Cephalocele, [ingitis. 
Cerebro-Spinal Men- 








evacuated. Patton, in the case of his own son, aspirated 
on the twelfth day, removing twelve fluidrachms of blood. 
Result was good and Patton recommendsit highly. For 
the external varieties, warm aromatic fomentations, cold 
spirit lotions, pressure, and setons have all had their day. 
As treatment in intracranial cephalhematoma has not yet 
been attempted; as the internal is almost always asso- 
ciated with the external variety, the latter being situated 
directly over the former, in the writer’s opinion it would 
be advisable to trephine the skull to evacuate the tumor. 
Edward Sydney McKee. 


BIBLIOGRAPHY. 


Bierbaum: Cephalhematoma Verum, Med. Zeit., Berlin, 1858, i., 185. 
Cephalhzematom, Jahrb. f. Kinderk., Erlangen, 1860, xxxv., 57; 
Kephalamatom, Ibid., 1861, xxxvii., 199; Cephalhzmatoma, Jbid., 
1863, xii., 165-167. 

Cleveland: Internal and External Cephalhzematoma. Cincinnati 
Lancet and Clinic, vol. vi., p. 350, 1881. 

Depaul: Deux cas de cephalématome, Journal des sages femmes, 
Paris, 1875, iii., 17; Cephalématome, Ibid., 1877, v., 313; Cepha- 
lématome, Gaz. des HOp., Paris, 1879, iii., 857. 

Dépp: Zwei hundert zwei und sechzig Falle von Cephalhimatoma 
Neonatorum, Journal de Chir. und Augenheilk., Berlin, 1843, u. f. ii., 
99-108; Zur Cephalématome, Annales de la Chir. Francaise et 

Etrange., Paris, 1844, x., 176-186. ‘ 

Gosselin: Bemerkungen ueber die Entstehung des Spit Cephalamatom 
in Folge yon rareficirinde Osteitis des Scheitelbeins, Arch. Gén., 7 
Sér., x., p. 5138, November, 1883; also, Schmidt’s Jahrbiicher, vol. cc., 
No. 2, p. 151, 1883. 

Geddings: Observations on Sanguineous Tumors of the Head, which 
form Spontaneously, sometimes designated Cephalhzematoma and 
Abscessus Capitis Sanguineus Neonatorum, N. Am. Arch. M. and 8. 
Sciences, Baltimore, 1835; On Sang. Tumors of the Head, Amer. 
Jour. Med. Sc., Phila., 18389, xxiii. 

Bee Cephalhzematoma. Quain’s Dictionary of Medicine, p. 224, 


Heady: Cincinnati Lancet and Clinic, 1897, xxxix., 207; Am. Jour. 
of Obst., 1897, xxxvi., 370. 

Hennig: Kopfblutgeschwiilste, Gerhardt’s Handbuch der Kinder- 
krankheiten, Bd. ii., S. 49, 71, Tiibingen, 1877, u. Jahresbericht der 
Poliklinik fiir Kinder, Leipzig, 1856. 

Homans: Double Cephalhzmatoma, Extr. Rec. Boston Soc. of Med. 
Improvement, 1856, ii., 149; also, American Journal Med. Sci., 
Philadelphia, 1855, N. S., xxix., p. 67. 

Jackson: Internal Cephalhzematoma. 
1855, N. S., xxix., p. 67. 

Jacobi: Cephalhzeematoma, Phila. Med. Times, 1875, vy. 507; Kephala- 
matom, Med. Chir. Centralblatt, Wien, 1876, xi., 507. 

Keating: Archives of Pediatrics, ii., 11-20, 1885. 

Kelley; Tr. Am. Gyn. Soc., 1890, xvi., 270. 

McKee: External and Internal Cephalhzeematoma. Cincinnati Lancet 
and Clinic, N.8., vol. xi., pp. 317-824, 1883. 

Monti: Jahrbuch fiir Kinderheilkunde, N. F., 1875, 407. 

West: External and Internal Cephalhzematoma. Med. and Chir. 
Trans., London, 1845, xxviii., 397, 411. 

Virchow: Die Krankhaften Geschwiilste, i., 185. 1863; also, Monat- 
schrift fiir Geburtskunde, Bd. xx., xxiv., xxvi., pp. 48, 173, 174. 

Withrow: Am. Journ. Obst., 1893, xxvii., 726. 


CEPHALOCELE. See Brain. 
CEPHALOMETRY ; CRANIOMETRY. See Skul. 
CEREBELLUM. See Brain. 


CEREBRO-SPINAL INJURIES. (MEDICO-LEGAL.) 
See Traumatic Affections. (Medieo-Legal.) 


CEREBRO-SPINAL MENINGITIS, EPIDEMIC.—Dert- 
NITION.—Cerebro-spinal meningitis (u7vevs, a membrane) 
is an acute infectious disease, with its main local ex- 
pression, as the name indicates, in the membranes of the 
brain and spinal cord. Two sets of symptoms distin- 
guish this disease: one common to all the acute infec- 
tions, and characteristic of general poisoning of the 
blood; the other peculiar to the local lesion in the cover- 
ings of the brain and spinal cord. The combination of 
these two sets of symptomsand lesions individualizes the 
disease. 

Synonyms.—No disease has received so many names, 
while there is not one against which valid objection may 
not be raised. Of cerebro-spinal fever (Royal College of 
Physicians) it may be said that while it recognizes the 
general infection it fails to indicate the part of the brain 
and cord affected. Cerebro-spinal fever is neither clear 
nor Classic. It is a term “which may be pardoned when 
used by the laity, but which educated physicians ought 
not to tolerate” (Stillé). More glaringly faulty, though 


Amer. Journ. of the Med. Sc., 


766 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


with abundant recognition of the brain symptoms, are 
the designations of the older French authors: Fvévre céré- 
brale, phrénésie, cephalalgie épidémique, meningite puru- 
lente epidémique, with which may be cited also the Ger- 
man IZirnseuche, and the old English terms malignant 
meningitis and epidemic meningitis. The early erroneous 
view of the disease as a variety of typhus fever is per- 
petuated in the names cerebro-spinal typhus, typhus 
cerebralis apoplecticus, typhus syncopalis, phrenitis typhodes, 
typhoid meningitis. 

The appearance of an hemorrhagic eruption, which 
characterizes the graver cases of nearly all the acute in- 
fections, has been more distinctly associated with this 
disease in the names spotted fever (Gallup), petechial 
fever (Wood), malignant purpura (McSwinney), malig- 
nant purpuric fever (Stokes,) pestilential purpura (Banks), 
febris nigra (Lyons), and in its association in this 
connection again with typhus as a typhus petechialis 
(North), and with a neurosis, as newro-purpuric fever 
(Mapother). Moreover, cerebro-spinal meningitis, on 
account of its eruption, has not escaped inclusion under 
the all-embracing title, black death (A. Smith). As was 
correctly remarked by Minet, nearly a century ago: “It 
is quite unfortunate that a single symptom—petechise— 
and one that is wanting in a great majority of cases, 
should have been seized upon to give it the odious and 
deceptive name of spotted fever, as that name has been 
arn by European writers to a very different kind of 

ever.” . 

The opisthotonos, perhaps the most striking single 
symptom of the disease, which is, however, by no means 
universally present, has been selected by the Germans. 
to name the disease a Genickkrampf, Genickstarre, Nack- 
enstarre ; by the Swedes a Nacksjucka, Dragsjucka ; and 
by the Italians a torticollo, Fancy has exercised its 
ingenuity in the title cerebro-spinal arachnitis (Mayne), 
a refinement totally unjustified in the morbid anatomy 
of the disease; and the limits of frenzy have been almost. 
attained by the frantic efforts of Italian writers to cover 
the entire field of the disease with the names tifo-apo- 
plettico tetanico and febbre-soporoso-conoulsivo. Terms as. 
delusive and diffuse as spotted fever are the popular 
names congestive fever, winter epidemic, and cold plague. 

From this array of titles, which is by no means ex- 
hausted, may be appreciated the difficulty of securing a 
proper name for a disease from its symptomatology or 
pathology. The name cerebro-spinal meningitis (Hughes, 
Law, Banks, Moore, and others) is at present the least. 
of all objectionable, and has hence, in the course of time, 
come into common use, though it gives undue promi- 
nence to the local lesion to the exclusion of the infectious. 
character of the disease. As was observed by Valleix, it. 
is “begotten of anatomical bias and an incomplete ap- 
preciation of the facts.” Gordon attempted to cut the 
knot of difficulty by calling the disease cerebro-spinal 
Fever, with cerebro-spinal meningitis, a combination too 
bulky for practical use. 

History.—Epidemic cerebro-spinal meningitis is a dis- 
ease of modern origin; perhaps it would be more strictly 
true to say of modern recognition, for previous to the nine- 
teenth century there was no possible differentiation of this. 
disease and forms of typhus fever, pernicious malarial 
fever, tetanus, and the various inflammations of the brain 
and cord, diseases known to be as old as the history of 
medicine. More recently Davis was justified in the state- 
ment thaf “in regard to the disease promiscuously styled 
‘spotted fever’ and ‘cerebro-spinal meningitis,’ as re- 
ported in our literature, no less than three or four dis- 
eases have been confounded together” (Trans. Amer. 
Med. Assn., xvii., 1866). Hence the possibility is not to 
be excluded that cases, or even epidemics, of cerebro- 
spinal meningitis occurred in ancient times. Medical 
historians (Ozanam, Alpin) have made repeated endeavors 
to identify this disease with the phrenitis of Hippocrates, 
and with certain epidemics of ancient Egypt, or (Tourdes, 
Boudin) at least to find its most essential features in the 
later writings of Forestus, Ignassias, Felix Plater, and 
Saalman; but the references cited go further to show in- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cephalocele, [ingitis, 
Cerebro-Spinal Men- 





terest and assiduity in antiquarian research than to con- 
firm their views. 

It is, however, not just to claim that there*could have 
been no possible recognition of this disease before the 
fifteenth century, when the first dissections were made 
of the spinal cord, for diagnoses in ancient times were 
wholly based on symptoms; but it is unreasonable to 
assume the distinct recognition of a disease whose symp- 
toms were not separated from other acute infections or 
from purely local lesions. 

It is generally conceded of cerebro-spinal meningitis 
that it first attracted notice as a separate disease in 
Geneva, February, 1805. Perhaps this first notice is due 
to the fact that the cases occurred in the practice of 
Vieusseux, an observer as keen as he was frank. He 
called the malady a ficvre cérébrale ataaique, and admitted 
that neither he nor his colleagues had ever seen a similar 
disease. These first victims were a woman and three chil- 
dren, two of whom died within twenty-four hours. The 
disease extended gradually to neighboring houses, in one 
of which four out of five children were attacked, and 
died within fifteen hours. It was characterized by sud- 
denness of attack, vomiting, excruciating headache, stiff- 
ness in the back of the neck, dysphagia, and convulsions 
(Laveran, “Dict. encyclop. des sc. med.,” 2d ser., 5 to 
6, p. 648). A young man in an adjoining house died on 
the same night of the attack, showing a violent discolora- 
tion of the whole body. Thirty-three persons fell vic- 
tims to this first outbreak of the disease, which lasted 
until May. The post-mortem examinations made by 
Mathey upon some of these cases revealed gelatinous 
exudation covering the convex surface of the brain, yel- 
low pus posteriorly and about the optic commissure, 
cerebellum, and medulla oblongata. It is remarked of 
this first attack that it remained quite strictly localized. 

The next outbreak of the disease, with unmistakable 
signs, occurred in our own country, with the first cases 
at Medfield, Mass., March 1806. These cases formed the 
preface to a long chapter in the history of the disease, 
known then as “sinking typhus,” ten years in duration, 
during which time it extended over, but remained con- 
fined to, the New England States. Meanwhile the dis- 
ease made its first appearance in France, at Grenoble, 
where it prevailed during the months of the spring of 
1814, remaining confined to the soldiers lately arrived 
from the army of Mont Blanc. Comte. describes it as a 
malady characterized by stiffness of the neck, with head- 
ache and delirium among its prominent symptoms, with 
traces of inflammation in the brain and cord observed on 
autopsy among its lesions. During the next year, Ram- 
pont described four cases at Metz, distinguished by the 
same array of symptoms and lesions. With the excep- 
tion of an extensive endemic in Vesoul, in 1822, which 
differed from previous attacks in its preference for the 
civil population, the disease did not show itself again in 
France until January, 1837, when it broke out with great 
virulence in the garrison at Bayonne, and rapidly ex- 
tended to invade the neighboring barracks at Dax, 
Meignon, and Tartos, and to assume, later in the course 
of the year, epidemic proportions, reaching Bordeaux by 
December of the same year; Rochefort, January, 1888; 
and Nimes and Avignon, in the interior, by the end of 
the year. It is remarked of this outbreak, at a place ap- 
propriately named Aigues-Mortes, where it first appeared 
in November, 1841, remaining confined to the civil popu- 
lation, and continuing until March, 1842, that it attacked 
160 persons of whom 120 died. 

The same regiment of light infantry which transported 
the disease from Bayonne to Rochefort conveyed it also 
to Versailles, where it appeared in February, 1839, six 
men inhabiting the same room being’ attacked within a 
period of a few days. Paris made its first acquaintance 
with the disease, after the lapse of several years, in De- 
cember, 1847. It continued to prevail in Paris up to 
May, 1849, confined exclusively to the inmates of the 
garrison and the prisoners at La Force, in which latter 
place ten of the twelve persons attacked fell victims to 
the disease. 





After France, Italy was invaded, the disease first ap- 
pearing in the kingdom of Naples, in the winter of 1839- 
40, and spreading thence, in the following winter, to the 
lands of the church. In the same year (1889), the most 
eventful in the history of the disease, as that from which 
dates any exact knowledge concerning its nature and 
individuality, cerebro-spinal meningitis first showed itself 
in Algiers, where it continued to number victims with 
annual recurrence in various parts of the land up to 1847. 

After the first recognized appearance of the disease, 
from 1805 to 1816, accounts of it cease for six years, 
when, in 1822, it reappeared at Vesoul, in France, and at. 
Middletown, Conn., to which remotely separated places 
it remained quite strictly confined. Then, after an ad- 
ditional five years, it again showed itself, in 1828, in 
Trumbull County, Ohio; in 1830 in Sunderland, England, 
and in 1883 at Naples. In 1842, when the disease again 
visited the United States, it appeared almost at the same 
time in Louisville, Ky.; Rutherford County, Tenn. ; 
and Montgomery County, Ala. 

Sweden was not reached by the disease until 1854, 
when it suddenly appeared in Gothenburg, extending 
thence in the course of the following year as far north as 
the city of Kalmar. Then, after a complete cessation of 
six months, it showed itself in a series of small epidemics. 
extending a degree and a half farther north, and with 
this fitful, almost freakish appearance and disappearance, 
it hovered about that country for seven years, striking 
lightly in one place and like lightning in another, until it 
had killed in all 4,138 of its inhabitants. It was only 
during the last two years of this visitation of Sweden 
that the disease first showed itself in Norway (March, 
1859), in very limited extent, but in such severe degree 
as to have carried off in the county of Opdal 14 of the 
29 persons attacked. 

Strange to relate, the first invasion of Germany did not. 
occur until very late in the history of the disease. Dis- 
regarding as unauthentic the earlier communications of 
Wirtemberg physicians, Hirsch feels compelled to accept 
the statements of Rinecker, who reports with due detail 
cases occurring in Wiirzburg, June, 1851, both in hospital 
and in private practice. But the first attack of any 
severity or extent was reserved for a later date and 
place, namely, for Silesia, Posen, and Pomerania, in 1864. 
Excepting Bamberg, anything like alarming proportions. 
were not reached anywhere in Germany, though the dis- 
ease prevailed with some severity at Erlangen, in July, 
1864. 

The comparative exemption of certain countries is an- 
other, and as yet inexplicable, feature of the disease, 
more especially of countries contiguous to and under the 
same general conditions as those severely visited. Thus. 
while Ireland has suffered repeated attacks—a severe 
epidemic having occurred in Dublin, in 1866, wherein 
“the British forces suffered much in proportion to their 
average strength”—England has never had anything 
more than isolated cases, and Scotland, where the ele- 
ments of crowd-poisoning are greatest, has never experi- 
enced an epidemic of the disease. And while epidemic 
proportions have been reached in Germany on the north, 
and in Italy on the south, Austria has remained almost. 
entirely free from attack. 

Our own country seems to have offered from the 
start a fertile soil for the development and spread of 
cerebro-spinal meningitis, and since the year 1842, when 
the disease began to make excursions over the various. 
lands of Europe, it has become almost indigenous with 
us. Mention has been made already of the simultaneous 
occurrence of the disease in Alabama and Pennsylvania, 
in 1848. In the following year it made its first appear- 
ance in New Orleans, and during the following decade 
sporadic cases occurred over various parts of the country, 
as in North Carolina, in 1856, and Massachusetts, in 1857. 
Four years later (1861), more and more frequent cases are 
reported, from Connecticut, Indiana, Kentucky, and 
Missouri. Three years later still (1864), the disease 
again appeared in Pennsylvania, carrying off 400 children 
of the 6,000 inhabitants of Carbondale. It was during 


767 


Cerebro-Spinal Men- 
ingitis, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





the winter of these early sixties that the disease began to 
prevail in both armies of the rebellion, assuming a very 
malignant type in North Carolina, where it affected 
citizens and soldiers equally in the Union and Confeder- 
ate armies alike (Stillé). 

Epidemic recrudescences were observed in New York, 
1872; Boston, 1874, and again in 1896-97; Cologne, 1885; 
Vienna, 1886 and 1897, and in Berlin, 1896. 

The view that cerebro-spinal meningitis did not extend 
to or prevail in other continents than “ North America 
and Europe, and the vicinity of the latter,” has been 
quite abandoned, as epidemics have been authentically 
reported by Kotsonopulos, at Nauplia, in Greece, in 1868; 
by Hoéschelman, in the Crimea, in 1868; by Diamanto- 
pulos, in Magnesia and Smyrna, in 1869-70; and by 
Sandreczky, in Jerusalem, in 1872. 

Without attempting even to mention all the epidemics 
that have prevailed in various parts of the world, it may 
be stated that, though doubtful cases prevailed before 
this time, cerebro-spinal meningitis belongs to the nine- 
teenth century, and that its history naturally falls into 
three periods, quite distinct: the first embracing the first 
cases of “ataxic cerebral fever.” observed at Geneva, in 
1805, and of “spotted fever,” in Massachusetts, in 1806; 
the second commencing with the outbreak at Bayonne, 
in 1887, and extending over various parts of Europe and 
America up to the year 1866, gradually merging into the 
third or present period, when the disease has become 
more or less universal. Thus it may be said of this dis- 
ease that it began in sporadic form, to become endemic 
in the course of the first observations; that on its second 
appearance it assumed the proportions of an epidemic in 
various lands, to finally overleap all barriers as a true 
pandemic disease. 

GENERAL ReEMARKS.—Cerebro-spinal meningitis be- 
longs among the rarest of epidemic diseases. Since the 
establishment of the disease as a pandemic affection, 
sporadic cases are of continual recurrence, but these cases 
remain isolated as a rule. The practitioner is often sur- 
prised at being confronted with a pronounced case of this 
disease in a crowded tenement house, in a palatial sub- 
urban residence, in a barrack or jail, in the ward of a 
hospital, in a distant farmhouse, when no similar case 
may have been reported, and probably no other case 
may show itself for years. So that individual cases, not 
distinctly marked, are apt to be overlooked for a time, 
or erroneously diagnosticated, and numerous instances 
are recorded in which the diagnosis has been fully estab- 
lished only upon autopsy. 

Now that the disease has made itself more familiar by 
frequent or constant appearance, much of the obscurity 
surrounding it is being dissipated, and cerebro-spinal 
meningitis is seen to take its orderly place among the 
acute infections, with its own specific cause, characteristic 
signs, and peculiar lesions. It has been stated already 
that two sets of symptoms distinguish this affection: 
one common to all the acute infections, and the other 
peculiar to the anatomical lesions of this particular dis- 
ease. But, as in all the acute infections, either set of 
symptoms may assume prominence in an individual case. 
Niemeyer’s statement, “I must again repeat that the 
symptoms and course of epidemic cerebro-spinal menin- 
gitis may be fully explained by the changes in the me- 
ninges of the brain and spine,” covers only the cases of 
normal or protracted course, and will not apply to the 
foudroyant forms of “a disease in which,” as Stillé re- 
marks, “the septic element sometimes so far overrides 
the inflammatory as to destroy life before the latter has 
developed characteristic change.” . If this explanation is 
borne in mind it is seen that cerebro-spinal meningitis does 
not differ more widely from other acute infections than 
they do from each other. 

The view that cerebro-spinal meningitis is a cerebral 
variety or form of typhus fever had advocacy enough in 
the earlier history of the disease to have fixed the name 
of typhus in connection with it. This view, which was 
ably supported by Boudin, Murchison, Upham, Baltzell, 
and others,, was based upon a seeming analogy of symp- 


768 


toms—suddenness of attack, petechial eruption, brain 
symptoms—in the two diseases, and an occasional coin- 
cident prevalence. But more extensive observation has 
proven beyond doubt that there is nothing more in com- 
mon between these diseases, to use the language of Bur- 
don Sanderson, “except so far as each was due to a 
specific poison.” Holmes writes graphically upon this 
question: “That a disease which is sometimes almost as 
sudden in its invasion as a stroke of lightning; which is 
rarely suspected of being contagious; which gives us a 
solitary case in a ship of war, a single case in a boarding- 
school, two cases only in an almshouse; which in civil 
practice affects the villages and isolated farmhouses of 
the interior (where typhus running the ordinary course 
is unknown) as much at least as the larger cities; which 
in a great majority of cases is fatal in a few days, or even 
hours; the mortality of which is very variable—such a 
disease presents so many points of difference, when com- 
pared with British typhus, that we should hesitate before 
pronouncing the two identical.” Clymer quotes Tourdes, 
Levy, Lebert, Niemeyer, Stokes, Gordon, and Hirsch, in 
protest against this view, citing from Hirsch the state- 
ment: “Apart from its very obscure pathological essence 
there is hardly anything in its symptoms or lesions which 
brings epidemic meningitis within that comprehensive 
and elastic term—typhus.” Differing as they do in all 
essential particulars, Radcliffe says, “doubt can only arise 
when the two diseases prevail together.” 

Any connection of this disease with malaria has been 
disproved in'the same way. Such fluctuations occur in 
the course of certain cases of cerebro-spinal meningitis as 
to simulate to some extent the periodicities of malaria, 
and the “intermittent” is recognized as one of the forms 
of the disease. But the geographical study of the two 
affections reveals the fact that cerebro-spinal meningitis 
does not visit malarious countries with special frequency 
or virulence; that it attacks regions entirely exempt 
from malaria—the high, dry, and sandy plateaus of Cen- 
tral Franconia, for instance; that it shows preference for 
the winter rather than for the autumnal season; that the 
two diseases have, in short, different spatial and temporal 
relations, or, if theyshould coincide, the symptoms of men- 
ingitis do not show increased virulence. Ziemssen quotes 
in this connection from Bonsaing, who noticed that the 
epidemic of meningitis at Pola “did not seek out the 
notoriously malarious parts of the city ”; and that “dur- 
ing the epidemic, and after its disappearance, malarial 
fevers were almost entirely absent.” If further proof 
were wanting to establish the non-identity of these affec- 
tions it could be found in the absence in meningitis of 
enlargement of the spleen and liver, and of the melanzemia, 
so characteristic of malarial affections, in the age of the 
victims of the two diseases, in the total inefficacy of 
quinine in controlling the disease, and above all in the 
examination of the blood for the plasmodium malariz, 
the specific cause of malaria, which is never found in 
pure cases of cerebro-spinal meningitis. These observa- 
tions, which establish the independence of cerebro-spinal 
meningitis, meet with striking confirmation at the hands 
of Diamantopulos, in his account of the epidemic in Asia 
Minor in September, 1870. Any connection with typhus 
or malaria-is, this author states, “ positively to be denied, 
as during the entire prevalence of meningitis in Magnesia, 
no case of either of these diseases occurred” (Schmidt's 
Jahrbiicher, 196, p. 239, 1882). However, typhus fever 
or malaria may coexist with cerebro-spinal meningitis. 

Lastly, it is claimed that cerebro-spinal meningitis is 
not confined to man, but that characterstic symptoms 
and lesions have been observed in some of the lower ani- 
mals. Gallup observed of the epidemic in Vermont in 
1811 that “even the foxes seemed to be affected, so that 
they were killed in numbers near the dwellings of the 
inhabitants”; and Smith remarks of the outbreak in New 
York, in 1871, that “it was common and fatal in the large 
stables of the city car and stage lines, while among the 
people the epidemic did not properly commence until 
January, 1872” (Stillé). Clymer quotes from Law, of 
Dublin, who writes, in reporting several sporadic cases 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cerebro-Spinal Men- 
ingitis, 





of the disease in 1865: “It is a fact worthy of recording 
that at the time we were attending this lady, nine rabbits 
out of eleven, which her son had, died all in the same 
way; their limbs seemed to fail them, they fell on their 
sides, and then worked in convulsions, and died. Two 
hens fell lifeless from their roost.” Statements of this 
kind must, however, be taken with much allowance, as 
the symptoms cited by no means identify the disease, and 
the lesions found upon the bodies of three of the rabbits 
examined—* congestion of the vessels at the base of the 
brain ” in two, and in the other “ vascularity of the mem- 
branes of the spinal marrow ”—are too vague and indefi- 
nite for a diagnosis. The same reservations must also 
be made in the case of the so-called epizoétic of meningitis 
among the domestic fowl in Algeria in 1846, among the 
dogs and hogs preceding the epidemic in Ireland in 1868 
(Collins and Ferguson), and more markedly still of the 
disease among the artillery horses in Grenoble, 1814, and 
the livery-stable horses in Paris, 1844 (Villatte), where 
post-mortem examinations were not made at all. 

ErroLtocy.—Every attempt to connect cerebro-spinal 
meningitis with any special climate has turned out a 
signal failure. The disease has ranged, almost at will, 
from Gibraltar in the south of Spain, and from Algiers 
in Africa, to the most northerly towns and villages in 
Norway and Sweden. And in our own country cases 
have been reported from Maine to Mexico. The inter- 
tropical regions proper have as yet remained exempt 
from the disease, but the prevalence of it elsewhere, in 
seasons of extreme heat and humidity, would indicate 
this exemption to be an accident of time rather than of 
space. 

Equally futile has been the endeavor to fix .the disease 
in connection with any special soil. The coast of France, 
the valley of the Rhine, the hills and mountains of Cala- 
bria and Algiers, up to an elevation of a thousand feet 
and more, the marshy banks of the Garonne at Bordeaux, 
the recently inundated fields at Avignon and Aigues- 
Mortes, the wet camping-groundsat Newbern, N. C., the 
rocky sides of Gibraltar, and the dry, sandy plateaus of 
Franconia, have all offered equally fertile soil for the 
development and dissemination of the disease. Subse- 
quent writers subscribe with unanimity to the statement 
of Hirsch that “conditions of the soil seem to be in every 
respect irrelevant to the occurrence of the disease.” 

But the season of the year has more to do with the dis- 
semination of this disease. Perhaps the most striking 
fact apparent in the study of the etiology of this affection 
is the frequency of its occurrence during the colder 
months of the year. Thus, of 52 epidemics in France 
and Switzerland, 23 occurred in winter, 13 in winter and 
spring, and but 2 in the midst of summer; while of 16 
epidemics in our own country, 6 occurred in winter and 
5 in winter and spring. The epidemics of Sweden and 
Norway, Denmark, Spain, and the Netherlands all oc- 
curred in winter. Various explanations have been offered 
to account for this preference of the colder season. That 
cold alone, or mere reduction of temperature, will not 
account for the genesis of the disease is proven by the 
fact that epidemics have occurred in the midst of summer, 
even in hot countries, as in Italy, the South of France, 
and the Southern States of our own country. Moreover, 
many cold countries—North Russia, Siberia—have never 
known the disease at all. Obernierattributes the prefer- 
ence for the colder months of the year to the fact that 
people are more confined to houses at this season, are 
subjected longer to the evils pertaining to the “house 
climate.” 

Leaving for the present extrinsic considerations, some 
attention must now be paid to those that are intrinsic; 
and first, concerning age. 

While it is acknowledged of cerebro-spinal meningitis 
that an almost freakish variation has occurred in its at- 
tack of individuals, it is generally conceded that it shows 
predilection for the period of youth. Thus, it is stated 
by Hirsch that of 1,267 fatal cases in Sweden in the years 
1855-60, where the age was stated, 889 were under fifteen 
years, 328 from sixteen to forty years, and 50 over forty 


Vou. Il.—49 


years of age. But some qualification must be made of 
these statistics, from the fact that cerebro-spinal menin- 
gitis is notoriously much more fatal in the early years of 
life. Stillé quotes from Schweitzer to the effect that in 
1866, in the Kronach district (Germany), of 115 cases, 75 
occurred under the seventh year, 22 between the seventh 
and twelfth years, and 10 between the thirteenth and 
twentieth years; and from J. L. Smith, from the “ Re- 
ports of the Board of Health of the City of New York,” 
who found that of 975 cases, 771 occurred in persons 
under fifteen years of age, and 336 in children under five 
years of age. In some epidemics children have been the 
only victims of the disease. This was the case at Con- 
shohocken, 1868 (Reid); Neustettin, 1865 (Litten); West- 
chester, N. Y., 1872 (Rodenstein); and at the Petitburg 
Colony, 1848 (Ferrus). In other cases the disease at- 
tacked children first and adults later, as at Polzin, 1864 
(Lehmann); Forchheim, 1864-65 (Seggel); Hanover, 1865 
(Neynaber), and Jerusalem, 1872 (Sandrecky). Emming- 
haus, who reports these data in his article on this disease 
(“Handbuch der Kinderkrankheiten,” 2, 488) makes the 
collective statement, from over fifty extensive observers, 
that of 1,485 cases, 1,183 were under fifteen years of age. 
All authors agree concerning this, as of all the acute 
affections, that the period of earliest childhood (suckling) 
is not affected in like degree. Smith found the propor- 
tion of liability to attack at the ages of under five years 
as 461; five to ten, 204; ten to fifteen, 106. Niemeyer’s 
figures for the first two quinquennial periods are as 54 
and 40, and Mende’s as 47 and 29. On the other hand, 
in Berlin, the disease was wholly confined to adults. 

It is definitely ascertained, regarding the period of 
childhood, that sex makes no difference whatever, and 
though different results have been reported in different 
epidemics affecting adults, it is probable that the aver- 
age number of each sex attacked remains about the same. 

It iscommonly stated that individuals of robust, vigor- 
ous constitution furnish the greatest contingent of cases. 
Hirsch remarks that statements to this effect were made 
to him by relatives and medical men, and Pfeiffer and 
Heiberg corroborate these statements from their own ob- 
servations. Yet all such statements of individual obser- 
vations must be taken with some allowance. We may 
recall how universally prevalent was this same idea re- 
garding pneumonia but a few years ago, whereas it is 
now conceded that the very reverse is true. At any rate 
it has been remarked by Leyden, of cerebro-spinal men- 
ingitis, how often weakly children ate attacked, and by 
Ziemssen how frequently the victims of this disease were 
subjects of chronic brain affections. 

Individual epidemics have been frequently noticed to 
have been distinctly connected with different social states. 
The selection of soldiers as exclusive victims has made 
this disease a familiar guest in army life. The recent 
conscripts and new recruits have been often the sole vic- 
tims of the disease. Pfeiffer says the disease “ prefers 
winter, soldiers, and children.” At times the disease has 
remained strictly confined to certain corps or companies. 
On the other hand, other epidemics have spared the gar- 
risons and camps to attack, as at Leipsic, the civil popula- 
tion. During the War of the Rebellion citizens and sol- 
diers suffered alike, and the colored race was not spared, 
whereas during the outbreak in Texas there was not an 
instance of the disease occurring among negroes. 

The same caprice has been exhibited in different epi- 
demics with regard to the inhabitants of cities and towns. 
Asa rule the rural population has suffered most. In this 
connection Stillé says of the disease: “It has passed by 
large cities reeking with all the corruptions of a soil sat- 
urated with ordure and populations begrimed with filth, 
as Vienna, Berlin, Paris, London, and New York, to dev- 
astate clean and salubrious villages and the families of 
substantial farmers inhabiting isolated spots.” Roth 
remarks of the 42 deaf-mutes attacked at Bamberg that 
88 were from rural districts, while only 4 were from the 
city itself. What made this circumstance the more re- 
markable was the fact that the disease prevailed in Bam- 
berg in unusual severity. 


769 


Cerebro-Spinal Men- 
ingitis, 


A strict localization of the disease to certain houses, 
flats, or stories has often been observed. Prisons, work- 
houses, orphan asylums, constitute at times breeding- 
places of cerebro-spinal meningitis. The epidemic in 
Ireland, 1846, was strictly confined to the prisons, and 
the disease broke out with the same seclusion in the 
orphan asylums in Philadelphia and Vienna in 1863, 
Washington in 1869, and Jerusalem in 1872. Keene re- 
ports a similar outbreak in the Naval School at Newport 
in 1863. 

Fatigue of the body (Bollet), exposure to cold and rain 
(Mannkopf), traumata (Leyden), sunstroke (Schweitzer), 
the pre-existence of other acute infectious disease (Im- 
merman and Heller) have all been cited as accidental pre- 
disposing causes in individual cases, but no one now 
would'claim that any of these factors stands in any direct 
relation to the disease. The same remarks apply to the 
alleged psychical causes of the disease, as fright from 
a peal of thunder (Ziemssen), mental strain, etc. The 
frequency with which the disease has broken out in school 
has the same significance as attacks at night in bed. 

The preference for the colder season and the predilec- 
tion for the age of childhood are ‘factors which are uni- 
versally acknowledged, but so many exceptions have 
been noticed to these rulesas to deprive them of the force 
of laws governing the disease. 

The mode of onset of the disease, the symptoms pre- 
sented during its course, and the characteristic lesions en- 
countered in the internal organs, assign the disease un- 
mistakably, in its nosological relations, with the acute 
infections. Examples of infection by contagion have 
been reported by Ziemssen, Prew, Neynaber, and others, 
and instances have been reported by Niemeyer and 
Fraentzel of transportation of the disease by detached 
troops. Hence search was made for something charac- 
teristic in the way of micro-organisms. Schweninger 
(Schmidt’s Jahrbiicher, cxcvi., p. 180, 1882) speaks of 
having found enormous accumulations of germs (mass- 
enhafte Pilze) in the brain in cerebro-spinal meningitis. 
Leyden (1888) found in the exudation and in the tissue 
of the pia mater of a sporadic case the diplococci, for- 
merly described by Eberth and Klebs, of oval form, united 
in short chains of two or three members, and assuming 
color with fuchsin and methylene blue. Marchiafava 
and Celli (Gaz. degli Ospitali, 8, 1884) made the same ex- 
amination in two cases of epidemic meningitis, discov- 
ering constantly in, preparations colored with a weak 
alcoholic solution of methylene blue, oval micrococci 
isolated or united as in diplococci. The micrococci were 
partly free and partly embedded in the protoplasm of 
the white blood corpuscles, rarely in the endothelial cells. 
Anything approaching chain-like formations were not 
observed. The tissue of the pia mater contained the 
same structuresas the exudation, but blood from the right 
heart and splenic pulp proved entirely free. Ughetti 
(Deutsche med. Wochenschrift, June 19th, 1884) reports, 
also, of examinations made in one of twenty-one cases of 
the disease, at Ulsterbianco (Italy), the presence of numer- 
ous spherical micrococci, partly isolated and _ partly 
grouped in pairs, in the sero-purulent fluid from the 
ventricles of the brain. The author injected a syringe- 
ful of this fluid under the skin of the back or abdomen 
in four rabbits, with entirely negative results. In an- 
other case the blood drawn by cups along the spinal 
column contained “innumerable micrococci” of exactly 
the same appearance as those from the ventricular fluid. 
This blood injected into three rabbits by the hypoder- 
matic method produced likewise no symptoms worthy 
of note. Aufrecht (Deutsche med. Wochenschrift, vi., 4, 
January 24th, 1885) found micrococci floating free in the 
serum, and embedded in the pus corpuscles; further, in 
miliary deposits in the liver, lung, and kidney, as well as 
in the splenic pulp and blood from the heart. They 
could be colored with fuchsin, and were endowed with 
active motion. Many other observers, among them 
Leichtenstern (1885) and Rovsing (1886) reported finding 
bacteria in meningitis. 

Netter, Friinkel, and Foa and Uffreduzzi (1886), study- 


770 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ing independently cases of cerebro-spinal meningitis, re- 
ported finding an encapsulated coccus resembling the 
Micrococcus pneumonize croupose of Sternberg (pneu- 
mococcus). ‘The micro-organism was found in the cere- 
bro-spinal fluid in cases of meningitis independent of 
pneumonia. The same micro-organism was found dur- 
ing the following year, by Weichselbaum and a number 
of other observers, in cases of meningitis secondary to- 
pneumonia. Both Netter and Weichselbaum observed. 
that the injection of the pneumococcus into the cranial 
cavity would produce meningitis. 

Weichselbaum (1887) isolated from six cases of cerebro- 
spinal meningitis a micro-organism which he called the: 
Diplococcus intracellularis meningitidis. The presence: 
of this diplococcus, which is also known as the meningo- 
coccus, in cerebro-spinal meningitis has been confirmed. 
by many investigators. Netter believes that the menin- 
gococcus may be a degenerated form of the pneumococ- 
cus, but this opinion is not generally accepted. Osler’ 
would give to the cases caused by the pneumococcus. 
the dignity of a special place in nosology as a pneumo- 
coccic meningitis, and would ascribe cerebro-spinal men- 
ingitis, both sporadic and epidemic, to infection by the: 
Diplococcus intracellularis meningitidis. 

Bonome (1889), in six cases of cerebro-spinal meningitis, 
found a micro-organism which he named the Streptococ- 
cus capsulatus meningitidis. Netter regards this organ- 
ism asa variety of the pneumococcus, a view which is. 
shared by Foa and Uffreduzzi but opposed by Bonome. 

To account for the ingress of micro-organisms into the 
recesses Of the brain and spinal cord Eichhorst invokes. 
the action of the lymph vessels in conveying the excit- 
ants of inflammation from neighboring structures, and. 
Weigert calls attention to the destructive suppurative: 
changes which he has encountered in the upper cavities. 
of the nose. In this connection Striimpell calls attention ~ 
to the remarkable loss of the sense of smell, and to the: 
prefatory coryza or nasal catarrh which he has repeatedly 
seen in this disease. Sears (Boston Medical and Surgical: 
Journal, August 9th, 1888) noted the frequency of pharyn- 
gitis during epidemics of cerebro-spinal meningitis. 

A case of intra-uterine meningitis has been reported by 
Gradwohl (Phil. Med. Jour., vol. iv., p. 445). The mother 
died at the seventh month of pregnancy, without abort- 
ing. Cultures of the diplococcus intracellularis menin- 
gitidis were obtained from the meninges of both mother- 
and foetus, and both showed the meningeal lesions of’ 
meningitis. 

One attack of cerebro-spinal meningitis confers the: 
immunity common to-most of the acute infections. 
Second attacks are rare. One such case is reported to: 
have occurred in an individual named Lacon, who left. 
the hospital cured, February, 1841, to return February 
4th, 1842, affected with the same disease, which proved. 
fatal on the following day (Companyo: “Essai sur la. 
mén. cérébro-spinale,” p. 76, Paris, 1847). 

PaTHOLOGY.—The disease begins with the aspect of 
an acute infectious malady, and maintains it throughout. 
its course. As a rule the onset is sudden, with the im- 
press of profound toxeemia. A chill comes on in the: 
midst of apparent health, with vomiting, excruciating: 
headache, and rapid prostration. Tenderness and stiff- 
ness in the back of the neck supervene in the course of a. 
few hours. The face is pale, the expression anxious and 
strange, the extremities are stiff and tremulous. The- 
slightest motion intensifies the pain in the whole body, 
the act of vomiting makes it atrocious. A sense of 
formication with hyperesthesia is felt first, as a rule, in 
the lower extremities, to which it may remain confined, 
or it may extend over the whole body. The special 
senses of sight and hearing become likewise supersensi- 
tive. A flare of light, the slam of a door, the rumble of- 
wheels in the street, a touch of the bed, produce a con- 
dition of agony. Even the approach of an attendant. 
with the gentlest ministrations is watched with appre- 
hension. Temporary relief of this distress is secured 
during a state of sopor or stupor which may occur, from. 
which the patient awakens or is aroused—children often: 


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Cerebro-Spinal Men- 
ingitis, 





with a cri hydrocephalique,—with a renewal of the same 
symptoms in greater or less degree. 

In the course of a few days, often during the same day 
of attack, the.stiffness of the neck increases to rigidity, 
or extends to constitute the characteristic opisthotonos. 
Convulsive twitchings of the face, or clonic spasms m 
the muscles of the extremities, may now occur, with deli- 
rium or outbursts of maniacal excitement under the 
slightest provocation. 

Soon various eruptions, especially herpes and petechie, 
more rarely erythema nodosum, ecthyma, and pem- 
phigus, begin to make their appearance, at first, as a 
rule, on the face, to extend later over large tracts of the 
body, or over the whole body (spotted fever). 

The temperature curve of the disease distinguishes 
itself by its irregularity. As a rule, it rises quickly at 
‘first to 102° F., or even 104° F., to fall in the course of a 
few days, or to undergo fluctuations in extreme degree, 
sinking at times below the normal (Laveran). An ex- 
treme hyperpyrexia not infrequently precedes a fatal 
termination, which is usually attended, however, with a 
reduction to correspond with the marble coldness of the 
skin. 

The pulse increases out of all proportion to the tem- 
perature, to experience, later on in the attack, greater 
fluctuation in frequency, volume, and tone than in al- 
most any other disease. The same variations are noticed 
also in the acts of respiration, which are often quick and 
slow in the course of the same hour of the day. 

The tongue is usually dry and red, in bad cases fissured 
and fuliginous, and sordes in these cases cover the teeth 
and gums. . 

The abdomen is sunken and retracted, often to such a 
degree as to show the outlines of the bodies of the verte- 
bre, or make distinctly apparent the crests and promi- 
nences of the iliac bones. Constipation is present, as a 
tule. The urine flows scantily and slowly from a paretic 
bladder, or in the worst cases is voided unconsciously 
in bed. Trismus, singultus, delirium, and coma, with 
ecchymoses and meteorism of the abdomen, mark the 
speedy advent of the close of the disease; or relaxation 
of the opisthotonos, relief of the pain in the head, with 
critical sweats or enuresis, indicate a favorable reso- 
lution. 

Although different epidemics exhibit great variations 
in the degree and number of the symptoms cited, cerebro- 
spinal meningitis usually shows itself besides, in the typ- 
ical cases mentioned, in one of three distinct forms or 
types, namely: the abortive, the intermittent, and the 
siderant or foudroyant. 

The abortive form exhibits all its symptoms in the 
lightest grade. The headache is slight, the stiffness of 
the neck trivial or temporary, and vomiting may not 
occur, or may not recur after the first attack. Such 
cases often entirely escape recognition, or are diagnosti- 
cated only because of the prevalence of an epidemic of 
the disease. 

The intermittent form is noticed more especially in 
certain epidemics, though such cases are wont to occur 
in any extensive outbreak of the disease. Not infre- 
quently isolated sporadic cases assume this form, to the 
great embarrassment of the practitioner. Quotidian and 
tertian intermissions or remissions occur in all the symp- 
toms of the disease, leading often for a time to errone- 
ous prognostications. The intermissions are by no 
means as distinct, as a rule, as the periodicities of ma- 
larial disease, yet they prove exceedingly deceptive to 
superficial observation. The exacerbations correspond 
undoubtedly to the irregular invasions or advances of 
the disease. 

The foudroyant is the fulminant form, in which the 
patient is often killed by the force of the poison before 
permanent local lesions have time todevelop. These are 
the cases which destroy life in the course of from six to 
thirty-six hours. The patients in these cases are often 
suddenly stricken with unconsciousness and convulsions, 
sometimes preceded for an hour or two with vomiting 
and pain in the head, in which condition they are carried 


home, pallid, cold, or lightly cyanotic, showing no reac- 
tion to the most powerful stimulants, to sink into coma 
and speedily succumb. 

Cerebro-spinal meningitis is particularly prone to a 
number of grave complications and sequele, prominent 
among which may be mentioned paralyses and paresis of 
various organs and members, and profound, often per- 
manent, lesions of the eye and ear. 

Morzsip ANATOMy.—The external appearance of the 
body in cerebro-spinal meningitis varies with the dura- 
tion of the disease. Rapid or foudroyant cases exhibit 
no change, but cases of longer duration show an emacia- 
tion which in protracted illness simulates that of cancer 
and tuberculosis. No trace of eruption is discoverable, 
as a rule, though occasionally the surface remains covered 
with petechie. Suggillations form quickly and in quan- 
tity over the body, and post-mortem rigidity sets in soon. 
Moreover, decomposition begins unusually early in rapid 
cases, as in other acute infections. In the most chronic 
forms, with extreme emaciation, bed-sores are common 
and extensive. 

The muscular tissue is, in the foudroyant cases, brown 
and fragile, in cases of average duration more pale from 
loss of blood. The molecular change of fatty degenera- 
tion invades its structure, and gives it the appearance, 
which is especially remarked of the heart, of being strewn 
with sand. 

The condition of the spleen varies greatly. It is usu- 
ally found swollen, in fulminant forms, with deeply 
darkened pulp, but not infrequently it is shrunk to such 
degree as to show a wrinkled capsule. In average cases 
it is rather the rule to find this organ of diminished size. 
As might have been expected, the intermittent forms 
show no enlargement of the spleen. The cloudy swell- 
ing, fatty and granular degeneration of the kidney and 
liver, ecchymotic state Of the mucose, cedema of the 
lungs, effusions in the serous sacs, post-mortem soften- 
ing of the stomach, swollen condition of the mesenteric 
glands, dark color and altered consistence of the blood, 
are changes which belong to all the acute infections, and 
are especially marked in this disease. 

The characteristic lesions are encountered at the ana- 
tomical seat of the disease, in the membranes of the brain 
and cord. But, as already stated, in the fulminant forms 
these changes may be absent altogether, and Woodward 
claims that cases of even more protracted course may be 
marked in this way. There were two elasses of cases 
observed, he says, in the War of the Rebellion. “In the 
first the autopsy disclosed grave anatomical lesions of 
the cerebro-spinal axis, accumulations of serum, sero-pus, 
pus, or tough yellow lymph, especially in the ventricles 
about the base of the brain and in the upper part of the 
spinal canal. In the second class of cases no perceptible 
anatomical lesion in the cerebro-spinal axis was observ- 
able.” The author further observes: “These two classes 
of cases rest upon equally reliable evidence, and are not 
to be disposed of on the supposition that the latter repre- 
sent merely an early stage of the former, since it is to be 
remarked that both anatomical conditions appear to have 
been found indifferently in protracted cases as well as in 
those which proved suddenly fatal” (Clymer, Aitkens: 
“Sc. and Pract.,” 1872). Considering the difficulty of mak- 
ing sections of the vertebral column and of establishing 
an accurate diagnosis between this disease and pernicious 
malaria without it, we may still look with some degree 
of scepticism upon the protracted cases without lesions. 
Most of us who form our own observations in civil prac- 
tice with the greater leisure for investigation, will still 
agree with Valleix, who remarked, long ago, “that when 
there is more or less absence of the meningeal changes, 
it is among those who have been struck down by the 
disease as by a thunderbolt.” Light lesions are easily 
overlooked. Thus in the two rapid cases reported by 
Levick, with unappreciable change, Parkes calls attention 
to the omission of stating whether or not there was opal- 
escence or unnatural dryness of the membranes. We 
are not to forget, also, how quickly even intense hy- 
peremias fade away entirely in the short interval be- 


171 


Cerebro-Spinal Men- 
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tween death and the autopsy. Leyden reports a case 


of this kind in which Recklinghausen made the exam- | 


ination. 

On opening the skull the membranes of the brain are 
revealed in a state of intense hyperemia. The sinus 
longitudinalis is distended to tension of its walls, and all 
visible vessels are filled to their utmost capacity. In 
fulminant cases there may be no trace of exudation, but 
the pia mater is already opaque and lustreless, sometimes 
ecchymotic, from infiltration into its texture. The sub- 
stance of the brain and cord is edematous and softened 
in the most superficial layers. 

In cases of longer duration the dura mater is stretched 
tense by the effusion beneath it, punctate hemorrhages 
are diffused over its surface, and the hyperzemia involves 
the porous substance of the bones of the spinal column, 
whose spongy structure appears saturated with blood. 
The pia mater is reddened with distended vessels, is 
Opaque in some places, ecchymotic in others, and is soft- 
ened in spots or more extensive surfaces. The first exu- 
dation is a light, clear or amber-colored serum, which 
soon becomes an opaque milky fluid of semi-gelatinous 
or mucilaginous consistence, sticky, “drawing to a 
thread,” which later becomes greenish, “leek-green,” or 
yellowish with pus. The viscosity of the exudate is due 
to the presence of mucin (Klebs). The effusion occurs 
first in the subarachnoid spaces and along the course of 
the vessels of the pia mater at the base and sides of the 
cerebrum, in the fissure of Sylvius and between the cere- 
brum and cerebellum, or extends over the whole surface 
of the brain to form a veritable cap. Or the exudation, 
more limited to the base, surrounds the emerging nerves, 
dissecting up their investing sheaths and following them 
out in their course. Both Tourdes and Netter have ob- 
served purulent flocculi in the fluid that is usually found 
in small quantities in the cavity of the arachnoid. In 
the spinal column the exudation is deposited first along 
the posterior aspect of the cord, as determined by gravity, 
but soon extends to its lateral surface and to affect or 
follow out the spinal nerves in the same manner as in the 
brain. However, Tourdesand Netter have each reported 
a case in which the false membrane was confined to the 
anterior surface of the cord. The thickest masses of exu- 
dation are found in the cervical and lumbar regions of 
the cord, though effusion in spots, bands, or islands oc- 
curs irregularly throughout its course. In its advance 
the suppurative process invades the sheath of the optic 
nerve to travel along its course, infiltrate the orbital fat, 
to account in life for an iritis, choroiditis, or an all-de- 
structive panophthalmitis. So, also, implication of and 
transit along the facial and auditory nerves lead to de- 
structive changes in the ear. 

Asarule there is no change in the arachnoid. Even 
the visceral layer of the arachnoid is not adherent to the 
false membrane beneath it but may be readily separated 
from the underlying purulent effusion by simple inflation. 
Sometimes parts of the arachnoid appear whitish or 
opaque, especially in old cases. 

But the ravages of cerebro-spinal meningitis do not re- 
main confined to the membranes of the brain. Mention 
has been made already of cedema of the substance of the 
brain and cord in rapid cases, and more profound lesions 
are to be observed in cases of longer duration. Striimpell 
(Deutsch. Arch. fiir klin. Med., xxx., 5 and 6, p. 505, 1882) 
described in detail these conditions. His autopsies re- 
vealed in nearly all the cases such participation of the 
brain and cord as to justify him in naming the disease a 
meningo-encephalitis and meningo-myelitis rather than 
meningitis alone. Beneath the inflamed membranes lies 
a border zone of hyperzemia and infiltration, composed 
of distended vessels, perivascular accumulations of round 
cells which dip deep into the substance of the brain, or 
more especially the spinal cord, with occasional punctate 
hemorrhages up to the size of a millet seed. Disseminated 
depots of pus of various size, with even larger abscesses, 
more especially in the substance of the brain (four cases), 
were noticed as a rule. But, aside from the effects of 
direct mechanical disturbance, there were few visible 


772 


histological changes in the ganglion cells and fibres of 
issuing nerves. 

Although these exudative changes belong more espe- 
cially to the average or more protracted cases, they have 
been noticed also in the cases of short duration. Thus 
Fronmiiller reports the case of a girl, aged fourteen, who 
died in four days, when the central canal of the cord was 
found dilated and “filled with pure pus”; and Gordon 
speaks of a case in which “ purulent effusion was found, 
although the whole duration of the attack was under 
jive hours” (Hartshorne’s “Reynolds,” p. 306.) More 
credible is the report by Ziemssen, of an “exquisite case,” 
in which the cord was wholly embedded in pus at the end 
of eleven days. 

The changes in the ear have been studied especially by 
Heller, who found the tympanum, vestibule, and the 
semicircular canals of both sides containing pus, which 
bathed the facial and optic nerves. The purulent fluid 
may be confined to either the middle or the internal ear, but 
usually is present in both. Acute otitis has been fre- 
quently observed preceding an attack of cerebro-spinal 
meningitis. In such cases the affection of the ear would 
seem to be primary and the meningitis due to an exten- 
sion of the inflammation. Heller, on the other hand, 
would attribute the affection of the ear to the propaga- 
tion of the inflammation from the meninges along the 
nerves to the ear; and Moos believes that the inflamma- 
tion of the ear and meninges occurs simultaneously. 

A microscopic examination reveals the fact that the 
inflammation affects the tissues through the blood-vessels. 
Numberless round cells infiltrate the intima and adven- 
titia to collect on the external surface and form the lines 
and layers of pus cells along their course. In the sub- 
stance of the brain and cord beneath and about the ves- 
sels “ proliferation of the nuclei in the neuroglia takes 
place, with swelling of the ganglion cells and granulo- 
fatty degeneration of the nerve fibres” (Eichhorst). Ex- 
amination of the blood reveals the presence of hyperleu- 
cocytosis varying from 12,000 to 82,000 per cubic milli- 
metre (Flexner and Barker). The polynuclear and 
neutrophile cells are the ones most increased; the number 
of eosinophile cells remains practically normal. Netter 
calls attention to the resemblance between the leucocytosis 
of cerebro-spinal meningitis and that of pneumonia, and 
suggests that the fact that the leucocytosis in cerebro- 
spinal meningitis is without prognostic value, such as it 
has in pneumonia, is probably to be explained by the 
fatal issue in cerebro-spinal meningitis being due to the 
organic changes in the nerve centres rather than to the 
infection itself. The presence of micrococci in the exu- 
dation has been mentioned already. 

SyMPTOMATOLOGY.—The symptoms of cerebro-spinal 
meningitis naturally fall into two groups, those belong- 
ing to the general infection, and those belonging to the 
local lesion. 

The period of incubation lasts from eight to ten days 
(Latimer). The period of invasion is very short. The onset 
of the disease isin the majority of cases sudden, with the 
impress of profound toxemia. Prodromal symptoms 
exist in but five per cent. of cases (Ziemssen), and the 
symptoms of this period are too vague, in the absence of 
an epidemic, to establish a diagnosis. Malaise, headache, 
anorexia, nausea, chilliness, wandering pains precede the 
outbreak of the disease in a few cases. These are symp- 
toms which may mean nothing or may serve as forerun- 
ners of any one of the acute infections. The disease dates 
from the initial chill or chilliness, and subsequent fever, 
with vomiting, headache, and stiffness of theneck. This 
chill may repeat itself several times in the course of the 
disease, more especially in the intermittent forms, and it 
signifies always a new invasion or advance of the disease. 
During and subsequent to the chill the temperature begins 
to rise, reaching 100° to 102° F., asarule, by the second or 
third day of the disease. In foudroyant cases it may run 
up rapidly from the beginning of the disease, reaching 
a pre-agonal acme at even 108° F. (Wunderlich). Post- 
mortem elevations are not uncommon in bad cases. But 
even excessive elevation of temperature in cerebro-spinal 


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Cerebro-Spinal Men=- 
ingitis, 





meningitis may be followed by recovery. A remarkable 
case is reported by Christian (Medical Record, vol. lvi., No. 
10), in which the temperature reached 118° F. on successive 
days. The patient recovered. On the other hand, some 
of the worst cases show little or no elevation of tempera- 
ture at all (Hirsch and Ziemssen). In one case reported 
by Stokes the highest temperature recorded was 98.8° F. 
The characteristic of the temperature in this disease is 
irregularity. Cerebro-spinal meningitis shows an atyp- 
ical temperature curve, a fact which distinguishes it 
at once from typhoid fever. Exacerbations and remis- 
sions occur so frequently in the course of the disease, even 
in the same day, as to baffle the most patient investi- 
gators. Ziemssen declares that few of the curves re- 
semble each other, and Biiumler confirms this statement 
from his own observatious. Wunderlich attempts to ac- 
count for this irregularity by the successive complica- 
tions on the part of the bronchi, lungs, intestines, serous 
membranes, etc., and Emminghaus appeals in explana- 
tion of it to the influence of cedema of the brain, basal 
lesions, affections of the cord, perhaps of a heat-regulat- 
ing centre. 

The pulse is increased in frequency as a rule. It is 
usually more full and strong at the beginning of the dis- 
ease, and may number not more than 80 to 100 
beats to the minute throughout its course. But the 
pulse is subject to the same deviations as the tempera- 
ture, to which at times it seems to bear no relation. 
Tourdes and Ziemssen mention variations of 30 to 
40 beats between observations at different times of the 
day, and every practitioner of experience has noticed 
fluctuations in the course of the same observation. In 
foudroyant cases the pulse may be increased to from 140 
to 160 per minute, to become thready and imperceptible 
before the end of the disease. Abnormal slowness, it 
may be stated here, is much less frequent than in basilar 
meningitis. The irritation of the pulse-regulating centres 
in the brain, the changes in the substance of the heart, 
the poisoning of the blood, as well as the various com- 
plications of the disease, have all been invoked to account 
for the varying conditions of the pulse. 

The respiration is affected in the same way. Many 
cases show no especial disturbance in frequency or 
rhythm, while others are characterized by extreme 
irregularity. Sighing respiration is very frequent in 
childhood, and arhythmia with dyspneea is not uncommon 
at all ages. Leyden accounts for the Cheyne-Stokes 
respiration, sometimes observed in the later stages of the 
disease, by pressure on the medulla occasioned by cedema. 
This explanation is based upon the observation of this 


symptom in animals by Schiff, after the artificial induc- - 


tion of hemorrhage in the vicinity of the medulla. 
Reference has already been made to a preparatory nasal 
catarrh in this disease, and in this connection may be 
mentioned the arrest. of the nasal secretion, catarrhus 
sicca, noticed among the prodromal manifestations by 
Summerell and Schuchardt. 

The symptoms on the part of the digestive system 
belong among the cardinal manifestations of the disease, 
as vomiting ranks in significance along with the chill, 
headache, and opisthotonos. It is only the mildest cases 
which show no disturbance of the stomach. It ceases 
frequently in a few days, to reappear in bad cases, and 
to remain, at times, a more or less constant attendant of 
the disease. It is especially provoked by the ingestion 
of food, sometimes even of water (Schilizzi), or by rising 
in bed. The contents of the stomach, then mucus in 
quantity, are rejected, and later a yellowish-green fluid 
is regurgitated from the duodenum through an inconti- 
nent pylorus. Hart says of his cases (St. Barthol. Hosp. 
Rep., xii., p. 105, 1876) that vomiting occurred without 
retching, was constant in bad cases, in which it was al- 
ways an ominous manifestation. As a rule, however, it 
is preceded or attended by great effort, with such ener- 
getic contraction of the abdominal muscles at times as to 
eject worms from the intestinal canal. Loss of appetite 
is characteristic of the disease, even in the absence of 
fever, when it is dependent probably upon irritation of 


the vagus (Kulenberg). Yetthe very opposite condition, 
boulimia, has been noticed. Reich speaks of a case of 
progressive emaciation, notwithstanding a “ voracious 
appetite” throughout, and Stillé observes that “in no 
other disease is the return of a good appetite and diges- 
tion so prompt and complete.” Constipation is the rule 
in this disease, from inhibition of peristalsis through the 
influence of the sympathetic, and is obstinate to the ac- 
tion of laxatives; yet diarrhoea from gastric catarrh, or 
dysentery from catarrh of the colon, occurs exceptionally 
in the later course of the disease. In the worst cases 
stools are voided continuously froma paralyzed sphincter, 
while the abdomen loses its sunken shape to become 
tympanitic. 

Ordinarily the urine is passed freely, and in normal 
quantity and character; exceptionally there is difficulty 
in its discharge and alteration in its composition. Thus, 
pain may be experienced in evacuating the bladder, or 
there may be anesthesia to such degree as to permit 
great distention of this organ. Emminghaus speaks of 
pear-shaped tumors above the symphysis, and Reeve 
mentions the case ofa woman who passed her urine “ by 
time,” having lost all sensation in the bladder. Any 
neglect on the part of the practitioner may lead thus to 
a troublesome cystitis. In the last stages of the disease 
there may be incontinence of urine as well as of feces. 
With any reduction in the quantity, the color and specific 
gravity are naturally increased, but the most curious 
anomaly of the urine in this disease is an increased 
quantity in the face of fever. This paradoxical condi- 
tion is accounted for by the pressure and destruction, 
from the exudation, of parts of the medulla. Resorption 
of these products during the stage of resolution may lead 
to irritation of the medulla, with polyuria or glycosuria. 
Albumin, usually in small quantity, is present in about 
one-third of the cases. As a rule the albuminuria is 
febrile in origin; acute nephritis was found by Friis in 
only three out of ninety-seven Cases. 

The skin shows the greatest variety of eruption of any 
one of the acute infections, with nothing peculiar or 
pathognomonic in any. <A_ scarlatinous blush, more 
especially of the face, is very frequent in the first days 
of the disease, and a roseolar exanthem, more especially 
upon the trunk and extremities, frequently follows later. 
Hirsch speaks of spots resembling measles, Ziemssen 
mentions urticaria, Kamph erysipelatous macule, Grim- 
shaw pemphigus, and Jenks bull, in individual cases. 
As to the petechiz which have falsely named the disease, 
they are most frequently distinguished by their absence. 
Davis states that they were present in but one-third of 
the cases seen by him; Tourdes saw only three cases in 
the epidemic at Strasburg, and Stillé observed no erup- 
tion whatever in thirty-seven out of ninety-eight cases, 
in the epidemic at Philadelphia. “ Neither Burdon San- 
derson nor Wunderlich mentions petechisze or vibices as 
occurring during life; and Hirsch, after noting their oc- 
casional presence, is obliged to draw upon American 
authors for an account of them” (Stillé). Yet bloody 
eruptions or extravasations do occur in this disease as 
frequently, but not more so, as in any acute infectious 
malady of equal gravity. Thus, in the first New Eng- 
land epidemic, and later in the outbreaks at Geneva, 
Dublin, and Naples, they were frequently present. 
Stokes and Banas speak of spots which coalesced over 
some portions of the body, “so as to cover a large extent 
of the skin, and render it completely black, as though it 
were wrapped in some dark shroud ” (Stillé). Not infre- 
quently the petechis or ecchymoses appear only post 
mortem (Day). 

The only eruption which has any real significance in 
this disease is herpes. It begins usually as early as the 
third day of the disease, and may continue in renewed 
eruption throughout its course, or, as: Hirsch remarks, 
weeks after full recovery. It shows itself first, as a rule, 
about the face, on the lips, nose, forehead, aud neck, or 
may extend to the chest, abdomen, back, nates, and even 
the extremities. Pneumonia is, perhaps, the only disease 
which shows herpes in equal frequency, but the herpes 


173 


Cerebro-Spinal Men- 
ingitis. 





of meningitis differs from that of pneumonia in having 
no prognostic value. In fact, Hirsch claims that a re- 
newed outbreak rather signifies an exacerbation of the 
disease. Ziemssen is inclined to regard it as of tropho- 
neurotic origin. 

As in all the grave acute infections or septic maladies, 
cerebro-spinal meningitis is sometimes associated with 
affection of the joints. Jackson likens the articular 
swellings to attacks of gout, and Collins speaks of the 
swollen, red, and tender state of various joints, espe- 
cially the knee, elbow, and wrist, and often alsothe smaller 
joints of the fingers and toes. Rineckerand Wunderlich 
observed this complication early in the disease, Salomon 
and Litten during its course, and Pfeiffer in the period 
of convalescence. While articular affections are rather 
rare in this disease, some epidemics, notably that in 
Greece, 1869, have been distinguished by their frequency. 

Of the symptoms produced by the local lesions, pain 
in the head is among the most prominent. Headache, 
crushing as if produced by a vice, or boring as from the 
penetration of nails or screws, is, as has been stated, one 
of the initial signs, and it constitutes always one of the 
most obstinate and distressing features of the disease. 
Strong men cry aloud in the agony of headache, and 
young children show, on account of it, the peculiar wild, 
strange look attending excruciating pain, which finds 
utterance at times in the er? hydrocephalique. But 
the localization of the pain does not of necessity localize 
the seat of the disease, nor does its intensity bespeak its 
gravity, signs which prove it to be partly due to the 
septicelement. Fortunately, it is subject to intermissions 
or remissions in the course of the disease, and not infre- 
quently it disappears altogether. The other signs of 
the disease may then still remain in force, though cessa- 
tion of headache may be usually regarded as one of the 
most favorable signs in prognosis. Warning should be 
entered here, however, against that ominous arrest of 
headache, along with a general euphora, which some- 
times immediately precedes the end. Vertigo may be 
associated with the headache, to greatly aggravate the 
sufferings of the patient by compelling the continued 
observance of the recumbent posture. Tourdes speaks 
of cases in which the giddiness was so intense as to cause 
patients to whirl and fall, unable to rise again. Such 
cases excite suspicion of implication of the semicircular 
canals. 

Pain of a similar character, indescribable in its intensity, 
is also felt in other parts of the body, in the spinal col- 
umn (rachialgia), in the extremities, or anywhere upon 
the surface in the course of the spinal nerves. Usually 
such pain is paroxysmal, stabbing, fulgurant, agonizing. 
It shoots out from the posterior nerve roots of the spinal 
cord, where the local lesion, as determined by gravity, 
is most intense, and carries with it sickening sensations 
of precordial depression. 

A more characteristic, though less frequent, sign of 
cerebro-spinal meningitis is hypereesthesia of the surface. 
It is commonly absent altogether in the lighter or abor- 
tive forms, and may not show itself throughout the short 
course of the foudroyant forms, but it is quite constant, 
at least in the earlier days of the disease, in cases of aver- 
age intensity. It is first seen, as a rule, in the lower ex- 
tremities, to which it may remain confined; next in the 
upper extremities, and lastly in the face and head. Like 
the pain described it may undergo remissions and exacer- 
bations, may disappear to recur later, or may last over, 
in regions, to the period of convalescence. When pres- 
ent it adds a peculiar poignancy to the suffering of the 
patient, who watches with anxious eyes every movement 
about the room. In aggravated cases it is manifest also 
during sleep, and even the stupor of coma does not en- 
tirely annul it. In such cases it interferes with, or even 
entirely prevents, an examination of the patient, which, 
however, may be unnecessary, as with the history and 
superficial inspection it frequently declares the disease. 
Hirsch, Fraentzel, and Ziemssen unite in saying that it 
is often absent throughout the whole course of the malady. 

Opisthotonos stands in the foreground in the semeiology 

% 


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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of this disease. It is rare that some degree of rigidity in 
the back of the neck is not present, though Burdon San- 
derson declares that in the Prussian epidemic, 1864-65, 
there were many cases in which there was no stiffness or 
retraction of the muscles. In the lightest cases there is 
simply a sense of increased resistance on attempts at 
flexion of the head upon the chest—a valuable point in 
differential diagnosis—or a slight degree of tenderness to 
pressure upon the cervical vertebre. In most severe 
cases rigidity is marked, with retraction of the entire 
head, to such degree at times as to give rise to extreme 
mechanical dysphagia. Leyden speaks of cases in which 
the head was bent back at a right angle to the spine, and 
Gordon mentions an instance in which, in addition to this 
deformity, the spine presented “a most wonderful uni- 
form curve concave backward.” The most striking 
illustration of the degree to which this extension may 
occur was reported by Neville Hart (St. Barthol. Hosp. 
Reports, xii., p. 105, 1876), in a case in which the press- 
ure of the occiput caused a slough between the scapule. 
In the experience of this author the degree of opisthot- 
onos corresponded with the gravity of the disease. Not 
infrequently the rigidity extends lower in the vertebral 
column, as in Gordon’s case just mentioned. Thus 
Jansen mentions an instance where the whole body could 
be lifted rigid with the hand behind the occiput, and 
Ziemssen and Merkel report cases of “orthotonos” in 
which attempts to flex the head pushed the body like a 
statue to the foot of the bed. With the other symptoms 
mentioned this condition may disappear, to reappear in 
greater or less degree, undergo fluctuations throughout 
the disease, continue to the fatal end—as long in one case 
as forty-nine days,—or remain in some degree until full 
recovery. Ziemssen speaks of convalescents going about 
with rigid spines, and cases are reported in which the 
condition lasted throughout life. . Usually the retraction 
is symmetrical, as pleurosthotonos is very rare. The 
rigidity is due to tonic contraction of the deep muscles of 
the neck, the splenii; the superficial muscles, the trapezii, 
remaining unaffected. It is easy to understand it in the 
presence of the abundant exudation about the medulla 
oblongata, but the absence of it in the presence of the 
same conditions remains as yet inexplicable. 

Besides these tonic, clonic spasms may occur in the 
muscles of the face, trunk, or extremities, as mere fibril- 
lar twitchings or veritable convulsions. Children are 
much more frequently affected in this way than adults, 
and the spasms occur more often in the graver than in 
the lighter cases. Sometimes the case begins with a 
well-marked epileptiform convulsion, and cases, as in 
the epidemic at Dublin, have been characterized by their 
persistence throughout the disease. The convulsions 
may be limited to one side of the body, and Netter re- 
ports a case in which the convulsive paroxysms were 
confined to one side of the face. Attempts at changing 
the posture, or agitation of the patient in any way, as 
by sounds or the approach of light, are often the excit- 
ing causes. Yet grave as is this complication in adults, 
it is by no means fatal of necessity. Thus Stillé records 
a case, cited from Vienna, in which “ convulsions occurred 
repeatedly during the first two days, and less frequently 
during the two following days, but the patient ultimately 
recovered.” - In the case of a young lady under the ob- 
servation of Whittaker, clonic convulsions of the upper 
extremities existed continuously for three days and 
nights, and were only stilled finally by narcotic doses of 
opium. ‘This patient escaped with life, but with lesions 
that left it of little value. As a sub-variety of convul- 
sions may be mentioned tremor, which occurs exception- 
ally, more especially in children, and jactitation, which 
may occur at any time, more especially in the graver 
cases, and more frequently toward the end. The tonic 
and clonic spasms, expressions of the stage of irritation, 
give place in time to paralyses as evidence of destructive 
change. Ptosis, paralytic strabismus, and paralysis of 
the facial nerve may be thus manifestations of. the later 
period of the disease, or may be associated with hemi- 
plegia as evidence of central lesion. Emminghaus quotes 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cerebro-Spinal Men-« 
ingitis, 





in this connection from Leyden, who saw in several cases 
paralysis supervene in the contracted muscles of the 
neck. Thus also hyperesthesia may eventuate in anes- 
thesia to such degree as to permit the penetration of a 
pin. Aphasia has been observed by Leyden and Netter. 

Of the special senses, besides that of touch, the senses 
of vision and hearing suffer most. Corresponding to the 
hyperzsthesia or hyperalgesia of the surface of the body 
is photophobia, to such degree, as a rule, as to necessitate 
the darkening of the chamber and the avoidance of arti- 
ficial light. Graver lesions than this functional disturb- 
ance, conjunctivitis, iritis, irido-choroiditis, neuritis, atro- 
phy of the optic nerve, even panophthalmitis, may occur 
‘in the course of the disease. The same exaltation of sen- 
sibility affects the ear with even greater distress, because 
offence in this regard is less preventable. Tinnitus 
aurium isfrequent. Suppurative processes in the middle 
and internal ear, perforation of the membranes, atrophic 
changes, are among the graver affections of this organ, 
to be mentioned later among the complications and 
‘ssequele. Loss of the sense of smell on one side was first 
observed by Ames. Alteration of the sense of taste has 
been reported by Corbin. 

Delirium is quite uniformly present at some stage of 
this disease. It sets in, as a rule, on the second or third 
day, to vary in degree, coinciding often with the fever 
or the headache, or to be replaced by stupor, apathy, or 
coma at various periods of the disease. Low forms of 
‘delirium are constantly associated with sleeplessness, or 
incessant mutterings, the so-called coma vigil, alternate 
with outbreaks of maniacal excitement. Illusions and 
hallucinations are, though rare, sometimes encountered, 
and permanent impairment of the intellect may result. 
Yet long-continued stupor is quite exceptional in menin- 
gitis, though complete oblivion of every ineident of the 
attack has been noticed not infrequently, even when 
the symptoms on the part of the nervous system have 
‘been of light degree. 

COMPLICATIONS AND SEQUEL#®.— With the elements of 
a general inflammation of the membranes of the brain 
and spinal cord, and the implication of the nerves irradi- 
ating thence over the body, together with affection also 
-of the substance of these organs, superadded to a gen- 
eral poisoning of the blood, it is not to be wondered at 
that complications and sequel of various kinds occur in 
this disease. Among the most frequent and serious of 
these complications are catarrhal pneumonia and croupous 
pneumonia. Of these affections catarrhal pneumonia, or 
broncho-pneumonia, is most frequently encountered in 
children, and, if developed as a secondary affection, read- 
ily undergoes, according to Ziemssen, favorable resolu- 
‘tion. But croupous pneumonia has a much more serious 
prognosis. It occurs more frequently in certain epidemics 
—fifteen times in the Erlangen epidemic of 1866 to 1872— 
cand develops by predilection in the later periods of the out- 
break of the disease. But Jiirgensen reports of his cases 
that the relation of the two diseases was in three cases 
just the reverse, as the meningitis supervened upon or 
followed the pneumonia. This author calls attention to 
the great difficulty of diagnosis in these cases when 
-opisthotonos happens to be absent. In this connection 
Maurer points to the arching of the fontanels in young 
infants as indicative of increased intracranial pressure, 
a sign of great value in a doubtful case. Schilizzi 
at Aigues-Mortes, Tourdes at Strasburg, Levy at 
Paris, and Laveran at Metz, have all found serous and 
sero-purulent exudations in the pleural cavity as com- 
plications of this disease. _Eichhorst emphasizes the 
frequency with which affections of the throat occur as 
not sufficiently remarked hitherto, and Pfeiffer found 
parotitis present in a number of his cases at Thiiringen. 

Peripheral or multiple neuritis has been observed in 
‘some cases (C. K. Mills, Medical News, March 3d, 1888). 
In the retrogressive changes which occur during and 
after the period of resolution, various thickenings, throm- 
botic occlusions, or permanent hyperemias may be left 
behind. Thus it is not surprising to learn that headaches 
sometimes remain for years, or for life, or that paralysis 





of various muscles, especially those supplied by cranial 
nerves, the abducens, oculomotor, and facial, develop 
during the disease or ‘after it has run its course. Per- 
haps the most deplorable, if not the most dangerous, 
damage is done in this way to the organs of sight and 


hearing. Hypersemia of the conjunctive, “redness of 
the eyes,” with irregularity of the pupils, and photopho- 


bia are to be noticed, as a rule, at the onset of the dis- 
ease, and affections of the cornea, synechix, opacities of 
the lens, iriditis, ete., have been mentioned in its course. 
Fish spoke of cases announced by blindness, to be fol- 
lowed later by symptoms on the part of the spine, and 
though the amaurosis was in his casesalways temporary, 
examples of permanent loss of sight are abundantly re- 
corded. Rudnew claims that a microscopic examination 
reveals suppurative inflammation of the uveal tract, as a 
rule, in this disease. The affection begins in the capil- 
laries of the choroid and proceeds to invade its entire 
structure. 

The ear is affected, as stated, in both its middle and in- 
ternal parts. In a case reported by Ziemssen the pain of 
an otitis media began as late as the twenty-fifth day of 
the disease, and perforation with the discharge of pus 
did not occur until the thirty-sixth day. Heller and Luce 
and Moos describe cases in which the trunk of the audi- 
tory nerve was embedded in pus, with hyperzmia of the 
neurilemma, suppurative inflammation of the cavity of 
the drum, hemorrhage and pus in the membranous laby- 
rinth. Per contra, Ziemssen has seen cases in which the 
floor of the fourth ventricle was “macerated by pus, and 
the auditory nerve, together with the facial nerves, com- 
pletely surrounded by the purulent exudation, without 
the occurrence of deafness during life.” But cerebro- 
spinal meningitis is one of the most common causes of 
deafness, perhaps the most common cause of all diseases 
affecting the internal ear. For in the vast majority of 
cases the affection is bilateral and permanent. Knapp 
states that in every one of thirty-nine cases the deafness 
was bilateral, and, “with the exception of two cases of 
faint perception of sound, complete.” Should this com- 
plication occur in the earliest years of life the patient is 
not only deaf but also dumb. The Bamberg Deaf and 
Dumb Asylum contained, April, 1874, forty-two pupils 
—deaf-mutes, without exception, from cerebro-spinal 
meningitis; and of the thirty-two inmates of a similar 
institution at Nuremberg, twenty-two were victims of 
this disease. Moos mentions further that one-half of his 
cases that recovered from the disease with some impair- 
ment of hearing showed also disorder in maintaining 
their equilibrium. 

That processes of cicatricial contraction, by thickening 
and shrivelling the pia and obliterating its plexuses of 
vessels, may lead eventually to chronic hydrocephalus, 
or that these accidents with the deeper lesions in the sub- 
stance of the brain and cord may beget aphasia, anarthria, 
impairment of memory or other faculties of the intellect 
up to complete imbecility, may readily be inferred. One 
case illustrative of the extent of damage that may be in- 
flicted by this disease upon a patient who barely escaped 
with life may be cited from the graphic descriptions of 
Gordon. This was a case in which the patient recovered 
from all the acute symptoms, but gradually, in fifty-eight 
days after the invasion of the disease, passed into a state 
of almost organic life. “He ate, drank, and slept well; 
he passed solid feeces and urine without giving any notice, 
yet evidently not unconsciously; he was excessively 
emaciated, and there wasa peculiar mouse-like smell from 
him; he seemed to understand what was said to him, but 
he could not answer; he never called for anything: his 
breathing was rather slow; his pulse 120; his heart act- 
ing with a peculiar strong jerking motion; his eye was 
quite well as also his knee (he had suffered from ulcera- 
tion of the right cornea and immense effusion into the 
right knee-joint); he could draw his legs and arms up to 
him; but he could not use his hands at all.” 

Duration. —Cerebro- spinal meningitis has no definite 
duration. Hirsch says of it that it may last from a few 
hours to several months. The first period applies to the 


175 


Cerebro-Spinal Men- 
ingitis, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





foudroyant cases, in which patients are killed as by a 
stroke, the last to the cases with complications or se- 
quele, which may indeed prolong the disease indefi- 
nitely. Gordon’s shortest case was one of five hours’ du- 
ration, and Jewell records a case of death in three hours 
and a half after seizure. These are, of course, most ex- 
treme and exceptional cases. Clymer states that more 
than one-half the deaths happen as early as from the 
second to the fifth day. This author quotes also from 
Parkes, who found the duration of the disease in 66 of 95 
cases, five days or less; in 1, eight days; in 28, eight days 
or over. Abortive forms terminate in resolution in from 
three to five days, foudroyant forms, with rare excep- 
tions, in death within three days, and intermittent and 
average forms in one or the other way, barring complica- 
tions and sequele, in from one to three weeks. Relapses 
arenot common. Second attacksare rare, but such cases 
have been reported by Boudin, North, Warschauer, Her- 
mann, and Kober. 

Draanosis.—In the presence of an epidemic of the dis- 
ease the diagnosis of cerebro-spinal meningitis is suffi- 
ciently easy. The existence of cases in the vicinity pre- 
pares the practitioner for new attacks. Cases which are 
affected with, or more especially quickly succumb to, 
any disease with predominant nervous symptoms should 
excite the suspicion of the physician in this direction. 
Sporadic cases, however isolated in space or time, are 
likewise readily recognized in the presence, in sufficient 
number, of the symptoms peculiar to the disease. The 
sudden seizure, often in the midst of health, with chill, 
vomiting, and prostration, followed by opisthotonos, 
hyperesthesia, herpes, irregular pulse, constipation, 
constitutes an array of symptoms that belong to no other 
disease. Unfortunately for the diagnosis many cases 
deviate from the regular type in essential particulars, 
more especially in the absence of characteristic signs, to 
such degree as to make the diagnosis difficult or at times 
impossible. Foudroyant cases differ most widely by the 
predominance of the symptoms of blood poisoning which 
are common to all the grave acute affections. Light is 
sometimes thrown upon these cases by the consideration 
of the season of the year, the age of the patient, the ex- 
istence of other cases more pronounced, or, if equally 
obscure, by the exclusion of simulating maladies or ac- 
cidents. Thus a meningitis from trauma, insolation, or 
otitis should be discovered by the history and inspection 
of a case; or occurring in the course of scarlatina, pneu- 
monia, septiczemia, it should be eliminated by the pres- 
ence of signs characteristic of these affections. 

The Kernig Sign.—Kernig, of St. Petersburg (1882), 
reported as characteristic of meningitis that when the 
hip is flexed, as when the patient is in the sitting posture, 
contraction of the flexors of the leg prevents full exten- 
sion of the knee without undue force, so that as a rule 
the limb may not be extended beyond 135° and sometimes 
not beyond a right angle. With the hip extended, as 
when the patient is lying down or standing upright, ex- 
tension of the knee readily occurs. Kernig’s observation 
has been confirmed by numerous observers, among them 
Bull, Henoch, Bliimm, Friis, Netter, Osler, and the 
writers. It has been suggested that an explanation of 
the phenomena may be found in a peculiar irritability of 
the roots of the nerves, in consequence of inflammation 
of the meninges, and that the irritability of the sacral 
roots is increased when these nerves are put upon the 
stretch by flexion of the hip, so that there occurs reflex 
contraction of the flexors upon attempting to extend the 
knee with the hip flexed. But such reflex contraction of 
the flexors does not take place with the hip in extension. 
For the production of the Kernig sign, it is necessary 
that the meningitis involve the spinal membranes. Thus 
the sign is found in tuberculous and simple meningitis as 
well as in cerebro-spinal meningitis. Kernig reported 
finding the sign present in 15 cases of acute menin- 
gitis, which included 138 cases of epidemic cerebro- 
spinal meningitis, 1 of tuberculous meningitis, and 1 
of suppurative meningitis. The diagnosis was confirmed 
by autopsy in 8 cases. Netter found the sign present 


776 





in 45 cases of meningitis. But the Kernig sign is 
not always present in meningitis. Thus, Henoch, Friis, 
and Netter have observed cases of meningitis in which 
the Kernig sign was absent. In general, the sign is 
found in about 90 per cent. of cases. Netter fownd the 
sign in 45 out of 50 cases; Friis in 53 out of 60 cases. It 
has generally been held that the sign is present only in 
meningitis, but one of the writers found the sign well 
marked in a case of scarlet fever, during the period of 
invasion, without other evidence of meningitis. 

The lumbar puncture (Quincke) often furnishes much 
more exact information, in that it may reveal the specific 
infectious agent causing the meningitis. The puncture 
is made between the spinous processes of the third and 
fourth lumbar vertebree (Quincke) or between the fifth 
lumbar and the first sacral vertebra (Chipault, Netter), so 
as to withdraw the cerebro-spinal fluid from the lower cul- 
de-sac of the dura mater surrounding the cauda equina. 
The patient is placed upon the side, with the legs flexed 
upon the body and the body inclined well forward 
(Quincke), or in the sitting posture inclined forward 
(Fiirbringer, Netter). The fluid may be withdrawn 
through a fine trocar, aspirating needle, or an ordinary 
hypodermatic needle. The puncture is made in children 
in the median line immediately above the spinous proc- 
ess, toa depth of about 2cm. In adults the puncture 
is better made at the level of the lower border of the 
spinous process and 5 to 10 mm. outside of the median 
line, to avoid the thick ligaments, in a direction from 
above downward, so as to puncture the membranes in 
the median line, and to a depth of 5 to 7cm. The punc- 
ture should be made under strict aseptic precautions, and 
the fluid should be removed slowly. When properly 
made, the operation is practically without danger, and 
is of great diagnostic importance since it will in very 
many cases reveal the specific infectious agent. The 
cerebro-spinal fluid is cloudy and purulent and contains 
micro-organisms both intra- and extra-cellular. Albumin 
is usually present in the cerebro-spinal fluid in a propor- 
tion varying from .1 per cent. to .4 per cent. Some- 
times no fluid may be obtained upon puncture, and 
sometimes the fluid that is obtained is perfectly clear and 
sterile, even in the presence of meningitis, especially in 
cases that have lasted for some days. A case of tuber- 
culous meningitis may no longer present tubercle bacilli, 
or only in such small numbers as to be detected with 
difficulty. Again, such cases may present the meningo- 
coccus as the result of a mixed infection. Thus the 
lumbar puncture is not an absolute criterion in the dif- 
ferentiation between tuberculous and other forms of 
meningitis. 

Examination of the blood has revealed the meningo- 
coccus (Netter), and the pneumococcus (Bozzolo, Netter). 
In making such examinations, .25-.50 c.c. of blood 
should be used. Rarely the specific infectious agent 
may be obtained from the urine or sputum. 

Of more value is the bacteriological examination of the 
nasal secretion. ‘Thus Scherer found the Diplococcus in- 
tracellularis in eighteen cases of cerebro-spinal meningitis, 
while in fifty other cases this organism was found only 
two times. One of these latter cases had a coryza follow- 
ing the disinfection of a room in which a patient died of 
meningitis; and there was some doubt about the diag- 
nosis of the second case, which may have been one of 
meningitis but had been treated for typhoid fever com- 
plicated by ocular paralysis. However, too much im- 
portance should not be ascribed to the result of the ex- 
amination of the nasal secretion, since the meningococcus 
has been found in the nasal secretion of healthy indi- 
viduals by Heubner, and the pneumococcus by Netter 
and many other observers. 

Typhoid fever distinguishes itself by the fact that it 
usually spares the period of earliest youth, that its onset 
is insidious, that it is attended with diarrhoea and disten- 
tion of the abdomen, that it often shows a rose-colored 
eruption, has a constant high pulse, a typical tempera- 
ture curve, and a definite duration. Moreover, typhoid 
fever almost never shows herpes, and almost always 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cerebro-Spinal Men- 
ingitis, 








shows enlargement of the spleen. The diazo reaction, 
commonly present in typhoid fever, is absent in menin- 
gitis. The presence of the reaction in meningitis indi- 
cates an unfavorable prognosis. The Widal test is posi- 
tive in typhoid fever, and negative in meningitis, except 
when the meningitis is due to infection by the typhoid 
bacillus. Further evidence would be furnished by the 
Kernig sign, which is present in meningitis and absent 
in typhoid fever, and by lumbar puncture. Malarial 
fever is marked by its preference for certain regions and 
certain seasons of the year. Periodicity is the criterion 
of malaria, and though this factor is simulated in the in- 
termittent cases of meningitis it is never so precise. 
Reeve says the early vomiting was the key to the diag- 
nosis of his first cases of meningitis. Whatever doubt 
may exist at first is quickly dissipated by finding the 
plasmodium malarize in the blood or by the administra- 
tion of quinine in sufficient dose. Tetanus is eliminated 
by its trismus, and hydrophobia by its characteristic 
paroxysms of inspiratory spasm. Tuberculous meningitis 
rarely shows symptoms on the part of the spinal cord, 
though opisthotonos and hyperzesthesia are not uncom- 
mon in this disease. Tuberculous meningitis is nearly 
confined to childhood. In the great majority of cases 
its victims are of tuberculous parentage or stock. It is 
not affected by the season of the year. It distinguishes 
itself especially by its long prodromal stage, by its 
periods of reduction of temperature and retardation 
of pulse, by the occasional signs of tuberculosis else- 
where, in the lungs or intestines, externally (scrofu- 
losis) upon the skin, or possibly in the bottom of the 
eye. Netter believes that confusion has often arisen 
in the differentiation from influenza, and that many 
cases of “grippal meningitis” are really cases of cere- 
bro-spinal meningitis. 

Proenosis AND Morrauity.—The prognosis of this 
disease is always grave. The factor of most importance 
in its determination is the type of the disease. Foudroy- 
ant cases perish with very rare exceptions; abortive 
forms recover with few exceptions, and average cases 
survive and succumb in about equal number. The 
character of the epidemic is the next consideration. Cer- 
tain outbreaks are distinguished by their mildness, as are 
others by malignancy. Thus Lowe and Wooley (London 
Lancet, June 26th and August 3d, 1867) report that not a 
single case died in the outbreak at Bardney, in Lincoln- 
shire, England, in January and February, 1867, though 
the disease was characterized by “severe rigors, tetanic 
convulsions, intense neural gic pain in the head and upper 
part of the trunk, increased sensitiveness of the surface, 
obstinate vomiting, restlessness, and in one instance, at 
least, by a dark purple eruption” (Hartshorne’s “ Rey- 
nolds,” vol. i., p. 308). On the other hand, Wunderlich, 
Stonone, and others, give instances in which not a single 
case recovered, Young reports of the attack at Granada, 
Miss., that every one of the 35 cases perished, and the 
same fatality attended the first outbreak of the disease at 
Memphis, Tenn. Between these extremes is every grade 
of gravity in different attacks. It is also true of this, as 
of most of the acute affections, that the first cases are 
most severe. The epidemic grows feebler, as a rule, 
with the gradual exhaustion of its most fertile soil. In- 
dividual considerations follow next. The prognosis is 
more grave in infancy and childhood than in adolescence 
and maturity. The ratio of mortality falls from 75 per 
cent. in children under one year of age to 53.5 per cent. 
in later childhood, and 35 per cent. in adolescence. Not 
to burden this section with a useless array of figures 
from different epidemics—useless because inapplicable to 
individual cases—the general statement of Hirsch may be 
given as indicating the average mortality of this disease. 
Of 15,632 cases analyzed by this indefatigable statistician, 
5,734 terminated fatally. Thus the average ratio of 
mortality of this disease, under all conditions, is given 
at 37 per cent. The influence of “bad hygiene” in ag- 
gravating the prognosis is too patent to require mention. 
Of more importance are the signs which prognosticate 
the result in individual cases. It may be stated, as a 








rule of this, as of all the acute infections, that a severe 
onset indicates a grave case. Thus a high fever at the 
Start, obstinate vomiting, marked opisthotonos, early 
convulsions, are signs of ominous import. As one-half 
the deaths happen before the fifth day (Clymer), a case 
which survives the first week has a more favorable out- 
look. The first three or four days are attended with the 
greatest anxiety. “Every day passed after the seventh 
day renders recovery more and more probable ” (Loomis). 
Typhoid symptoms at any stage of the disease imprint 
upon it an unfavorable prognosis. Arching of the great 
fontanel, as indicative of intracranial oedema and exu- 
dation, is a very bad sign. Almost all such cases end 
fatally (Maurer). <A return of headache and vertigo 
which has disappeared, especially if associated with 
vomiting and convulsions, evidences of consecutive 
hydrocephalus, is likewise ominous (Ziemssen). Yet 
secondary hydrocephalus is not absolutely hopeless, as 
Ziemssen saw “some cases in which a complete, and 
others in which an incomplete, recovery took place.” 
Profuse sweats, with cold surface, are characteristic 
of a fatal issue (Hirsch). The persistence, after re- 
covery from the disease, of anorexia, debility, and ema- 
ciation, perhaps with diarrhcea, gives a poor outlook, 
especially for children (Emminghaus). A sudden high 
elevation of temperature, or hyperpyrexia, after a 
chill in a previously apyretic case, means a complica- 
tion, and not a fatal issue, but a hyperpyrexia without 
chill, and with a profuse sweat, is pre-agonic (Immer- 
mann. ) 

PROPHYLAXIS.—Occasional instances are reported 
which would seem to prove the possibility of cerebro- 
spinal meningitis being a contagious infection, as by 
Niemeyer, Fraentzel, Hirsch, Stokes, Simon, and Ziems- 
sen. Cases should be treated as if contagion were possi- 
ble. Flint suggests that the “removal of persons from 
without the area in which the disease prevails is desir- 
able.” Inasmuchas certain barracks, asylums, tenement- 
houses, schools, etc., become at times centres or depots 
of the disease, these institutions should be thoroughly 
cleansed and ventilated, or, what is better still, vacated 
or closed. For while it is admitted that “ crowd-poison- 
ing,” with all the defective hygiene the term implies, 
cannot develop the disease, it is as fully acknowledged 
that these circumstances eminently favor its spread. At 
least this was the condition, in aggravated degree, which 
attended its most extensive outbreak in Dantzic in 1865, 
when the disease prevailed, according to Hirsch, “exactly 
in that season of the year in which, on account of incle- 
ment weather, many individuals were crowded together 
into small and dirty rooms, kept constantly closed by 
their occupants, and from which all ventilation was ex- 
cluded, and in which the before-mentioned unfavorable 
hygienic conditions (dampness, great filth, and an at- 
mosphere loaded with putrid emanations) were extremely 
perceptible.” While it is not necessary that the physi- 
cians and attendants shall take the same precautions with 
their own personnel as in many of the contagious dis- 
eases, yet in the light of existing knowledge. full dis- 
infection should follow post- ‘mortem ex xaminations, and 
short and limited contact should be had with the bodies 
of the dead. During the prevalence of an epidemic 
caution should be enjoined against excessive muscular 
effort, the unrestrained excesses of childhood, for ex- 
ample, against exposure to cold and wet, or excessive 
mental labor. 

Tuerapy.—A patient affected with this disease should 
lie upona comfortable bed, not too hot, ina spacious, con- 
tinuously ventilated room, the windows of which can be 
darkened if necessary while they still admit the air, as re- 
mote from the street with its offensive sounds as may be. 
The temperature of the room should be regulated, witha 
thermometer near the head of the bed, at 65° F., by an 
open fire, preferably in a grate. The physician and the 
necessary attendants should be the sole visitors. Quiet 
should reign supreme. In no other disease is continuous 
or officious ministration so meddlesome and mischievous. 
Even cleanliness or a more comfortable posture must 


TTT 


Cerium, 
Cestoda. 








be sacrificed at times to peace of mind. The diet is to 
be simple and light at first, but as nutritious as possible 
with returning health: beef-tea palatably made, soups 
of any kind, milk if it does not increase constipation, 
scraped raw meat, with a little salt, and gruels, if 
not distasteful. Plain water, seltzer water, Apolli- 
naris, or any simple carbonated drink, should be prof- 
fered at proper intervals, without over-solicitation or 
any anxiety should everything be refused. With the 
beginning subsidence of the disease an egg may be 
dropped into the soup, or sweetbreads, fish, the white 
meat of fowl may for a few days preface the more solid 
meats. 

special attention is to be paid to the bladder. The 
soft catheter, thoroughly cleansed, warmed above the 
heat of the body, and greased with pure vaseline, brings 
this organ, when refractory, under control. Constipa- 
tion is overcome with calomel, two to ten grains, or 
castor oil, in preference to an enema, which causes too 
much disturbance. 

The treatment proper is purely symptomatic, and has 
reference to the two sets of symptoms, general and local. 
Of these the symptoms produced by the local lesions— 
pain, opisthotonos, hyperssthesia—assume prominence in 
the great majority of cases. For the relief of these 
symptoms no remedy equals in value opium. Opium is 
the “sheet-anchor” in the treatment of cerebro-spinal 
meningitis. It acts solely by its anodyne influence. 
It protects, by obtunding, the nervous system until the 
force of the poison is spent. Surprising amounts of the 
drug may be given in this disease without narcotic effects. 
Thus Steiner often gave ten grains at a dose in cases of 
severe convulsions without producing stupor; Chauffard, 
three to fifteen grains; and Boudin, seven to fifteen grains 
at first, and later, one to two grains every hour before 
soporific effects were produced. Stillé was in the habit, 
he says, of prescribing one grain every hour in very 
severe, and every two hours in moderately severe cases, 
without inducing even an approach to narcotism in any 
case. “Under the influence of the medicine the pain and 
spasms subsided, the skin grew warmer and the pulse 
fuller, and the entire condition of the patient more hope- 
ful.” When quick effects are to be had, or when the 
drug is rejected by the stomach, resort will be had, of 
course, to the hypodermatic use of morphine. Ziemssen 
gives expression to an experience made by every prac- 
titioner with this disease when he says that morphine is, 
without doubt, “indispensable” in its treatment. But 
“medicus systematicus periculosissimus vir” ; that would 
be indeed a routine physician who would prescribe opium 
indiscriminately in every case. 

The use of the warm bath in cerebro-spinal meningitis 
was introduced by Aufrecht, of Magdeburg (1894), with 
the report of a single case cured by daily warm baths. 
Voroshilsky, of Odessa (1895), employed the warm baths 
three times a day in sessions of ten minutes at a tempera- 
ture of 104° F. with good results in two cases. These 
observations were confirmed by Borling and Kellmeyer, 
of St. Petersburg, and Steckel, of Vienna, and more 
recently by Netter, who reports six cases treated with 
warm baths repeated every three or four hours, with no 
mortality. This experience leads Netter to declare that 
the warm bath is “a specific method of treatment of 
cerebro-spinal meningitis.” 

Venesection in this disease belongs to history, or is 
only at most to be practised in relief of intracranial 
pressure, as in apoplexy, in the most sthenic cases, and 
in these cases the same results may often be effected by 
milder means, as by purgatives, calomel, and jalap. But 
local blood-letting by cups along the spine, or by leeches 
behind the ears, may often relieve the headache and un- 
rest. Cold in the form of bags of ice to the head or 
along the spine is of great value when the period of ex- 
citability, hyperesthesia, and jactitation may have given 
place to the state of sopor and indifference. Radcliffe 
claims that “the application of cold to the head and 
spine either by means of ice or a freezing mixture in 
Esmarch’s (or Chapman’s) india-rubber bags, has fur- 


778 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


nished by far the most satisfactory results of all direct 
treatment.” 

Vomiting is best relieved by ice, champagne, efferves- 
cent drinks, milk and lime water, bismuth, soda, carbolic 
acid, or creosote. No drug equals in efficacy sips of 
water excessively hot. 

Hiccough is often brought under control by the same 
means prescribed for vomiting, by the administration of 
a few drops of the oil of cajeput, or by clysters of sodium 
bromide. More obstinate cases of either vomiting or 
singultus call for the subcutaneous use of morphine. 

The hypodermatic injection of an aqueous solution of 
corrosive sublimate along the spinal column has been 
recommended by Angyan in daily doses of 1. cgm. for 
adults and .5 cgm. for children, continued until the rigid- 
ity disappears. Angyan reports thirty cases treated in 
this way with twenty-one recoveries. 

Kay lauds the virtue of permanganate of potassium in 
grain-to-the-ounce solution, a tablespoonful every hour, 
and reports four cases with three recoveries. 

It is useless to encumber space in a work of this kind 
with more than a mention of other remedies lauded in 
the treatment of this disease. As to quinine, which was 
recommended by the committee of the American Medical 
Association, it is now admitted to be of no avail what- 
ever, except in antipyresis, a call which is seldom made 
in this disease. But in the exceptional cases, in which 
high fever does occur, quinine in scruple dose, salicylic 
acid or antipyrin in double the quantity, are more valu- 
able than the cold bath, because of the commotion created 
by the bath. Blisters, moxa, ferrum candens, are brutal 
assaults in the height of the disease, but may be justifi- 
able in the treatment of sequele. The same remarks 
apply to the use of electricity. Ergot, iodine, physos- 
tigma, mercury, the benzoates, the bromides (which 
may be substituted for opium in a very mild case), other 
anodynes, belladonna, witha host of other remedies, have 
been recommended on theoretical grounds, or praised as 
specifics by practitioners of the “experience ” school, who 
for the most part remain untrained to eliminate “the 
personal equation,” but none of them stands the test of 
time. 

Lumbar puncture has been recommended in treatment, 
but is not at the present time believed to be curative, al- 
though after the withdrawal of a small amount of fluid 
there is often marked improvement of the symptoms. 

The various symptoms presented in the course of the 
disease are treated precisely as are the same symptoms in 
any acute infection, after methods mentioned in detail in 
this work in the history of diseases in which these symp- 
toms assume especial prominence. 

James T. Whittaker. 
George EB. Malsbary. 


CERIUM.—A single salt, only, of cerium is official in 
the United States Pharmacopeceia, namely, cerous oxalate, 
entitled Cerit Oxalas, Cerium Oxalate: formula, Ces- 
(C20,4)3, 9H2,0. This salt is “a white, granular powder, 
without odor or taste, and permanent in the air. Insoluble 
in water, alcohol, ether, or in solutions of potassium or 
sodium hydrate; soluble in diluted sulphuric or hydro-_ 
chloric acid” (U.S. P.). In effect cerous oxalate most 
nearly resembles the insoluble bismuth compounds, being, 
from its insolubility, devoid of active properties, but yet 
like many other insoluble metallic powders, having a 
power to allay local nervous irritability. This influence 
is utilized to combat reflex nausea and vomiting, especially 
the vomiting of pregnancy, and also to repress irritative 
dry coughs. In this latter application, when successful, 
the present drug has the advantage over the ordinary run 
of cough medicines of not disordering the stomach, but, 
on the contrary, of tending to quell any irritation of that 
organ. The oxalate may be given in doses of from .30 
to .65 gm. (gr. v. to x.) several times a day, best taken 
dry upon the tongue. Such doses may be kept up for 
a number of days in succession with no other effect than 
causing, at first, a little dryness of the mouth. For 
cough, the medicine should be persisted in even if, as 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


may happen, there be no benefit for the first two or three 

days; and especially should doses be given on the empty 

stomach early in the morning and late at night.* 
Edward Curtis. 


CERVICAL FISTULA. See Zeratology. 
CERVICO-BRACHIAL NEURALGIA. See Neuralgia. 
CERVICO-OCCIPITAL NEURALGIA. See Newralgia. 


CESTODA.+—The branch or Phylum Platyhelminthes, 
commonly known as the Flat Worms, is characterized 
by a bilaterally symmetrical body somewhat flattened 
dorso-ventrally and usually elongate, by 
the mass of parenchymatous tissue which 
fills all the spaces of the body, by the ab- 
sence of any true body cavity, by a pro- 
tonephridial excretory system, and by 
the complicated sexual apparatus which 
with rare exceptions is hermaphroditic, and 
which produces so called compound eggs. 
Among the most prominent orders of the 
branch are the Trematoda or Flukes (g. v.) 
and the Cestoda or Tapeworms to be con- 
sidered here. 

The order Cestoda includes a large num- 
ber of forms which manifest considerable 
differences in anatomical detail, but are 
comparatively uniform in general appear- 
ance and structure. The small group of 
‘Cestodaria, or Monozoa, which differ from all others in 
possessing but a single set of reproductive organs, and 
consequently but a single segment in the body, is in- 
cluded by some investigators in the order under con- 
sideration, but by others placed intermediate between 
the trematodes and the cestodes, forming as it undoubt- 
edly does a group transitional from the one order to the 
other. The species of Cestodaria are, however, rare and 
infest the lower animals, so that they will not be dis- 
cussed here. 

In the Cestoda s. str. the body is characteristically rib- 
bon-like and divided into “links,” segments, or proglot- 
tides. In most cases, including all the tapeworms of man, 
the segmentation is evident 
externally. At the posterior 
end of the chain the proglot- 
tides are larger and more dis- 
tinct, and often so loosely 
attached as to separate from 
the series under the slightest 
disturbance. In fact such 
separation takes place nor- 
mally as the segments become 
ripe. Toward the other end 
of the chain the proglottides 
grow gradually smaller and 
less distinct until near the an- 
terior end it is usual to find a 
short region, the neck, in 
which no trace of segmenta- 
tion is visible. The anterior 
end has the form of a bul- 
bous swelling, known as the 
head or scolex (Fig. 1203), on 
which are borne the organs of 


muscles. 


Sj 





pay, fixation. The latter are either 

uy lst ie laa aed of suckers, hooks, or both, and 
7 sOlLum, Snowing ate ] =y 
Scolex, Suckers, Rostellum te suckers may be either 


elongate grooves or bothridia, 
cup-shaped hollows or aceta- 
‘bula, or, as in some marine tapeworms, of a folded form 
which is much more complicated. 

At the apex of the head is found in the Txeniade a 


with Hooks, and Neck. X 45. 








* Report to New York Therapeutical Society; the Medical Record, 
June 12th, 1880. 

+A general discussion of parasitism and its effects will be found 
winder the heading Parasites. 


Cerium, 
Cestoda, 








muscular organ, the rostellum which bears the hooks, 
usually in one or more annular rows. In form and de- 
gree of development the rostellum is a very variable 
organ; at the one extreme in Zwenia saginata it is reduced 
to a small muscular sucking apparatus, often spoken of 
as the apical or fifth sucker of that species, while in other 
forms it is powerfully developed and capable of exten- 
sion or retraction into a pocket at the apex of the scolex. 
It isa valuable feature in the distinction of various species. 

In the head one finds the central nervous system in the 
form of a bilateral ganglionic mass with one or two ring- 
like commissures from which nerves are given off directly 
to the suckers and rostellum, and from which the longi- 
tudinal nerve trunks pass backward throughout the 





throughout nearly its entire extent. 














Fig. 1204.—Transection of Proglottis of Teenia solium, Somewhat Diagrammatic. In, 
Main lateral nerve; 
longitudinal excretory canal ; ml, longitudinal body muscles; mc, transverse body 

The section is represented as having cut one of the ring commissures 


ln’, accessory lateral nerve ; 17", ventral longitudinal nerve; lex, 


(Original.) 


length of the chain. Three of these trunks, the main 
lateral nerve (Fig. 1204, Im) and two minor (/n’) are 
grouped together on each side of the proglottis, while the 
two dorsal and the two ventral longitudinal nerves (/n") 
are located nearer the median line. The various longitud- 
inal trunks are connected by commissures which at stated 
intervals pass around the proglottis; they also give off 
branches by which the various organs are innervated. 

Near the lateral nerve trunks are located the main 
longitudinal canals (/ex) of the excretory system which 
originate in an irregular network in the head and from 
which are given off numerous branches often in the form 
of a network of fine vessels in each proglottis. In many 
forms a prominent transverse canal near the posterior 
margin of each proglottis joins the longitudinal canals 
(cf. Fig. 1205, @). Terminating the finer canals of this 
system are found the characteristic flame cells which are 
peculiar to this type of excretory system. 

A cross section of a proglottis (Fig. 1204) shows the 
various layers of which it is composed. Externally the 
cuticula, a resistant, elastic membrane, covers the body 
and is reflected a short distance inward at the various 
external orifices. The older view, by virtue of which an 
epithelium is wanting in cestodes and the outer layer 
represents a basement membrane, has been definitely set 
aside by the recent investigations of Blochmann; the 
cuticula is really the product of the subcuticular cells, 
though they are apparently separated from it by a con- 
siderable interval. Immediately beneath it occurs a deli- 
cate double layer of dermal muscles, having externally 
circular, and internally longitudinal fibres, the myoblasts 
of which lie deeper in the body. Between these fibres 
the bases of the subcuticular cells extend from the cutic- 
ula to the deeper lying bodies of the cells; the remain- 
ing space of the body between the various organs is filled 
with parenchymatous tissue. Within the parenchyma 
occur usually large numbers of calcareous bodies, highly 
refractive spherical or oval masses of small size, the 
function of which is yet uncertain. They are, however, 
characteristic features of cestode structure. 

The cross section is divided by the parenchyme or body 
musculature into two regions, an external cortical layer 
and the median area or medullary région. In the latter 
are found most of the reproductive organs, although in 
the Bothriocephalidz the vitellaria lie in the cortical 
layer. The body muscles are of three sets, longitudinal, 
transverse, and dorso-ventral or sagittal. The longitudinal 


19 


Cestoda,. 
Cestoda, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








muscles (Fig. 1204, m/) form the outer layer of the mus- 
cular mass broken only at the sexual pore, and though 
variable in amountare alwaysnumerous. The transverse 
muscles (mc), often called circular, constitute a plate just 
within the longitudinal fibres; at the side these fibres in- 
tersect and spread through the longitudinal muscles like 










MEANT Te TOTES og a ORT AD ENTE 


° a 

> is} OVE © oo) Oj 
0 2.0. 66.0 905 DOL; 9 
Bo Mo Oe 0.96 (OShe, Ok 
° Of ono 








7 
Panes 





Fic. 1205.—Sexually Mature Proglottis of Tenia saginata. OC, 
Transverse commissure of excretory canals; Cl, genital cloaca; 
D.st., vitellarium ; H, testicular follicles; NV, lateral nerve trunk ; 
Ov, ovary; Ut, uterus; W, longitudinal excretory canal. X 10. 


the rays of afan. The sagittal fibres extend singly or in 
small bundles from dorsal to ventral surfaces directly 
through the proglottid; they are scattered and not so 
numerous as the other systems of fibres. 

Absolutely no trace of an alimentary tract has yet been 
discovered in the cestodes. Imbibition is the only known 
method of taking food, and the adult tapeworms are ac- 


vit. ut. cir. vd. 





sh.gl. 


vit.d. ovd. Ov. 


Fic. 1206.—Central Portion of the Sexually Mature Progilottis of 
Dibothriocephalus latus from the Ventral Surface. cir, Cirrus sac; 
ov., ovary; ovd., oviduct; sh.gl., shell gland; wt.,loop of uterus ; 
vag., vagina; vd., coil of dorsal vas deferens; vit., vitellaria ; vit.d., 
yolk duct. The numerous follicular testes lie beneath, 7.¢., dorsal 
to the vitellaria shown here. (After Sommer and Landois.) 


cordingly limited to those organs, alimentary canal and 
serous cavities, in which the parasite is bathed in a nutri- 
ent fluid. 

The organs of the reproductive system are grouped so 
that each proglottis contains a complete set, and even 
when the body is not segmented externally, examination 
of the internal structure shows them to be repeated. 
Each proglottis contains all the organs of both sexes 


780 


(Fig. 1209) and appears in this respect a complete her- 
maphroditic individual. The organs first make their ap- 
pearance in the anterior proglottides as indistinct cords 
of cells which gradually assume the character of the 
sexually mature condition. In general the male organs 
reach maturity a little in advance of the female, and 
copulation with an older proglottis of the same or of a 
different chain may hence be inferred. The male system 
consist of numerous small testes, the vasa efferentia of 
which unite near the centre of the segment to a common 
vas deferens, and the latter, which is commonly provided 
with an enlargement, the vesicula seminalis, and which 
terminates in a copulatory organ, the cirrus, opens with 
the vagina into a genital cloaca (c/) at the common genital 
pore, located either at the margin or on the surface of 
the segment. The female organs may 
be said to take their origin from the 
genital pore with the vagina which 
leads inward, furnished at some point 
with an enlargement, the receptaculum 
seminis, in which the supply of sperm 
is stored up. The ovary, either single 
or paired, empties by an oviduct which 
joins the vagina near the shell gland 
and which often has near its origin a 
muscular organ, the oocapt, by which 
the eggs are taken from the ovary and 
forced onward to the vagina. The 
vitellarium is a single, large racemose 
gland (D.st., Fig. 1205), or a multitude 
of small follicles (v7t., Fig. 1206) in 
which are produced the masses of yolk 
material to be included in the eggs. 
Vitelline duct and oviduct join the con- 
tinuation of the vaginal canal in the 
shell gland, and to this portion of the duct the name 
ootype has been given. Here the ovum coming from 
the ovary is fertilized by the spermatazoon from the 
seminal receptacle, is surrounded by a mass of yolk 
material from the vitellarium, and the whole encased in 
a capsule formed by the secretion of the shell gland, 
which rapidly hardens into a thick chitinous shell. The 
completed eggs are then forced onward into the uterus. 
Since they consist not only of a fertilized ovum but also 
of a mass of disintegrated yolk cells, the name com- 
pound egg has been applied to them. Such eggs occur 
only in the flat worms. 

The uterus may possess a special external opening or 
may be without such. In the latter case it is small at- 
first, but with the accumulation of eggs it becomes irregu- 
larly enlarged by the formation of lateral outpocketings 
so as to occupy with its branches almost the entire space 
of the proglottis (Fig. 1207). In the course of this trans- 
formation other organs gradually disappear until the ripe 
segment is little more than a muscular sac which encloses 
the branching uterus crowded with eggs. The manner 
of branching is characteristic of the species, as is also the 
way in which ripe proglottides are detached either singly 
or in groups, and both features together with other de- 
tails in the structure of the reproduct- 
ive system are discussed in connection 
with the individual species. 

The eggs of the cestodes are oval 
and provided with a thin shell which 
is often supplied with a lid. Within 
this occurs in many eggs (Fig. 1208) 





Fig. 1207.— Ripe 
Proglottis of 
Tenia saginata 
with branched 
uterus. “ee 
(After Braun.) 





Fig. 1208.—Egg of 


a thicker second shell, so-called, of a Zenia  soliwm. 
aah Mess: x 380. (After 
structure characteristic for the family — Leuckart.) 


in which it occurs. In reality this in- 

ner structure is not a shell but an embryonic membrane, 
and takes its origin during the early growth of the germ 
cell, which occurs in most cases while the egg is still 
retained in the uterus of the adult cestode. When the 
uterine egg is examined soon after its formation, the 
shell is seen to contain a single germ cell surrounded 
by a number of yolk cells which, in some cases, have 
lost their cellular identity and constitute merely a mass 
of granular yolk substance. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





The embryo originates from the development of the 
egg cell alone while the yolk cells serve as nutriment 
during its early growth. From the division of the egg 

} 2 cell, which under- 
| } Wy Yj there arises a spheri- 
[H. cal embryo ‘sur- 

CAE rounded by one or 

membranes. From 
the latter may or- 


goes total cleavage, 
4S ——.._moreembryonic 






Ss SS iginate an inner 
= ‘ SS shell, as is the case 
Ses ION . in Teniade (Fig. 


1208), or a ciliat- 
ed mantle, as in 

Bothriocephalide 
\\ (Fig. 1209). The 
\ spherical embryo 
(Fig. 1210), which 
is known as_ the 
onchosphere, is uni- 
formly character- 
ized by the presence 
of three pairs of hooks of variable shape and by great 
mobility, and in this condition is ready for introduction 
into the secondary host. This may be the result of a 
direct migration, as when the ciliated bothriocephalid 
embryo, swimming about in the water, 48 swallowed by 
a suitable host; or it may be of passive character, as when 
the teenioid egg containing an embryo enveloped in its 
membranes arrives by chance in the alimentary canal of 
the larval host; in the latter case, at least, it is necessary 
that the eggs should be introduced into the stomach and 
be subjected to the action of the gastric juice to disinte- 
grate the shelland membrane. Were this not so it is clear 
that the harboring of the adult in the intes- 
tine would be, in those cases in which the 
larva parasitizes in the same animal, a 
source of extensive secondary infection. In 
such cases it is well known, as for instance 
in Tenia solium of man,that any reversal of 
the ordinary peristaltic action of the canal, 
which brings loose proglottides into the 
stomach and subjects them to gastric digestion, will re- 
sult in the release of the six-hooked onchospheres, and 
in the infection of the host with the larve. Once that 
the membranes are broken down and the onchospheres 
set free they bore their way actively, by virtue of the 
hooks, through the wall, probably in most cases of the 
proximal portion of the intestine, and are believed to be 
distributed further by virtue of the portal circulation; 
at least the liver and the connective tissue adjacent to 
it are the chief seats of the larve. Having come to rest 
at such a point the embryo throws off its hooks and 
forms onits surface a thick cuticular layer beneath which 
are differentiated the muscle fibres, 
while about each embryo is formed a 
cyst by the activity of the host. The 





\ 


= 


Fic. 1209.—Free Swimming Onchosphere of 
Dibothriocephalus latus in ciliated 
mantle. X 500. (After Schauinsland.) 





FiG. 1210.—Free 
O nchosphere, 
Magnified. 


with a loose parenchymatous tissue in 
which soon appear irregular spaces 
that later fuse to form a large central 
cavity. Thus has been reached the 
first form of the larval stage known as 
the bladder worm or cysticercus (Fig. 
1211). A growth of two to four weeks 
is sufficient in most cases to bring the 
cysticercus to the diameter of a milli- 





Fig. 1211. — Young 
Cysticercus of 
Toenia saginata 
with beginning of 
Scolex Ingrowth, 
Seen in Optical 


fied cat tes meter, when the second stage in the 
Leuckart.) development is entered upon by the 


appearance of a meniscoid prolifera- ' 


tion of cells at some point on the bladder; into this 
projection there penetrates from the exterior a hollow 
cylindrical ingrowth of the cuticula (Fig. 1211) forming 
the starting-point of the scolex of the adult worm. As 
the growth becomes larger the ingrowth presents the 
form of a flask (Fig. 1212, A); it is still covered through- 


centre of the sphere is filled at first 


Cestoda, 
Cestoda, 


out by acuticular layer, and at the base of the flask there 
arise in reverse the structures which characterize the 
head of the tapeworm: at the centre the rostellum with 
its crown of hooks, and on the sides the suckers having, 
when fully developed, the characteristic form and size 
(Fig. 1212, B) of the adult. 

Under proper conditions the head begins to be everted, 
starting from the base and continuing until, with the 





Fic, 1212.—Formation of Scolex in Reverse on Cysticercus of Tenia 
serrata. A, Early stage; B, fully developed scolex. Magnified. 
(After Leuckart.) 


neck, it ultimately projects above the surface of the 
bladder (Fig. 1213). This process may at times take 
place while the bladder worm is still retained within its 
host. In other instances the consumption of the flesh in 
which the cysticercus is enclosed and the digestion of the 
surrounding tissue form the stimulus for the evagina- 
tion of the scolex. It is interesting to note that under 
the influence of the alimentary secretions of the definite 
host the bladder of the cysticercus is entirely digested, its 
remnant appearing as a ragged fringe (Fig. 1214, A), at 
the base of the fully extended scolex 
and neck. Having attached itself the 
scolex enters upon a period of rapid 
increase in length, which is soon ac- 
companied by the appearance of the 
first proglottides (Fig. 1214, B). The 
scolex system of excretory canals 
originates early (Fig. 1208) even be- 
fore the suckers and rostellum have 
appeared, and persist unchanged in 
the scolex of the fully developed 
adult. 

In the formation of the proglot- 
tides it may be noted that the ter- 
minal proglottis is the oldest, and that 
new segments are continually formed 
in the vicinity of the neck. The sexual organs appear 
early as strings or masses of embryonic cells in the 
midst of the parenchyma. Formation of proglottides 
and growth proceed so rapidly that the tapeworm has 
matured and set free the posterior joints in a brief 
period. These reach the exterior with the fecal mat- 
ter, often manifesting great independ@énce and power 
in movement. They contain masses of eggs stored 
up in the uterus with which the beginning of the 
life cycle is again reached. 

The normal seat of the tapeworm is 
in the alimentary canal, and usually in 
the small intestine, where the worm lies 
close to the wall with its head more or 
less embedded in the villi. Occasion- 
ally one of the smaller species wanders 
from this place into the ductus chole- 
dochus, and more rarely into the liver 
itself. This seems to be the normal 
habit of a few species not found in 
man. The occurrence of tapeworms 
in the human stomach or anterior 
thereto, as reported by various medi- 
cal observers, is due either to a post- 
mortem wandering or to regurgitation. 
On the other hand the reported oc- 
currence of Cestoda in the bladder, and 
the discharge of proglottides from the 


781 





ts) 


Fic. 1213. — Cysticer- 
cus of Tenia ser- 
rata with Everted 
Scolex. (After 
LeuckKart.) 





Fig. 1214. — Young 
Tenia serrata. 
A, Immediately 
after digestion of 
bladder by new 
host; B, with a 
few proglottides. 
(After Leuckart.) 


Cestoda,. 
Cestoda, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





urethra, can be explained, in so far as the cases do not 
rest on erroneous observations, only on the basis of in- 
jury or accidental introduction. Portions of a tape- 
worm have been at times discharged from abscesses or 
fistule which have probably had at some time a con- 
nection with the intestine. Leidy’s discovery of a speci- 
men in a cucumber admits, however, of no such natural 
explanation. Though often torpid when examined after 
discharge, the tapeworm is undoubtedly, it must be re- 
membered, active in its warm-blooded host. To its con- 
tractions are due the serious symptoms which often ac- 
company its presence. Even the discharged proglottides 
live for several days outside the host under ordinary cir- 
cumstances and perform migrations and movements of 
considerable extent. By virtue of this apparent com- 
pleteness and activity, the separate proglottides are fre- 
quently diagnosed as flukes. 


The effect of the parasite on its host may be regarded 


first from the standpoint of loss of nutriment. This has 
been carefully computed by Leuckart for the largest hu- 
man tapeworms, and amounts in one year for a single 
specimen of Dibothriocephalus latus to from 500 to 700 
gm., and for Tenia saginata to from 1,500 to 2,000 gm. 
Although the presence of a number of individuals may 
heighten this materially, yet the amount is entirely in- 
adequate to explain the far-reaching effects which are 
manifested by man as the result of the presence of only a 
single one of these parasites. The severe symptoms are 
noticeably of a nervouscharacter. Anemia is a frequent 
manifestation, and this displays at times a pernicious ten- 
dency which in one case at least has terminated fatally. 

Many of the symptoms affecting individuals who har- 
bor tapeworms have been attributed to poisons developed 
by the parasite within the body of the host. Not only is 
this evinced by the subsidence of the nervous and 
epileptic symptoms on the removal of the tapeworms, 
but the affections of the eyesso frequent in those afflicted 
may naturally be due to the effects of a poison absorbed 
from the intestine and circulating in the blood. The 
fluid extracted from a hydatid cyst has been shown by 
experiment on man and animals to be toxic. To this 
quality may doubtless be attributed the severe symptoms 
or even death consequent upon the rupture of such a 
cyst or its operative puncture. An extract from Diboth- 
riocephalus latus has been shown to exert a globulicidal 
effect on dogs, and one of Tenia saginata has been found 
to kill tubercle bacilli. 

The symptoms of tapeworm disease are by no means 
well defined and may include almost any possible com- 
bination. In experimenting upon himself, however, 
Stiles noted during the presence of Tenia saginata as the 
most constant symptom one not heretofore recorded. He 
says: “During the time of infection it would very fre- 
quently happen as I walked along the street or across the 
room that I suddenly felt a peculiar sensation almost ex- 
actly similar to the sensation one feels upon the sudden 
descent of anelevator.” Despite the indefiniteness of the 
clinical aspect of tapeworm infection, any suspicions of 
such trouble may be definitely tested by a microscopical 
investigation of the feces. The presence of adult ces- 
todes will be manifested by an abundance of their char- 
acteristic eggs. 

The specifics which are most frequently employed in 
driving out tapeworms are Cortex granati, of which the 
effective principle is an alkaloid known as “ pelletierine,” 
Flores Kouso containing the amorphous kosotoxin, 
Rhizoma filicis containing the amorphous filicie acid, and 
kamala with the resinous kamalin (see Anthelminthics). 
In bringing about the evacuation of the parasite some 
precautions are necessary to insure success. When a 
patient is passing a tapeworm the parasite sometimes 
breaks in two owing to the transition from the warm 
bowels to the cold air or to a cold porcelain vessel. By 
the use of a vessel containing warm water this sudden 
change and its consequent evil effects may be avoided. 
In the next place cestodes are frequently expelled ina 
knotted mass, and any obstruction in the lower portion of 
the canal may delay their passage sufficiently to permit 


782 








the parasite to secure a new hold on the wall. Con- 
sequently success may depend upon thoroughly clearing 
out the canal. 

The distribution of each species will be considered 
under its proper heading; here, however, some general 
items may be noted concerning the frequence of tape- 














worms. Stiles gives the following table of: 
CASES OF TAPEWORM IN MAN. 
Total number SEX OF PATIENTS. 
Authority. of cases 
reported. Male. Female. 
IWAWTUGCK Gin i.sicelce vices sivctslse 173 56 117 
Crisp 'higecemitt eietatetemnne eikiereretrs 247 96 151 
BERL OM a rare citetnietec lettuce ee 26 10 16 
IMOnaGH Ts Bier whe iviese les btctorsteiscere ote 240* 111 129 
MROMEL sax/Saltatsiniatcice eis oieeteele 10* 3 7 
KYADDON teat wien claimctee eter 367 126 241 
IOLA sete niiaateis teres cies 1,063 402 661 
* Children. 


He attributes the evident sex difference merely to the 
fact that women ordinarily prepare the food, and are 
hence more exposed to chance infection thanmen. Statis- 
tics of French maritime hospitals give for the period 
1886-90 about 1.5 per cent. of cases for tapeworm infec- 
tion, and records of the United States hospital service 
during the war contain a total of only .012 per cent. 
treated for tapeworms. This percentage is under the 
circumstances naturally abnormally low as compared 
with conditions in times of peace. 

The occurrence of various species in different regions 


























may be adjudged from the following table. Such 
figures exist only for a very few localities: 
ow S 4 Alera) 
on aches 3 s i} =| as . 
Ss nl ‘Ss =8 |aale s1 + 
ne |S28] as as |23 he Lael o 
Authority. | Country.| 23 [534] 8S | B= |SSiSelEs| 
= Bb KS S\Agi =e) g 
Parona ....|Milan ....|1899...} 150| 121 1 11 | 4|..|.. | 14 
Parond ..ns\ltaly e.cee 1868-99} 513 | 397 Cy AOS ieee ~ 4 19 
Krabbe..... Denmark. |1869...| 100 37 53 DCT eerene 
Krabbe..... Denmark. |1869-87| 200 | 1538 74. IGS Sal Teenie 
Krabbe..... Denmark. |1887-95| 100 89 At OT 6 ae eee 
Stiles iors. U8. Ace 1897... 3] ae) Many | Rare | each 1 ete 











Cestodes have been known from the earliest times, and 
both tapeworms and bladder worms are distinctly recog- 
nized in the oldest medical works which have come down 
to us. One of the hermetic books of the Egyptians, that 
on medicaments now known as the Papyros Ebers, and 
dated about 1550 B.c., gives in hieratic writing extensive 
sections on these parasites and their treatment, which 
are taken in part from the writings of earlier physicians. 
The proscription placed by Moses on the use of certain 
flesh has its undoubted ground in the abundant presence 
in such animals of bladder worms. Hippocrates notes 
the presence of echinococcus bladders in man and an 
operative method for removing them. He also speaks of 
the evacuation.of fragments like pumpkin seeds as diag- 
nostic of the tapeworm. Both he and Aristotle speak of 
the bladder worm of the pig as well known, and advise 
the detection of its presence by examining the lower sur- 
face of the pig’s tongue where the cysticerci appear as 
swellings. This method is followed even to-day. Aris- 
totle showed also that the tapeworm in contrast with the 
free round worms of the intestine was attached to the 
wall of the canal. Pliny adds to the accounts of his 
predecessors which he quotes only fabulous reports of 
the length of tapeworms (up to three hundred feet!) and 
erroneous observations on their presence in cold springs. 
Galen mentions bladder worms from the abdomen of 
slaughtered animals and notes the tendency of the liver to 
“produce” these forms in its surrounding fascia. 

It was 1600 a.D., however, before even two species 
were differentiated among human tapeworms, and 1700 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cestoda, 
Cestoda, 





A.D. before the tapeworm head was recognized. About 
this time cestodes from other hosts began to be studied 
and the animal nature of the bladder worms, which had 
previously been regarded as tumors or concretions, was 
successfully maintained. Even then authors noted the 
resemblance of certain cestodes and cysticerci, and in 1782 
Goeze united the two groups, but this procedure was not 
accepted by later authors for more than half a century. 
The origin of these parasites was universally attributed 
to spontaneous generation, the tapeworm being said to 
originate from the inner wall of the canal, from surplus 
food of a thick character like milk or cheese, or from 
febrile mucous secretions, while the cysticerci were gener- 
ally regarded as tumors (hydatids). This belief lasted 
long, even after the discovery of the eggs in many 
species. Linnzeus was responsible for propagating an- 
other serious error, that the cestodes were free living as 
well as parasitic; and this was not finally refuted until 
the end of the eighteenth century. It was Zeder who in 
1800 first divided the parasitic worms into five classes to 
which Rudolphi in 1804 gave the Greek names, Nema- 
toidea, Acanthocephala, Trematoda, Cestoidea, Cystica, 
which they still bear. Of the last two, the tapeworms 
and bladder worms, Kiichenmeister was able to prove 
about the middle of the century by feeding experiments 
that the latter were only developmental stages of the 
former, thus incorporating both in the group of cestodes. 
Among these those forms with only a single segment 
may be distinguished as the Cestodaria from the Cestoda 
8. str., in which group are included the large majority of 
the tapeworms, and all of the forms reported from man. 
The latter may be arranged according to the following 
scheme which adopts the system proposed by Braun. 
The groups omitted here contain no forms recorded as 
human parasites. Annotation is made of the stage in 
which each species is a human parasite and of those forms 
thus far recorded in this country: 
Order Cyclophyllidea. 


Family Tzeniade. 


Tenia saginata. Adult in man. We S.A, 


africana. 
‘* solium. st st UW. Sa A. 
*“  confusa. a > U.S. A; 
“serrata. Larva in man (?) 
““ marginata. oe 2) US. As 
** echinococcus. “ S WI8Ae 


Davainea madagascariensis. Adult in man. 


Hymenolepis nana. U.S. A. 
diminuta. a He .S. A. (?) 
Dipylidium caninum. S 


Order Pseudophyllidea. 
Family B thriocephalide. 
Dibothriocephalus latus. 
cordatus. 
Dibothrium Mansoni. Larva in man. 
Diplogonoporus grandis. Adult “te 


KEY TO ADULT TAPEWORMS OF MAN. 


Scolex with four circular suckers; proglottides with marginal genital 
pore and without uterine orifice. 
Cyclophyllidea—Teeniadze. (A.) 
Scolex with two longitudinal sucking grooves; proglottides with 
superficial genital pore and with special uterine orifice. 
Pseudophyllidea—Bothriocephalide, _(B.) 
(A.) Large forms; uterus in ripe proglottides with median longi- 
tudinal trunk and numerous lateral branches; eggs 
with thin outer and thick inner shell Eepabryopnore). 
a.) 


Adult in man. U.S. A. (?) 


(a.) Head unarmed with small apical fifth sucker. 
Ripe proglottis 12 to 19 mm. long by 5 to 7 mm. wide: 
uterus with 20 to 30 slender lateral branches. 
Tceenia saginata. 
Ripe proglottis 7 mm. long by 12 to 15 mm. broad ; 
uterus with 15 to 24 simple radiating branches. 
Tenia africana. 
(aa.) Head armed with circlet of hooks. 
Ripe proglottides 10 to 12 mm. long by 5 mm. wide; 
- uterus with 7 to 10 thick branches; ovary on pore 
side divided by vagina. Tcenia solium. 
(aaa.) Head unknown. 
Ripe proglottides 27 to 35mm. long by 3.5 to 5 mm. 
‘wide; uterus with 14 to 18 heavy irregular forked 
branches. Toenia confusa. 
(AA.) Small forms; eggs with thin transparent shells, in ripe pro- 
glottides grouped in capsules or irregularly ated 


ute 
(b.) Genital pores unilateral. 
Ripe proglottides broadly elliptical, 2 mm. long by 1.4 
mm. wide. Davainea madagascariensis. 
Ripe proglottides trapezoidal, 0.14 to 0.30 mm. long by 
0.4 to 0.9 mm. wide. Hymenolepis nana. 





Ripe proglottides trapezoidal, 0.75 mm. long by 2.5 
mm. wide. Hymenolepis diminuta. 
(bb.) Genital pores on both margins of each proglottis; genital 
organs also double. 
Ripe proglottides elliptical. Dipylidiwm caninum. 
(B.) Genital organs single in each proglottis. 
Head elongated oval; length of worm 2 to 7 meters. 
Ripe proglottides 2 to 4 mm. long by 10 to 12 mm. wide. 
Dibothriocephalus latus. 


Head short, cordiform ; length of worm hardly over 1 


meter. 
Ripe proglottides approximately 5 to 6 mm. square. 
Dibothriocephatus cordatus. 
(BB.) Genital organs double in each proglottis. 
Head not known ; length about 10 meters. 
Ripe proglottides 0.5 to 0.8 mm. long, 10 to 15 mm. 
wide. Diplogonoporus grandis. 


In all cases reference should be made to the fuller de- 
scriptions given for each species in the text, and thus the 
results obtained by use of the brief criteria contained in 
the key controlled. Especial attention 
should be paid to those species which 
are as yet incompletely known; the 
writer will be glad to assist in the 
identification of any such. 

The Cyclophyllidea possess a scolex 
with four circular suckers, often with 
an apical rostellum on which hooks are 
found when present. Segmentation is 
pronounced and the ripe proglottides 
do not separate until fully developed. 
There is no uterine aperture and the 
common sexual pore is located on the 
margin of the proglottides. The eggs 
are thin shelled and without a cover. 
The adults lie in the alimentary canal 
of the higher vertebrates. The order 
contains but a single family, the Tzeni- 
adee. 

For the genus Taenia the following 
characteristics are diagnostic. Large 
species with ripe proglottides much 
longer than broad. Uterus with me- 
dian trunk and subsequently formed 
lateral branches during the develop- 
ment of which the remaining sexual 
organs disappear save cirrus and va- 
gina. Larva, a cysticercus, ccenurus, or echinococcus, 
found in herbivorous mammals and also in man; adult in 
man and the carnivorous mammals, 

TANIA SAGINATA Goeze.—T. inermis Brera, T. den- 
tata Nicholai, T. lata Pruner, T. mediocanellata Kiich- 
enmeister, T. tropica Moq. -Tand.* 

Length 4 to 8 meters or even to 74 meters (Bérenger- 
Féraud). Head (Fig. 1215) somewhat four-sided, 1.5 to 2: 
mm. in diameter, without rostellum and circle of hooks 
but with a sucker-like depression in its place which is 
often pigmented. Neck long, narrower than head. Pro- 
glottides number more than 1,000 and increase gradually 
in length until the ripe segments of characteristic 
pumpkin-seed appearance measure 16 to 20 mm. long 
by 4to 7mm. broad. Gen- 
ital pores irregularly al- 
ternating, marginal, and 
posterior to the centre of 
the proglottis. Uterus in 
ripe proglottis with me- 
dian stem and twenty to 
thirty-five slender lateral 
branches, themselves often 
branched. Egg shell deli- 
cate with one or two polar 
filaments (Fig. 1216), em- 
bryophore ovoid 35 to 40 z 
by 20 to 80 @ in diameter. Adult exclusively in small 
intestine of man; larva (Cysticercus, bovis) in the muscles 
and viscera of cattle. 

Structure.—The arrangement of the reproductive or- 
gans in a sexually mature proglottis (Fig. 1205) is best 





Fic. 1215.—Anterior 
End of Tania 
saginata, Some- 
what Contracted. 
Me Se GALL er 
Leuckart.) 





Fig. 1216.—Uterine Egg of Tenia 
saginata Showing Shell with 
Polar Filaments and in the Centre 
Onchosphere within the Embryo- 
phore. X 375. (After Leuckart.) 





* Only the synonyms most frequently met are given under each 
species. 53 


783 


Cestoda. 
Cestoda. 





visible in a segment taken about 40 to 50 cm. from the 
head. The general structure of these organs has been 
described above. Characteristic for this species are the 
two ovaries of unequal size, that at the pore side being 
the smaller and without the small accessory lobe cut 
off by the vagina as in 7’ solium. The whole proglottis 
has a more open aspect, and the various organs show 
relatively greater antero-posterior diameter than in 7’ 
solium. The uterus in the ripe proglottis (Fig. 1207) 
manifests a more crowded structure, the lateral branches 
are slenderer. and more numerous, and two or three are 
stunted or lacking opposite the sexual pore. 

Development.—In 1861 Leuckart fed ripe proglottides 
of this species to calves and succeeded in obtaining the 
then unknown cysticercus, although various facts had 
pointed out cattle as the probable intermediate host. 
These results have been confirmed by many other in- 
vestigators. At six weeks the size of the cysticercus 
(Fig. 1211), shelled out from its cyst, is: length 3 mm., 
breadth 5 mm., diameter of the head 1 mm.; at twelve 
weeks corresponding measurements are 4, 4, 1.8 mm. 
(length of head); at twenty-four weeks, 6, 4, 2 mm.; at 
forty-eight weeks 7, 5, 2.6mm. The length of life of the 
cysticerci is brief; at less than eight months they have 
been found completely calcified. A temperature of 47° 
to 48° C. is always fatal. Of course the internal portions 
of roasting pieces are often far from reaching this tempera- 
ture. On the other hand exposure to cold-storage con- 
ditions for three weeks is sufficient to destroy all these 
cysticerci contained in a piece of beef. 

Artificial infection of man with the adult by eating 
flesh containing living specimens of Cysticercus bovis has 
been tried with equal success. An average growth of 72 
mm., or about thirteen to fourteen proglottides daily, 
was determined. 

Anomalies.—T. saginata appears to be peculiarly sub- 
ject to variation and malformation. Excessive pig- 
mentation of the head and chain led to the establishment 
of the species 7. nigra Laboulbéne (1875) for a tapeworm 
expelled by a Frenchman who had lived for some time in 
the United States. Two genital pores, on the same or 
opposite margins of the proglottis, but each connected 
with a set of reproductive organs, indicates the probable 
disappearance of the segmental boundaries, and this 
may be manifested over a considerable stretch of the 
worm, giving the appearance of an unsegmented body. 
Welch has observed such an unsegmented region 5 cm. in 
length. Intercalated proglottides or roughly triangular 
joints are not of infrequent occur- 
rence. A common malformation 
consists in the perforation of a series 
of proglottides. This anomaly has 
received a specific name, 7. fenes- 
trata, at the hands of one observer. 
The fenestration appears first at 
the centre of the proglottis and be- 
comes more accentuated toward the 
posterior end of the chain. Its cause 
is not understood. 

Finally there occurs a prismatic 
or triradial variety (Fig. 1217) which 
05 was described by Bremser as the 
result of the fusion of two individu- 
als. The proglottis is Y-shaped in 
cross section, and the scolex bears 
six acetabula. Specimens of this 
sort were named 7. capensis by 
Kiichenmeister and 7. lophosoma by 
Cobbold. 

Onchospheres of 7. saginata have 
been observed of considerable size, 
and armed with from twelve to 
twenty-two hooks; and Cobbold 
has described specimens of Cysticercus bovis from the 
heart of a calf with only three, two, one, and even no 
suckers on the head. : 

The form described by Weinland as 7. soliwm var. 
abietina, from a specimen collected by Agassiz from a 





Fic. 1217.— Portion of 
the Chain from Pris- 
matic Specimen of 
Tenia saginata, 
Showing also the Oc- 
casional Separation of 
the Three Wings for a 
Short Distance. 0s, 
Sexual Pore. Natural 
size. (After Cattaert.) 


784 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











Chippewa Indian, is regarded by many as a small speci- 
men of 7. saginata with unusually dense and delicate 
branches of the uterus (Fig. 1218). 

Distribution.—The adult occurs only in man and is 
cosmopolitan. Its presence in the Orient is recorded in 
writings of great antiquity; in Africa, Europe, and 
America it is also abundant, and its frequence has in- 
creased during recent years, whereas the 
contrary is true of 7. soliwm. The evi- 
dent reason lies in the custom of eating 
beef rare, but pork well done. The fig- 
ures given by Bérenger-Féraud for 
French maritime hospitals during the 
six quinquennial periods from 1861 to 
1890 show a steady relative increase of 
cases from 0.2 to 14.8 per mille. In Paris 
the increase, though real, was much less, 
being from 0.3 to 0.6 per cent. in the same 
time. 

The larval form, C. bovis, has been 
produced experimentally in rare in- 
stances in other hosts, sheep and goat, 
but many experiments on these and other 
hosts have been entirely without results. 
In its normal host (cattle) the bladder 
worm was apparently rare, even in regions where 7. 
saginate occurred abundantly. This apparent contra- 
diction has been explained by the demonstration that in 
most cases normal infection is only mild and the cysti- 
cerci are so small and scattered as not to be easily found 
in the beef. Their predilection recently discovered for 
the pterygoid muscles affords, however, a surer means of 
diagnosis now than was formerly known. 

A limited number of observations on the presence of 
C. bovis in man are on record, They include cases from 
the brain and eye, and the determination of the species 
rests on the absence of hooks and rostellum. Since, 
however, these organs may be wanting in C. cellulose, the 
larva of 7. soliwm (q. v.), the determination in the cases 
under discussion must be viewed with suspicion. 

Pathology.—Most common in hosts between twenty and 
forty years of age, the beef tapeworm has been encoun- 
tered in the aged and even in newborn infants. Its normal 
place of fixation is near the pylorus, where the head is 
firmly fastened to the mucosa by its suckers. It may, 
however, be found exceptionally in the stomach. Symp- 
toms of its presence are direct and local in the digestive 
system, or nervous-and reflex in character. The latter 
are rarer but may be severe. A. Stieda has recently de- 
scribed a case in which this species, in spite of its lack of 
hooks, had bored through the wall of the duodenum and 
some distance in a circuitous course into the pancreas. 
In this case there were neither abcesses nor preformed 
orifices of which the worm could have made use, while 
other evidence supported the view of active burrowing 
on its part. Possibly the rare cases in which tapeworms 
have made their exit through the navel or bladder may 
be susceptible of a similar explanation. This is, how- 
ever, the only case on record which has been subjected 
to a thorough scientific investigation. 

The proglottides of this species are expelled spontane- 
ously and in the interval between stools. The move- 
ments after expulsion are active and long continued as is 
evinced by the discovery of segments high on the walls 
of sick-room or outhouses. The anterior margin is lacer- 
ated by separation from the chain, and in crawling the 
proglottis distributes eggs from the uterine branches. 
These detached segments are frequently diagnosed as 
flukes, a conclusion apparently strongly confirmed by 
their independent activity. 

This species cannot be regarded as equally dangerous 
with 7. solium since here there is no chance for auto-infec- 
tion by the onchospheres. The disturbances attending its 
presence in the alimentary canal, however, are such as 
to call for its removal. Despite the absence of hooks in 
the species this is, as a rule, more difficult of accomplish- 
ment than in the case of the pork tapeworm. The re- 
moval of the body without the head and neck constitutes 





Fic. 1218.—Ripe 
Proglottis of 
Tenia solium 
(= T. saginata 
var.) var. abie- 
tina Weinland. 
(After Wein- 
land.) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Cestoda, 
Cestoda, 





but a temporary relief since a new chain is produced in 
a short time. 

TANIA AFRICANA Vv. Linstow 1900.—Length 1.4 me- 
ters, greatest breadth 12 to 15 mm, Scolex unarmed, no- 









aot 
< —<te 
ees 


cor 
er wieisies DP | 










TAS ti 


Fic. 1219.—Ripe Proglottis of Tania africana. Xx 5. (Afte 
Linstow.) 


tably small, 1.4 mm. wide by 0.5 mm. long. Proglottides 
number about 600, decidedly broader than long; ripe 
proglottides measure 7 mm. long by 12 to 15 mm. broad. 
Uterus (Fig. 1219) with fifteen to twenty-four simple 
-branches radiating from median trunk. Eggs thick 
shelled, 31 to 844 in diameter. Hooks of onchosphere 
8 long. Adult parasitic in natives of German East 
Africa; development unknown. 

This species, only recently described, was obtained 
from black soldiers near Lake Nyassa in Africa. It 
differs radically from the common unarmed tapeworm of 
man, as is evident from examination of the sexually ma- 
ture proglottis (Fig. 1220). Of importance in consider- 


cir t. Ov. eX. 
‘ °°, 


5% 8o° 


°- 





vit. *s Shgl. 
Fig. 1220.—Sexually Mature Proglottis of Trenia africana. | cir., 


Cirrus ; 7.s., receptaculus seminis ; sh.gl., shell gland; vag., vagina ; 
vit., vitellarium. X 5. (After von Linstow.) 


vag 


ing its development is the report that these natives are 
accustomed to eat the flesh of the zebu raw, 

Tantra souium L. 1767.—T. pellucida Goeze 1782 T. 
vulgaris Werner 1782, 7. solium Rud. 1810. Length 2 
to 3 meters, rarely 6 to8 meters. Head (Fig. 1203) spheri- 
cal 0.6-0.8 mm. in diameter. Rostrum short, often pig- 
mented, with a double crown of twenty-four to thirty- 
two hooks in which large and small alternate regularly 
(Fig. 1221). Large hooks 0.16 to 0.18 mm. long, smaller 
0.11 to 0.14 mm. long. Neck long and slender. Proglot- 
tides eight hundred to nine hundred in number, at 1 
meter from the head 
Square with sexual or- 
gans fully developed; at 
end of chain when ripe, 
10-12 mm. long, 5-6 mm. 
broad. Uterus with 
prominent median stem 
and on each side seven 
to ten heavy branched 
lateral outpocketings. 
Embryophores 31-86 yu 
in diameter. Adult in 
small intestine of man; 
larva (Oysticercus cellu- 
lose) in muscles and vis- 
cera of domestic pig, 
rarely also of dog, man, 
and ape. 

Structure.—In general 
appearance the pork tapeworm is distinctly more delicate 
and its chain less muscular than the beef tapeworm, pre- 
viously described, and all its measurements display this 
difference. The scolex is decidedly smaller and has a 
prominent rostellum with two rows of hooks. The points 
of the hooks lie in a circle, but since they alternate regu- 


Vou. II.—50 





Fig. 1221.—Apical View of Scolex of 
Tenia solium. X 60 (After 
Leuckart.) 


‘ent individuals measured from 1 to 6 


larly in size, the bases form two concentric circles. The 
hooks of the two sets show characteristic differences in 
figure (Fig. 1222) as well as in size. 

The sexually mature proglottides do not exceed 4.5 to 5 
mm. in width by 2.5 to 8 mm. in length, being thus de- 
cidedly inferior in 
size to those of 7. 
saginata. On ex- 
amination one sees 
the same organs in 
much the same re- 
lation as in the beef 
tapeworm; but 
there are minor dif- 
ferences which 
serve to distinguish 
the two species. Most prominent is the unequal size of 
the two ovaries (Fig. 1223), the one next the genital pore 
being the smaller and being oval in outline rather than 
circular. In addition a small ovarian lobe lies in the 
angle between the vagina and the uterus, as if cut off 
by the former canal from the ovary to which it appar- 
ently belongs. This accessory lobe is a constant and 


reliable peculiarity of 





Fic. 1222.— Large and Small Hooks of 
Teenia solium. X 180. (After Leuckart.) 


the pork tapeworm. 
anne a One may notice also 

eet eerste i323) |I the generally com- 
pressed form of the 
various organs most 
marked in the flat- 
tened vitellarium 
near the posterior 
edge of the proglot- 
tis. 

The differences be- 
tween the two species 
are less evident from 
examination of the 
ripe proglottides. 
Usually the segments 
of the pork tapeworm are given off in sets of two or 
three rather than singly. The individual proglottis is 
thinner, less muscular, in general also smaller and more 
transparent; yet these are highly variable features and 
often deceptive. The form of the uterus, however, gives 
to the proglottis a characteristic appearance. There are 
only seven to ten lateral branches which are more heavily 
and unevenly branched, while the ends of the branches 
are not infrequently enlarged (Fig. 1224). 

Development.—The eggs (Fig. 1208) are oval, the outer 
shell is thin without polar filaments and 
transient; the inner shell is thick, radi- 
ally striated, and spherical. The oncho- 
sphere is also spherical, measuring 20 in 
diameter. The development of the em- 
bryo is slow; in eight days it had only 
reached a size of 33 by 24 v, and at the 
end of three weeks its diameter was but 
0.8 mm., while in thirty-two days differ- 





Fig. 1223.—Sexually Mature Proglottis 
of Tenia soliwm, Showing Reproduc- 
tive Organs. X10. (After Leuckart.) 


mm. by 0.7 to 2.6 mm. Even in the 
smallest, however, a head projection 
could be seen, and in the second month 
suckers and hooks are formed while the 
neck has grown so long as to produce 
one and a half complete circles within 
the bladder. By the close of the third 
month the bladder worm is probably 
ripe and capable of successful transfer- 
ence. 

The longevity of the Cysticercus cellu- 
lose is dependent upon various circum- 
stances. Not infrequently it degener- 
ates at an early period, but more often 
later, by the loss of its liquid and by de- 
position of lime, into a mere calcareous 
granule. The same individual has, how- 
ever, by means of the ophthalmoscope, 





Fig. 1224.—Ripe 
Proglottides of 
Teenia solium, 
Showing Form 
of Uterine 
Branches. X 2, 
(After Braun.) 


785 


1 


Cestoda. 
Cestoda. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





been observed living in the eye for twenty years. Free 
cysticerci live only a brief time in water, but in flesh at 
normal temperature they remain living up to twenty- 
nine days. 

Many experiments have demonstrated that the Cyst7- 
cercus cellulose of the pig, when introduced into the hu- 
man alimentary canal, gives rise to Tenia solium. From 
ten to twelve weeks are necessary for full development 
and for the expulsion of the ripe proglottides. Efforts to 
bring the cysticercus to development in other hosts than 
man have as yet failed. 

Anomalies.—Though less frequent than 7. saginata, 
much the same malformations occur. Both incomplete 
and complete fusion of two or more segments and fenes- 
tration of parts of the chain are on record. An unusu- 
ally slender structure of the chain gave rise to Cobbold’s 
species, 7. tenella, sometimes regarded as a distinct variety 
even yet. A scolex bearing six suckers has been observed 
both with an ordinary chain and with one of the pris- 
matic or triradial variety with proglottides Y-shaped in 
cross section. 

The onchosphere has at times more than the usual six 
hooks, and the Cysticercus cellulose is subject to various 
malformations. Absence of hooks, of a rostellum, and 
presence of six acetabula may be noted. Some abnormal 
forms have received special names; such a one is @. 
racemosus (C. botyroides or C. multilocularis) which is very 
irregular inform. This variety occurs especially at the 
base of the brain and is not surrounded by a cyst, to 
which, no doubt, is due its peculiar form, adapted to the 
space in which it lies. In some cases this variety is 
without a scolex or possesses at most but an abnormal 
rudiment of one. 

Most interesting of all is the form which led to the 
establishment of a new species, Cysticercus acanthotrias, 
and by deduction a new tapeworm, Tenia acanthotrias. 
The Cysticercus acanthotrias was first observed by Wein- 
land in 1858 at an autopsy of a white consumptive in 
Virginia. The bladder worms were in the dura mater, 
muscles, and subdermal tissues. Though in size and 
form like C. cellulose, these hydatids (Fig. 1225) possessed 
three rows, each of fourteen to sixteen hooks, longer and 
slenderer than those of that form and measuring severally 
153 to 196 uw, 114 to 140 uw, and 63 to 70 uw. The dis- 
covery in several cases of identical bladder worms in 
European countries and the improbability of the exist- 
ence there of an unknown large tapeworm with three 
circles of hooks, together with the occurrence in one case 
at least of this peculiar form side by side with C. cellu- 
lose, have led most investigators to regard C. acanthotrias 
as merely a variety of the common pork bladder worm. 

Distribution.—Tenia solium is not so widely dis- 
tributed as 7. saginata, although partaking of the cos- 
mopolitan character of the latter. It is rare in tropical 
lands, and wanting 
among such races as 
abstain from the use 
of pork. On the other 
hand, especially in 
those regions where 
the inhabitants are ac- 
customed to eat the 
flesh of the pig in a 
poorly cooked condi- 
tion, the parasite is 
most abundant. Cer- 
tain provinces of con- 
tinental nations come 
within these limits. 
Contrary to the state- 
ments of a number of 
standard authorities, I 
am confident from the 
evidence gathered that 
this species is very rare at present in the United States. 
Some figures have been adduced to show that it is be- 
coming decidedly rarer in both France and Germany. 
In Denmark it was, in 1869, the commonest human ces- 





Fic. 1225.—Apical View of Scolex and 
Hooks of Cysticercus acanthotrias. 
x 50. CAfter Weinland.) 


786 





tode, being present in 53 out of 100 cases; in 1887-95 
it was not found once in 100 cases (Krabbe). 

Oysticercus cellulose is present not only in the pig but 
also in the wild boar, deer, dog, cat, rat, brown bear, ape, 
and even man himself. In the pig the bladder worm is 
more abundant in such animals as are allowed to range 





Fic. 1226.—Brain Cysticercus. 
ternal structure. a-a’, Stalk of racemose body (scolex). 
(After Kratter and Bohmig.) 


Fresh specimen opened to show at 
xX 3. 


than in those that are stall fed. In Germany the ratio of 
infected animals varies in different provinces from 1 in 
100 to 1 in 2,000 according to reports of meat inspectors. 
As these cover, however, only the cases in which the 
infection is prominent, the actual figures are much larger. 
Leuckart calculated some years ago that two to three 
pigs per hundred were infected. This bladder worm 
also seems to be growing rarer during recent years. 

Pathology.—Tenia solium lies with the head fastened 
in the anterior portion of the small intestine. The pro- 
glottides are passed in groups with fecal matter; excep- 
tionally through abnormal communications they reach 
the body cavity, bladder, and abscesses, or finally are 
thrown out per os by vomiting. The troubles caused by 
the worm do not differ from those due to 7’. saginata, yet 
the former is a much more dangerous parasite since its 
bladder worm may also develop in man. When abun- 
dant the bladder worms produce in pork the conditions 
known as “measles,” and measly pork is the ordinary 
means of introducing 7. soléwm into the human system. 
Rarely it may be caused by the consumption of the in- 
fected flesh of the wild pig or deer. Smoking and salt- 
ing, unless extended and thorough, will not kill the 
bladder worms in pork and ham. Thorough cooking, 
however, renders them entirely harmless. As early as 
1558 the cysticerci were observed in the dura mater of an 
epileptic. While the brain and eye are apparently the 
most frequent seats of the bladder worms, the latter 
occur also in the muscles, subdermal tissue, heart, lung, 
liver, peritoneum, etc. Particularly dangerous are, of 
course, the cerebral cysticerci (Fig. 1226) which produce 
effects parallel to brain tumors. In this location they are 
not rarely the cause of sudden death. According to 
Verdun and Iversenc the bladder worm of the cerebral 
vesicles is ordinarily free and not of the racemose variety. 
The acephalocystic vesicle is most common, next comes 
the simple form with a single head, and rarest are those 
consisting of a few vesicles united by the stalk. The 
fourth ventricle is the most frequent location of the par- 
asite. The symptoms due to the presence of such cys- 
ticerci do not permit of certain diagnosis; most general 
are, however, signs of compression due to ventricular 
hydrocephaly. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


The introduction of the onchospheres into the human 
stomach, which is a necessary preliminary to further de- 
velopment in the system, is brought about by impure 
drinking-water, by the use of salads or uncooked vegeta- 
bles contaminated by the embryophores, and by the care- 
less use of unsanitary closets. More frequently, no doubt, 
the host of the adult tapeworm infects himself through 
lack of cleanliness in defecation, or possibly, as has been 
suggested, by internal auto-infection, Any circum- 


stances which might lead to the passage of adult pro- 
glottides containing ripe onchospheres from the intestine 





Fig. 1227.—Ripe Proglottis of Tenia confusa. X 2.5. (Original 
photomicrograph. ) 


back into the stomach would result in infection by those 
onchospheres which remained there a short time as if 
they had been introduced through the mouth. 

The danger of internal or external auto-infection de- 
mands immediate action by the physician for the removal 
of the parasite under great care that all regurgitation 
should be prevented. The success of the operation must 
be confirmed by the discovery of the tapeworm head, and 
the parasite destroyed rather than merely thrown away. 

Tania conrusA Ward 1896.—This species, originally 
described by the writer and later studied in greater detail 
by one of his students (Guyer), was obtained in Lincoln, 
Neb. In general appearance it is much like the two 
species just described, but may be recognized at once by 
the extraordinary length of the ripe proglottides, some 
measuring as much as 35 mm. long by only 4 to 5 mm. 





Fig. 1228.—Sexually Mature Proglottis of Tania confusa. X 15. 
(After Guyer.) 


broad. The shape of these proglottides differs also from 
that of the terminal segments in the other species (Fig. 
1227, of. Fig. 1207 and Fig. 1224). The head of this 
species is unknown, consequently its exact position and 
relationship are for the time being uncertain. The whole 
body is thinner and more fragile than that of 7. saginata. 
It measures 5 to 8 meters in length and has some seven 
hundred to eight hundred proglottides, nearly all of which 
are longer than broad. The sexually mature proglottides 
(Fig. 1228) are distinguishable by the long reniform lobes 





Cestoda, 
Cestoda, 





of the ovary. In the ripe proglottides the median stem 
of the uterus bears fourteen to eighteen irregularly 
branching offshoots swollen at the end into irregular 
club-shaped masses. Of the approximately forty points 
of difference in structure between this and the common 
species, 7. saginata and T. soliwm, as tabulated by Guyer, 
the most important are subjoined. Nothing is known of 
the life history of this species. 





T. saginata. T. solium. T. confusa. 





Size of terminal)}12-19 mm. long/10-12 mm. long/27-35 mm. long by 


proglottides. by ae mm.| by5mm. wide} 3.5-5 mm. wide. 
wide. 
Greatest breadth../12-14 mm...... (5111) ar 8-10 mm. 
Length of proglot-|Only in last 100.|In last half..... In nearly entire 


tides exceeds 
breadth. 
Proglottides 35 
ecm. behind 
head measure. 


1.5-2.6mm. long 
by 5-10 mm. 
wide. 








0.8 mm. long by 
1.3 mm. wide. 


worm. 


1-2.5 mm. long by 
0.8-3 mm. wide. 








Sexually mature|4-6 mm. long,|2.5-3 mm. long|44.5 mm. long, 
proglottides| 810mm.wide| 4.5-5 mm.| 3.5-4.5 mm. 
measure. wide. wide. 

N@GK IS 2. clei ee's Unsegmented...|Unsegmented . .|Segmented. 

Calcareous bodies.|Abundant; to/Sparse; to 0.012/Sparse; to 0.011 

0.018 mm. mm. mm. 

Longitudina])|Dorsal to genital|Ibidem......... Divide, passing 
nerve trunks. ducts. both dorsal and 

ventral to ducts. 

Depth of genital|0.22 mm........ Smaller........ 0.05-0.08 mm. 
cloaca. 

Width of genital/1 mm........... Seller ances. 0.45-0.6 mm. 
pore. 

Ovarian lobes....|/Round......... Part of smaller|Reniform. 

cut off by 
vagina 

Lateral branches|20-30 .......... N=LO errenstectent 14-18 
of uterus. 

Size and form of|0.03mm., slight-|0.03 mm., near-|0.039 by 0.03 mm... 
eggs. ly oval. ly round. oval. 

Pyriform process.|Present........ In young pro-|Absent entirely. 

glottides. 





Further information is needed regarding the frequence 
and distribution of this form, which though distinguish- 
able on careful examination, has doubtless often been re- 
garded as the common species—whence the name confusa. 

TANIA SERRATA Goeze 1782.—Length 0.5 to 2 meters. 
Head 1.8 mm. in diameter with a double crown of thirty- 
four to forty-eight hooks, the larger 225 to 250 u long, the 
smaller 120 to 160 ~. Embryophores oval, 36-40 » by 
31-36 u. Adultin small intestine of dog; larva (Cysti- 
cercus pisiformis) in peritoneum of rabbits. 

The single record of its presence in man, reported from 
Algeria, is undoubtedly an error in the determination of 
the species found. In its normal host it is common 
everywhere in Europe and America so far as the records 
stand at present. 

TANIA CRASSICOLLIS Rud. 1810.—Length 0.15 to 0.6 
meter. Head 1.7 mm. in diameter with a double crown 
of twenty-six to fifty-two hooks, the larger 380-420 « 
long, the smaller 250-270 “. Embryophores spherical, 
31 to 37 ~ in diameter. Adult in small intestine of do- 
mestic cat and related wild species; larva (Cysticercus: 
Fasciolaris) in rats, mice, etc. 

Braun records after Krabbe that in Jutland chopped 
mice are consumed uncooked on bread as a popular 
medicament against enuresis. Evidently the introduc- 
tion of living larve of this species into the human ali- 
mentary canal would be not only possible but probable 
under these circumstances. 

TANIA MARGINATA Batsch 1786.—Length 1.5 to 5 
meters. Head reniform, 1 mm. in diameter. Hooks 
thirty to forty-four in a double row; the larger measure 
180 to 220 u in length, the smaller 110 to 1604. Ripe 
proglottides 10 to 14 mm. by 4 to 7 mm. Uterus with 
short main trunk and five to eight large branches on each 
side. Embryophores spherical, 31 to 36 u in diameter. 

The adult lives in the small intestine of dog and wolf; 
larva (Cysticercus tenuicollis) is found in the peritoneum 
of apes, ruminants, and pigs. Experiment has shown 
that the larva will not develop to the adult worm in the 
human alimentary canal. The larva has been reported 


7187 


Cestoda, 
Cestoda,. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





twice as a human parasite; but the record of its presence 
in the liver of man in Iceland has been shown to bea 
mistake. Hodges also reported its occurrence in man in 
the United States, but Wyman, who examined the speci- 
mens, stated that the hooks resembled rather those of 
Cysticercus cellulose, while the size of the cyst and the 
number of hooks favored C. tenwicollis. Since the latter 
features are known to be much more variable than the 
former, it is probable that the determination is erroneous 
in this case also. 

Since the most dangerous of all human parasites is a 
dog tapeworm, and since several other canine cestodes are 
either known to be found or suspected to be parasitic in 
man at some age or in some stage of life, the dog tape- 
worms are evidently most important for the physician 
from the sanitary point of view, quite apart from the fact 
that by virtue of their serious effects on other domestic 
animals these cestodes demand attention from an eco- 
nomic standpoint. A strict control should be exercised 
over the condition of the dog in every household where 
such a pet is found, and the removal of the army of stray 
curs should be urged in every community; for these 
vagrants are the very ones most likely, by virtue of their 
omnivorous habits, to become infected and, in consequence 
of their nomadic life, to carry parasites from place to 
place. The presence of tapeworms in dogs may be 
recognized by the proglottides found in the feces, and 
I have known of such having been taken from the back 
of a dog and submitted to a physician as a curiosity! 
Manifestation of an anal or subcaudal pruritus on the 
part of the dog is also good evidence of their presence. 
In all such cases the health of the family demands that 
the physician insist on the treatment of the dog for their 
removal. 

As the determination of the species may be of impor- 
tance in such cases there is appended a table, modified 
from Neumann, of the canine cestodes thus far reported: 





to suckling pigs. The development proceeds so slowly 
that in one month there has been formed a spherical solid 
only 0.25 to 0.85 mm. in diameter enclosed in a connec- 
tive-tissue cyst formed by the host, the 
entire mass making nodules in the liver 
barely 1 mm. in diameter. At two 
months the larvee are twice as large, 
the wall consists of a thick external 
lamellar cuticula and a delicate granu- 
lar internal membrane enclosing a 
watery fluid. At five months the di- 
ameter of the parasite has become 10-12 
mm., but no structure is yet visible in 
the interior. To the parasite in this 
condition, consisting of cuticula, paren- 
chyma layer (endocyst), and fluid con- 
tents, the name Acephalocystis has 
been applied .by some authors, and 
frequently the organism makes no 
advance in structure beyond this con- 
dition. Normally, however, there ap- 
pears a protuberance on the endocyst 
(Fig. 1230, a) which develops rapidly 
into a brood-capsule () in which the 
parenchyma is external and the cutic- 
ular layer internal. According to the 





Fic. 1229.—Entire 
Specimen of 


views of some investigators these may Twnia — echino- 

become detached and continue their  ¢coccus from the 

d ] t floati . tl . Dog. X12. (Af- 
evelopment floating (f) in the cavity ter Claus.) 


of the mother cyst, in which case, 

however, a cuticular layer is formed on the outside and 
disappears within. In the opinion of others such free 
daughter cysts or secondary capsules arise in the wall of 
the parasite when a cuticular layer is formed about small 
centres of detached parenchyma; as these grow they 
burst out from the wall, and if they fall within the 
mother cyst and continue their development within the 








Numerous proglottides. 
Strobila several centi- 





230-260 » long, genital 
pore very salient. 
Teenia serrata. 
136-157 » long, genital 
pore not very salient. 


Bifid ; hooks 


Never more than T. serialis. 
slightly broader than 180-220 » long, length of 
long. Small hooks mature segments double 
with guard— that of their width. 


Entire; large 


T. marginata. 
hooks— 


150-170 « long, length of 


meters long. Seg- mature segments treble 
ments— their width. 
Baap to Much broader than 1 t the distal “ ich euddent 
- 4 ; i ts which suddenly 
Head armed; geni- uch broader than long except the distal segment 
Wyareadckers tal pore marginal elongate ; genital pore usually large and ee ee 
onthe head. , and— Three or four segments ; some millimeters long........... Ws. een ee eee T. echinococcus. 
) Double’ and Dila tera <.i,<%cg cc s.cicistes eleiniswie ciab scale tyaiete ainjatese ciate erentaeleniaratcta etateter= sie Dipylidium caninum 
(Head unarmed. Sexual orifices On \the ventral surface........c.0.ccs- teers cectecsass ences osenekene Mesocestuides lineatus 








TANIA ECHTNOCOCCUS von Siebold 1853.—Small ces- 
todes (Fig. 1229) measuring from 2.5 to 5 or 6 mm. in 
length with only three to four proglottides the last of 
which measures when ripe 2 mm. in length by 0.6mm. in 
breadth. Head 0.3 mm. broad with prominent rostellum 
bearing ina double row twenty-eight to fifty hooks which 
vary considerably inform and size. Onchospheres oval, 
32-36 uw by 25-380. Adult found in large numbers in small 
intestine of dog, wolf, jackal, dingo; the larva (Hehino- 
coccus polymorphus) in many organs of a multitude of 
hosts, including man. 

Structure.—The adult of this species was long regarded 
as an immature form by virtue of its small size and 
limited number of proglottides until von Siebold pro- 
duced it by feeding dogs with echinococcus bladders 
from sheep. The experiment has been repeated success- 
fully many times with echinococcus from various sources 
including man, and shows a developmental period of 
seven to eight weeks to be necessary for the production 
of ripe individuals. The experimental production of the 
echinococcus has proved more difficult, but Leuckart has 
succeeded in following it by feeding the adult tapeworms 


788 





cavity of the latter, the form known as an endogenous 
echinococcus is produced; this variety occurs most fre- 
quently inman, pig, and horse. If, on the other hand, the 
daughter cysts burst out from the wall of the mother 
cyst, their continued growth (g-/) outside gives rise to 
exogenous echinococci. Evidently a group of several 
distinct individuals may easily be confounded with a 
group consisting of motherand daughter cysts. Further 
development may also give rise to a third generation of 
cysts inside the second (/). Any or all capsules may re- 
main sterile, 7.e., without heads, and such are the aceph- 
alocystic forms noted above. In most cases, however, 
heads are formed on the brood capsules or on the second- 
ary cysts. According to the recent investigations of 
Goldschmidt a proliferation of the parenchyma layer in 
a brood capsule forms a low elevation (m). As this 
grows there arises inside the capsule an annular furrow, 
and this growing outward cuts off a pyramidal elevation 
(n) which by virtue of its early developed muscles dis- 
plays great mobility, hanging outward from the ‘brood 
capsule (0) or thrusting itself into the same as a solid 
linguiform structure (p). The external chitinous cover- 


_ REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ing of the fully formed head takes its origin in a second 
annular furrow outside the first, which gradually sur- 
rounds the parts already described (g) and on its comple- 
tion leaves the head projecting into the cavity of the 
brood capsule. Suckers and hooks originate and the 
entire structure presents the form of an inverted scolex 





Fic. 1230.—Diagrammatic Representation of Echinococcus Seen in Section. a, Origin of a brood capsule ; 
b, c, d, further stages in its development; e, fully developed brood capsule; f, endogenous daughter 
cyst formed from brood capsule; g, origin of an exogenous daughter cyst; h, i, j, k, its further 
development ; 1, an exogenous daughter cyst forming an exogenous and an endogenous cyst of the 
third generation; m, origin of a scolex as a minute elevation in the wall of a brood capsule; n, its 
delimitation by a shallow internal groove; 0, later stage ; p, the same as last, but invaginated ; q, the 
enclosing of the papilla by a second outer furrow; 1, a fully developed scolex with head inverted. 


(Original.) 


(r). In each daughter cyst (d, e) five to ten, or even as 
many as thirty-four heads may develop, so that the entire 
number in one echinococcus reaches into the thousands. 
By the rupture of the brood capsule scolices may ex- 
tend directly into the cavity of the hydatid or even 
be found floating free in its contents. The echinococ- 
cus is now mature, and if eaten by a suitable host these 
scolices will develop in its alimentary canal into adult 
tapeworms. 

The form of the hydatid cyst is subject to considerable 
variation, the more extreme types of which have received 
special names. Evaginations in the 
wall (s) frequently occur under 
mechanical influences in the en- 
vironment and suggest the origin of 
the form known as LH. racemosus 
(Fig. 1231), from which, however, 





tinctly separated in all cases. The 
latter, known also as an alveolar 
colloid, represents a mass of many 
small hydatids 0.1 to 5 mm. in diam- 
eter which in section display nu- 
merous irregular cavities filled with a transparent gelat- 
inous substance and embedded in a common stroma 
of connective tissue. Gall duct and blood-vessels may 
be detected in places, but the liver cells are completely 
atrophied. These growths were long interpreted as col- 
“loid cancers until Virchow demonstrated their hydatid 
origin. The scolices or hooks, often rare and single or 
at most few in any bladder, are entirely wanting in forty 
per cent. of the specimens tested. These multilocular hy- 
datids undergo regularly degenerative processes by which 
a central cavity is formed filled with a fluid containing 
among tissue remnants also calcareous corpuscles, second- 
ary bladders, brood capsules, scolices, hooks, heematoidin 
and margarin crystals, concretions, etc. The size of the 


Fig. 12381.—Hchinococ- 
cus racemosus. 
Natural size. (After 
Leuckart.) 


EH. multilocularis cannot be dis- ' 


Cestoda, 
Cestoda, 





hooks (Fig. 1232), which varies very considerably, is due, 
as Leuckart has shown, to the age and stage of develop- 
ment of the specimen. 

Anomalies.—A specimen of 7. echinococcus has been 
described with six suckers on the head. Regarding the 
larval form some observers hold that the varieties noted 

. above as Acephalocystis, H. 
racemosus, and H. multilocula- 
ris are abnormal. According 
to others the latter form, 
which appears to be confined 
to Switzerland, represents a 
different species from the 
common type. Isolated cases 
have, however, been report- 
ed from other localities, one 
even from the United States 
(Stiles). 

Distribution. — The adult 
parasite appears to be most 
common in Iceland, where it 
occurred in 28 per cent. of 
the dogs examined. In Aus- 
tralia the percentage is even 
higher, 40 to 50 per cent. 
being recorded. On the con- 
tinent of Europe it occurs in 
from 0.4 to 7 per cent. of the 
dogs examined’ in different 
localities. Stiles records its 
presence, though very rarely, 
in dogs examined at Wash- 
ington, D. C. I have found 
no other record of the pres- 
ence of the adult tapeworm 
in this country. When pres- 
ent its occurrence in large 
numbers is natural. The hy- 
datid is most abundant in 
Iceland and in India, where 
from one-fourth to three- 
fourths of all domestic animals are infected. In Ger- 
many, where records are of a most precise nature, the 
percentage of infection varies very greatly, being as 
low as 5 per cent. in a few cases and as high as 65 
per cent. in one lo- 
cality (for precise 
figures see Stiles and 
Hassall, p. 122). In 
the United States 
hydatids have been 
recorded from cattle, 
hog, and camel, and 
for localities in Mary- 
land, the District of 
Columbia, Mis- 
souri, Nebraska, and 
Louisiana. In New 
Orleans 117 cases of 
liver echinococcus 
were recorded from 
2,000 hogs. 

In man the fre- 
quency of hydatid 
disease corresponds 
in general with that 
for domestic animals. 
In Iceland estimates 
of the number of in- 
habitants infected 
vary from 2 to 15 
per cent.; in Austra- : 
lia 3,000 cases were reported between the years 1861 and 
1882. In Europe the results of autopsies are given in 
the table at the top of the next page, which is taken 
from Ostertag. 

In this country the hydatid is rare in man. Sommer 
has compiled statistics of one hundred recorded cases 





Fig. 12382.—Echinococcus Hooks. a, From 
bladder worm of cow; b, from young 
Teenia echinococcus; ¢c, from adult 
Tenia echinococcus; d, the three 
forms superposed to show gradual modi- 
fication in <form. x 500. (After 
Leuckart.) 


789 


Cestoda. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Cestoda, 
Total HYDATIDS PRESENT. 
Locality. number of 
autopsies. Cases. Percentage. 

ROstock. ventas creiaanere 1,025 25 2.43 
IBréslanhscscuwasckitesiae 1,360 20 1.47 
Bering. ceca ns sles sions cle 4,470 33 76 
GOtUNZON ea nc okinas eae 639 3 46 
Dresden. .cs..shie sect 2,002 if 34 
Vienna: stessiekmoreancty 1,229 3 24 
PVAQUC annie pies beens cot 1,287 3 23 
PrlangVeniccesoascaccuseas 1,812 2 ald 








from which the following data are taken. It is entirely 
unknown how many patients were infected outside the 
limits of this continent; certainly some of them acquired 
the parasite in other countries. 





By SEx. 
alesis rice trtscatentele ae 47 Dnstateds. ccieiecvicts 25 
Females ........... 28 
By NATIVITY. 
SA ZOTIAM cecietaistelelele.s sie 1 IMUIETOT t's 5 ccie ce 2 
Colored’=. we cscehiene 1 INCRTO Wee eons cee srele 2 
FON GiSh jeje ciste sieves 5 POG atone erceniesiers 1 
Foreigners ......... 2 SIGGEY Su Steonuaacoe uf 
TON CH Seri cafe esis 2 Welsh .2<shcs sieve 1 
GeYMAN. 5 sine. 00s 15 Wher crass stlcene 4 
Trishson. tok tants sre 2 UNStatedirnisacc cts « 54 
[talianeencccicesie 5 —_ 
JAPANESE Fac siete vives i TOLL  cericitsteis 100 
IMGXICAN scene ciecene 1 
BY STATES. 
ATSDEINA  attkien esis 2 N@W YOrk <. vis c00 33 
CAlifOrnigicec csi oe Ohio Re yeaa We 
Connecticut........ 1 Pennsylvania...... 10 
District of Columbia. 4 Tennesseé........++ 
jUUhbatay Wacgarauacons 3 TOXAS Asch S onicleiine 1G?) 
indiana see veers 1 WErmiontyr owes sere viele 
Kentucky... < caens tte 2 Wirginiancteicct 2 
Louisiana .......... 1 (or 2?) Washington........ a 
Massachusetts. ..... 5 (or 6?) Unstated 22.0 80.20 se 15 
Michigan: t.csces se il a 
Missourii see eewes 7 Totalcn ce cteester 100 
New Jersey ........ u 





Caution should be exercised in the identification of 
supposed echinococcus bladders from domestic animals 
since the hydatid of Twnia serialis of the dog, which is 
abundant in the United States, is large, at times even of 
very considerable size, and produces numerous secondary 
bladders both internally and externally, so that the gen- 
eral appearance suggests that of echinococcus. The size 
and form of the scolices and of the hooks are so very 
different that even a superficial microscopic examination 
serves to distinguish the two forms. The hydatid of 
Tenia serialis is common in the rabbit and has also been 
reported from the horse. 

Pathology.—The larva gives rise to the hydatid or 
echinococcus disease, the symptoms of which vary with 
the seat of the parasite. Cases are on record in which the 
hydatid has existed for 2, 4, 8, 15, 18, and even 30 years 
inman. It may be found in any organ, but is most fre- 
quently recorded from the liver or lungs. At times its 
presence is not suspected until revealed by post-mortem 
examination; and the danger depends in any case upon 
the precise location and the size attained by the hydatid. 
In some situations hydatids exert a fatal pressure upon im- 
portant vessels or nerves or destroy the tissue of essential 
organs. They often cause fatal results by bursting into 
a serous cavity or a blood-vessel, the toxic effect of the 
fluid having been noted already. Somer gives the follow- 
ing table for 1,806 cases recorded in various countries: 


CLASSIFICATION BY HABITAT. 











United Other 

States. Canada. countries. Total. 
LAVOE i. koaseiies vetigna ceitmapebare 62 i 942 1,011 
GUNG oscis Veeawciceniswieenee 0 i 140 147 
Passed per TeEctUm....eserere 2 300 2 
Spleen aac caeceeecs Aer ciate 3 2 37 42 
Brainy vshen sonore mee eet cide Raa 3 36 3 
Abdominal wall........ sondaads 1 do 1 
APONTE sdoodisddanacages odd. 2 AO aon 2 


790 




















United Other 

States. |C824a.|ountries.| Total. 
EXPOCtOTELOG.s aecteterte stellate cision a 2 A 2 
Common bile duct co.cc. cc. cee 2 eet 2 
BOn@s Se sais cae s carrie e¥oaye rete oie 1 wae 1 
Bla ders. coeas sevice Sh aceensret iors 6 5 > 6 
ELY.Os ahaeigare te tetenumale tetera ewe i 5 ae 1 
Pericardignie..sopemachi skiers 1 : al 
OVATICSAc5.N ee oonwce cale von ee is il x aah 1 
Wlerushkincantns venience tin 3 ne 3 
Trinkets reac fevers einesinreiets i 0 4 4 
KiGMCYS <5 shicsac’s gsi con eieteleis @eieis re 3 Si 123 126 
Neck (fascia) ........ eta cele luacare a AG Rete af 
RlOMACH, cose te auc utteentc seenes al i 5 2 
Extensors Of thigh.)c, +s. sssie a6 1 aa 1 
PICULAveeiatettsies = Gelsine eee ene ae 1 We 19 20 
Circulatory apparatus ........... af an 53 53 
CranialiGAvit¥2., cic teccnnteantsaces ae ne 91 91 
Spinal canal..... i Wacascetetente te ein ii, Bie 13 13 
PelVIS Manabasee sta cu weuse caret 3 2 70 75 
Peritoneum and omentum....... 1 ; 61 62 
Mesentery and omentum ........ 1 A i 
Female genital organs and mam- 

WHOTIOS paeincnc Wis ehaintisalee tener ae Ab 60 60 
Male genital orgams.............. ie ate 9 9 
Face, orbit, and mouth.......... on ae 41 41 
IN@CK crite Bidens otaittumeal ott a iyakisre ee ae 18 18 
‘ADGOMED! aan sais vel weles sways alstoret 2 Ay <aae 2 
OMOUGUIN  yeicisisiss olattew sinectee ee 1 1 
Brain v(ventricles)ic.insstels sete es 1 1 

Totals vs ac cciteae scatie veneer 113 12 1,681 1,806 


Prevention.—As “hydatid disease is the most fatal zoo- 
parasite disease which affects man, fifty per cent. of the 
cases dying within five years after infection,” too great 
insistence cannot be laid upon the necessity of guarding 
against the disease and stamping it out. Measures 
should be taken to destroy all stray 
dogs, to prohibit the presence of dogs 
at abattoirs, to destroy all hydatids 
found in slaughtered animals, and to 
discourage all intimate association with 
dogs. Methods for the treatment of 
echinococcus diseases in man have been 
suggested, but surgical interference 
alone has met with satisfactory re- 
sults. 

DAVAINEA R. Blanchard 1891.— 
Small cestodes with prominent rostel- 
lum, sometimes retractile, armed with 
many small hooks of characteristic 
form, which may be caducous. Geni- 
tal pores unilateral, or alternating ir- 
regularly. Eggs in capsules. Devel- 
opment unknown. 

DAVAINEA MADAGASCARIENSIS R. 
Blanchard 1891; Tania demerariensis 
C. W. Daniels 1895.—Length up to 24 
cm. with five hundred to six hundred 
proglottides. Head (Fig. 1283) with 
retractile rostellum having ninety 
hooks, 18 “ in length, which may be 





Fig. 1233.—Anterior 
End of Davainea 


wanting. Genital pores unilateral.  madagascarien- 
Ripe proglottides 2 mm. long, 1.4 © sis. x14. (After 
mm. broad. .Eggs in groups sur- Blanchard.) 


rounded by heavy capsules of paren- 

chyma forming the characteristic egg balls which fill the 
entire ripe proglottides. Onchospheres 8 in diameter 
with six delicate nearly straight hooks, surrounded by 
two transparent membranes of which the outer has two 
pointed prolongations. 

The growth of the cestode is very rapid. At 3 cm. 
from the head proglottides may be seen in copula. The 
last hundred segments, which make up more than half~ 
of the entire length of the worm, contain only eggs about 
which the capsules are forming. The characteristic ap- 
pearance of the ripe proglottis is given in the figure 
(Fig. 1234). Of the development nothing is known. 
Blanchard surmises that the larval host is a cosmopolitan 
insect (e.g., cockroach), which tallies well with known 
facts regarding the parasite. 

Ten cases of the occurrence of this cestode in man are 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


onrecord; they are distributed over the tropics, including 
both hemispheres. With one exception all individuals 
affected were infants or chil- 
dren. Although not yet re- 
corded from any other host, it 
should be noted that the spe- 
cies may be only an adventi- 
tious parasite of man. 
HYMENOLEPIS Weinland 
1858;  Diplacanthus W ein- 
Jand.—Scolex small, rostellum 
retractile, armed; suckers un- 
armed. Genital pores on left 
margin; three testes in each 
proglottis. Ripe uterus fills 
entire proglottis. Eggs spheri- 
cal or elongated with three 
widely separated membranes. 
Larval stage a cercocystis or 
staphylocystis. 
HYMENOLEPIS NANA R. 
Blanchard 1891; 7. egyptiaca 
Bilharz, Diplacanthus nanus Weinland.—Length (Fig. 
1285) 10 to 15 mm, rarely 20 mm., breadth 0.5 to 0.7 mm. 
a» Spherical scolex (Fig. 1236) 0.25 to 
¢ 0.3 mm. in diameter with retractile 
rostellum armed with a single circle 
of twenty-four to thirty hooks which 
are only 14 to 18ylong. Neck long, 
proglottides about one hundred and 
fifty in number, very short, the 
largest measuring only 0.4 to 0.9 
mm. wide by 0.14 to 0.3 mm. long. 
External egg membrane measures 30 
to 40 rarely 50 u, in diameter, the 
onchosphere membrane 16 to 20 yp. 
Adult in the small intestine of man. 
The development of this species 
is still unknown. Grassi regards it 
as identical with H. murina from the 
rat. According to his investigations 
this latter form develops directly 
without any secondary host, so that 
the chance consumption of ripe pro- 
glottides or of onchospheres would 
ultimately produce the adult tape- 
worm. Other authors have empha- 
sized a series of differences in detail 
which militate against the identity of 
the two forms. In experiments with 
six persons who had swallowed ripe 
proglottides of H. murina, Grassi ob- 
tained specimens of H. nana only 
once, Which in a region where the 
latter is abundant proves nothing. 
On the other hand the same investi- 
gator was unable to infect rats by 
feeding them ripe proglottides of ZH. 
nana. The evidently close relation- 





Fig. 1234.—Ripe Proglottis of 
Davainea madagasca- 
riensis just Liberated from 
the Chain. xX 10. (After 
Dayaine.) 






tion in favor of a similar mode of de- 
velopment. 
Discovered in 1851 by Bilharz in 
Egypt it has been reported occasion- 
ally from Russia, Germany, Eng- 
land, France, Argentine, and the 


Fa. ke Tae United States. In Italy it appears 


a pscege pe of Hy- to be com- 

menolepis nand. ] 

x 15. (After Leuck- paratively 

art.) abundant. 
The single 


record of its occurrence in the 
United States (Spooner, 1873) 
is somewhat uncertain since the 
author mentions the possibility 
that the form described be- 
longed to the following species. 

Hymenolepis nana has been 


ship of the two species is presump- ' 


Fig. 1238.—Reproductive Organs of Hymenolepis diminuta. 
(After Zschokke.) 


Cestoda, 
Cestoda, 





found chiefly in infants, less commonly in children, and 
only very rarely in adults. It occurs in considerable 
numbers, two hundred and fifty to one thousand and 
over, and gives rise to more serious disturbances than 
are attributable to the large cestodes. In addition to gas- 
tric disturbances, secondary 
reflex nervous symptoms, 
even epilepsy, have been 
observed; though of long 


standing they disappear 
with the removal of the 
parasites. 


HYMENOLEPIS DIMINUTA 
R. Blanchard 1891; 7. di- 
minuta Rud., 7. leptocephala 
Creplin, Z. jflavopunctata 
Weinland, 7. varesina Pa- 
rona, 7. minima Grassi.— 
Length 20 to 60 cm., width 
3.5 mm. Head (Fig. 1237) 
small, claviform, with rudi- 
mentary unarmed _ rostel- 
lum. Neck short. Proglot- 
tides short and indistinct at 
first, increasing gradually 
to a maximum near the posterior end of the chain of 
0.66 mm. long by 3.5 mm. wide. External egg mem- 
brane, 60 to 86 yw in length, internal with polar projec- 
tions; onchospheres, 36 by 28 «. Adults in small in- 
testine of various rats and mice, and rarely also of man; 
larvee (cerocystis) in various insects, 
chiefly the meal worm (Asopia fari- 
nalis). 

The structure of the species is typi 
cal for the group. It has been studied 
with great care by Zschokke. The 
arrangement of organs in the sexually 
mature proglottides is evident from 
the figure given (Fig. 1238). In the 
ripe proglottis the egg-filled uterus 
occupies the entire space within the 
walls of the segment save for the 
large flask-shaped cirrus. Sterile pro- 
glottides of smaller size and without 
eggs occur at times in the series. 

The larval form, a cerocystis, oc- 
curs in many insects, Lepidoptera, 
Coleoptera, and Orthoptera. Its usu- 
al host is the larva and adult of a 
small moth (Asopia). The develop- 
ment to the adult form has been ob- 
served in white rats and in man 
where some fifteen days intervene 
before the appearance of ripe eggs 
in the feces. 

This species was first collected 
from man in Boston in 1842, and 
described by Weinland in 1858, who 
regarded it as a new species, 7’ flavo- 
punctata. In 1884 Leidy recorded it from Philadelphia. 
It has also been observed as a human parasite in Italy 
and France, and may be met with more widely since its 
normal host, the rat, is a cosmopolite. 

Heretofore it has been found only in infants and chil- 
dren, and the introduction of the larval parasite was 
probably due to eating fruit or other food in which an 
infected insect or grub was concealed. 





Fig. 1236.—Seolex of Hymeno- 
lepis nana with Rostellum 
Retracted. > 80. a, Isolated 
hook. x 480. (After Leuckart.) 





Fig. 1237.—Ante rior 
End of Hymeno- 
lepis diminuta. 
Magnified. (After 
Zschokke.) 





(Letters as before.) Magnified. 


Co 


Cestoda, 
Cestoda, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Diryurp1um R. Leuckart 1863.— Rostellum retractible, 
armed with several annular rows of alternating hooks. 
Genital pores opposite, organs doubled. Uterus at first 
a reticulum, which later becomes 
changed- into sacs holding. one or 
more eggs each. Eggs with double 
shell. 

DIPYLIDIUM CANINUM Railliet 1893; 
T. moniliformis Pallas, 7. cwewmerina 
Bloch, 7. elliptica Batsch.—Length 
10 to 40 cm., greatest width 1.5 to 8 
mm. Scolex (Fig. 1239) small with 
retractile claviform rostellum armed 
with three or four rows of thorn- 
shaped hooks which decrease in size 
from 15 in the first row to 6 win the 
last; suckers elliptical, neck short. 
First proglottides small, becoming 
trapezoidal and finally characteris- 
tically of melon-seed form. Eggs 
spherical, 43-50 « in diameter; oncho- 
sphere, 82 to 86 “ in diam- 
eter. Adult parasitic in 
the small intestine of the 
dog, cat, and rarely also 
3 man; larva (cryptocystis) 
=. in the body cavity of the 
dog flea and dog louse. 

The most striking fea- 
ture of the structure of this 
species is the doubling of 
the reproductive organs, 
a complete set with genital pores and copu- 
latory organs being present on each side of 
the proglottis (Fig. 1240). The branches of 
the uterus, however, become cut off as small 
capsules containing eight to twelve eggs 
each; in the ripe proglottis the mass of such 
capsules fills the entire middle field, and a reddish-brown 
substance deposited around the eggs imparts a charac- 
teristic pink color to these segments. Prismatic and 
fenestrated specimens have been observed, and also in- 
dividuals in which four sets of organs lay in a single 
proglottis. 

The onchosphere is transformed in the body cavity of 
the dog flea, or even of the human flea, into a tailed 
larva, or cryptocystis. When the dogs, annoyed by the 
work of the fleas, hunt out and destroy these pests, it 
is easy to see how they infect themselves. 

With a single exception all recorded cases of this tape- 
worm in man are among children who have by some 





Fig. 1239.—Anterior 
End of Dipylidiwm 
caninum. (Orig- 
inal.) 






Bhi s Voyat i, 






‘6.Nn. 


Fig. 1240.—Median Portion of Sexually Mature Proglottis of Dipylid- 
ium caninum; ¢, cirrus; ov, ovary; 7s, seminal receptacle; t, 
testis; uw, uterus; v, vagina; vt, vitellarium. X 25. (From Railliet, 
after Neumann.) 


chance obtained the larva of the parasite from playing 


withdogs. The first case on record dates from Linneus, 
and other cases have been reported from England, Ger- 


792 











many, France, Russia, and Scandinavia. Judging from 
the frequence of the parasite in dogs in this country, 
similar cases should not be rare here. I have found none 
definitely recorded. 

The order Pseudophyllidea is characterized by the pres- 
ence on the scolex of two poorly developed sucking 
grooves which may be in some cases much modified. 
Of the three sexual pores the uterine orifice lies always 
on one surface of the proglottis, whereas the two others 
may be on the same or opposite surface, or on the margin 
of the proglottis. The sexual organs are generally single, 
rarely doubled; their development does not transcend the 
stage of maturity so that no parts degenerate. Eggs 
usually with cover. Among the twenty-one genera 
known, only two are of immediate importance here. 

DrIBoTHRIOCEPHALUS Liihe.—Scolex elongated; suck- 
ers not powerfully developed; genital organs single; 
genital pores ventral; uterusin coils in centre of the pro- 
glottis producing a characteristic rosette figure (Fig. 
1241). 

BSerooeten LATus Lithe 1899; Tania lata 








Fig. 1241.—Ventral Aspect of Sexually Mature Proglottis of Dibothriocephalus 
se oe Female Reproductive Organs. 1206.) xX 12. (After 
Leuckart. 


(Cf. Fig. 


and 7. vulgaris L. 1748; Bothriocephalus latus Bremser 
1819; Dibothriwm latum Dies 1850. Length, 2-9 meters, 
rarely up to 20 meters, grayish yellow; head elongated 
oval, 2-8 mm. long, 0.7-1 mm. broad, transversed by 
two deep lateral grooves. Proglottides, three thousand 
to four thousand in number, usually broader than long 
but becoming gradually quadratic. All sexual pores on 
mid-ventral line, cirrus and vagina opening close together 
and in front of uterus. Eggs, 68-70 4 by 45 uw. Adult 
parasitic in small intestine of man, dog, and cat; larva 
(plerocercoid) in the muscles and among the viscera of 
various fish. 

Structure.—The longitudinal sucking grooves, charac- 
teristic of these forms, occupy in reality the upper and 
lower face of the head, appearing at the sides in con- 
sequence of the torsion of the neck. In external appear- 
ance the chain is clearly distinguishable from the other 
large human tapeworms, 7. saginata and 7. soliwm, by 
its greater thickness at the middle of the segment. The 
arrangement of the sexual organs in the proglottis (Fig. 
1206) also differs radically from that already described in 
the genus Zenia. The numerous testes occupy a lateral 
position in the medullary region of the segment, and the 
vas deferens extends in loops toward the anterior end, 
terminating in a muscular cirrus pouch with a seminal 
vesicle. Next the male genital pore lies the orifice of 
the vagina which passes directly posteriad in the median 
line, and after forming a receptaculum seminis joins the 
common yolk duct near the centre of the voluminous 
shell gland. The vitellaria or yolk glands are racemose 
structures occupying the cortical layer of the segment in 
the lateral fields; their numerous ducts converge and 
ultimately unite into the common yolk duct noted above. 
The paired ovaries lie one on either side of the shell gland 
in the posterior region of the proglottis, and the oviduct 
joins the vagina and the yolk duct in the shell gland. 
From the union of these ducts originates a canal which 
expands, and as the uterus, lying in irregular loops ven- 
tral to the vas deferens, extends forward to the special 
uterine orifice, a simple pore in the mid-ventral line a 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





short distance behind the common opening of the cirrus 
and vagina. In the last proglottides the uterus is often 
empty of eggs and the genital glands are atrophied. 

Development.—Ripe proglottides contain numbers of 
brownish, elliptical eggs in which may be distinguished 

the egg cell surrounded by masses of 
A, yolk cells. After lying in water sev- 
* eral weeks a ciliated onchosphere (Fig. 
1209) is hatched out and swims about 
in the surrounding water. Sometimes 
) this embryo throws off the ciliary cov- 
ering, but ultimately dies without at- 
taining any further development. How 
the onchosphere is transformed into a 
plerocercoid remains still undiscovered. 
Braun was inclined to believe in the 
necessity of another intermediate host, 
and Leuckart and others have endeav- 
ored in vain to infect directly with 
onchospheres the various fish which 
harbor the larval form. The bladder 
worm of Dibothriocephalus latus was 
first discovered by Braun in the mus- 
cles and viscera of food fish in the 
Baltic provinces. It is an elongated 
form known as a plerocercoid (Fig. 
1242), and measures 8-30 mm. in length. These larve 
were abundant in fresh fish from Dorpat markets, and 
living specimens were also obtained from smoked, 
salted, and frozen fish as well as in the roes of the 
pike, which salted are eaten raw as caviar. Experi- 
mentation on dogs, cats, and man established the con- 
nection of this larva with the adult Dibothriocephalus 
latus. Other authors, notably Zschokke in Switzerland 
(Geneva), have discovered the larve in perch, salmon, 
trout, grayling, and whitefish, and in some instances 
have determined experimentally their relation to the 
species of cestode under consideration, confirming fully 
the discoveries of Braun. In Scandinavia, Lombardy, 
Switzerland, and Japan the existence of the plerocercoid 
in various fishes and the consumption of some part of the 
latter in a raw condition by the native population ex- 
plain the method of human infection which has been 
further determined experimentally in specific cases. 

Once introduced into the human alimentary canal the 
development of this tapeworm is very rapid, being 
from 5 to 9 cm. per day in the various cases. Eggs ap- 
pear in the feeces of man in from twenty-four to thirty 
days after infection. 

Anomalies.—Slender specimens (var. tenella) have been 
recorded, as also some with exceptionally large proglot- 
tides. One specimen of the prismatic variety is on record 
(of. T. saginata) and fenestration of greater or less ex- 
tent is not rare. Most frequent, however, is the redupli- 
cation of the genital pores and organs which Leuckart 
says he has never failed to find in some proglottis of each 
specimenexamined. Undera separate name (Bothrioceph- 
alus cristatus) Davaine described a variety which is dis- 
tinguished from the common by possessing a projecting 
longitudinal ridge on each flat surface of the head. 

Geographical Distribution.—The peculiarities in the 
distribution of this species are intelligible in the light, of 
its development. It is abundant on the shores of the 
Baltic, especially the Russian and east Prussian, and 
around the lakes of French Switzerland, while the terri- 
tory adjacent to these regions furnishes sporadic cases 
varying greatly infrequence. Small centres, like Munich 
(Bavaria), are known to exist, where the origin of the 
parasite has been attributed to the fish of a certain lake 
or lake region. In Africaanew centre has been reported 
recently in the territory around Lake N’gami. In Japan 
this form is the most abundant of human and canine 
parasites. Its presence in other regions than those 
noted has been recorded occasionally, and usually in per- 
sons known to have come from the infected regions. Of 
this type is the record of its presence in Philadelphia 
made by Leidy. According to Zschokke this species is 
becoming rarer in Geneva, its frequency having fallen 





Fig. 1242.—P lero- 
eercoids of Di- 
bothriocepha lus 
latus from Pike. 
A, Natural size; 
B, C, with scolex 
protruded and re- 
tracted. X2. 
(After Leuckart.) 


‘following species of which the 


Cestoda, 
Cestoda, 


in thirty years from ten to one per cent., and in Paris where 
it was abundant in the eighteenth century it is no longer 
autochthonous. 

Pathology.—It is sometimes solitary, though several in- 
dividuals occur together in the majority of cases and 
nearly one hundred have been recorded from a single 
host. Evidently its frequence depends upon the habits 
of the individual in eating raw or poorly cooked fish no 
less than upon the locality. The effect of the parasite 
is often unnoticed; in other cases are noted gastric and 
nervous disturbances, and even pernicious anemia, which 
disappear with the removal of the worm. These troubles 
have been attributed to the production of some toxic 
substance by the parasite. It should be noted that a self- 
infection is impossible. 

DIBOTHRIOCEPHALUS CORDATUS (Leuckart 1862),— 
Length, 80 to 115 cm. Head (Fig. 1243), 2 mm. in di- 
ameter, flattened cordiform, with deep bothridia on ven- 
tral and dorsal surfaces. Segmentation begins directly 
behind the head; the proglottides, which increase rapidly 
in width, become mature within 3 cm. The largest 
proglottides measure 7-8 mm. in length by 3-4 mm. in 
breadth and number about six hundred. Eggs, with 
cover, measure 75 « by 50 uw. Adult parasitic in seal, wal- 
rus, dog, and man in Greenland; larva unknown. 

The adult is a common parasite in its native land, but 
records of its presence outside of Greenland are based on 
errors. However, sporadic cases may occur in those 
who have become infected while visiting its native home. 
The intermediate host is doubtless a fish. 

DrsotHrium Mansont Ariola 1900. Ligula Mansoni 
Cobbold; Bothriocephalus liguloides Leuckart.; B. Man- 
sont R. Bl.—Adult unknown. Larva a plerocercoid; 
length, 12 to 20 or even to 85 cm.; breadth, 8-6-12 mm. ; 
flattened without proglottides, but marked by irregular 
folds. Anterior end enlarged, bearing the head which may 
be drawn in or evaginated, and on which two faint both- 
ridia are visible. Parasitic in connective tissue of man in 
Japan and China. 

Ten cases of the occurrence of this parasite are re- 
ported, one from China and the rest from Japan. It 
was first found by Manson in an autopsy when a dozen 
specimens were taken from below the peritoneum, and 
one free in the peritoneal cavity. IJjima and Murata 
have described in detail seven cases from Japan; in 
three the parasite was passed with urine or taken from 
the urethra, in three cases also it was drawn from tumors 
of the eye, and in one from a cavity in the subcutaneous 
connective tissue of the thigh. 

Doubtless the larva wanders about in the body of its 
host, in which, as appears from the details of the last case 
cited, it may remain active as long as nine years. Ulti- 
mately it reaches the surface of the body or of an internal 
organ (bladder) from which it eventually attains the ex- 
terior. Of its origin or its further development nothing 
is known. No trace of reproductive organs could be 
found in the specimens studied. In its unusual size and 
in the presence of longitudinal grooves on the ventral 
surface, this larva resembles the 


adult alone is known. 
DiIPpLoGoNoPorus Lénnberg 
1892; Krabba R. Blanchard 
1894.—Genital organs doubled in 
each proglottis; in other respects 
identical with those of Débothrio- 
cephalus. Genital orifices of each 
set ventral on either side of the 
median line of the body, but in of 





cian 
Fi | 





Fic. 1243.—Anterior End 
Dibothriocephalus 


2 F ae s cordatus in Lateral 
the median line of either uterine nq gurface_ Views. 


field. _ x65, (After Leuckart.) 
DIPLOGONOPORUS GRANDIS Lithe 
1899; Krabbea grandis R. Blanchard.—Length, 10 meters 
or more; maximum breadth at anterior end 1.5 mm., in 
broadest region 25 mm. Proglottides very short, near 
posterior end only 0.45 mm. in length by 14 to 16 mm. 
in breadth. Scolex unknown. Genital organs double; 
two lateral rows of sexual openings on the ventral sur- 


793 


Chalybeate Springs. 
Chancroid. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








face, located in longitudinal grooves with genital sinus 
in front and orifice of uterus behind it. Eggs brown, 
Found in 


thick shelled, 63 ~ by 48 to 50 ~ in diameter. 





Fic. 1244.—Sinistral Set of Reproductive Organs from Sexually Mature 
Proglottis of Diplogonoporus grandis. xX 140. (After Ijima and 
Kurimoto.) 


man in Japan; larva unknown. The first account of this 
remarkable species was given by Ijima and Kurimoto. 
It is unique not only in the extreme size manifested, but 
also in the double genital apparatus which occurs in 
some species from seals, but save for this species is un- 
known among human parasites of this group. The sex- 
ual organs (Fig. 1244) are characteristically bothrioceph- 
aline, but they are found in double sets right and left 
in each segment, and the orifices open at the bottom of 
two longitudinal grooves which are characteristic fea- 
tures in the appearance of the worm (Fig. 1245). 

The authors report that the patient 
had suffered for five years from diz- 
ziness and colic which had finally be- 
come so severe as to call for his ad- 
mission to the hospital at Nagasaki. 
Here the parasite was removed and 
even on the following day all the 
trouble of long standing had entirely 
disappeared. In view of our rapidly 
growing intercourse with the East this 
should be looked for among the un- 
welcome additions which are sure to 
be made to our helminthological fauna. 

Quite recently Kurimoto has given 
an account of a second case (also from 
Japan) in which two specimens of the 
same parasite were passed. Unfor- 
tunately, both scolices were wanting 
here also. In other particulars the 
agreement with the original specimen 
of this species was complete. Anomalies such as fenes- 
tration, intercalated proglottides, and those of asymmet- 
rical form were frequent. Henry B. Ward. 





Fig. 1245.—- Ventral 
View of Portion 
of Chain from Di- 
plogonoporus 
grandis. a, Ven- 
tral groove. Nat- 
ural size. (After 
Ijima and Kuri- 
moto.) 


BIBLIOGRAPHY. 


Blanchard, R.: Histoire zoologique et médicale des téniadés du genre 
a pmenolepis Weinland. Bibliothéque générale de Médecine, Paris, 

Braun, M.: Cestodes. Bronn’s Klassen und Ordnungen des Thier- 
reiches, Bd. iv., Abt. i., 1894-1900. Die thierischen Parasiten des 
Menschen. Wiirzburg, 1895. 

Goldschmidt, R.: Zur Entwicklungsgeschichte der Echinococcus- 
AU ie Zool. Jahrb., Abt. Anat., Bd. xiii., pp. 467-494, pl. x xxiii. 


Guyer, M. F.: On the Structure of Tzenia confusa Ward. Zool. Jahrb., 
Abth. Syst., Bd. xi., pp. 469-492, pl. xxviii. 

Huber, J. C.: Bibliographie d. klinischen Helminthologie. Hefte 3, 4. 
Miinchen, 1892. 

Tjima, I.: The Source of Bothriocephatus latus in Japan. Jour. Coll. 
Sci. Jap., vol. ii., pp. 49-56, 1888. 

Tjima, I. and Kurimoto, T.: On a New Human Tapeworm (Bothrio- 
Neto sp.). Jour. Coll. Sci. Jap., vol. vi., p. 371-385, pl. xviii., 

8 


Ijima, I. and Murata, K.: Some New Cases of the Occurrence of Both- 
riocephalus liguloides Lkt. Jour. Coll. Sci. Jap., vol. ii., pp. 149- 
162, pl. v., 1888 

Krabbe, H.: Forekomsten af Bandelorme hos Mennesket I Danmark. 
Nord. Med. Arkiv., No. 19, 12 pp., 1896. 

Kratter, J. and Bohmig, L.: Ein freier Gehirncysticercus als Ursache 
plétzlichen Todes. Beitr. pathol. Anat. u. allg. Pathol., Bd. xxi., 
pp. 25-42, 1 plate, 1897. 


794 


Kurimoto, T.: Beschreibung einer zum ersten Male im menschlichen 
Darm gefundenen Art von Bothriocephalus. Zeitsch. f. klin. Med., 
Bd. xl., pp. 16, 2 plates, 1900. \ 

Liihe, M.: Zur Anatomie und Systematik der Bothriocephaliden. 
Verhandl. Deutsch. Zool. Ges., pp. 80-55, 1899. 

Limstow, O. v.: Tenia africana. Centralbl. Bakt. u. Parasit., Abt. 
i., Bd. xxviii., pp. 485-490, 2 figures, 1900. 

Leuckart : Die Parasiten des Menschen, etc., 2 Aufi., Leipzig, 1879-86. 

Neumann, L. G.: A Treatise on Parasites and Parasitic Diseases of the 
Domesticated Animals. Translation by Fleming, London, 1892. 

Nuttall, G. H. F.: The Poisons Given Off by Parasitic Worms in Man 
and Animals. Am. Nat., vol. xxxiii., pp. 247-49, 1899. 

Seat A.: Traité de zoologie médicale et agricole. 2. Ed. Paris, 

893-95. 

Sommers, H. O.: Further Statistics on Echinococcus Disease in the 
United States. N. Y. Med. Jour., vol. Lxiv., pp. 263-265, 1896. 

Stiles, C. W. and Hassall, Albert: The Inspection of Meats for Animal 
Parasites. U.S. Dept. Agr. Bureau Animal Industry, Bull. 19, 1898. 

Stieda, A.: Durchborung des Duodenums und des Pankreas durch eine 
bhp Centralbl. f. Bakt. u. Par., Abt. i., Bd. xxviii., pp. 430-437, 

Verdun, P. et Iversenc: Note sur un cas de cysticerque du ventricule 
latéral gauche. Arch. Parasitol., T. i., pp. 9, 2 figures, 1898. 

Ward, H. B.: The Parasitic Worms of Man and the Domestic Animals, 
Report Neb. Bd. Agr., pp. 225-348, 1895. A New Human Tapeworm 
(Tenia confusa). West. Med. Rev., vol. i., pp. 35-36, 1896. Note 
on Tonia confusa. Zool. Anzeiger, Bd. xx., pp. 321-322, 1897. 

Weinland, D. F.: Human Cestoides; An Essay on the Tapeworms of 
Man. Cambridge, 1858. 

Zschokke, F.: Recherches sur la structure anatomique et histologique 
des Cestodes. Trav. couronné, Genéve, 1888. 

Also numerous shorter papers by the same and other authors. 


CHALYBEATE SPRINGS. — Meriweather County, 
Georgia. 

Post-OFrFrice.—Chalybeate Springs. 
tages. 

Accrss.—Take Southeastern Railroad to Bostwick, 
thence Talbottom Branch Road to Talbottom, thence 20 
miles west to Springs. 

These springs were discovered by Mr. Rawlings about 
1835, and opened by him for the reception of visitors a 
few years later. The improvements were of a rude char- 
acter until about 1850, at which time they were consider- 
ably enlarged. With the exception of a few years’ in- 
terval they have been open to the public ever since. 
Analysis by Prof. W. J. Land: 


ONE UNITED STATES GALLON CONTAINS: 


Hotels and cot- 





Solids. Grains. 
Silicic acid: (SOlmDE) ii cesiem saalaniaetiantete a ieca. plover eralaketats teres 2.83 
TFON PLOLO-CALOOMALC. ciasciere sist wisls\ola'e vietsin iets) yeints etree : 62 
Iron sesqui-carbonate... te el 
Lime Carbonate:iccicciaas obs ctsecctis ce siete sulere esis recente 76 
Potassium: SUIPNHAtTE. o0..0 602 vsckssiecs cicwices ¢erecechiietne 33 
Sodium: sulphates. vases eeee nee nin. oeempeeeaies cmele 
Aluminum sul phates, ¢oojs.003 «2.0 <0 csicieis ses lees ala meteneenete ones case 
BodIUM: CHIOTIGG <0 0.0.0 c'si00 0 s0'e.'e aioe cle esn'e cleie\cistele diate a ieee -03 

OGG Sv ciare's 0:0: e1e giaye. © Sisle's. 01mm eeie tte ecelevo/etialsieaiere a Tear eeatanatE 5.30 


Carbonic acid gas, 6.55 cubic inches. 


The water is a light chalybeate. There are also traces 
of hydrogen sulphide, carbonate of magnesia, crenate of 
iron, and a minute trace of nitric acid, lithium, and or- 
ganic matter. The proportion of soluble salicylic acid is 
larger than usual. This compound is not used in medi- 
cine, but silica is contained in the human body, and may 
not be without therapeutical value. It is possible that 
the trace of sulphureted hydrogen also slightly influences 
the action of the water. It has been recommended in all 
cases requiring a chalybeate water. The flow is abun- 
dant, being about twenty-five gallons per minute. Near 
by is a sulphur and magnesia spring, but no analysis has 
been made of the waters. The improvements are exten- 
sive, consisting of two hotels and cottages, sufficient to 
accommodate five hundred guests. Bathing facilities are 
ample, both hot and cold water being supplied. The cli- 
mate of this region is of a salubrious character. 

James K. Crook. 


CHAMA-LIRIUM. See Unicorn Root, False. 


CHAMIQUEL.—Coalcoman, Michoacan, Mexico. A 
lukewarm mineral water classified by Dr. Zuniger as a 
sulphureted calcic water, and containing, according to 
Forbes, of Coalcoman, carbonic acid, large quantities of 
lime and magnesia, silica, and traces of copper and iron. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chalybeate Springs, 
Chancroid, 





No bathing facilities have been established so far. The 
bathers are recruited from among those suffering from 
leprosy and diseases of the skin. V. J. Ponce de Léon. 


CHAMOMILE.—ANTHEMIS. Roman Chamomile. 
“The flower-heads of Anthemis nobilis L. (fam. Composi- 
te), collected from cultivated plants” (U.S. P.). In this 
definition the Pharmacopceia recognizes the fact that un- 
der cultivation the aroma and flavor of the chamomile 
grow finer and less rank and heavy, notwithstanding 
that the percentage of volatile oil, and very likely the 
medicinal] strength, are somewhat decreased. 

The chamomile plant is a native of Europe and is 
largely cultivated in temperate regions. It is a low 

perennial, hairy herb with a 


Sic branching rhizome, and rather 
ZAK “O\ Sige numerous stems, most of which 
Ah CAISS 


are short and bear leaves only. 
The flowering stems are long, 
slender, prostrate, often root- 
ing at the base, but ascending 
and branched above, and _ bear- 
ing the flowers at the ends of 
the branches. Flower-heads ra- 
diate, about 2 cm. (#1n.) across, 
with, in the “single” (natural) 
form, a single row of white 
rays and a yellow disc. Invo- 
lucre of two or three rows of 
blunt, appressed, scarious-mar- 
gined scales. Receptacle 
chaffy, conical, solid, longer 
than broad; ray flowers fer- 
tile, limb three-toothed; disc 
flowers perfect, tubular below, 
bell-shaped above. Achenia 
obovate, slightly compressed, 
pappus none. The oil glands 
, are mostly on the corolla tubes, 
=k: and less abundant on the ray 
\ than on the disc flowers. 

The plant is a native of 
Europe, and is largely culti- 
vated in temperate regions. 
Under cultivation, ligulate 
flowers largely replace the tu- 
bular disc flowers, so that the heads become “double” 
and large and white, which condition, by careful and 
rapid drying, should be preserved in the dried heads. 

Chamomile contains nearly one per cent. of a blue vola- 
tile oil, turning greenish or yellowish with keeping and 
having a specific gravity of .905 to .915. The important 
constituents of this oil are anthemol (C:oHi.O) and cumin 
aldehyde (Cy>H,1,C3;H;,CHO). The composition of the re- 
mainder of the oil is very,complex. With the oil there 
are an amaroid, some resin, and a little tannin. 

Chamomile is one of the very best of the aromatic bit- 
ters, and is strongly carminative and somewhat antispas- 
modic. The dose is 1 to4 gm.(34toi.). There is no 
official preparation. The best form of administration is 
a tincture, so as to contain all the oil. Asa simple stom- 
achic a decoction or infusion is excellent. This should 
be well diluted, taken slowly before meals, and the dose 
should be small. The oil is often given as a carminative 
and antispasmodic, in doses of M™ i. to v. 

Atiinp PLaAntTs.—The genus contains about eighty 
species, and includes the common mayweed (Anthemis 
cotula Linn.). They are generally less agreeable than 
chamomile, and although of similar qualities, not in use. 
Chrysanthemum parthenium Pers. (Feverfew) is some- 
times used as a substitute or adulterant of this article. 
It can be told by its flatter and less chaffy receptacles. 
Henry H. Rusby. 


CHAMOMILE, GERMAN.—MATRICARIA. “The 
flower-heads of Matricaria Chamomila L. (fam. Composi- 
te)” (U. 8. P.). This drug is the product of a daisy-like 
plant, one to two feet in height, native of Europe and 





Fig. 1246.—Chamomile, Wild 
or Single-Flowered Plant. 
One-third natural size. 
(Baillon.) 


.is the pathogenic organism. 





Western Asia, and introduced, as a roadside weed, into 
many countries. The reflexed rays are about fifteen in 
number, nearly half an inch long, white, three-toothed. 
These rays, together with its elongated, conical, and hol- 
low receptacle, which bears no scales, distinguish it 
pon all drugs or substitutes which might be mistaken 
or it. 


Its active constituents are its anthemic acid, which is 
very bitter, and less than half of one per cent. of a dark 
blue volatile oil. There are also asmall amount of tannin 
and some anthemidin. 

The drug is very largely used as an ingredient of pro- 
prietary “teas” and other herb mixtures, but possesses 
only ordinary aromatic-bitter properties of the Composite, 
which see. The ordinary dose is 1 to 4 gm. (gr. xv. to 
lx.), and it is commonly given in infusion or fluid ex- 
tract. Henry H. Rusby. 


CHANCRE. See Syphilis. 


CHANCROID.—Chancroid is a local, contagious, vene- 
real disease, appearing as suppurating ulcers about the 
genitals, and is due to contact with secretions from the 
same kind of ulcerations. Aside from causing more or 
less severe inflammatory reaction in the lymph glands in 
the immediate vicinity of the sores, chancroid is always 
a local process and never causes constitutional infection. 

Until within the last half-century it was generally be- 
lieved that syphilis and chancroid were due to the same 
cause, but their individual entity has now so long been 
established that the old opinions interest us simply asa 
matter of history. The two diseases very frequently 
exist in the same individual at the same time, but they 
are, of course, due to inoculation at the same time and 
spot with two entirely separate and distinct poisons. 

At the outset too much emphasis cannot be placed on 
the necessity of a careful examination and accurate diag- 
nosis of all venereal sores. Cases of initial syphilis are 
constantly being diagnosed as chancroids. Many men 
have married with their doctor’s approval (and reassur- 
ance that their sore wasa soft oneand therefore harmless), 
only to see syphilis appear in themselves and be trans- 
mitted to their wives and children. 

To the clinical observer the purulent secretion from 
chancroids is the medium which conveys the contagion, 
and it has been claimed that the leucocytes alone contain 
the virus, and that inoculations with a solution from which 
the pus cells had been removed yielded negative results. 
We also know that cold has apparently little effect upon 
the vitality of the organism, while it is readily destroyed 
by heat, drying, and antiseptics. 

ErroLtogy.—Chancroid is undoubtedly due toa specific 
micro-organism, but what that organism is has not yet 
been conclusively demonstrated. 

At the present time there are only two opinions that 
are deserving of consideration: first, the claim that the 
ordinary pyogenic bacteria are capable of producing typi- 
cal chancroidal ulcers; second, that the bacillus of Ducrey 
It has also been claimed 
that cases of chancroid have arisen de novo, there having 
been no active chancroidal ulcerations present in the party 
giving the infection. 

In asserting that chancroids are of purely pyogenic 
origin, it has been pointed out that the secretions from 
chancroids always contain streptococci, staphylococci, 
and non-pathogenic bacilli, as well as the streptobacillus 
first described by Ducrey and claimed by him to be the 
specific organism of chancroid. It is also claimed that 
chancroid is to mucous membranes what impetigo and 
pus infection are to the skin, and that the streptobacillus 
is an accidental accompaniment and not the cause; and, 
furthermore, that chancroid is usually found in broken- 
down prostitutesand among the poorer classesin general, 
a class whose vitality is lowered by lack of proper food, 
over-indulgence in alcoholics, by filth and unhygienic 
surroundings; in other words, a class in whom we know 
that slight abrasions of the skin become easily infected 
with pus cocci, suppurate freely, and do badly in general. 


795 


Chancroid, 
Chancroid, 


Certainly the genitals in the uncleanly, with heat, mois- 
ture, and decomposing smegma, furnish an excellent 
medium in which the pus organisms may grow. 

Now it is well known that chancroid is by no means 
confined to the cachectic and debilitated, but may occur 
in the robust and healthy when exposed to chancroidal 
infection. If pyogenic bacteria alone were capable of 
causing chancroids, those individuals with long foreskins 
and excoriative balanitis, with acquired phimosis and a 
foul, subpreputial discharge, would develop chancroids. 
Furthermore, women with peri-urethral or vulvo-vagi- 
nal abscesses, complicating gonorrhcea, or men with ul- 
cerations dependent on scabies of the genitals, would 
also develop chancroids. Clinical experience shows that 
such is not the case. 

It was pointed out by Ducrey that in repeated in- 
oculations with chancroidal pus the accompanying 
streptococci, staphylococci, and other bacteria rapidly 
disappeared, leaving nearly pure cultures of the strepto- 
bacillus, which he looks upon as the pathogenic organ- 
ism of chancroid. Unna, Krefting, Wielander, and others 
have found, both in smear preparations and in sections 
from the floor and walls of chancroidal ulcers, these same 
bacilli described by Ducrey. 

They are short and thick, with rounded ends, and have 
a slight constriction in the middle which gives them a 
sort of figure-of-eight or dumb-bell appearance, and tend 
to group themselves in parallel chains. The bacilli usu- 
ally lie outside the cells, though occasionally within 
them, and they are said not to be found in the pus of 
suppurating chancroidal buboes. The bacilli of Ducrey 
stain readily with fuchsin or gentian violet, and are de- 
colorized by Gram’s method of staining. 

Bacteriological investigation is handicapped by the 
inability to grow the bacilli on artificial media, and also 
from the fact that up to the present time animals have 
not been successfully inoculated. 

Until these bacilli can be cultivated and inoculations 
made producing characteristic lesions, and from these 
lesions the organisms recovered, the claims for the Ducrey 
bacillus cannot be accepted as conclusive. 

CuinicAL Hisrory.—There is no period of incubation 
in chancroid. The process begins as soon as the virus 
gains an entrance to the tissues, and usually is noticed 
within two or three days after exposure. 

The first thing that appears is a small papule witha 
yellowish centre situated on an inflammatory base and 
surrounded by a slight halo of congestion. The yellow 
vesicle in the centre increases and soon ruptures, leaving 
a small ulcer with a grayish, velvety base and sharp. well- 
marked edges, giving ita punched-out appearance. The 
edges become undermined and give way, and the size of 
the ulcer increases in this manner, the surrounding con- 
gestion spreading as the ulceration advances. The floor 
of the ulcer then has a grayish, uneven, worm-eaten ap- 
pearance, is bathed in pus, with little tendency to bleed, 
unless roughly handled. There may be only one ulcer 
at the start, or there may be several, but soon fresh points 
of auto-infection appear and each new ulceration goes 
through the stages of destruction, rest, and repair like 
its predecessors. This tendency to spread by auto-inoc- 
ulation is one of the most striking and constant of the 
characteristics of chancroid. The floor and edges of a 
chancroidal ulcer, no matter how long it has existed, are 
never indurated unless it has been cauterized. 

Within a short time after the appearance of chancroidal 
ulcerations the glands in the immediate vicinity may be- 
come inflamed. Usually but a single gland in the chain 
swells, becoming both painful and tender, but the glands 
in both groins may become affected. Not infrequently 
the glands break down and require surgical care. 

In trying to determine the character of a doubtful sore, 
great care should be taken to notice the condition of the 
neighboring glands, for their behavior in chancroid is so 
entirely unlike the condition in syphilis that it is one of 
the chief features in diagnosis. 

In chancroid the glandsare either not affected at all, or 
when affected, are inflamed, painful, and tender, and 


796 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





tend to suppurate, while in syphilis the process is non- 
inflammatory, the glands are neither painful nor tender, 
and they very rarely undergo suppuration. 

In men with long foreskins soft chancres situated on 
the mucous membrane of the prepuce or along its free 
margin often cause an acquired phimosis with a good 
deal of heat, redness, swelling, and pain. The whole 
prepuce then feels thickened, brawny, and tender, and 
may entirely obscure the beginning induration of a sore 
beneath, so that in this condition one should be very 
guarded as to the outcome of such a case. When the 
ulcers are seated about the ostium preputii, micturition 
is usually painful, as the urine comes in contact with the 
raw surfaces. This pain may be greatly relieved by 
urinating with the penis immersed in warm water. 

It is not uncommon to find the lymphatics running 
along the dorsum of the penis inflamed and tender, and 
occasionally a gland at the base of the penis swells and 
may even suppurate. 

Location.—Chancroid is usually located about the 
genitals. Extra-genital chancroids do occur, but are 
very rare as compared with the extra-genital initial lesions 
of syphilis. In men the most common site of chancroids 
is in the sulcus, back of the corona glandis, next the 
frenum. Here minute tears occur from mechanical vio- 
lence during intercourse and are readily infected. 

Ulcerations in this location are more painful and tend 
to bleed more easily than in other spots. They also fre- 
quently perforate and destroy the franum entirely. 
The resulting ulcers are slow to heal and may give rise 
to a good deal of hemorrhage, owing to the abundant 
blood supply. 

Another common spot is along the free margin of the 
prepuce. Here the ulcers are irritated in handling the 
penis in urinating, in retracting the foreskin for pur- 
poses of cleanliness, etc. 

In women the lesions of chancroid are situated about 
the clitoris, introitus vagine, and on the labia, perineum, 
and about the anus; very rarely, on the cervix uteri or 
the walls of the vagina. 

When extra-genital chancroids do occur, it is usually 
by auto-infection rather than by direct infection; ¢.g., a 
careless patient in caring for his chancroids may smear 
some of the discharge on his fingers and inoculate some 
part of his integument by scratching. 

The number of lesions in a case of chancroid is variable; 
it may remain as a single sore, but is usually multiple, 
the multiplicity being due to the highly inoculable char- 
acter of the chancroidal pus. The virus can undoubtedly 
penetrate sound mucous membranes when deposited 
thereon, while on the skin entrance is gained through 
hair follicles or minute abrasions. 

The power of reproducing itself in the same individual 
is perhaps best shown in the case of filthy women who 
allow the discharges from chancroids about the vulva to 
run down over the perineum and about the anus, or even 
the upper part of the thighs, thus causing very numer- 
ous ulcerations in the localities named. 

In determining the character of a doubtful sore, it is 
sometimes of value to try auto-inoculation. In doing 
this a spot well removed from the large chains of lymph 
glands should be selected. The pus from chancroids is 
always capable of auto-inoculation. 

The size of chancroidal ulcerations varies from that of 
a pea in mild cases up toasilver dollar or larger in severe 
serpiginous cases. The size of the lesion is of compara- 
tively little value in making a diagnosis. The shape of 
the ulcer is perhaps oftener roundish or oval, but this 
depends upon the location and is of no importance. 

The duration of the disease is modified so much by the 
patient’s general physical condition and habits of life, as 
well as by the medical management of the case, that it is 
difficult to give anything like an exact time limit. 

There are three fairly well-marked stages in the dis. 
ease: the period of destruction, followed by an interval in 
which the condition remains about stationary, the ulcer- 
ations not extending; and this in turn is followed by the 
period of repair, where the character of the ulcer changes; 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





it appears less sluggish, bright red granulations begin to 
show in the floor of the ulcer, and there is then a greater 
tendency to bleed; any necrotic tissue which may be pres- 
ent comes away and the sore heals by granulation. In 
uncomplicated cases in otherwise healthy individuals, the 
course is run in from two to six weeks. Too vigorous 
exercise, alcoholic indulgence, and complications such 
as phimosis, gangrene, or phagedena (the two latter are 
very rarely seen at the present time), may extend the 
course much longer. 

Draenosis.—Chancroid is to be differentiated from the 
initial lesion of syphilis, from the mucous patches of sec- 
ondary syphilis and the gummatous ulcerations of late 
syphilis, from herpes progenitalis, from ulcerations ac- 
companying scabies of the genitals, and from epithelioma. 

The initial lesion of syphilis is to be distinguished from 
chancroid by its well-marked period of incubation, the 
sore usually appearing in from two to four weeks after 
exposure. Instead of a suppurating ulcer we are apt to 
find a more or less well-marked infiltration of the tissues 
about the sore with an erosion of the surface, and with 
very little purulent secretion. The striking features of 
chancroid are the non-indurated, suppurating ulcers 
which are always capable of auto-inoculation. In syph- 
ilis, on the other hand, we are impressed by the indura- 
tion (the sore often feels like a foreign body in the tissues 
when taken between the thumb and fingers), and by the 
fact that the number of sores, representing so many 
points of inoculation, always remains the same from the 
beginning to the end. 

Another important difference is the behavior of the 
neighboring lymph glands in the two diseases. It has 
already been pointed out that usually in chancroid a 
single gland in the chain is swollen, painful, and tender, 
and the process not infrequently ends in suppuration. 
In syphilis the glands in the whole chain are affected, are 
non-inflammatory, neither painful nor tender, they are 
freely movable under the fingers and have a peculiar 
hard, shotty feel. It is rare for the glands accompanying 
the initial lesion to break down. 

In a case of chancroids one can never rule out the 
possibility of a coexisting syphilis until the incubation 
period of the latter is past. 

In women especially, mucous patches of syphilis oc- 
curring about the vulva and anus may very closely 
simulate chancroids. The same lesions are found in men 
usually about the glans penis. These lesions will be 
found to have not the clean-cut edges, purulent secre- 
tion, or the velvety, worm-eaten-appearing base of chan- 
croids, but a grayish, smooth, opaline appearance. The 
secretions from these mucous patches are highly con- 
tagious and foul-smelling, but are never capable of auto- 
inoculation. 

The diagnosis, in the case of mucous patches, can gen- 
erally be easily determined by the presence of other 
syphilitic manifestations or by the history. 

At times a late syphilitic ulcer may appear about the 
genitals and very closely simulate a chancroid. The 
history of a previous syphilis, the non-involvement of 
the glands in the vicinity, and the lack of evidence of 
auto-infection will hardly allow a mistake to be made. 

Herpes pregenitalis.—In herpes there is a sense of 
burning and itching before the eruption appears. At 
first the contents of the vesicles are clear and not yellow 
like chancroids, though they may become yellowish later, 
when pus is present. The covering of the vesicle easily 
ruptures and the small ulceration resulting may extend 
somewhat in depth, but not in breadth, unless two or 
more vesicles run together. There is seldom any disturb- 
ance in the lymph glands and the disease runs a self- 
limited course. The spots dry up and disappear in a 
week or ten days There is oftenno history of exposure, 
and certain individuals are prone to repeated attacks. It 
occurs in both sexes, and it is not very uncommon to see 
a person with a herpes progenitalis and a herpes labialis 
at the same time. 

Ulcerations about the genitals due to scabies are to be 
distinguished from chancroid by the presence of burrows 


Chancroid, 
Chancroid, 








and marks of scratching on the foreskin, and evidence of 
scabies on other parts of the body. 

A. peri-urethral abscess occurring in the sulcus, back 
of the glans, might at times suggest a chancroid, but if 
its sharply circumscribed appearance and inflammatory 
character are borne in mind, together with the history of 
a ‘previous gonorrhcea, the liability of a mistaken diag- 
nosis is very small, 

CoMPLICATIONS.—The complications of chancroid are 
phimosis and paraphimosis, lymphangitis and suppurat- 
ing bubo; phagedeena and gangrene are very rarely seen 
nowadays. 

Phimosis and paraphimosis not infrequently occur 
during the course of chancroid. In phimosis the whole 
prepuce may become swollen, red, or reddish purple in 
color, tender and doughy to the touch, with a more or 
less profuse foul, purulent discharge. 

Often there will be one or two small ulcerations at the 
margin of the foreskin which show the nature of the 
sores within. Occasionally, in unrelieved cases, the pre- 
puce ulcerates through and allows the glans to protrude. 
Paraphimosis is less common, though not much less 
severe a complication. The swelling of the parts may 
be very great, and the line of ulceration which occurs in 
the line of constriction back of the cedema, at right angles 
to the shaft of the penis (nature’s attempt at relief of 
the condition), becomes infected with the chancroidal 
virus and extensive destruction of tissue may result. 

Lymphangitis and Lymphadenitis.—As has already been 
mentioned, the lymphatics of the penis are often involved 
and are felt as a hard, tender cord beneath the skin. 

The condition of the lymph glands has already been 
described. 

TREATMENT.—In the treatment of chancroids it is 
essential that the patient keep as quiet as possible. All 
excessive or violent exercise, running, skating, dancing, 
etc., is to be avoided. 

The next step is to keep the sores thoroughly cleansed 
with soap and water and antiseptic solutions. It is al- 
ways well to use the lotions as hot as is grateful to the 
patient, for heat in itself is exceedingly beneficial in the 
treatment. The principal solutions in use to-day are 
corrosive sublimate, 1 to 1,000 or 1 to 2,000; creolin, 1 to 
250; lysol,1to 500; formalin, 1 to 50; carbolic acid, 1 to 50; 
boric acid in saturated solution. After cleansing with the 
wash, the surface of the ulcers should be carefully dried 
and dusted over with one of the following powders: 
aristol, europhen, iodol, calomel, acetanilide, or iodoform. 

Perhaps the last named is the most efficacious of any 
of the powders named for use in the early stages or up 
to the appearance of healthy granulations. Of courseits 
odor is a great objection, and its use is as a promotor of 
healthy granulations. It should ordinarily be used as a 
fine powder, but may be suspended in ether or gly- 
cerin. The deodorized iodoform is of little value. Care 
should always be taken not to irritate the sores, either 
by manipulation or by the dressings employed. 

This may be termed the conservative or symptomatic 
treatment; opposed to this may be given the heroic or 
radical treatment. 

Here the attempt is made to change at once the chan- 
croidal ulcer into a simple one by thoroughly destroying 
the surface of the sore. This is usually accomplished by 
the actual cautery or by the application of caustic acids. 
Nitric and carbolic are the ones commonly used to-day. 
Excision should rarely, if ever, be done. Before cauter- 
izing a sore it should be carefully cleansed and cocainized, 
and then the acid applied thoroughly to the floor and 
edges of the ulcer, with a bit of absorbent cotton wound 
around the end of a wooden toothpick. Care must be 
taken to restrict the action of the acid to the diseased 
tissue, and the action of nitric acid can be controlled by 
the use of bicarbonate of soda. 

The stick of silver nitrate is a popular caustic with the 
laity, but its use is to be severely condemned. — Its action 
is superficial, irritating to the tissues, productive of 
cedema and suppurating bubo, and should never be em- 
ployed as a means of destruction of the sore, but asa 


197 


Change of Life, 
Change of Life. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





stimulant to sluggish granulations it may be of service. 
However, it should never be used early. Caustics should 
never be applied to a sore that cannot be thoroughly ex- 
posed and properly cared for. After cauterizing, the sore 
should be treated with moist bland dressings for a time, 
lint soaked in lead-water wash or a solution of boracic 
acid or black wash, and changed frequently. After a few 
hours this dressing should be changed to one of the 
powders already named. 

As a general rule, ointments and greasy preparations 
should not be employed, except, perhaps, over the 
powder to keep the cloth from sticking and thus prevent 
bleeding when the dressing is changed, or when the ulcer 
is granulating, to promote healing. Internal medication, 
unless the individual is much run down, is not usually 
needed. General tonics (iron, cod-liver oil, syrup hypo- 
phosphites, etc.) may often be of service in debilitated 
cases. 

Mercury should never be given in a case of chancroid. 

In old sluggish chancroidal ulcers, a thorough curetting 
is sometimes of service. In women the treatment is more 
difficult by reason of the inability to keep the parts clean 
and reach all the points of infection. Hot injections of 
soap and water or borax and water followed by a cor- 
rosive douch, 1 to 5,000, should be used once or twice 
daily, and one of the powders already mentioned dusted 
on all the available spots. 

A ten to forty per cent. solution of formalin gently 
applied, or a saturated solution of pyoktanin blue, has 
been highly recommended in sluggish cases. 

In general, it is always advisable, in the vast majority 
of cases, to avoid using any sort of caustic. When used, 
it should be applied only to carefully selected cases, and 
should be used with the greatest care. 

C. Morton Smith. 


CHANGE OF LIFE.—This term, in common use, sig- 
nifies the series of phenomena which are apparent at 
the end of the child-bearing period. 

It is applied exclusively to women, though an analogy 
has been observed between some of the conditions which 
affect women at the period in question and similar con- 
ditions which have frequently been noted in men at the 
time when their physical powers have reached their 
culmination. 

The term which is generally accepted and used by 
medical writers as correlative with change of life is meno- 
pause. 

This term is sufficiently explicit for only one link in the 
chain of phenomena which comprise the change of Jife, 
to wit, the cessation of the monthly flow. For this reason 
the common term is the more exact and comprehensive 
and therefore presents claims for its general use. 

The change of life is really one of the great epochs in 
the life of woman, for it not only serves as the boundary 
line between the period in which she is able to reproduce 
herself and her species—period of fruitage,—but it marks 
the limit of the progressive stage of her physical condi- 
tion in general, deterioration being henceforth the pre- 
vailing process, whether it develops slowly or rapidly. 

Time of its Occwrrence.—Like all the other functions of 
animal life, this one also is subject to great variations 
both as to the time of its occurence and the events which 
characterize it. 

According as it occurs early or late in life it may be 
premature, normal, or retarded, and it may be natural or 
artificial according as it is or is not solely the product of 
physiological forces. 

In temperate climates we may expect its appearance 
in the majority of cases between the fortieth and forty- 
fifth years; family or race peculiarities may advance it 
two or three years or defer it for an equal period. It 
is premature when it occurs prior to the fortieth year 
and it is retarded when it occurs later than the fifty- 
fifth. 

Influences which Modify its Occurrence and its Course.— 
Race. The nearer a tribe or race of human beings ap- 
proaches the lower animals in its intellectual develop- 


798 





ment the less marked will be the menstrual function in 
its women. 

Menstruation is quite clearly the development or evo- 
lution of the rut or wstruation in the lower animals. In 
the apes and monkeys we observe very frequently a dis- 
tinct regularity in what may be termed for them the 
menstrualflow. Neither in the animals nor, so far as my 
knowledge extends, in the lower orders of human beings 
are there well-defined conditions which might constitute 
the change of life, at least as this experience is observed 
in the more advanced races. 

In proportion as a community or race advances in 
civilization do we see the menstrual function and the 
change of life assume distinctness and character. While 
it does not follow that their unusual or pathological 
features are necessarily the result of civilization, since 
there are countless examples in which no appreciable 
disturbance, is experienced from either, it is certainly 
true that such disturbance does accompany civilization. 

Climate. The influence of extremes in temperature 
acts upon the change of life precisely as we would antici- 
pate. In the tropics vegetation is luxuriant, matures 
early, and is profuse in its fruitfulness, but the duration 
of its life is shortened by the very excess of this profuse- 
ness. It is the same, to a certain extent at least, with 
human females who are native to the tropics: they ma- 
ture and bear their children early, and in frequent in- 
stances reach the menopause between twenty and thirty. 
This has been observed especially of the Arabs of the 
desert. To the Caucasian races transplantation to the 
tropics means a distinct lowering of vitality, with a great 
diminution in reproductive power and a consequent 
tendency to the early cessation of the menstrual function, 
and the advent of the change of life. In the Arctic 
regions the effect of extreme cold upon vitality is similar 
to the effect of extreme heat, though it may be made en- 
durable to a greater degree than the latter. The natives 
of the Arctic regions are stunted in form and more or less. 
deficient in vitality. This is especially the case after 
they have endured the rigors and the darkness of the 
long Arctic night. The women seldom mature earlier 
than the twentieth year, menstruate very infrequently, 
and seldom have more than one or two children. The 
duration of life is not great, and the change of life comes 
between thirty and forty. 

Altitude. The significance of this factor is due, of 
course, to the change in the air pressure. Women may 
gradually become habituated to any condition of atmos- 
pheric pressure, but the effects which obtain prior to. 
such habituation are very distinct. A change to the sea 
level by one who has lived away from the sea and at. 
more or less of an elevation generally suspends or other- 
wise disturbs the menstrual flow, and in cases in which 
there is decided constitutional disturbance it is possible 
that the change of life might be hastened by such resi- 
dence. 

Those who go from the sea level to reside at altitudes. 
of six thousand to seven thousand feet or more experience, 
on the other hand, increased profuseness in the menstrual 
flow, the externalair pressure being greatly reduced. Of 
the influence of such reduced pressure upon the change of 
life except in prolonging its duration and increasing the 
frequency and profuseness of its hemorrhages, I am not 
prepared to speak. I know of no statistics bearing 
directly upon this subject, which is one of the many fruit- 
ful themes in climatology still awaiting investigation. 

General. Physical Condition.—The general condition of 
a woman has much to do with the inauguration of the: 
change of life and with the events by which it may be 
characterized. Those who suffer with grave constitu- 
tional and visceral diseases which seriously impair their 
vitality are almost certain to experience an arrest of 
menstruation and often other symptoms which accom- 
pany the change of life. Those who suffer with tubercu- 
losis, syphilis, general anzemia, chronic diseases of the 
liver or kidneys, etc., are in this category. The acute 
wasting diseases sometimes produce so profound an im- 
pression that the menstrual function is entirely obliter- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


ated. On the other hand, the malignant diseases of the 
genital organs, if present at a time when the change of 
life might be expected, cause its unlimited delay. I do 
not recall a case of such disease, in a very large experi- 
ence, in which the change of life ensued after the malig- 
nant disease had begun its destructive career, In fibroid 
tumors of the uterus, especially those which are charac- 
terized with much discomfort and hemorrhage, it was 
formerly the custom to hold out the hope that all trouble 
would cease when the change of life brought its beneficent 
issue. In most cases this has proven the most unsatisfac- 
tory will-o’-the-wisp hunting by which a poor mortal 
could be deluded. The change of life again and again 
escapes the grasp, until finally it comes to mean that 
transformation which arrives for us all “ when this mortal 
shall put on immortality.” 

The beneficent influence of modern gynecology has 
removed the veil of ignorance in regard to this subject, 
and the early removal of these tumors has alike brought 
on the change of life and the relief of many troublesome 
symptoms. The change of life comes quite early in 
women who become excessively fat. Such women are 
usually sterile. Their physical condition unfits them for 
the normal experiences of pregnancy and parturition, 
menstruation is infrequent, scanty, and painful, and it is 
not unusual for the change of life to occur within a few 
years of the appearance of the obese condition. 

Surgical Procedures.—Certain surgical operations are 
conducted with the deliberate intention and purpose of 
bringing about the change of life. Such are all opera- 
tions in which the ovaries are entirely removed. It is 
estimated that in ninety per cent. of cases of removal of 
the ovaries menstruation is at once arrested. If the 
uterus and Fallopian tubes are also removed the percent- 
age in which such a result is obtained will be even greater. 
There are no other surgical procedures which act so direct- 
ly to induce the change of life as does extirpation of the 
ovaries. Operations which may be followed by prolonged 
suppuration and invalidism by impairing the general 
nutrition and reducing vitality may result in arresting 
menstruation temporarily or permanently and in bring- 
ing about the premature appearance of the change of life. 

Occupation.—Both a direct and an indirect influence 
may be exerted by occupation upon the subject which is 
under consideration. - Such occupations as keep a woman 
in an elevated temperature during most of the day are 
very disturbing to the menstrual function, have a very 
decided tendency to produce obesity and may induce the 
change of life prematurely. Cooks, laundresses, and 
bakers are particularly subject to such influences. Other 
occupations which impair nutrition and vitality also dis- 
turb the menstrual function and hasten the change of life. 
Workers in chemical factories and laboratories upon 
arsenic, copper, lead, phosphorus, and other poisonous 
substances, workers in mines, cellars, in badly lighted, 
badly ventilated, and damp surroundings are included in 
this category. Other sufferers are those whose work is 
exhausting and unwomanly and predisposes to wrinkles 
and premature old age; such are fishwives, field workers, 
bearers of heavy burdens on the shoulders or head, me- 
chanics’ assistants who may carry tubs of mortar, casks 
of water or other heavy burdens, all these being types of 
laborers which one sees much more frequently among the 
laboring classes in Europe than in this country. 

Excessive Fertility.—With many women the reserve 
capital of vital force is not large. Bearing children in 
rapid succession until five, six, or more have been borne 
in as many years exhausts that capital, and then follows 
the change of life while the woman is yet young. The 
reason for this is perfectly plain and is seen in the results 
which follow over-productiveness in animal or vegetable 
life wherever we may take the trouble to investigate it. 
Such a result can hardly be regarded as disease, but sim- 
ply as the taking up of a certain amount of capital to 
which nothing remained to be added by way of replenish- 
ment. 

Dissipation and Vice.—The number of women who 
lead irregular and vicious lives is so great that it would 


Change of Life. 
Change of Life. 





seem as if important deductions might be made from the 
study of such lives. It has happened to my experience 
to see quite a large number of women of the vicious and 
depraved class of all ages. These women suffer greatly 
both with acute and chronic diseases of the pelvic organs; 
they frequently suffer with profuse hemorrhage from the 
uterus, and their excesses very often result in sterility, 
so that if the vicious life is followed by marriage, it is 
not likely to be a fruitful marriage. It has been a matter 
of surprise to me, again and again, that the excesses in 
sexual intercourse on the part of prostitutes and others 
do not arrest menstruation and bring on the change of 
life. Of course irregular habits, late hours, excesses in 
alcohol, etc., frequently break down the health, and the 
menses may be arrested as the result of ansemia, etc., if 
the woman does not die promptly from exhaustion or 
some acute disease, as is the result with many. As a 
matter of fact I have seldom been called to record such 
an occurrence; indeed, the stimulation of the sexual 
organs and the careless, irresponsible life of many of 
these women seem to improve nutrition, and for a long 
time, at least, their physical condition is surprisingly 
good. 

Phenomena and Duration.—There are certain phe- 
nomena which are almost invariable and others which are 
only occasional to the change of life. We must also re- 
member that with some women the transition is imme- 
diate and without appreciable symptoms, except that the 
ordinary monthly flow abruptly ceases. The leading 
symptoms are practically the same whether the condi- 
tion is the natural change or one which is induced by 
disease or surgical procedure. To those who experience 
it while still far removed from the usual period of time 
when it is to be expected, the symptoms may be exagger- 
ated; but not necessarily so, for I have seen young girls 
go through this change with scarcely any discomfort or 
unusual happening. 

Cessation of the Menstrual Flow.—The leading symptom 
is the disappearance of the regular monthly bloody dis- 
charge. Thiscessation may occurabruptly, the flow ap- 
pearing one month, disappearing the next and never reap- 
pearing. This may be explained by the fact that physical 
maturity has been reached, just as the fruit falls from the 
tree when it is ripe; or it may be the result of disease, of 
removal of the ovaries, of intense emotion, etc. If the 
cessation of the menses occurs in young women, the pos- 
sibility of its restoration in due season must be considered. 
Instead of an abrupt cessation the flow may reappear at 
regular or irregular intervals, two months, four months, 
six months or longer, finally ceasing altogether after one, 
two, or three years. 

Kacessive Flowing.—A very marked feature in some: 
cases, when the flowing has become irregular, is its pro- 
fuseness. It was formerly thought proper to do nothing 
for this symptom on the supposition that it was simply 
a natural discharge. I have striven diligently for years 
to combat this view. Excessive loss of blood is always 
unusual, abnormal, and should be investigated and 
arrested. The condition of the uterine mucous mem- 
brane usually calls for active treatment in such cases by 
the application of astringent substances to it or the re- 
moval of granulation tissue, which may be the cause of 
the hemorrhage, by the curette. Tumors and other dis- 
ease of the uterus assume particular importance at this 
time, and one should never leave to the unaided efforts of 
nature the disposal of a burden at this time which she 
may be unable to dispose of or only with great risk to 
the patient’s life. 

Flushing and Other Vaso-Motor Disturbances.—Almost 
as common a symptom as the arrest or irregularity of the 
menses is the vaso-motor disturbance which occurs with- 
out warning many times a day until toward the end of 
the change, and is manifested now by flushing and heat, 
and now by pallor and chill. The experience of each 
paroxysm may continue but a moment, but it is annoy- 
ing and in some cases depressing and weakening. What 
should cause this peculiar vaso-motor influence, now 
paralyzing and again stimulating the vascular system, 


799 


Channel Islands, 
Chatoolanee Springs. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 








can be only a matter of conjecture. It is an experience 
which is so universal that it may be regarded as not far 
removed from the physiological. It is one of the first 
symptoms which occur, it continues two or three years, 
and by that time it has become endurable by its very 
frequency. With some women it continues uninter- 
rupted to the end of life. It seems to make no difference 
whether the mencpause is natural or induced as to the 
frequency and intensity of this symptom. It may be 
expected, however, that with those to whom the change 
comes early in lifs it will continue longer, as a rule, than 
with those to whom it comes as an entirely natural 
experience. 

Mental and Nervous Phenomena.—One of the many 
notions concerning the change of life which formerly 
prevailed was that since it was a erdtical time all sorts of 
unpleasant things might be expected to develop in con- 
nection with it. Ifa woman became crazy at that time 
it was the change of life which did it, and it was more 
than likely that she would become crazy if she had any 
predisposition or predilection to mental instability. 

The arrest of the menses and the disturbance of the 
blood tension undoubtedly may cause brain disorder in 
those who are predisposed to such trouble, and this may 
vary in its manifestation between headache and violent 
delirium terminating in mania or melancholia. Many 
women are gueer or unusually hysterical at this time, 
neuralgias of all varieties are frequent, insomnia is not 
infrequent, and a disposition which has heretofore been 
amiable may be suddenly or gradually transformed into 
one to which the most unusual or grotesque desires or 
actions are possible. The outbursts in such cases should 
not all be attributed to the change of life, they are due in 
part to the previous inheritance of the individual and in 
part to the tissue changes which take place. Besides, 
the great majority of women have none of these experi- 
ences at all, so that they must be considered exceptional 
and not a customary accompaniment. 

Changes in Nutrition.—Changes in nutrition are a 
noteworthy feature of this period, the active upbuilding 
time of life is over, and the tissues now and henceforth 
are less substantial. Muscular tissue tends to degenerate 
and atrophy, and fat is accumulated. This may lead to 
improvement in the general appearance and rounding 
of the figure, but it may also lead to grossness and obes- 
ity. Personal beauty is lost in some cases while an un- 
usual attractiveness is acquired in others. 

This period and the remaining years of life being the 
era of degeneration, it is not strange that cancer of the 
breast, the womb, and other genital organs should be 
found at this time more frequently than in earlier life. 
Cancer is not necessarily a feature or customary accom- 
paniment of the change of life. This is a fact which I 
have insisted upon for years in spite of a prevalent opin- 
ion to the contrary, both in the profession and in the 
laity. It frequently coexists simply because the change 
of life stands at the entrance of the degenerative period. 
We look for cancer in men in its greatest frequency at 
the same period of life that we look for it in women; the 
ending of the child-bearing period and the cessation of 
the menses must therefore have little to do with the de- 
velopment of malignant disease. 

Disturbances in Various Organs of the Body.—These 
have been frequently noted, and in a book which was 
written by me upon this subject (“The Menopause,” D. 
Appleton and Co., 1897) various complicating affections 
have been alluded to. It has always seemed to me very 
necessary that one should carefully distinguish those 
complications which merely coexist from those which 
cause or are caused by the change of life. Dimness of 
vision has been reported as an accompaniment in many 
cases, also liver engorgement or other derangements in 
efficient wor king power of the kidneys and urinary blad- 
der, loss of appetite, indigestion and constipation, rapid 
action of the heart and dyspneea. These, it will be ob- 
served, are all functional disturbances, and it is such 
rather than organic lesions of which the change of life 
is most likely to be the cause. 


800 


Impregnation after the Change of Life has Occurred.— 
The question is an interesting one, and it has often been 
asked whether impregnation could occur after the men- 
strual flow had entirely ceased. This question may be 
regarded as entirely settled, indeed it may be said that 
impregnation has very little to do with the menstrual 
flow or the menstrual flow with it. It is said that the 
Esquimau women are impregnated customarily before 
the menses have appeared. Many instances have been 
observed in which a similar event has occurred in our 
own latitude before the appearance of the menses. The 
facts in regard to impregnation after the menses have 
ceased and the change of life has been concluded are 
equally authentic and definite. It is not usual for such 
an event to occur, but it does occur occasionally. It is 
believed that the ovaries continue their functional activ- 
ity from the beginning till the end of life, and in not a 
few instances pregnancy has taken place many years 
after it was supposed the child-bearing function had 
ended. Iam personally familiar with cases in which this 
interval has been ten to fifteen years, women from fifty 
to fifty-five years of age giving birth to healthy children. 
Equally strange are those cases in which pregnancy 
occurs when both ovaries have been removed. I know 
of two such cases reported by reputable and talented 
men. Hither the ovaries were not entirely removed, or 
there was a supernumerary ovary, or there was some 
hidden cause which cannot be explained. 

Andrew F. Currier. 


CHANNEL ISLANDS. 


CHARCOAL.—The essential constituent of charcoal is 
the element carbon, which, as it occurs in charcoal, pre- 
sents itself asa black substance, insoluble, infusible, odor- 
less and tasteless. The medicinal virtues of carbon reside 
solely in the singular absorbent property of this element. 
As represented by the substance charcoal, carbon tends 
strongly to absorb and hold fast gases and many organic 
principles, notably alkaloids and odorous and coloring 
matters. And in the case of such of these bodies as are 
oxidizable, the fact of their retention in the meshes of the 
charcoal mass leads to their ultimate chemical transfor- 
mation by oxidation. Charcoal thus operates indirectly 
as an oxidizing agent, and thus is.practically available 
as a decolorizer, deodorizer, detergent, and, so far as 
noxious products of zymotic processes are concerned, also 
as a disinfectant. Charcoal is used by the pharmacist to 
decolorize and to separate organic principles, and by the 
physician to deodorize and hasten oxidation in the con- 
tents of receptacles for excreta, to deodorize foul dis- 
charges, and, given internally, to absorb and hold the 
substance of vegetable poisons, such as alkaloids, until 
their evacuation can be determined, and, by absorption 
and secondary chemical conversion, to dispose of the 
noxious products, fluid and gaseous, of fermentation of 
the ingesta in a dyspeptic stomach. 

Charcoal is official in the United States Pharmacopeeia 
in the following forms: 

Carbo Animalis, Animal Charcoal. Under this title is 
recognized the common so-called animal charcoal or bone- 
black, that is derived as a black pulverulent residue from 
the heating of bone to redness ina closed vessel. Animal 
charcoal occurs in “dull black, granular fragments, or a 
dull black powder, odorless, nearly tasteless, and insolu- 
ble in water or alcohol. When ignited, it leaves a gray- 
ish or yellowish-white ash, amounting to about eighty- 
five per cent. of the original weight of the portion taken ” 
(UNS5 P.). 

Animal charcoal is official as the basis for the following 
preparation : 

Carbo Animalis Purificatus, Purified Animal Charcoal. 
Animal charcoal, in No. 60 powder, is digested with di- 
luted hydrochloric acid on a water-bath for many hours, 
and the undissolved residue then freed from the acid b 
thorough washing with water, dried, and put up in well- 
stoppered bottles. By this procedure the calcic salts, 
which form so large a proportion of the weight of crude 


See Guernsey. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Channel Islands, 
Chatoolanee Springs, 








animal charcoal, are dissolved out, and the carbon is 
thereby obtained practically pure. Purified animal char- 
coal is “a dull black powder, odorless, tasteless, and in- 
soluble in water, alcohol, or other solvents” (U. 8. P.), 

Probably because of a peculiarity of its texture, animal 
charcoal decidedly surpasses wood charcoal in the prop- 
erty of decolorizing and ot separating and holding vegeta- 
ble principles. It is, therefore, the form of charcoal most 
used by the pharmacist, and should be selected also by 
the physician where the purpose is to withhold swallowed 
vegetable poisons from absorption. But in this applica- 
tion it should be remembered that the action of the char- 
coal is, so to speak, mechanical only, and the use of the 
same, therefore, should be merely accessory to measures 
to secure evacuation. The charcoal should be given 
freely, by the spoonful, in suspension in water, until 
from half a tumblerful to a tumblerful shall have been 
taken. 

Carbo Ligni, Charcoal. Under this title is recognized 
officially “charcoal prepared from soft wood and very 
finely powdered.” When well prepared, wood charcoal 
contains but a very small percentage of mineral matter, 
and, therefore, may be regarded as practically all carbon. 
For medical purposes it is pulverized, and yields an ex- 
ceedingly fine, light, black powder, odorless, tasteless, 
and insoluble. Upon exposure it attracts moisture, and 
it is in best condition, therefore, when freshly made. It 
should: be kept in tightly closed receptacles. 

Wood charcoal possesses in high degree the property 
of absorbing gases of certain kinds, and notably the foul- 
smelling products of zymotic processes. For deodoriz- 
ing purposes it may be relied upon to absorb and effect 
the decomposition of from fifteen to twenty timesits bulk 
of gas. It thus makesa good application to privy vaults 
or cesspools, a pailful of powdered charcoal, as freshly 
made and as well preserved from damp as possible, being 
thrown into the receptacle once or twice a week. To 
wounds or sores yielding offensive discharges charcoal 
may be applied by dusting upon the surface, by strewing 
upon the face of a poultice, or by quilting the powder 
between two layers of cotton wadding, such quilt being 
then used as the wound dressing. In dyspepsia, with 
acidity and flatulence, relief often may be secured by ad- 
ministering powdered charcoal in quantities ranging from 
half a teaspoonful to a tablespoonful. It should be, if 
possible, freshly made, and is more effective if taken dry. 
Otherwise it is given mixed with water or milk. Char- 
coal should not be taken in large doses too frequently, 
for under such circumstances considerable mechanical 
irritation has been known to follow. In mild dyspeptic 
cases, quite small doses, such as from 0.12-0.30 gm. (gr. 
ij-v.) may be all-sufficient, and such quantities may be 
taken without objection. 

A sample of charcoal that has lost potency by keeping 
recovers the same on being recalcined. 

Edward Curtis. 


CHARLESTON, S. C.—A city of 65,000 inhabitants, 
and one of the chief seaports of the South, situated 
upon a point of land between the mouths of the Ashley 
and Cooper rivers, several miles from the Atlantic Ocean. 
It is an attractive. old-fashioned town, with rich vegeta- 
tion of a more or less semi-tropical nature. It is a con- 
venient and interesting place to spend some time in, on 
one’s way north from the more Southern resorts, espe- 
cially in the spring. The magnolia gardens in the vicin- 
ity are most interesting and well worthy of a visit. In- 
deed, both by water and land the excursions are many 
and attractive. The writer recalls very vividly the delight 
of a visit here in the spring when returning from Florida. 
The mild balmy atmosphere, the profusion of roses, the 
jasmine, the strawberries, the quaint and attractive streets 
and residences, and the numerous excursions, were a con- 
stant source of pleasure. 

As will be seen from the climatic table, the winter and 
spring climate is amild, equable, marineone. The prox- 
imity of the sea renders the relative humidity greater 
than at the resorts farther inland; hence this is not a 


VOL LE —ol 








favorable climate for a permanent residence for the 
consumptive. 


CLIMATE OF CHARLESTON, S. C. LATITUDE, 32° 47’; LONGITUDE, 
79° 56’. PERIOD OF OBSERVATION, 12 YEARS 10 MONTHS. 























Janu- Novem-| x, 
Data. ary. March July. Ber Year. 
Temperature (Fahr.)— - 
Average or normal,..... 49.5° 57.8° 82.8° 762° 65.9° 
Average daily range....| 14.6 15 14.1 14.1 
Mean of warmest.......| 58.4 67.1 90,2 65 
Mean of coldest......... 43.8 52.1 76.1 50.9 
Highest or maximum...| 80 85 104 82 
Lowest or minimum ....| 23 28 67 28 
Humidity— 
Average relative........ 75.4% | 69.6% | 74.38% | 74.7% | 73.8% 
Precipitation— 
Average in inches ...... 3.77 4.47 7.18 3.51 59.9 
Wind— 
Prevailing direction .... N. S.W. S.W. N.E S.W. 
Average hourly velocity 
pte ect Clee onre Oierrecins 7.3 8.8 Kies 3) 7.9 
Weather— 
Average number of clear 
GAYS omcyastte sie chatte wise 9.5 2.7 10.4 11.5 134 
Average number of fair 
GAYS esata ie saeeenee at 10.5 10.8 14.6 10.5 140.3 
Average number of clear 
and fair days'..-...... 20 23.5 25 22 274.3 




















Edward O. Otis. 


CHARLESTON ARTESIAN’ WELLS. — Charleston 
County, South Carolina. 

Post-OFrFIce.—Charleston. 

Several artesian wells in the city of Charleston have 
been found to be impregnated with mineral ingredients. 
Those mentioned in the Geological Reports are the “Old 
Artesian Well,” the “Citadel Green Well,” the “ Commer- 
cial Cotton Press Well,” and “Chisholm’s Mill Well.” 
We introduce the following analysis of the first of these, 
made in 1868 by Dr. C. U. Shepherd, Jr. : 


OLD ARTESIAN WELL. 
ONE UNITED STATES GALLON CONTAINS: 





Solids. . Grains. 
SOG DICHEDONALO: avec. octets nies tester fe rertials o/csletore 71.06 
Calciumubicarbonat® vc.ccc me citnaces wom cie Gace ca tn caeele cake 12 
Magnesium bicarbonaters ceils ieresieoty ane: te. .02 
Sodium! chloride sueaccanee mae ce eee ean ecen 63.38 
SULICa Maa ieccsee te teh ee see tibia serene Trace 
OTTANICHMATLEA rateisteiateieis hs wtostencte ce sels slalalciens cise suteicitiece ce Trace. 
EY OUR OXIG Csr clots ctercateel toe ete ste cbetetat tots ats ctitorctiiaetentare Trace. 
ATU UD OXING canes ieee nckeic ke Lbia tte tee on nee 79 
Cardoliciacld Tee siursctceuittcsidasiho cet ee tee. aoe cies Trace. 

135.37 


This water has a temperature of 87° F., and is there- 
fore a thermal. The well is 1,250 feet deep, and the 
flow of water is estimated at 1,200 gallons per hour, 
The Commercial Cotton Press Well contains a consider- 
able proportion of sulphate of magnesium. 

James K. Crook. 


CHATTOLANEE SPRINGS. — Baltimore 
Maryland. 

Post-OFFIcE.—Chattolanee, Hotel. 

Access.—Via Northern Central Railroad from Balti- 
more, 33 miles. 

These springs are delightfully located in the Green 
Springs Valley. They are six in number and yield 
1,500,000 gallons of water daily. The waters are not 
strongly mineralized, but are quite remarkable for their 
great purity and freedom from organic matter. The 
following analysis was made by Messrs. Lehman and 
Mager, of Baltimore: ; 


County, 


ONE UNITED STATES GALLON CONTAINS: 


Solids. Grains 
MAGnesitimiCarDOnelonacde steven cas ses eet coc bce arses 1.81 
CAlGIUM:CAFDONAIOS. sastitcaiiee vaceinslecge ceeea beasts ne 4.62 


Chattanooga, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Cherry. 

Solids. Grains. 
Sodium Chloride. assests ectteeretecstreteloiomech eteteans alii 
SOGTIM: SULPNALS,/. ors sieves eiclbieieralclele of Serer ioniclelne stareulen es 08 
Potassium sulphates, cricsen oc tetinccte ve selen ociee deliveries 10 
TVOD, ‘ORTAG Sa ieves etaterouncotatadua ome ettete ys eiee ciate letnie, cei siciptnie pts heea Trace 
AGH 5 Ss ui icterstalerate ote Stctereca cttve ts bintets s tictne wis oteisverersiorerate sis Trace. 
STITCH ards isiane nratereromrocd epee et taarecs texatbre osu arate raleiocs a ere otaletebeiate 24 
Carbonic. acid (com Dime) eracwrcutine sce cine sirre/neteisieleisiete a 

TOtBLSOUGS ye mesic c ce clr elev nielulucs nl iatettpsie eet emrateye Mere 8.28 
Temperature of water at springs, 52° F. 

The water is of the light alkaline-calcic class. In ad- 


dition to its properties as a table beverage it is said to be 
very useful in dyspepsia and indigestion and the early 
stages of Bright’s .disease. The water is extensively 
sold in Baltimore and other cities. James K. Crook. 


CHATTANOOGA, TENN.—A city of about 50,000 in- 
habitants, situated in the southeastern portion of Ten- 
nessee, upon the Tennessee River. It is 762 feet above 
sea level, and the surrounding mountains are from 1,320 
feet—Missionary Ridge—to 2,160 feet—Lookout Moun- 
tain,—both of which points are easy of access. The 
scenery is varied and beautiful, and the atmosphere is 
exhilarating and pure. The spring is early, opening in 
March, and the vegetation rich and varied. The soil is 
dry and loamy, and the drainage good. There are oc- 
casional winds and fogs, but the city is so surrounded by 
mountains that it is greatly shielded in this way from the 
winds. The climate is indicated in the accompanying 
table, kindly obtained for the writer by Dr. W. A. 
Applegate, of Chattanooga. From this it is seen that 
the winter climate is moderate and the summer not ex- 
cessively hot. The relative humidity is quite high, and 
the average number of clear and fair days not remarkably 
large in comparison with other health resorts in the 
South. The daily range of temperature is also seen to 
be large. 


CHATTANOOGA, TENN. 





LATITUDE, 35° 4’; LoneirupE, 85° 15’. 


in the pure and bracing atmosphere, mild winter tem- 
perature, and attractive scenery, substantial climatic ad- 
vantages in the treatment of pulmonary tuberculosis; for 
the chief end of all climatic treatment of consumption 
can well be accomplished here, namely, constant ex- 
posure to pure outdoor air. A sanatorium, for instance, 
on Lookout Mountain, conducted as Falkenstein or the 
Adirondack Cottage Sanatorium is, would doubtless ex- 
hibit equally good, if not better, results. Formerly 
malaria was very prevalent here, but since the sanitary 
condition of the city has been improved, this disease is 
said to have disappeared to a very great extent. 

The outdoor attractions are many and varied; excur- 
sions to the various battlefields—Chickamauga, Mission- 
ary Ridge, Lookout Mountain, and Orchard Knob—are 
all full of interest. The view from Lookout Mountain, 
as the writer can testify from personal experience, is a 
striking one, looking down upon the winding river and 
the other lesser heights. The roads are good, and driv- 
ing and wheeling are popular amusements. 

The accommodations are excellent both as regards. 
hotelsand boarding-houses. “ Lookout Inn” on Lookout 
Mountain is open all the year and affords the best of ac- 
commodations. 

Chattanooga is a railroad centre and is easily accessible: 
from all directions. Edward O. Otis. 


CHAULMOOGRA.—CuawovL-Munert. The seeds of 
two species of Gynocardia (fam. Flacourtiacee) of South- 
eastern Asia; also the oil expressed from them and the: 
bark, the latter not being an article of commerce with us. 
The seeds of commerce are commonly referred to G. 
odorata R. Br. This species, however, does not yield 
the ordinary seeds, which contain no prussic acid, but a. 
different variety, rare in commerce and rich in prussic 
acid. The species yielding the commercial seeds appears. 
undescribed, though it is indefinitely referred to by vari- 


CLIMATIC DATA FROM OBSERVATIONS FROM 


1879 To 1899 INCLUSIVE. 























Pr) ae ee 
3 3 5 
=| 2 = 
s e = 
Temperature (Fahr.)— 
WA VEFAGE:OF NOTMAL scr. scieie-vie aleve cicts ois elsiolarereferelniets 41.4° 45.4° | 51.1° 
Average daily: Tang enna eunaeecielioes RCO 16 17.4 | 18.7 
Mean Of WArMesisescentcees scmvied circu <laisitenies 42.2 54.0 | 56.6 
Mean OF COldESL tarts cisisetiecia at vivetele ale creeiniereaters 33.6 33.8 | 45.7 
Highest: Or MAXIMUM oo icre clove nat cele cenit sl AD, 78 85 
*LOWESL OL MINIT. eres tescieiay Gieleleiere iniacataieloten 2 —2 15 
Humidity— 
AVETAZO TELALIVE ck cs oe siecs nee ate aterp els mieletres © 76% 71% | 67% 
Precipitation— 
Average im INCHES. cscccrccce cr vic cvecien siaratels crise 6.19 5.82 | 5.95 
Wind— 
Prevailing GITeCUONG. cea krle shine ate chieiside nits N.E N.W. | N.W 
Average hourly velocity in miles .............. 6.9 7.5 LS 
Weather— 
Average number of Clear dayS..........+..005- 7 rf 9 
Largest number of clear GAYS........scecereers 12 13 18 
Smallest number of clear dayS...............5. 2 3 4 
Average number of fair dayS.........+..sseees Bl 10 1 
Largest number of fair days ..........esseees: 17 17 15 
Smallest number of fair dayS............0.000s 4 6 5 
Average number of cloudy days ...........006 13 11 ih 
Largest number of cloudy days................ 22 16 17 
Smallest number of cloudy days................ 7 8 4 
Average number of rainy days...........e+e+- 14 12 13 
Smallest number of rainy Gays .........eee.0e- 9 6 7 
Largest number of rainy days .........seeeeeee 24 22 21 














ba a : 
4d 24 eae 
eT he 21/8) 20a : 
BE, el 8 | SB Bd 2 eee 
aft a] es [ < 2.1 6.) Bees 
61.0 | 68.5° | 75.9°| 78.4°| 77.0° | 71.82 | 61.6° | 50.3° | 43.7°| 59,9°: 
20.1 | 20.8 | 19.8 18.4 18 19.2 *| 20.1" | 1S: b aiee 19.3 
65.0 | 71.8 | 78.9 81.1 80.8 | 75.8- | 67.2 | 55.8 | 57.2 66.3 
55.4 | 65.4 |72:2 | 754-| 73.8 168.1 |565 | 454 1381 | 553 
9 |93 |98 | 101 | 100 (98 |or |79 173 88.4 
2 140 | 45 56 188 «ley 116 1 8 26.9 
64% | 69% | 73% | 5% | tre | vee | 74% |vIx | 74e | 14.28 
4.52| 3.89] 449] 4.22] 3.80] 3.70] 2.71| 371] 4.31| 52.81 
s S.W.|S.W.| S.W. N.E. N.E. | N.E. Ss. Ss. 
el: dD 4.9 4.8 4.6 4.6 5.2 6.1 6.6 5.9 
1s 4",9 8 9° 119 [15° (21° 8) eee 
18 19 16 16 15 21 23 22 14 207 
2 4 2 5 5 8 6 1 47 
13 be t'15 16 1 6 «112-«4140. “| 9° ae 
18 23 19 22 19 18 15 14 15 212° 
Glare al it 8 10°'| 6 ]:4> 1 See 78 
8 6 6 1 7 6 6 9 12 102 
14° 118° || 45 13 13 |12 |13 |15 |17- | 180 
3 1 1 1 3 0 3 3 8 42 
11 11 12 14 12 9 8 9 11 186 
rae Sasa ars 6 5. 1(25.1°8 | eae 63 
17, 116 | 19 19 18 |16 |13 19 |17 | 228 





* Lowest on record is — 10° on February 138th, 1899. 


Judged from its climatic conditions solely, Chattanooga 
would hardly fall within the list of genuine health resorts, 
although, like so many partisan reports upon health re- 


sorts, its “climate conditions” are vaunted as “unsur- | 


passed by any point in this country.” It is needless to 


say that the writer who makes this statement gives | 


neither full climatic tables nor any series of results ob- 
tained in the treatment of disease. Undoubtedly a resi- 
dence in some of the high localities about the city offers, 


802 





ous authors. The bark employed is possibly that of the: 
G. odorata, because prussic acid is developed in its in- 
fusion, which is also astringent, hence much like wild- 
cherry bark. It is used asa febrifuge. The fruit pulp 
is used to poison fish. The seeds and the oil expressed 
from them are extensively employed, externally and in- 
ternally, in the East, as a remedy for leprosy and for 
various skin diseases. 

The plant is a tree, and bears directly from its trunk. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chattanooga, 
Cherry. 


SS 


and large branches, globoidal berries, as large as a shad- 
dock, containing numerous seeds. The latter are about 
one inch or one inch and a quarter long, irregularly ovoid, 
angular from pressure, and dull gray. The kernel shrinks 
away from the testa in drying, the latter being thin and 
brittle. The oily kernel, at first white, becomes brown. 
It has a disagreeabfe odor and taste. The seeds consist 
of about half their weight of a brownish-yellow fixed 
oil, of a specific gravity of about .945. The active por- 
tion of this oil appears to be its 12 percent. of gynocardic 
acid, with 2 of cocinic, 4 of hypogeic, and 60 of palmitic 
acids. The oil has been considerably employed in pro- 
fessional practice, both externally and internally, in skin 
diseases. The dose is  iij.—iv. after meals, gradually in- 
creased. Doses of Tl x. have been found irritating to most 
persons, resulting in vomiting and purging. 

Gynocardic acid has also been employed and is said not 
to cause nausea. An ointment made of fifteen to twenty- 
five grains of this acid to the ounce of vaseline has been 
recommended as an application to dry patches of eczema. 

False chaulmoogra is the seed of Hydnocarpus anthel- 
mintica Pierre, a related plant. It is similarly used in 
native practice, and also as an anthelmintic. : 

Henry H. Rusby. 


CHEILITIS GLANDULARIS APOSTEMATOSA. — 
Deriv.—yeiAoc, the lip; glandularis, having the appear- 
ance or form of glands; and apostematosus, from atéornua, 
an abscess. 

SynonyM.—Myxadenitis labialis. 

Under this name Richard Volkmann (Virchow’s Archiv 
fiir pathol. Anatomie, 1870, L., pp. 142-144) describes 
five cases of a peculiar chronic inflammation of the lower 
lip. 

Pearerone Swelling of the lower lip gradually en- 
sued without being especially painful and the lip became 
hard and tense, giving the face an unpleasant, idiotic ex- 
pression. The mobility of the lip was very much im- 
paired and in one case almost lost. The swelling in- 
volved the entire width and breadth of the lower lip to 
its union with the chin. In one instance the upper lip 
was also affected. The surrounding cutaneous integu- 
ments were somewhat erythematous in appearance. 
Upon close examination the mucous glands in all cases 
were found to be swollen to the size of a hemp seed and 
even larger, and were very numerous throughout the 
mucous membrane. When the lip was everted the fol- 
licular openings were seen to be much dilated and in 
some instances admitted a fine sound. On pressure, 
which gave rise to only moderate pain, an opaque 
mucous or muco-purulent discharge appeared, giving to 
the lip, which had been previously dried carefully, the 
appearance of being covered with small dew drops. In 
three cases abscesses occurred which originated in the 
glands or in the surrounding peri-acinous connective 
tissue. Furuncles formed in the fleshy part of the lip, 
which became inflamed without being especially painful, 
and at times the skin, but more frequently the mucous 


membrane, was perforated with small openings, and ° 


showed very marked tendency to fistulse and secreted a 
muco-purulent discharge for weeks and months. In one 
case there existed simultaneously on the inside of the 
lower lip twelve to fifteen such openings which admitted 
a larger sound with ease and led to irregular fistulous 
passages extending through the substance of the lip. 
True ulceration did not occur in these openings, in any 
case, and no evidence of syphilitic ulcers or plaques 
could be demonstrated on the lip or on the mucosa of the 
mouth and pharynx.* Two of the cases, although sub- 
jected to energetic treatment for some time with potas- 
sium iodide and local applications of silver nitrate, the 
point being introduced into the follicles under anesthesia, 
and applications of lead water, showed but very little im- 
provement. The remaining three cases were cured in 
four to eight weeks; potassium iodide, gargles of potas- 
sium chlorate, and mild cauterization being employed. 
All of the patients were adults. Three had previously 
been syphilitic shortly before the attack, and in one of 


these a fading syphilitic eruption on the palm was still 
present; with the exception of a few slightly enlarged 
lymphatics no local evidence of syphilis could be detected. 
Two patients were in perfect health and denied all his 
tory of syphilis. The course of the disease in all five 
cases was very similar, although differing in severity. 
It is quite certain that catarrhal inflammation of the labial 
glands existed in all these cases, accompanied by suppura- 
tion in places; actual suppuration occurred partly in the 
gland and partly in the peri-acinous connective tissue, 
hence Volkmann proposes to call the affection cheilitis 
glandularis or myxadenitis labialis. He is undecided as 
to the réle syphilis plays in this disease; he is, however, 
inclined to think that it does not exert a direct influence. 
It is more probable that the etiological factor is to be 
sought for solely in the catarrhal condition of the mouth 
and pharynx, which always existed simultaneously, and 
probably spread by means of the secretion of the oral 
cavity through the outlets of the labial glands to the 
acinous bodies. Emmanuel J. Stout. 


CHELOID. See Kelozd. 


CHEQUEN.—CueExkan. The leaves of Hugenia Chequen 
Molino (fam. Myrtacee). A large and beautiful white- 
flowered shrub of Chili and Bolivia, closely resembling 
the common European myrtle. The leafy twigs were 
originally used, but in this form by far the greater por- 
tion is inert woody fibre. The leaves average about 
half an inch or more in length, frequently with an ob- 
scure tooth on one side, thick, coriaceous, bright green, 
smooth and punctate, and aromatic in taste and odor. 
They contain four or five per cent. of tannin and two or 
three of volatile oil, the latter consisting chiefly of pinene, 
with some cineol. Chequen belongs, therefore, to the 
Eucalyptus series of aromatic drugs, its action being 
specially upon the respiratory mucous membrane, 
through which the oil is largely excreted. Its use is as 
a tonic expectorant, particularly in catarrhal conditions. 
It is commonly given in the form of the fluid extract, in 
doses of 4 to 8 c.c. (fl. 3 i.-ij.). Henry H. Rusby. 


CHERRY, WILD.—Prunus Virginiana. “The bark 
of Prunus serotina Ehrhart, collected in autumn” (U. S. 
P.). The bark of Prunus Virginiana L. should not be 
collected. It is the choke-cherry and is mostly only a 
shrub. This contradiction will probably be corrected in 
the next edition of the Pharmacopeia by dropping the 
word “ Virginiana” from the title. 

P. serotina is a large, graceful tree, with spreading, 
slender branches covered with red or purplish, smooth, 
shining bark; that of the trunk, however, is dark and 
exfoliating. Its wood is the valuable cherry, so exten- 
sively used for house-finishing and cabinet work. In 
general aspect it resembles the domestic cherry trees, 
but is much larger and hasa rounder and more spreading 
top. The flowers are small (less than 1 cm. across), and. 
borne in long, slender, rather erect, terminal racemes. 
Calyx cup-shaped, five-toothed. Corolla, of five-reflexed, 
broadly obovate white petals. Stamens, twenty or so: 
perigynous. Ovary, simple, one-celled, two-ovuled. 
Fruit, a round, black, bitterish-sweet drupe, nearly 1 cm. 
in diameter. Stone, one-seeded. 

The wild cherry tree grows in nearly all parts of the 
United States and Canada. In the Middle States, and in 
some of the Western ones, it is very abundant and large; 
in the extreme South it is less common, and in New 
England, although common, it does not attain its maxi- 
mum size. 

Wild cherry has been recognized by each edition of 
the Pharmacopeceia, from the first, in 1820, to the present. 
Although occasionally employed in Europe, it is essen- 
tially a local drug. : 

The bark should be collected in the autumn, when its. 
hydrocyanic odor and taste are the most perceptible, and 
that of the root, moreover, is said to be preferable to: 
that of aérial portions; but it is an abundant and cheap: 
drug, largely called for in domestic and other informal: 


803. 


Chest. 
Chest, 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





medicine, and apparently indiscriminately gathered. 
Much of it is nearly devoid of its proper odor. The 
Pharmacopeia description is as follows: “In curved 
pieces of irregular fragments, one-twelfth of an inch (2 
mm.) or more thick, outer surface greenish brown, or 
yellowish brown, smooth, and somewhat glossy, marked 
with transverse scars. If collected from old wood and 
deprived of the corky layer, the outer surface is nut- 
brown and uneven; inner surface somewhat striate or 
fissured. Upon maceration in water it develops a distinct 
bitter-almond odor; its taste is astringent, aromatic, and 
bitter. The bark of the small branches is to be rejected.” 
The spurious bark of the choke-cherry is much thinner 
and tougher, consisting largely of bast fibres, which are 
lacking in the genuine. 

Wild-cherry bark contains substances analogous to the 
emulsin and amygdalin of bitter almonds. Upon being 
macerated in water and subjected to distillation it yields 
hydrocyanic acid, and a volatile oil having the properties 
of that of almonds. It also contains tannic acid. 

Wild cherry is used as a sedative bitter tonic and a 
sedative expectorant; the sedative property due to its 
hydrocyanic acid, the bitter probably to its amygdalin 
only. It is somewhat astringent. 

The above qualities express its entire value as at pres- 
ent understood. As a substitute for quinine it is entirely 
obsolete. Dose from 2 to 4 gm. (3ss. ad i.). The fluid 
extract (Hatractum Pruni Virginiane, strength 4+) and 
the infusion (Infusum Pruni Virginiane, strength zé5) 
are official, and represent it well. The syrup (Syrupus 
Pruni Virginiane, U.S. P., 15 per cent.) is frequently 
used as a basis for cough mixtures; its taste is rather 
pleasant. 

ALLIED PLants.—See Almonds, Bitter and Sweet. 

AuLIED Drues.—Cherry-laurel leaves, Peach seeds, 
and also Almonds and Hydrocyanic Acid. 

W. P. Bolles. 


CHEST, DEFORMITIES OF THE.—The chest is a 
box or cage enclosing and protecting the heart, lungs, 
and great vessels; but it is also an organ, which by its 
rhythmical expansion and contraction plays an impor- 
tant part in the respiratory act. It consists of the tho- 
racic skeleton and of the soft parts covering it; but the 
position of the clavicles, scapulse, and shoulders is so 
closely related to the shape and development of the chest 
as to require some discussion in this article. 

The size, shape, and mobility of the chest vary with 
the race, age, sex, development, occupation, and idiosyn- 
crasies of the individual, and it is as difficult critically to 
define its normal limits as it is those of the nose, ear, or 
any other organ or part. It is often impossible to say 
when normality becomes peculiarity, or peculiarity de- 
formity. 

According to Vierordt,! one expects to find in a well- 
constructed thorax, bilateral symmetry, slightly marked 
supraclavicular depressions, and a barely recognizable 
prominence at the junction of the manubrium and corpus 
sterni. The true ribs should so leave the sternum that 
there is increasing obliquity from above downward, 
making the angle between their free borders almost a right 
angle. The thorax should be well developed, and the 
scapulee should lie flat upon the back; only the lower in- 
tercostal spaces should be visible. The dimensions of the 
chest should be proportionate to the size and develop- 
ment of the body, and inadult life its transverse diameter 
should exceed its antero-posterior in the ratio of three to 
two or less. Vierordt’s Tabellen® give various chest 
measurements according to the most reliable observations. 
The mean value of chest play, or the difference in chest 
circumference between inspiration and expiration, is thus 
given as three or four inches. According to Lee,* the 
average expansion of eight hundred United States re- 
cruits was three and four-fifths inches. 

Departures from the typical standard are very frequent, 
and may be quite marked in perfectly healthy persons. 
The two sides are rarely perfectly symmetrical; indeed, 
Vierordt himself says in another place that in right- 


804 


handed people the right semicircumference of the chest 
is the larger by .5 to 2.cm.; in the left-handed, on the 
contrary, the left semicircumference of the chest is equal 
to or but slightly greater than the right. The chest may 
be small above and wide below; the angle of Louis may 
be more than usually prominent, and the epigastric angle 
exceptionally acute. The supraclavicular fossee may be 
marked, without disease; but if they are unequal, apical 
tuberculosis may be suspected. Certain ribs, as the sec- 
ond, third, and fourth, may project in front, or the lower 
ribs may be depressed. All these peculiarities are more 
or less atypical without being exactly abnormal. 

The broad chest of man with the square shoulders, and 
scapulz placed posteriorly, correlated with the upright 
posture and pendant, but freely mobile and active arms, 
is one of the most characteristic and striking peculiarities 
of the human skeleton. According to Hutchinson;‘ this 
position of the scapule is a very important factor in the 
development of respiratory power. Human respiration 
is, or should be, bellows-like, the fixed flap being the 
spine and posterior chest wall, rather than piston-like, as 
it often is in cramped or rigid chests. 

In the human embryo at the fourth month the quadru- 
pedal or deep chest, with the antero-posterior diameter 
exceeding the transverse, still persists; at birth these 
diameters are nearly equal. The infant is round-chested 
and round-bellied, and only after three or four years of 
age do the chest and abdomen begin to assume the more 
flattened shape characteristic of adult life. Inadult man 
the proportions of the chest are the reverse of those in 
the quadruped, the transverse exceeding the antero-pos- 
terior diameter in the ratio of three to twoorless. Of the 
quadrupeds only certain monkeys, moles, and bats, all 
animals possessing great power and freedom of motion in 
the anterior extremities, have broad chests. The evolu- 
tion of the human chest may be arrested before it is com- 
plete, either from congenital defect in growth or vigor 
or from faulty habits in childhood; we then get a long, 
rounded chest, a degenerate or rudimentary type, and 
one often associated with other defects, as will be pointed 
out in the sections on the phthisical chest and on round 
back. 

Chest deformities may be divided for convenience of 
discussion into four groups:® the congenital; those due 
to static conditions, whether pathological or not; those 
due to external constriction or pressure; and those due 
to conditions of the internal organs. Deformities of the 
chest due to violence, to new growths, to local disease, or 
to double or non-viable monstrosities, are beyond the 
scope of this article. 


I, CONGENITAL DEFORMITIES. 


The individual bones of the chest may be imperfect or 
wanting, fissured, misshapen, or augmented, and the 
thoracic skeleton may be deformed as a whole. 

Spine.—The thoracic spine, like the cervical and lum- 
bar, may contain too many or too few vertebre. 
Dwight ® states that since he has been looking for such 
anomalies, he has found them with surprising frequency. 
The commonest anomaly of number in the dorsal region 
is to have eleven or thirteen vertebre present. Noble 
Smith? quotes a case in which four and one-half thoracic 
vertebra were absent, namely, the right half of the third, 
the fifth, the sixth, the eighth, and the ninth. There 
were only .two cervical vertebre present in this case. 
Wedge-shaped half vertebree on one side or the other, as 
in the above case, are not extremely rare; or a vertebral 
body may be made up of two unfused halves. The arches 
may be incomplete—spina bifida,—a condition which may 
extend toa great part or the whole of the spine, and is 
then called rhachischisis, with which, as with ordinary 
spina bifida, protrusion of a sac and various anomalies of 
the soft parts frequently occur. In these cases various 
abnormal and often extreme bendings and curves of the 
spine and accompanying chest deformities are often seen. 
The best recent article on rhachischisis is that by Thorn- 
dike.® 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chest, 
Chest, 





It is well for bone specialists to remember, and prob- 
ably for others to forget, the possibility of anomalies in 
number when counting vertebre in the living subject; 
also that one or more spinous processes may be bifid, or 
project to one side or posteriorly without pathological 
significance. 

Sternum.—According to Dwight,® the sternum is about 
9.5 per cent. of the total height for men and about nine 
per cent. for women. It may be entirely or partially 
absent, or more or less fissured longitudinally or per- 
forated. These defects, like the unclosed arches of a 
spina bifida, are due to the failure of the primitive layers 
to unite in the median line. When large the gap is cov- 
ered by a membrane; when small it may be entirely un- 
noticed during life. Holes, fissures, and defects are more 
common and of greater extent toward the upper part of 
the sternum. The xiphoid is often deflected, split, or 
perforated. 

Ribs.—Supernumerary ribs may occur, especially in 
the lower cervical and upper lumbar regions. Cervical 
ribs on one or both sides may sometimes be palpated at 
the root of the neck during life, and may cause trouble 
by pressure on the brachial plexus and require removal. 
In these cases the pleural sac may rise abnormally high, 
and has been opened (Planet *). Ribs may also be absent 
or rudimentary. Hurtlet!° reports five cases of rudimen- 
tary first ribs in English, and Helm! sixteen cases in 
general surgical literature. Cases occasionally occur in 
which several ribs on one side with their costal cartilages 
are imperfectly developed and fail to meet and unite with 
the sternum, or in the case of the lower ribs with the 
cartilage above, by varying intervals. They may end 
near the sternum or free border, below the axilla, or 
farther back, leaving a depression or furrow of greater 
or less extent to one side of the sternum, or in the lateral 
chest wall, covered only with skin and membrane, which 
may rise and fall with respiration, pulsate with the heart 
beats, and through which the underlying organs may be 
palpated. Through this unprotected area the lung may 
protrude, or if in the precordial region an ectopia cardis 
may take place. When such a tendency exists the gap 





Fig. 1247.—Osborne’s Case of Defect of Ribs. (From Haynes.) 


should be protected by a celluloid, hard-rubber, or metal 
plate, and pulmonary hernias have been known to recede 
under such treatment, or to disappear spontaneously. 
These defects of the skeleton of the chest wall are due 
to an arrest of growth of foetal structures, which fail to 
join by a larger or smaller interval. 


The following cases are cited as examples of this de- 
formity : 

Abercrombie’s !? case was a boy of two months, with 
absence of the second and third costal cartilages, left side; 
the corresponding ribs ended free, leaving a small unpro- 


| 
Giw 

Se 
Yi 


Fic. 1248.—Haynes’ Case of Defect of Lower Ribs on the Left Side. 
(From Haynes.) 


tected space. The fourth rib lay near its cartilage, but 
was not joined to it. There was a notch on the left side 
of the sternum near the third interspace. 

Bennett’s !* case was that of a man who died suddenly 
after an injury. The autopsy disclosed a defective third 
rib, right side, which failed to reach its cartilage by a 
considerable interval. This case and another reported by 
Bennett emphasize the danger of mistaking certain con- 
genital chest deformities for the effect of injury, recent 
or remote. 

Osborne’s 4 case was a boy witha triangular depres- 
sion on the left side of the chest due to defective devel- 
opment of the second, third, and fourth ribs, which were 
separated from their cartilages by a considerable interval. 
The extremity of the fourth rib was joined to the fifth 
costo-cartilaginous articulation. 

In Townsend’s" case the ribs of the left side, except 
the first two, were represented by short rudimentary 
processes. 

Lallemand’s '* case was a man with a depression as big 
as a fist on the left side of the chest, due to a deficiency 
of the third, fourth, and fifth ribs. 

Harold’s '7 case wasa backward boy of seventeen years, 
whose costal cartilages in the left side below the fifth rib 
were missing; at this level the left half of the sternum 
and xiphoid were deficient, and the pericardium was pro- 
tected only by soft parts. 

Homer Gage !8 reported a case of congenital absence of 
the sixth, seventh, eighth, ninth, and tenth ribs, left side, 
ina girl of seventeen years. There was severe lateral 
curvature, convexity to the right, with severe deformity 
of the chest, and a protrusion in the unprotected area, 
supposed to be due to a hernia of the stomach. The heart 
was displaced to the right, though the viscera were not 
transposed. 

In Hayne’s!* case the cartilage of the seventh rib, left 
side, ended three-fourths of an inch from the sternum, 
and the seventh, eighth, and ninth cartilages were not 
joined, but ended free. ; 

Sometimes the costal defect is accompanied by total or 
partial absence of the greater and smaller pectoral muscles 
of the same side, as in the case reported by Levy,*? in 
which the third and fourth ribs of the right side ended 
below the axilla, leaving a marked depression. There 
was a well-marked lateral curvature with convexity 
toward the right. 


805 


Chest, 
Chest, 


Schlesinger *! has shown that congenital absence of the 
pectoral muscles is frequently associated with defects of 
ribs or other thoracic anomalies, and cites the case of a 
man of twenty-two years who had in addition to a de- 
fect of the third, fourth, and fifth ribs, and of the costal 
portion of the pectoral, a congenital elevation of the 
shoulder—Sprengel’s disease—ail on the left side. It 
would seem that defects in the costal apparatus are more 
common in males and on the left side, that they are fre- 
quently associated with other thoracic anomalies, and 
that they sometimes occur in individuals otherwise or 
generally defective. 

Other thoracic deformities sometimes accompany con- 
genital malformations of the heart; there may be in such 
cases a projection or gibbosity of the front of the thorax 
above the xiphoid, “thorax en proue,” or “thorax en 
caréne,” or the thorax may be prominent in front with 
flattened sides (see Charrin and Le Noir *’). 

Occasionally there is a fusion of ribs, usually the first 
two, which are then sometimes called a bicipital rib. 
Other ribs may be fused at one or more points (Deutsche 
Chirurgie **). 

Stiller’s Costal Stigma — Costa Fluctuans. — Stiller 
maintains that the majority of cases of enteroptosis begin 
in youth and are associated with abnormally movable 
tenth ribs. This mobility may approximate that of the 
two lowest pairs of ribs, and is due to a congenital and 
possibly inherited defect in the cartilage, which joins the 
tenth ribs with the cartilage above. Heclaims that enter- 
optosis and nervous dyspepsia are identical, and that 
children exhibiting the costal sign will always go on 
to have enteroptosis, atony of the stomach, constipation, 
and nervous dyspepsia or dyspeptic neurasthenia. He 
finds these conditions nearly as common in men as in 
women, and concludes that tight lacing and pregnancy 
have but little to do with enteroptosis. 

Absence of the Pectoral Muscles.—This deformity occurs 
more frequently on the right side, and may involve both 
the large and small pectorals, but the pectoralis minor 
and the clavicular portion of the former often escape. 
The affected side of the chest hasa flattened or excavated 
appearance, but the patient has full use of the arm and 
suffers no inconvenience, and may even be a good soldier 
or gymnast. An infant six weeks old with absence of 
the costal portion of the left pectoral was exhibited by 
the writer to the Orthopedic Section of the New York 
Academy of Medicine in January, 1898, and by a singu- 
lar coincidence a boy of sixteen years with the same de- 
formity on the right side was shown at the same meeting 
by Dr. Royal Whitman. In these cases there are usually 
certain anomalies of the neighboring soft parts such as 
deficient subcutaneous tissue, scanty hair over the af- 





fected area and in the axilla, imperfectly developed mam- . 


milla, breast, and anterior axillary border of the affected 
side. In certain cases defects of ribs and anomalies 
of the scapula may exist, as in a case reported by the 
writer,*> and one described by Schlesinger,*! who has col- 
lected one hundred cases of pectoral defect from medica] 
literature, and who states that in about one-quarter of 
the cases the pectoralis minor is alsa absent; in one-tenth 
of the cases there is considerable anomaly of the thoracic 
skeleton, and in one case in twenty or twenty-five there 
is pulmonary hernia or displacement of the heart. 

Tunnel Chest, Funnel Breast, Trichterbrust, Thorax 
en Entonnoir.—This deformity is one of the most inter- 
esting of the congenital chest deformities, and has at- 
tracted considerable attention since Ebstein’s*® paper 
appeared in 1882, though the condition had been previ- 
ously described. Stedman?’ gives the earlier references, 

In these cases there is a considerable depression involv- 
ing the lower portion of the sternum, and the adjacent 
cartilagesand ribs. This depression may be large enough 
to contain a man’s fist, and is usually congenital, but its 
etiology is obscure. Some authors suppose it to be due 
to a defect in development, others to the pressure of the 
foetal chin or heels. Certain authors regard it asa stigma 
of degeneration, as it has been found in the insane, epi- 
leptic, and neuropathic; others have observed it in robust 


806 











REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





and well-developed individuals. It occurs more fre- 
quently in men; out of thirty cases twenty-three were 
males. 

Arneill 8 reports six cases, of which five occurred in 
one family. These were a student, his brother, father, 
and two paternal uncles. This patient was twenty-five 
years old, six feet tall, and weighed one hundred and 
seventy-four pounds; he was well developed and in ex- 
cellent health. In his case the antero-posterior diameter 
of the thorax was, at the right nipple 17.5 cm., at the left 
16.8, and at the depression in the median line 11.4. The 
greatest depth of the depression was 6.5cm. In the 
brother the depth was 4.7, and in the father 3.75. There 
was one sister who was free from defect. Of Klem- 
perer’s®® three cases two were brothers. The writer has 
recently reported the cases of a mother and daughter. 

A number of cases of acquired funnel chest have been 
reported. The deformity may be acquired by traction 
from within, from adhesions, or bronchiectasis, or by’ 
pressure from without, as in certain occupations. An 
excellent account of 
this and other chest 
deformities may be 
found in an article by 
Marie.*° As already 
noted, there is little or 
no interference with 
function, and some in- 
dividuals are able to 
take violent exercise, 
as respiratory capacity 
does not seem to be 
diminished. Ebstein ?° 
has described some 
cardiac displacement 
upward and to the left. 

Thorax en Gouttiere. 
—Somewhat similar to 
funnel chest is the 
“thorax en gouttiére ” 
of Féré and Schmidt, *! 
where the sternum 
forms the bottom of a 
longitudinal trough or 
gutter whose sides are 
the incurved costal car- 
tilages. These authors 
claim that ten per cent. 
of epileptics show this 
deformity. 

Clavicles.—The clav- 
icles may be wholly or 
partly absent on one 
or both sides. In par- 
tial absence it is usually the outer extremity which is 
wanting. The shoulders drop forward and inward, and 
may even be made to meet in front, but there is surpris- 
ingly little interference with function. The writer’s 
clavicle splint * may be used to keep the shoulders in 
position, acting on the principle of artificial clavicles. 

Congenital Hlevation of the Scapula—Sprengel’s Disease. 
—This condition was first described by Sprengel in 1891, 
and is not yet thoroughly understood. An excellent dis- 
cussion of the subject may be found in the recent paper 
by Nové-Josserand and Brisson,*4 who report twenty 
cases in literature and their own observation of a girl of 
nine years with the right scapula 3 cm. higher than the 
left. Besides being elevated the scapula was rotated so 
that the inferior angle was nearer the spine, and the spine 
of the scapula pointed downward and outward. The 
upper border of the scapula pointed upward into the 
neck, producing a noticeable deformity. The right scap- 
ula was somewhat smaller than the left, but the clavicles 
were equal. The movements of the shoulder joint were 
free, but the arm could not be raised as high as on the 
opposite side. The muscles responded normally’ to elec- 
tric stimulation. The above description is typical, and 
applies to most cases. In about half the cases there is a 


Fig. 1249.— Funnel Chest. (Arneill’s 


cases. ) 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chest, 
Chest, 





slight scoliosis, of which the convexity may be from or 
toward the affected side. 

In some cases there is facial asymmetry, the side of 
the elevated scapula being the less developed. There 
is little disability, sometimes none, and when treatment 
is required remedial gymnastics are sufficient. The 
writer *° has reported a case of small scapula with absent 
pectoral muscle on the right side. This case seems to 
belong in this group, though the elevation of the shoulder 
was slight. 

A peculiar form of congenital high shoulder, in which 
the scapula was joined to the spine of the seventh cervi- 
cal vertebra by a bony process, has recently been de- 
scribed by Wilson and Hugh.* 

Congenital Scoliosis.—This deformity involves more or 
less all the bones of the thorax. The cases in which lat- 
eral curvature is congenital are rather rare, though Marie *° 
thinks that many cases of lateral curvature which de- 
velop in childhood may be due to congenital defects of 
the thorax or spine, which remain latent or without visi- 
ble effect for years, but finally produce a visible curva- 
ture. He includes such cases under the term “déforma- 
tions thoraciques congénitales tardives.” In a recent 
study Hirschberger * attributes a certain number of cases 
of congenital lateral curvature with defects of the spinal 
column to intra-uterine pressure, with scanty amniotic 
fluid. Another group is associated with other anomalies, 
showing a widespread developmental fault. A few cases 
only are due to paralysis. 

The chest deformities associated with lateral curvature 
will be more fully described in a subsequent section. 


II. AcqurRED DEFORMITIES. 


(a) Chest Deformities Due to Statie Conditions.—This 
group comprises the chest deformities due to the various 
forms of lateral curvature of the spine, weak and round 





Fig. 1250.—Chest Deformity in Severe Scoliosis. 


back, to spondylitis, and in part to certain constitutional 
diseases affecting the bones, such as acromegaly, osteitis 
deformans, and spondylitis deformans. 

Lateral curvature of the spine, or scoliosis, is the name 
of a striking symptom, whose causation varies widely in 
different cases, and in many isexceedingly obscure. The 
list of diseases and conditions with which lateral curva- 


ture is more or less frequently associated is a long one, 
but in all the efficient cause is an asymmetrical or uni- 
lateral weakening of the skeleton or muscles, often due 
to aone-sided incidence of stress, as an habitual faulty or 
one-sided posture, loss of an arm, short leg, congenital 
defects of spine or chest, torticollis, Sprengel’s disease, 
sacro-iliac disease; in other cases to asymmetrical soft- 





Fig. 1251. — Antero-Posterior Chest Deformity in Severe Scoliosis. 
The posterior boss is on the right side only. 


ening, hardening, or distortion of certain parts of the skel- 
eton as in rickets, cretinism, achondroplasia, acromegaly, 
diffuse hy perostosis (leontiasis), osteomalacia, rheumatism, 
spinal osteo-arthritis, osteitis deformans (Paget’s disease), 
pulmonary osteo-arthropathy, and often tuberculous spon- 
dylitis; also in certain nervous and paralytic disorders 
which affect the spinal and trunk muscles in an asymmet- 
rical manner, such as poliomyelitis, sciatica, Friedreich’s 
ataxia, syringomyelia, hysteria, athetosis, paralysis of 
certain spinal muscles, and some of the chronic muscular 
atrophies and dystrophies. The commonest and most im- 
portant class, however, is that in which the lateral curva- 
ture is attributed to muscular weakness and habitual 
faulty postures, but in which no very obvious predis- 
posing cause is evident and about the causation of which 
very little is really known. 

The distortion of the spinal column is probably the 
most important but by no means the only element in the 
deformity. The entire thorax becomes by degrees warped 
and twisted, and while the different varieties of lateral 
curvature vary in their characteristics, and the ordinary 
or postural deformity in the degree of distortion finally 
reached, it is not too much to say that the severer grades 
are among the most distressing, and, unfortunately, the 
most common of severe chest deformities. In many cases 
the distortion or debility affects not only the trunk, but 
the pelvis, head, and extremities. , 

The spine usually has a dorsal and a lumbar curve in 
opposite directions. The convexity of the dorsal curve 
is to the right in a large majority of cases. The spine is 
also twisted on or near its axis in the same direction in 
which it curves, owing to its lying free from support in 
the thoracic and abdominal cavities: the line of the ver- 


807 


Chest, 
Chest, 





tebral bodies thus comes to be much more curved than 
the line of the spinous processes—in other words, the de- 
formity is much severer and more complicated than it 
appears to be from external inspection. After the de- 
formity has lasted some years, the bodies of the vertebrae 
become wedge-shaped and twisted, the intervertebral 
discs compressed, and the deformity becomes fixed. The 
development of this spinal distortion has a profound ef- 
fect upon the shape of the chest, which becomes shortened 
in height, reduced in most of its measurements, and is 
rendered stiffer and less flexible. The ribs on the side of 
the dorsal convexity become more bent at their angles, 
making a projection under the corresponding scapula; 
this projection is sometimes very prominent, producing a 
large posterior bosse. The ribson this side are more sep- 
arated at the sides and in front and become broader, but 
are crowded together behind, where they may form false 
articulations with the spineand with each other. On the 
concave side the ribs become straighter and narrower, 
and there is a flattening or depression in and below the 
scapular region. The scapula is usually-lower and less 
prominent on the side of the dorsal concavity, higher and 
more prominent with projecting inferior angle on the 
convex side. With aright dorsal convex curve, the left 
side of the thorax is prominent in front, and the left 
breast and left free margin of the ribs protrude; the diag- 
onal from right back to left front is much longer than 
normal, and exceeds all other horizontal measurements; 
the opposite diagonal is much shortened, and a horizontal 
transverse section of the chest shows an irregular ellip- 
soid, lying in the direction of the long diagonal. Both 
lungs are cramped, the right the most, breathing capac- 
ity is much diminished, the heart is displaced to the left, 
and the abdominal and pelvic organs are crowded. The 
direction of the sternum is changed, and the whole thorax 
and trunk are strangely shortened and twisted. It is 
strange that chronic pulmonary disease is so seldom met 
with in these severe cases of lateral curvature. They are, 
however, not strong, and do suffer from their deficient 
respiration and imperfect circulation in a delicate organ- 
ization, poor blood, and defective nutrition. Satter- 
thwaite *? has specially studied the displacements of the 
heart due to lateral curvature, and Faber ** the respira- 
tory difficulties. , 

The foregoing description may serve to indicate the 
principal characteristics of the chest deformities accom- 
panying the commonest form of lateral curvature. In 
the lateral curvature due to morbid processes affecting 
the osseous system, the bones of the chest will present, 
besides the deformities of lateral curvature, those due to 
the special morbid process, such as softening, hypertro- 
phy, or local distortion. In paralytic lateral curvature 
there is less rigidity, and there may even be increased 
flexibility, and paralysis of certain muscle groups will be 
found. 

For thesymptomatology and treatment of lateral cur- 
vature, and for its effects on other parts of the body, the 
reader is referred to other sections of this work. 

Chest Deformities Associated with Paralytic Affections. 
—The commonest is lateral curvature and its accompany- 
ing thoracic distortions as mentioned in the preceding 
paragraph, and the commonest variety of paralytic lateral 
curvature is that associated with a certain number of the 
severe cases of acute poliomyelitis, in which the trunk or 
spinal muscles are asymmetrically involved. 

In the progressive myopathies of the scapulo-humeral 
type, and of the facio-scapulo-humeral type, and in 
pseudo-hypertrophic paralysis, there often occurs, ac- 
cording to Marie,*° a flattening of the upper part of the 
thorax. Atrophy of the pectorals in connection with this 
deformity causes the upper part of the chest in front to 
have an excavated aspect. In some cases this depression 
is found in the lower part of the chest giving an appear- 
ance similar to funnel chest, and these deformities may 
be combined with scoliosis. Certain of these atrophic 
affections produce a wasp figure, the obliquity of the ribs 
being increased, and the chest being straight at the sides 
and cylindrical, with a marked depression or constriction 


808 


changed, the feet 


REFERENCE -HANDBOOK OF THE MEDICAL SCIENCES. 


between the lower ribs and the thoracic crests, owing to 
atrophy of the waist muscles. 

Round back, kyphosis, round shoulders, stoop shoulders, 
are faulty postures or deformities, in which the head, 
shoulders, and upper chest fall or sag forward, from im- 
proper poise and muscular weakness. The result is a 
rounded back, and consequent changes in the shape of 
the chest, position of the head and shoulders, and, indeed, 
a general fault of attitude, a de-energized position in 
which the principal stress is shifted from the muscles to 
the ligaments. There has been considerable confusion in 
the nomenclature and in the description of this affection, 
or rather symptom. Round shoulders is a term in com- 
mon use, but is unsatisfactory since the faulty position 
of the shoulders is a secondary symptom, largely due to 
the shape of the back and chest, for which reason the 
term round back is preferred by the writer, though this 
term also fails to indicate the general disturbance of poise 
which is usually present. The term kyphosis is unfortu- 
nate, since it is also used to designate the deformity due 
to Pott’s disease of the spine, from which it is exceedingly 
important to distinguish it. 

Round back or weak back, then, is that position of re- 
laxation into which the body falls when the upper trunk 
is no longer held up by weakened spinal muscles. Ex- 
cluding the angular projection of Pott’s disease, which 
becomes rounded only in the latest stages, the affection 
may be divided into several varieties, namely, those due 
to: (1) Imperfect development of the chest; (2) congeni- 
tal or acquired weakness—convalescence; (3) oldage; (4) 
paralytic affections; (5) certain diseases which affect bone 
and general nutrition, such as rickets, scurvy, cretinism, 
spondylitis deformans, osteitis deformans (Paget’s dis- 
ease), acromegaly, pulmonary osteo-arthropathy. The 
list is very similar to that given for scoliosis, but whereas 
in that case the bony or muscular support was weak- 
ened on one side, 
in this the weak- 
ening is approxi- 
mately symmetri- 
cal. 

Most of these 
kyphotic conditions 
have in common the 
forward sagging of 
the spine for lack of 
bony or muscular 
support or both. 
The head and up- 
per chest fall for- 
ward, the spine be- 
comes more or less 
rounded, the chest 
becomes compress- 
ed at its upper 
part, but may be- 
come narrower 
rather than flatter 
as a whole; the 
ribs drop down- 
ward, the shoulders 
and scapule down- 
ward and forward, 
their inner borders 
receding from the 
spine and their in- 
ferior angles be- 
coming more prom- 
inent. The posi- 
tion of the pelvis is 





(Original. ) 


Fic. 1252.—Severe Round Back. 


are weak or flat and 

everted, and there is a tendency to knock-knee. The 
chest is usually less flexible than normal, respiratory 
capacity and power are diminished; there is often a trans- 
verse furrow at the upper border of the abdomen. The 
attitude is that of fatigue, weakness, debility, relaxation. 
It is doubtless an attitude which may be produced or 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


intensified by habitual faulty positions, such as those as- 
sumed for many hours daily by school-children or clerks 
at their desks. This factor, however, must usually be 
associated with fault of structure or inherited or acquired 
vice of nutrition, muscle tone, or skeletal resistance, in 
order to be effective. It is to be noted that the non- 
pathological form of round back often affects children as 
early as the fourth or fifth year, and that, as already re- 
marked, it is rather a general than a localaffection. Weak 
and pronated feet, week eyes, and slight degrees of lat- 
eral curvature often accompany it. These children are 
often physically delicate and mentally unstable. They 
may inherit an imperfect physique, or their life is so 
precocious or intense, as to interfere with ample and sym- 
metrical development. In other words, a good many of 
these children are degenerates or bordering on degen- 
eracy, and present the rounded back and drooping shoul- 
ders as striking symptoms, but usually show other un- 
mistakable signs of imperfect development. Tbe writer 
believes that in a certain proportion of these round-backed 
children, the evolution of the chest has been retarded or 
arrested atacertain stage either from inherited tendency 
or from causes acting in early childhood, irrespective of 
faulty attitudes, and that this rudimentary chest stands 
in close relation with the pre-tuberculous type of chest 
described by Hutchinson. It is probable that ina certain 
class of cases the faulty attitude is in large measure de- 
pendent on the long, narrow, and deep chest, which 
favors drooping shoulders and abducted scapule, and to 
the instinctive desire of the delicate, under-nourished, 
and over-stimulated child to shift the strain of bodily 
weight from the tired muscles to the insensitive liga- 
ments. 

It follows that purely local treatment rarely fulfils the 
indications, and that management with a view to general 
development and a proper regulation of the life is of pri- 
mary importance. The chest should be amply developed 
in early years by a free, open-air life, with plenty of tree 
and hill climbing, romping, rambling, swimming, run- 
ning, and ball-throwing, sports that involve well-distrib- 
uted and vigorous exercise, and especially develop arm 
action and respiratory power. 

The habits should be regulated and over-stimulation 
avoided. When the chest deformity is pronounced, spe- 
cial corrective and gymnastic exercises are of great ben- 
efit. Remembering that the faulty attitude is general, 
it is often necessary to begin by strengthening, placing, 
and shoeing the feet, in order to secure a correct pose. 
Thus the pupil should be drilled in the proper poise of 
the body, chest forward and up, abdomen and hips back, 
weight on balls of feet. After these matters have been 
attended to, breathing and corrective exercises may be 
successfully applied to the chest. Supporting apparatus 
is seldom, and shoulder straps are never, required. The 
senseless admonition to throw the shoulders back without 
attention to these preliminaries would be productive of 
much harm if it were not almost invariably disregarded. 

The round back of certain occupations and of conva- 
lescence are varieties of the round back of weakness. The 


round back of old age isaccompanied by changes of form | 


in the chest similar to those described. It is due to the 
gradually increasing muscular weakness and ligamentous 
rigidity due toadvancing age. Thespinal muscles, whose 
tonus is diminished, no longer suffice to hold the spine 
erect and the chest free. The drooping spine compresses 
the intervertebral discs anteriorly; their elasticity is im- 
paired, and the false attitude finally becomes fixed. The 
only efficient prophylactic is an active and well-distrib- 
uted muscular life in youth and manhood with thegvoid- 
ance of debilitating influences. 

In round back due to paralytic disorders the spine is 
often extremely flexible, though respiratory power is 
diminished from muscular weakness. The chest often 
remains collapsed, and the breathing may be abdominal. 
The management is usually that of the disorder upon 
which the round back depends. Special exercises and 
supports are sometimes of service, and the writer has 
found the prone position on an inclined padded board or 


Chest, 
Chest, 


mattress to have an excellent influence in stimulating the 
spinal erector muscles to action, and in correcting the 
deformity. 

The round back of paralysis agitans is similar to that 
of old age. 

The round back or so-called kyphosis of rickets, infan- 
tile scurvy, cretinism, and marasmus usually comes on in 





Fig. 1253.—Rounded Kyphos of Cured Pott’s Disease. (Original.) 
infancy before the child is able to walk, and consequently 
before the evolution of the normal antero-posterior curves 
of the spine. The sitting posture probably has much 
to do with its production, and the projection is of a 
different character from that described in the first part of 
this section. It is rounded and situated in the middle or 
lower part of the back, though it may involve nearly the 
whole spine, which is more or less flexible and free from 
muscular spasm; there is no characteristic pain. It dif- 
fers in all these respects from the kyphosis of spondylitis, 
with which it is sometimes confounded, and which it is 
exceedingly important to differentiate. Mechanical sup- 
port is rarely required, as the deformity usually recedes 
under recumbency for longer or shorter periods, together 
with the treatment appropriate for the dyscrasia. In the 
rare cases in which the deformity persists and becomes 
rigid after the cure of the disease, the treatment is 
difficult, and mechanical support may be required. 

In acromegaly the dorsal spine may become rounded, 
and the ribs, sternum, and clavicles hypertrophied, giv- 
ing a massive, deep chest. The bent back and exagger- 
ated senile attitude may occur in osteitis deformans 
(Paget’s disease) and in osteo-arthritis of the spine. 

Angular Kyphosis.—In Pott’s disease the integrity of 
the spinal column is destroyed by local tuberculous ulcer- 
ation, and the upper section of the trunk falls forward 
until it finds support, giving rise to a kyphos, or hump 
of the back, which is at first always angular, and to vari- 
ous changes in the shape of the chest, especially if the 
disease affects the thoracic vertebree. In disease of the 
upper dorsal region the upper part of the chest is flat- 
tened in front. In disease of the mid-dorsal region the 
ribs become more sloping, in severe cases resting on the 


809 


Chest, 
Chest, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ilium or within the pelvis; the chest becomes shortened 
and laterally compressed ; the sternum and lower ribs be- 
come prominent, and the antero-posterior diameter of the 
chest is increased. The chest also becomes very rigid, 
and the breathing abdominal and accelerated. 

The changes in the shape of the chest take place very 
slowly, and are only fully developed after several years. 
Therearealways 
rigidity and 
spasm of the 
spinal muscles 
during the act- 
ive stage, and 
often restless- 
ness or crying 
at night, ab- 
dominal pain, 
and a character- 
istic attitude. 
These points and 
others differen- 
tiate it from the 
rachitic spine al- 
ready described. 
The treatment is 
that of Pott’s 
disease, which 
includes atten- 
tion to hygiene 
and. nutrition, 
long - continued 
spinal support 
by special appli- 
ances, the avoid- 
ance of exercise, 
and more or less 
recumbency. 

The Rachitie 
Chest. — Besides 
lateralcurvature 
and kyphosis 
there are other deformities of the chest so frequently 
found in rickety children as to merit separate mention. 

Harrison's Groove.-—The greatest softening in the ra- 
chitic chest takes place in the cartilages of the lower ribs, 
where the chest is unprotected by the lifting action of 
the upper and lateral chest muscles. Just below the nip- 
ples there is nearly always a depression, which in severe 
cases extends upward near the costo-sternal junction or 
outward toward the axillary line. It has often been 
thought that this depression was due to the traction of 
the diaphragm, but it lies above the diaphragmatic at- 
tachment. The free border of the ribs is usually promi- 
nent, owing to enlarged liver and spleen and distended 
abdomen. These lateral depressions of the chest are in 
such a position that they are comfortably filled by the 
flexed forearms of the child, but it is improbable that the 
pressure of the arms has anything to do with their pro- 
duction. According to Stone,*® flattening of the sides of 
the chest is less common than the formation of a trans- 
verse groove and occurs in about a quarter of the cases. 
The enlar gement of the costo-chondral junctions, which 
forms the rachitic rosary, is often so great as to be 
plainly visible. 

Pigeon Breast, Pigeon Chest, Chicken Breast, Keeled 
Chest, Pectus Carinatum. —The submammary flattening, 
the formation of a transverse sulcus, the flattening of the 
sides of the chest, and the flattening of the t pper anterior 
chest enter into the formation of pigeon breast, which is 
simply the final outcome of a process of which the flat- 
tening is the first stage (Stone). In pigeon chest the 
sternum, and especially its lower part, is prominent, and 
the costal cartilages slope away abruptly at the sides. 
The antero- posterior diameter of the chest is increase, 
the lateral diminished, and the chest is much narrowed 
in front; it is also shorter than normal. 

The reverse condition with a depression over the ster- 
num may occur as the result of rickets. Both these de- 





Fig. 1254.— Kyphos and Chest Deformity of 


Cured Pott’s Disease. (Original.) 


810 








formities may be more pronounced on one side. These 
rickety chests are not only misshapen, but after the sub- 
sidence of the rickets they may remain unduly rigid and 
dwarfed. 

Besides impeding respiratory movements, these ra- 
chitic chest deformities cause very little trouble, and when 
fully developed are practically incurable. Ameliora- 
tion may sometimes be obtained by respiratory and gen- 
eral exercises. During the stage of development the 
treatment of the rickets is very important. 

Similar conditions are sometimes due to obstruction of 
the air passages by adenoids, swollen turbinates, enlarged 
tonsils, polypi, or hypertrophic rhinitis. Tubby *° relates 
several such cases, giving illustrations of the deformities 
produced. He says the proof of the dependence of the 
chest deformities upon the conditions named is given by 
their rapid improvement after the removal of the ob- 
struction to respiration. A mild grade of these conditions 
is not uncommon in school-children, and is often accom- 
panied by mouth breathing, and by inattention and ap- 
parent mental dulness, which clears up when the cause is 
corrected. 

(b) Chest Deformities Due to Lacing.—Certain chest 
deformities are due to pressure from without, and of 
these the commonest is the constriction of the waist 
and lower chest by corsets among civilized women. 
The use of corsets, even when loosely laced, prevents 
the proper expansion of the lower ribs in respiration, 
and forces the breathing into the upper thorax. This 
effect has been so universal that the exaggerated upper 





Fig. 1255.—Rachitic Chest, Showing Pigeon Breast and Harrison’s 
Groove. (Hospital for Ruptured and Crippled.) 


thoracic breathing of women is usually described as a 
normal peculiarity of the sex, but it has been pretty 
well éstablished that boys and girls breathe alike until 
the girls put on corsets, and that women who do not 


wear corsets breathe very much like men, that is, with | 


a bellows action of the whole chest, and not with a 
piston action of part of it. The evil effects of this ab- 
normal constriction are seen not only in respiration, but 
even more in the crowding and displacement: of the 
viscera. The liver may be deeply indented with the 
marks of the compressing ribs, and the ribs themselves 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chest, 
Chest. 





are often misshapen about the waist. The stomach, in- 
testines, and pelvic organs are frequently displaced 
downward, with many resulting ills. The rigidity and 
compression of the stays weaken the waist, back, and 
abdominal muscles, and interfere with the natural sup- 
port and normal mobility. 

Cobbler’s Chest.—Some occupations cause special chest 
deformities, such as the cobbler’s chest, due to the press- 
ure of the last against the end of the sternum, producing 
a depression similar to funnel chest, but lower. 

Tailors who sew in a bent-over attitude often have a 
hollow chest. 

(ce) Deformities Due to Changes in the Thoracic and Ab- 
dominal Contents.—The last division of chest deformities 
includes those that are due to changes in the thoracic or 
abdominal contents. 

The Inflated, Distended, or Emphysematous Thorax.— 
The typical chest of emphysema is large and rounded or 
barrel-shaped. It is, in fact, a chest which permanently 
retains the shape of extreme inspiration, owing to the 
ballooning of the enlarged and dilated lungs, or, accord- 
ing to Campbell,*! to overaction of the inspiratory mus- 
cles, the antagonistic pulmonary elasticity being impaired. 
The ribs are strong and leave the sternum nearly ata 
right angle, making the thorax appear short. The ster- 
num is prominent, especially at the angle of Louis, and 
the epigastric angle is large. The supraclavicular depres- 
sions are shallow or effaced; they may even be converted 
into elevations, if the pulmonary apices are markedly 
emphysematous. This is by no means always the case; 
they may even be deepened. The chest is immobile, and 
the breathing abdominal. While one may-safely infer the 
presence of emphysema from the rigid, inflated chest, one 
should not call the large, deep chest of well-built and active 
men emphysematous, nor should one forget that in many 
cases of emphysema the lungs are not enlarged, and the 
chest fails to present the above-described characteristics. 

One-sided distention of the chest, particularly in its 
lower part, may occur in pleuritic effusion and empy- 
ema of one side, in which conditions there may be bulg- 
ing of the lower intercostal spaces. In proportion as the 
breathing is crippled on the affected side, there will be 
inflation and overaction of the well side, especially at the 
upper part in front. Hypertrophy of the heart, pericar- 
dial effusion, and aneurism may cause enlargement in the 
precordial region, and marked enlargement of the liver 
or spleen may cause a bulging of the ribs on the corre- 
sponding side. Chronic distention of the stomach and 
bowels may cause prominence of the lower ribs on both 
sides. Effusions and enlargements of the internal organs 
will affect the shape of the chest in proportion to its flex- 
ibility. These deformities are therefore most marked in 
children, less in adults, and least often observed in the 
aged. In individuals with rigid chests changes in the 
internal organs may produce but slight effect. 

The Phthisical, Phthinoid, Alar, Paralytic, or Rudi- 
mentary Chest.—This is partly a rudimentary and partly 
an atrophied chest. It has usually been described as flat 
or flattened, but Hutchinson’? has shown that it may 
be not only relatively but absolutely longer, narrower,’ 
deeper, and rounder than normal, approximating the 
quadrupedal type. It is apparently a chest whose evo- 
lution has been arrested at a lower stage. In the chest 
of phthisis the ribs are depressed, and the intercostal and 
supraclavicular spaces may be sunken. The epigastric 
angle is diminished; costal breathing is lessened on the 
affected side. 

If chest development is arrested in childhood or ado- 
lescence, the liability to phthisis is increased, and one 
may infer a certain predisposition to pulmonary tubercu- 
losis from the existence of this chest in the young. The 
investigations of Gabrilowitch** confirm these views. 
He found that the ratio of the circumference of the best- 
shaped chest to the total height was as1to1.6. The 
ratio of the mean antero-posterior diameter to the trans- 
verse was as .70 to 1 in normal individuals, but in phthisi- 
cal individuals the proportion was .73to1. Rothschild * 
criticises Gabrilowitch’s methods and conclusions, and 


gives the ratio of chest depth to chest breadth as 1 to 1.8 
in healthy individuals, and as 1 to 1.5 in phthisical sub- 
jects with thorax paralyticus. He gives the chest cir- 
cumference as one-half the total height, and the length 
of the sternum as one-fifth the chest,circumference in the 
healthy, less in thorax paralyticus. He-also states that 
the angle of Ludovici and the angular movement of the 
sternum in respiration are less in phthisis (see measure- 
ments by De Giovanni*). The whole subject apparently 
requires more exact and extensive study. 

During the destruction of lung tissue atrophy of the 
muscles of the chest takes place, and is most pronounced 
on the side most seriously involved, and unilateral if the 
disease is unilateral. 

Carcasonne * finds that atrophy of the scapulo-thoracic 
muscles takes place early and independently of general 
emaciation; it may even precede auscultatory signs. 
This atrophy is not accompanied by functional changes 
in the muscles, nor is their electric excitability altered; 
it advances with the progress of the pulmonary lesion, 
and is of considerable diagnostic value. The analogy of 
this concomitant atrophy of the muscles of related areas 
with the primary atrophy in joint disease is evident. In 
the latter case, however, the tonus and mechanical and 
electric excitability are said to be increased. 

The very great importance of an active out-of-door 
life, of exercise stimulating deep breathing, and of free 
use of the armand shoulder muscles for the round-shoul- 
dered and alar-chested, isapparent. Swimming, running, 
climbing, and throwing are particularly indicated. 

Unilateral shrinking of the chest occurs in phthisis of 
one side. The deepening of one supraclavicular fossa is 
an evilsymptom. Overashrunken cavity the chest may 
present a depressed appearance, with hollow intercostal 
spaces. From the atrophy already mentioned, as well as 
from the traction of adhesions, there may be depression 
of the chest wall without cavity. After pleurisy and 
empyema, if the lung does not expand, the affected side 
of the chest may become markedly shrunken, and the 
whole thorax deformed with a scoliosis, whose convexity 
is toward the well side. Henry Ling Taylor. 


BIBLIOGRAPHICAL REFERENCES. 


1 Medical Diagnosis, Philadelphia, 1898. 

2 Anatomische, physiologische, und physicalische Daten und Tabel- 
len, Jena, 1893. 

3 Medical Record, July 29th, 1899. 

4 Journal American ‘Medical Association, September 1st, 1897, p. 512. 

5 Encyclopedia Medica, Edinburgh, 1899. 

§ Medical Record, September 8th, 1894. 

7 Clinical Sketches, London, 1895. 

8 Transactions American Orthopedic Association, vol. xii., 1899. 

® Thése de Paris, 1890 

10 Journal of Anatomy and Physiology, vol. xxx., London, 1896. 

11 Anatomische Anzeiger, 1894-95, p. 540. 

12 Transactions Clinical Society of London, vol. xxvi., 1893, p. 225. 

13 Transactions Academy of Medicine of Ireland, vol. i., p. 163. 

14 Archives of Pediatrics, vol. viii., p. 346. 

15 Boston Medical and Surgical Journal, vol. Ixxxv., p. 114. 

16 Ephéméris médicale de Montpellier, 1826, p. 144. 

17 Lancet, February 19th, 1898. 

18 Transactions American Orthopedic Association, vol. ii., p. 233. 

19 American Medical and Surgical Bulletin, November 15th, 1894, 

20 British Medical Journal, May 13th, 1899. 

21 Wiener klinische Wochenschrift, January 4th, 1900. 

22 Cyanose et déformation thoracique. Société de Biologie, Novem- 
ber 8th, 1899. 

23 Deutsche Chirurgie, vol. xlii., Stuttgart, 1888. 

24 PAS klinsche Wochenschrift, August 28th and September 
4th, 1899. 

25 Pediatrics, February 15th, 1900, p. 154. 

26 Deutsches Archiv fiir klinische Medicine, April, 1882, p. 411. 

27 Reference Handbook of the Medical Sciences, vol. ii., p. 80, 1886, 

28 Philadelphia Medical Journal, March 11th, 1899, p. 559. 

29 Deutsche medicinische Wochenschrift, 1888, No. 36. 

30 Gazette hebdomidaire, February 16th, 1896. 

31 Journal de l’Anatomie et Physiologie, xxix., 1893, p. 564. 

32 Pediatrics, December Ist, 1899. 

33 Archiy fiir klinische Chirurgie, vol. xlii., p.545. 

34 Revue mensuelle des maladies de l’enfance, March, 1900. 

35 Annals of Surgery, April, 1900. : 

36 Zeitschrift fiir orthopadische Chirurgie, vol. vii., p. 129, 1899. 

37 New York Medical Journal, September 30th, 1899. 

38 Jouré et Boyer, Paris, 1899. . 

39 Transactions American Orthopedic Association, vol. xi., p. 337, 1898. 

40 Deformities, a Treatise on Orthopzedic Surgery, London, 1896, p. 24. 

41 Respiratory Exercises, New York, 1899. 

42 British Medical Journal, October 28th, 1899. 

43 Berliner klinische Wochenschrift, May 22d, 1899. 


811 


Chest, 
Chest, 





44 St. Petersburger medicin. Wochenschrift, No. 18, May 19th, 1900. 
45 Morfologia del corpo humano, Milan, 1891. 
46 Thése de Paris, 1899. ; 


CHEST, PHYSICAL EXAMINATION, OF THE.— 
Physical examination of the chest is accomplished by 
the use of the special senses of sight, hearing, and touch 
in the application of the methods of inspection, palpation, 
mensuration, percussion, and auscultation. The phe- 
nomena observed by these methods of investigation are 
called physical signs. To recognize and properly inter- 
pret the physical signs caused by abnormal conditions 
of the thoracic viscera it is essential that the observer 
should thoroughly understand the normal physical signs 
and be able to recognize them. 

The physical signs obtained on examination indicate 
to the observer the condition of the organs examined, 
and from the consideration of these physical signs to- 
gether with the subjective symptoms and history of the 
patient, the diagnosis of the disease producing the patho- 
logical changes is made. The diagnosis should never be 
made from the physical signs alone. 


PuysicaL EXAMINATION OF THE LUNGS. 


Topography of the Chest.—For convenience in descrip- 
tion and for reference the surface of the chest is divided 
into anterior, lateral, and posterior regions by vertical 
and transverse lines. 

Vertical Lines.—Anterior median or mid-sternal; 
sternal line drawn parallel to the edge of the sternum; 
mid-clavicular line drawn downward from the middle of 
the clavicle, usually passes through the nipple in men, 
and is, therefore, sometimes called the mammary line; 
parasternal line, drawn midway between the sternal and 
mid-clavicular lines; anterior axillary line drawn through 
anterior fold of axilla; mid-axillary line and posterior 
axillary line drawn through middle of axilla and posterior 
fold respectively; scapular line drawn vertically through 
angle of scapula when the arm hangs at the side; pos- 
terior median line. 

Transverse Lines.—On the anterior surface of the chest 















Yi 





Osment 


7] 


Si 





Fic. 1256.—-Anterior Surface of Chest. : 
broken line, fissures between lobes and line of pleura ; 
dot and dash line, stomach ; 





k, fissure between right middle and lower lobes. 
Untersuchungs-Methoden,”’ etc.) 


812 


y) 
7) 


| 


, Continuous line, border of lungs; 
, dotted line, liver ; 
, double line, heart and great vessels. 
vena cava superior; C, right auricle; D, pulmonary artery; H, left auricle; F, left ven- 
tricle ; G, right ventricle ; ab, border of right pleural sac ; cd, border of left pleural sac ; ef, 
edge of right lung; gh, edge of left lung; 7, fissure between right upper and middle lobes; 
(From Sabli’s ** Lehrbuch der klinischen 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


transverse lines are drawn parallel to the lower borders 
of the third and sixth ribs, the latter of these lines pro- 
longed also divides the upper from the lower axillary 


relia) ‘ 





Fig. 1257.—Lateral Surface of Chest. _————, Continuous line, 
lower border of left lung; ------- , broken line, fissure between left 
upper and lower lobes, lower border of pleura; . , dotted line, 
spleen and liver; —--- --- , dot and dash line, stomach and kidneys; 
ab, lower edge of left lung ; ac, lower border of pleural sac; f, edge 
of left lobe of liver; g, posterior, h, anterior end of spleen (when 
oval in shape); k, lower edge of left kidney; n, greater curvature 
of stomach. (From Sahli.) 


settee 


regions; on the posterior surface lines are drawn parallel 
to the second rib, through the spine of the scapula, and 
joining the angles of the scapule. 

Anterior Regions. —Supraclavicu- 
lar, above the clavicle; clavicular, 
that portion of chest covered by clav- 
icle; infraclavicular region, from 
lower border of clavicle to lower bor- 
der of third rib; mammary region, 
from lower border of third to lower 
border of sixth rib; inframammary 
region, from lower border of sixth to 
free border of ribs; upper sternal to 
lower border of third rib, and lower 
sternal, from lower border of third 
rib to ensiform cartilage. 

Lateral Regions.—Axillary region 
to lower border of sixth rib; infra- 
axillary, from lower border of sixth 
to free margin of ribs. 

Posterior Regions.—Upper scapular, 
from second rib to line of spine of 
scapula; lower scapular, from spine 
of scapula to angle of scapula; in- 
frascapular, from line joining angles 
of scapule to twelfth rib; interscap- 
ular region, that portion of posterior 
surface which lies between the scap- 
ula and the spine. 

Relation of the Borders and Fissures 
of the Lungs to the Surface of the 
Chest.—Anteriorly, the apices extend 
from half an inch to an inch and a 
half above the clavicle, and _ pos- 
teriorly as high as the seventh cer- 
vical vertebra (Fig. 1259). The an- 
terior borders pass down behind the 
sterno -clavicular articulation and 
meet in the median line opposite the 


Kal 


’ 


A, Aorta; B, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chest, 
Chest, 





second ribs. They remain in contact as far as the 
fourth ribs; at this point the right border passes down 
to the sixth rib in the median line, thence passing out- 





U0 
= 


Fic. 1258.—Posterior Surface of Chest. - 





spleen and liver; ------- , dot and dash line, kidneys. 


Sahli.) 


ward and downward, the lower border in quiet respira- 
tion reaching the sixth rib in the mid-clavicular line, 
the eighth in the mid-axillary line (Fig. 1257), the ninth 
or tenth rib in the scapular line, and the eleventh rib 
near the spine; at the fourth rib the left border passes 
outward to the fifth costo-chondral junction, then down- 
ward and inward to the sixth rib, and then outward and 
downward. The lower border of the left lung is usually 
a little lower than the right. 

The Fissures between the Lobes.—The fissure between 
the left upper and lower lobes and between the right 
middle and lower lobes may be indicated by a line drawn 
from the third dorsal vertebra to the sixth rib in the mid- 
clavicular line (Fig. 1258). This line corresponds roughly 
with the vertebral border of the scapula when the elbow 
is raised and the hand placed on the head. The fissure 
between the right upper and middle lobes meets the 
fissure between the upper and lower lobes at the axillary 
border of the scapula and passes almost horizontally for- 
ward to the junction of the fourth costal cartilage with 
the sternum (see Figs. 1256, 1257, 1258). 

The right lung consists of three lobes, which bear the 
following relations to the surface of the chest: Anteriorly 
the upper lobe extends to the fourth or fifth rib, and the 
middle lobe from the fourth to the sixth rib. Laterally 
the upper lobe extends to the fourth rib, the middle lobe 
to the sixth rib, and the lower lobe to the eighth rib. 
Posteriorly the upper lobe extends from the apex to the 
spine of the, scapula, the lower lobe extends from this 
point to the base. On the left side the upper lobe oc- 
cupies the whole of the front of the chest; laterally the 
upper lobe extends to the fourth rib, below this the 
lower lobe to the base (Figs. 1256 to 1259). 

Trachea and Bronchi.—The trachea deviates in its lower 
part a little from the median line and bifurcates behind 


, Continuous line, lower border of lungs; 
------- . broken line, fissures between lobes, and line of pleura; ......., dotted line, 
é, Fissure between left upper 
and lower lobes; f, fissure between right upper and lower lobes; g, beginning of fissure 
between right upper and middle lobes; ab, lower edge of lung; cd, lower border of 


pleural sac ; h, spleen; i, lower border of liver; k, left kidney; 1, right kidney. (From 


the right edge of the sternum at the junction of the lower 
border of the second costal cartilage and the sternum. 
This point corresponds posteriorly with a point a little 
to the right of the spine of the fourth dorsal vertebra. 
The general course of the main bronchi may be pro- 
jected on the posterior surface of the 
chest as follows: The right bronchus 
starts at a point to the right of the spine 
of the fourth dorsal vertebra and extends 
in nearly a straight line to a point on 
the eighth rib two inches to the right of 
the spine. The left bronchus originating 
at the same point, passes outward and 
then downward to a point on the eighth 
rib three inches from the median line. 
The calibre of the right bronchus is 
larger than that of the left, and this 
bronchus forms a more direct continua- 
tion of the trachea than does the left. 
This explains the fact that most for- 
eign bodies which pass into the trachea 
through the larynx are found in the right 
bronchus. The bronchi are nearer to the 
posterior surface of the chest than to the 
anterior. The position and relations of 
the bronchi are important and help to 
explain the physical signs in the inter- 
scapular regions, and the differences in 
the signs at the apices of the lungs. 
Diaphragm.—The dome of the dia- 
phragm on the right side extends as high 
as the fourth intercostal space in the mid- 
clavicular line, in the axillary line to the 
sixth rib, and in the scapular line to the 
eighth rib. On the left side the diaphragm 
occupies a somewhat lower position. 
Liver.—On the right side in mid-cla- 
vicular line the liver extends from the 
fourth space to the free border of the 
ribs. From the fourth space to the sixth 
rib the liver is separated from the chest 
wall by a wedge of lung tissue, below 
this point it is in contact with the chest 
wall. In the right axillary and the scapular lines the 
liver’s upper border corresponds with the lower border 
of the lung (Figs. 1256 to 1258). 





Fig. 1259.—Posterior Surface of Chest, Showing the Relation of the 
eras and Lower Limits of the Lungs to the Chest Wall. (From 
abli. 


813 


Chest, 
Chest, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Spleen.—The spleen lies beneath the ninth, tenth, and 
eleventh ribs. Its upper border follows the ninth rib, 
and its anterior border extends to a line drawn from the 
tip of the eleventh rib to the left sterno-clavicular articu- 
lation (Figs. 1257 and 1258). 

The lungs may be examined with the patient in either 
the standing, or sitting, or recumbent position. It is im- 
portant that the position be a comfortable one, and that 
the patient’s arms and legs are symmetrically placed. 
The patient should also be stripped to the waist. 

INSPECTION.—By this method of examination the form, 
the size, and the movemenst of the chest in respiration are 

studied, and un- 
der this head the 
investigation of 
the organs of the 
thoracic cavity 
by means of the 
a-raysS may also 
be included. 
Form.—The 
normal adult 
chest is elliptical 
in shape, the 
transverse di- 
ameter longer 
than the antero- 
posterior, and 
(Gee.) the two sides 
practically sym- 
metrical; on measurement, however, the right is usually 
about half an inch larger than the left (Fig. 1260). 

The supraclavicular regions are somewhat depressed, 
and there is generally a slight depression just below the 
clavicles; the remainder of the anterior surface of the 
thorax is convex from above downward and from side to 
side. The epigastric angle is nearly aright angle. The 
spine is usually straight, but may incline slightly to 
the right in the upper and middle dorsal regions. In 
children’s chests the two diameters are nearly equal, and 
the chest nearly circular in form. The apex beat of 
the heart is often visible in the fifth intercostal space 
about one inch inside the mid-clavicular line. 

As the result of disease deviations from the normal form 
of the chest occur; the more common of these are the 
rickety, pigeon-breast, phthisical or alar, emphysematous 
or barrel-shaped chests, and the deformities due to spinal 
disease. Changes in the contour of the chest may be 
demonstrated by means of the cyrtometer (see Cyrtom- 
eter). In addition to these general deformities there may 
be retraction or enlargement of the chest walls. 

Retraction or sinking in of the chest wall, generally of 
the intercostal spaces, may be general or local. General 
retraction is caused by obstruction to the entrance of 
air into the larynx or trachea, foreign bodies in the 
larynx, diphtheritic membrane, tumors pressing on the 
trachea. Local retraction is the result of collapse or 
contraction of the lung. An example of this local re- 
traction is seen at the apices of the lungs in phthisis, 
and at the bases as the result of an old pleurisy with 
adhesions, or of empy- 
ema. 

Enlargement or bulging 
of the chest wall may be 
localized or may involve 
the whole of one side. In 
the former case it is usu- 
ally due to abscess, tumor, 
or enlargement of the 
liver, spleen, or heart; in 
the latter to fluid or air 
in the pleural cavity. 
The location of the bulg- 
ing often suggests the 
cause. General enlarge- 
ment of the chest is also seen in cases of emphysema. 

The size of the normal chest varies greatly; the average 
circumference at the level of the nipples is thirty-four 


Fig. 1260.—Normal Chest. 







gore res 


FiG. 1261.—Rickety Chest. (Gee.) 


814 





inches; it may vary from twenty-eight to forty-four 
inches. <A tape measure is a sufficiently accurate means 
of determining the size of the chest. 

Movements.—During normal respiration the chest ex- 
pands and contracts, the expansion varying from two to 
four or five inches. In 
men and in children the 
respiration is chiefly ab- 
dominal, in women it is 
of the thoracic type. The 
normal number of respira- 
tions is 18 or 20 per min- 
; ute; women habitually 
/ breathe more rapidly than 
men. The mobility or ex- 
pansibility of the chest 
may be modified by dis- 
eased conditions. Emphy- 
sema and asthma cause a 
generally diminished ex- 
pansion; pleurisy with effusion, pneumonia, and pain, 
the result of dry pleurisy or injury, may produce a uni- 
lateral diminished expansion. At the apices a diminu- 
tion of the expansibility is usually due to tuberculous 
disease, at the bases to chronic pleurisy with adhesions. 

Expansion is generally increased by exercise, and lo- 
cally when one lung, or part of oné lung, is called upon 
to do extra work; for example, the sound lung in pneu- 
monia, or the upper lobe of the diseased side in a pleur- 
isy with effusion. The rapidity and rhythm of the 
respirations are to be noted on inspection. Dyspnoea 
may be due to fever or to some interference with the free 
entrance or exit of air, in which case it is called inspira- 
tory or expiratory dyspnoea. Orthopneea is the term 
applied to breathing of such difficulty that the patient 
is obliged to remain in the sitting posture. Cheyne- 
Stokes respiration is the marked irregularity in rhythm 
seen in cases of ureemia and cerebral disease. 

Litten’s sign or the shadow on the lower portion of the 
chest due to the movements of the diaphragm may also 
be seen on inspection. To observe this phenomenon, the 
patient should lie on his back in a slightly raised posi- 
tion with his feet toward the light, which need not be 
very intense. The observer stands with his back to the 
light three or four feet from the patient and looks at the 
chest at an angle of about 45°. During respiration a 
shadowy line is seen to move over the surface of the chest 
from above downward. This shadow begins at the sixth 
rib and moves down with inspiration over two or more 
intercostal spaces; during expiration the shadow moves 
upward. This moving shadow is caused by the separa- 
tion of the diaphragm from the walls of the thorax dur- 
ing inspiration and the 
returning contact during 
expiration. 

The sign indicates the 
mobility of the lungs,and_ ; 
its absence, or restriction 
in the excursion of the 
shadow, is noted when 
there is fluid or air in the 
pleural sac, when pneu- 
monia of the lower lobe 
exists, when fhere are 
pleuritic adhesions or a 
thoracic tumors, and when ios 128, Ea Cae 
the lungs are emphyse- 
matous. In very stout persons and in patients with 
very thick chest walls it is sometimes impossible to de- 
tect this sign. 

Examination by x-Rays.—The x-ray has been utilized 
in the examination of the chest. The use of the method 
depends on the fact that normal lung tissue is easily trav- 
ersed by the ray, and any change in density in the lung 
tissue is indicated in the fluoroscope by lighter or darker 
areas; lighter than normal when the density of the lung 
is less than normal, as in emphysema or pneumothorax, 
and darker than is usual when the density is increased, 







- 
~ - 
wee ee” 


posers mne 
“~ 


Fig. 1262..—Pigeon Breast. (Gee.) 






' 
' 
‘ 
‘ 
‘ 


Mee ene --* 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chest, 
Chest. 





as in tuberculosis, pneumonia, carcinoma, pleurisy, or 
empyema. The diaphragm can be seen to move up and 
down during respiration; normally it should descend 
from one to two and a half inches in inspiration, and any 
diminution in the movements of the diaphragm is sug- 
gestive of disease; frequently this limitation in the ex- 
cursion of the diaphragm is one of the earliest signs of 
tuberculosis. In pneumonia the darkened areas are dis- 
tinct, and in a central pneumonia the consolidated area 
may be seen before any physical signs are noted by per- 
cussion or auscultation; the movement of the diaphragm 
is also limited on the affected side. 

In pleurisy with effusion the lower part of the chest is 
dark and the heart is displaced toward the sound side. 

In emphysema the lungs appear brighter than normal 
and the diaphragm does not rise as high during expira- 
tion as it does in the healthy chest. 

PaLPATIoN.—This is the examination of the chest by 
the application of the hand to the chest walls; by this 
means irregularities in form, local points of pain or tender- 
ness, local expansion, and vocal or friction fremitus can 
be appreciated. Vocal fremitus is the thrill conveyed to 
the hand placed upon the chest wall while the patient 
is speaking. It is due to the transmission downward 
through trachea, bronchi, and lung substance of the 
vibrations produced by the vocal cords in the act of 
speaking. The intensity of the fremitus varies in differ- 
ent individuals, and is always more marked in men than 
in women; it is diminished by anything which interferes 
with the transmission of the vibrations to the palpating 
hand. Thus thick chest walls, from muscle or fat, thick- 
ened pleura, or bronchi partially occluded with mucus 
diminish the fremitus. The fremitus is absent when 
there is fluid or air in the pleural cavity, or when the 
pleura is greatly thickened. Consolidation of the lungs, 
on the other hand, by making a better conducting 
medium for the vibrations, causes distinct increase of the 
vocal fremitus. 

In some cases of bronchitis in which the breathing is of 
the sibilant and sonorous variety, vibrations which arise 
from the sibilant and sonorous rhonchi can be felt. This 
is called “ bronchial fremitus.” Friction fremitus, caused 
by the rubbing together of roughened pleural surfaces, 
is occasionally felt in cases of pleurisy. 

Prrcusston.—The sounds produced by percussion en- 
able the examiner to determine the condition of the 
organ beneath the part of the chest percussed. To 
recognize the difference in percussion sounds, it is neces- 
sary to analyze each sound with regard to its quality, 
pitch, intensity, and duration. 

Percussion may be either immediate or mediate. It is 
important that the patient should be stripped, and that 
the arms and legs should be in symmetrical positions. 
For the examination of the anterior surface of the thorax, 
the patient should stand erect with the hands hanging at 
the sides and the face pointed straight forward. For ex- 
amination of the axillary regions, the hands should be 
placed on the head, or elevated above it; and for the 
examination of the posterior surface, the arms must be 
crossed and the hands placed on the opposite shoulders, 
the back slightly bowed, and the head bent forward. 
The object of these positions is to put the skin and the 
underlying muscles on the stretch, and, in the examina- 
tion of the back, to increase the breadth of the inter- 
scapular space. 

In immediate percussion the chest wall is struck directly 
by the finger or the percussor; this method is rarely used. 
In mediate percussion the finger of one hand, or an in- 
strument called a pleximeter, is interposed between the 
chest wall and the percussing finger or percussor; this is 
the method commonly practised. The pleximeter or the 
finger, used as such, should be applied firmly to the chest 
wall in the intercostal spaces, and the blow of the hammer 
or the striking finger should be given as quickly, evenly, 
and as nearly at a right angle to the pleximeter as possi- 
ble. For the examination of organs lying near the sur- 
face, the pleximeter should be lightly applied, and the 
blow of the percussor should also be light; for deep- 


seated organs, the pressure must be firmer and the blow 
more forcible. 

When using the finger for the percussor, the blow 
must be given from the wrist and not from the elbow or 
shoulder. The blow should strike the middle of the 
pleximeter, and the finger striking the blow must be 
quickly lifted, as the character of the note is decidedly 
changed and dampened if the finger is allowed to remain 
in contact with the pleximeter. 

It is more satisfactory to use the hands for percussion 
than to depend entirely on the percussor and pleximeter. 
The hands are always ready; and, when percussing with 
the fingers, the observer appreciates the sense of resist- 
ance beneath the finger, in addition to the sound pro- 
duced by the blow. When demonstrating the sounds 
produced by percussion to a large number of students, 
the use of hammer and pleximeter is more satisfactory. 
When it is necessary to compare the percussion notes on 
the two sides of the chest, the percussion for comparison 
must be made at the same point on each side, the force of 
the blows must be the same, the position of the patient 
must be so arranged that the two sides will be symmetri- 
cal, and the percussion should be made at the same period 
of the respiratory cycle. 

On percussing a normal chest beneath the left clavicle 
a sound is produced, due to the vibration of the lung tis- 
sue and the thoracic walls. This sound is called the nor- 
mal or pulmonary resonance, and it is recognized by the 
following characteristics: the quality is pulmonary or 
vesicular, pitch is low, intensity variable, and the dura- 
tion considerable. The intensity depends on the force of 
the blow, on the thickness and elasticity of the chest walls, 
and on the volume of air contained in the portion of lung 
under percussion. The finger appreciates with this pul- 
monary resonance an elastic feeling, which is character- 
istic when percussing over normal lung substance. 

The percussion note in the right infraclavicular region 
is usually slightly less resonant than that on the left side, 
the quality is less pulmonary, the pitch higher, the in- 
tensity less, and the duration shorter. This is probably 
dependent on the greater muscular development on the 
right side, and also on the larger amount of connective 
tissue in the right lung, the result of the greater size of 
its bronchi. 

Normal pulmonary resonance is heard in the following 
regions: supraclavicular, infraclavicular, axillary, inter- 
scapular, and infrascapular. 

If percussion is made in the lower part of the mammary 
region on the right side, a sound is produced differing 
from the normal pulmonary note in that the quality is. 
dull, the pitch higher, the intensity less, and the duration 
shorter. This change in the character of the note in this 
region is due to the presence beneath the lung of the liver, 
and this solid organ modifies or dulls the normal sound 
produced by percussing over lung tissue. 

Duiness is heard wherever the amount of lung tissue is 
small, or is encroached upon by solid organs, or when the 
normal amount of air-containing tissue is diminished as. 
the result of disease. 

In the normal chest dulness is found in the mammary 
region on the right side from the liver and on the left 
from the presence of the heart. In the infra-axillary re- 
gions, on the right from the liver and on the left from the: 
spleen; also in the scapular regions from the excessively 
thick layers of musclesand bone. Disease, by producing 
airless tissue in the lungs, the pleura, the pleural cavity, 
or the chest walls, causes dulness, and, depending on the: 
amount of airless tissue, the dulness may be slight or 
marked. 

There is dulness in the early stages of tuberculosis, 
usually at the apices of the lungs, from the presence: 
there of the tuberculous deposit. In the second stage of 
pneumonia there is marked dulness over the consolidated 
area. In cases of pleurisy with effusion, where the 
amount of exudate is not large, there is dulness. The 
same sign is produced by thickened pleura, or by chest 
walls much thickened by muscle or fat. Enlargements. 
of the heart, liver, or spleen, tumors, aneurisms or ab- 


815. 


Chest, 
Chest, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





scesses, if covered by a thin layer of lung, will cause dul- 
ness on percussion. When percussing over a dull area, 
the finger appreciates a sense of resistance. This feeling 
of resistance or lack of elasticity increases as the dulness 
is more marked. 

Filatness.—W hen the percussion note is entirely without 
resonance it is said to be flat. The quality is flat, intensity 
not great, pitch high, and duration short. A typical flat 
note can be obtained by percussing the thigh. This sound 
is heard when the percussion is made over solid organs, 
or over organs, normally air-containing, in which, as the 
result of disease, the air has been displaced by dense tissue 
or fluid. Flatness indicates absence of air. In the normal 
chest flatness may be obtained on the right side in the in- 
framammary region and in the infra-axillary region below 
the eighth rib from the underlying liver; also in the left 
infra-axillary region over the spleen. 

Percussion over the fluid, in cases of pleurisy with effu- 
sion, gives typical flatness, and it isin these cases that the 
very marked sense of resistance on percussion is so easily 
appreciated. Flatness on percussion may be heard in 
cases of pneumonia where the consolidation is complete, 
also in phthisis, where the consolidated area is extensive ; 
and over tumors and enlarged solid viscera, where the 
mass or organ is in contact with the chest wall. 

Tympanitic Resonance.—Percussion over a hollow vis- 
cus containing air elicits a drum-like or tympanitic note; 
the quality is tympanitic, pitch high or low, intensity 
usually marked, and duration variable. Typically tym- 
pany is heard on percussing over the stomach and intes- 
tines; in the normal chest it is heard only over the larynx, 
trachea, and in Traube’s space. The variety in pitch de- 
pends on the size of the viscus and the tension of the 
contained air. Percussion over the stomach givesa much 
lower note than that over the intestines, the former being 
a much larger viscus than the latter. Tympanitic reso- 
nance is caused by the following conditions: 

1. Large collections of air, forexample over the trachea, 
the stomach, the colon, and smallintestines; over cavities 
in the lung substance, especially if superficial, and over 
pneumothorax, when there is a free communication 
with a bronchus; if the opening is not free, the air in 
the pleural sac is under pressure, and the note on percus- 
sion is not tympanitic but dull. 

2. Percussion over consolidated or compressed lung, 
which is in contact with a hollow viscus or air-containing 
organ, often produces tympanitic resonance, by conduc- 
tion from the adjacent air-containing viscus. This tym- 
panitic resonance is not uncommon over the lower lobe 
of the left lung even in health, and is the resonance trans- 
mitted from a stomach distended with air through the 
normal lung. 

3. Lung that has lost its normal tension or is in a con- 
dition of relaxation is tympanitic on percussion. This 
occurs in cases of pleurisy with effusion, in the early 
stages of consolidation, pneumonic or tuberculous, and in 
cedema of the lungs. 

4. In emphysema tympanitic percussion is common. 

The presence and location of cavities may be deter- 
mined by careful recognition of the tympanitic note. Sev- 
eral methods have been described by observers, the fol- 
lowing being the most useful: 

Wintrich’s change of note. If the cavity communi- 
cates directly with a bronchus, the percussion note va- 
ries in intensity and pitch, and also in the distinctness of 
its tympanitic quality, as the patient opens and closes his 
mouth. When the mouth is open the percussion note 
is of greater intensity, higher pitch, and more markedly 
tympanitic in quality than it is when the mouth is 
closed. ; 

A change in the patient’s position by altering the rela- 
tion of the bronchus to the cavity may also produce a 
change in the tympanitic quality of the percussion note. 

Gerhardt’s change of note depends on the presence of 
fluid in the cavity, the level of which is changed as the 
position of the patient is varied from the upright to the 
recumbent. In the upright position, over the lower por- 
tion of the cavity there may be dulness or even flatness 


816 





on percussion, and tympany over the upper part of the 
cavity. This condition of physical signs is due to the 
fact that the fluid gravitates to the lowest part of the 
cavity. When the patient assumes the recumbent posi- 
tion the fluid level is changed, and tympany is elicited 
on percussion over that portion of the chest wall which 
was dull when the patient was erect. This sign, though 
seldom found, is a positive indication of the presence of 
a cavity. 

In addition to the varieties of percussion resonance 
already mentioned, the following are heard in diseased 
conditions of the chest: , 

Vesiculo-Tympanitic Resonance.—The quality is a com- 
bination of normal pulmonary and tympanitic resonance, 
the pitch high; the more the tympanitic quality predomi- 
nates the higher will be the pitch; the intensity is in- 
creased, and the duration varies. This is the resonance 
heard commonly in cases of emphysema, and it is often 
called the wooden or “bandbox” resonance. It may be 
heard in pleurisy with effusion over that portion of the 
lung which is above the fluid, and over the sound lobe in 
pneumonia. 

Amphoric Resonance.—The quality is amphoric, pitch 
variable, intensity and duration are considerable. This 
sound is like that produced by flipping the cheek when 
tense, and has a peculiar musical quality. To produce 
the sound well the percussion should be practised during 
expiration, and the patient should be instructed to keep 
the mouth open; it is also necessary that the ear of the 
observer should be near the patient’s mouth. This sound 
is heard over cavities, usually of considerable size with 
smooth and rigid walls, which communicate freely with 
a bronchus. It may more rarely be heard over pneumo- 
thorax, but only when there is free communication be- 
tween the air-containing pleural sac and a bronchus. 
Percussion over consolidated lung, which is in contact 
with a large bronchus, may give amphoric resonance. 

Cracked- Pot Sound.—The quality of this sound is jin- 
gling, pitch high, intensity and duration not marked. It 
is like the sound produced by striking the hands folded 
together on the knees. This sound is indicative of cavi- 
ties with flaccid walls which contain air, and which com- 
municate with a bronchus. Percussion should be prac- 
tised in the same manner as has been described under 
amphoric resonance. 

AUSCULTATION.—Auscultation is examination of the 
chest by the ear to hear the sounds produced in normal 
and abnormal conditions of the lungs during respiration, 
coughing, and speaking, also to detect the presence of 
any adventitious sounds. 

There are two methods of auscultation, the immediate 
and the mediate. In the former the ear is placed directly 
on the chest, or on the chest covered with a thin cloth; 
and in the latter the stethoscope* is used. 

The immediate method is more satisfactory for the ex- 
amination of the lungs than the mediate method, except 
in cases in which it is necessary to Jocalize faint adven- 
titious sounds, or when it is desirable to auscultate those 
portions of the chest where it is difficult or impossible to 
place the ear in close contact with the thoracic wall; for 
example, in the supra- or infraclavicular fosse. Under 
these conditions the stethoscope is of great use, not only 
from the fact that it can be used where the ear cannot, 
but also because it eliminates outside sounds and inten- 
sifies the sounds produced within the chest. The stetho- 
scope, however, by modifying and intensifying the respi- 
ratory sounds, may cause confusion, and it is only after 
considerable practice that true deductions can be made 
as to the conditions of the lungs from the sounds heard 
through the stethoscope. 

On auscultation over normal lung substance a rustling 
or breezy sound is heard with inspiration and expiration; 
this is the normal pulmonary or vesicular murmur. The 
sound heard on auscultation of the trachea and larynx is 
quite different from that heard over normal lung tissue: 





* For descriptions of the various forms of stethoscopes, and their 
modifications, see article on Stethoscopes. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chest, 
Chest, 





it is a much harsher and more tubular sound, and is called 
laryngeal, tracheal, or tubular breathing. 

Of the several theories as to the cause of the respira- 
tory sounds, the following is the most satisfactory: A 
fluid, either liquid or gas, in this case air, passing with 
sufficient velocity through a narrow opening into a wider 
channel produces a sound. Such a condition obtains at 
two points in the respiratory system, the larynx and at 
the ends of the bronchioles, where they enter the alveoli 
of the lungs. At the larynx, the arrangement of the vo- 
cal cords is such that sounds are produced in both inspi- 
ration and expiration. At the bronchiole endings a 
sound is produced during inspiration, but not during 
expiration, as the air then is passing from a larger into a 
smaller space. 

The laryngeal sounds, therefore, are of purely glottic 
origin, and may be distinctly heard over the larynx, the 
trachea, or the back of the neck. 

The pulmonary murmur heard over the chest wall is a 
combination of the laryngeal sound, modified by trans- 
mission through the bronchi and lung tissue, and the 
sound produced in the bronchioles. The intensity of the 
laryngeal sound is greatly diminished by its transmission 
through the thin-walled smaller bronchi, which contain 
so many openings that the sound is much diffused. For 
this reason vesicular breathing is a very soft sound. 
The inspiratory portion is heard throughout the inspira- 
tory act, and is composed of two elements, the glottic 
and the alveolar; the expiratory portion, consisting only 
of the glottic element, is a mere puff, oftentimes indeed 
itis inaudible. The fact that the expiratory sound is 
conducted to the ear of the examiner against the current 
of air producing the sound is another factor in causing 
the marked diminution in the intensity of the expiratory 
sound. 

Respiratory sounds are studied by considering the 
quality, pitch, intensity, and duration of the sound, and 
also the rhythm. The inspiratory and expiratory sounds 
should be separately considered. 

Pulmonary or Vesicular Breathing.—Normal vesicular 
inspiration has a breezy or rustling quality, low pitch, 
variable intensity, and the sound is heard throughout the 
inspiratory act; the quality of expiration is soft and blow- 
ing, low in pitch, and short in duration; the rhythm is 
unbroken, 7.é., there is no pause between inspiration and 
expiration. Expiratory sound isnot always audible. In- 
spiratory sound is three or four times as long as expira- 
tory. Pulmonary breathing is heard over the anterior, 
lateral, and posterior surfaces of the thorax. 

Puerile or Supplementary Respiration.—On listening to 
the chests of children and also of adults, when the lungs 
are doing extra work, as after violent exercise or where 
a sound lung is doing the work for a diseased lobe in ad- 
dition to its own, the normal vesicular breathing is heard 
much more distinctly than usual. The quality is the same 
as that of normal vesicular breathing, but the intensity 
is much increased or exaggerated. This is called “ puer- 
ile,” “supplementary,” or “exaggerated ” respiration. 

Diminished Respiration.—In diminished respiration the 
quality is that of normal vesicular breathing, but the 
intensity is. greatly diminished. This occurs whenever 
there is any interference with the circulation of the air 
in the lungs, or with the conduction of the sounds to the 
ear of the examiner. 

The free entrance and exit of air may be prevented by 
the presence in the trachea or bronchi of secretions, diph- 
theritic membrane, or foreign bodies, by spasm of the 
bronchi, or by the pressure of tumors. Emphysema and 
tuberculosis, by diminishing the elasticity of the air vesi- 
cles, also restrict the free circulation of air in the lungs, 
and pain or great’ muscular weakness may so interfere 
with the respiratory movements that but little air enters 
and leaves the lungs. 

The conduction of the breathing sounds to the ear may 
be obstructed by the presence of fluid in the pleural sac, 
or by thickened pleura or chest walls. 

Suppressed Respiration.—Absence of respiration occurs 
when there is complete obstruction of a bronchus from 


Vou. Il.—52 


any of the above-mentioned causes, no matter what the 
condition of the lung substance may be; also over fluid 
in the pleural sac, in pneumothorax, if the opening be- 
tween the bronchus and the pleural sac is closed, and 
over cavities filled with fluid. 

Prolonged Expiration.— At the right apex a slight pro- 
longation of the expiration is not uncommon in normal 
chests. When heard in other situations, however, it is an 
abnormal sign and indicates a difficulty in expelling the 
air during expiration—in other words, an expiratory dysp- 
nea. In emphysema and asthma prolongation of expira- 
tion is heard all over the chest. It may also be heard in 
cases of bronchitis, in which the bronchi are partially oc- 
cluded with mucus; and in tuberculosis, from the loss of 
elasticity of the lung substance due to the consolidation, 
it is one of the earliest physical signs. bi 

Cogwheel or Interrupted Inspiration.—The inspiratory 
murmur may be interrupted or jerky in rhythm; this is 
sometimes heard when examining the chests of very ner- 
vous patients, and it is often one of the physical signs of 
early tuberculous consolidation. It occurs in this condi- 
tion because, from the presence in the bronchi of deposits 
of tubercle, an obstruction is offered to the entrance of air 
into the lobules, which instead of being distended at the 
same time by the entering air are expanded at different 
times, thus producing the uneven or interrupted rhythm. 
Unless accompanied by other physical signs, it is of no 
value in diagnosis. 

Laryngeal, Bronchial, or Tubular Breathing. — This 
breathing is normally heard over the larynx and trachea, 
and also may be heard over the back of the neck. The 
inspiration is tubular in quality, of high pitch, marked in- 
tensity, and the duration of the sound somewhat shorter 
than the inspiratory act. Expiration has the same tubu- 
lar quality, but the pitch is higher, the intensity usually 
greater, and the duration as long as or even longer than 
that of inspiration. The rhythm is broken by an appre- 
ciable pause between the inspiratory and expiratory 
sounds. 

When bronchial breathing is heard over those portions 
of the chest where normally vesicular breathing should 
be heard, it isa sign that the lung is in a condition of 
consolidation. 

The occurrence of bronchial breathing over consoli- 
dated lung may be explained in this manner: The bron- 
chial tubes are like speaking tubes, normally poor ones, 
as their walls are thin and interrupted by the numerous 
openings of the bronchioles; the laryngeal sounds in their 
transmission from the point of production to the chest 
wall through these poor conducting tubes are much 
diffused and changed in character. When the lung is 
consolidated, however, the thin walls of the bronchi are 
stiffened and supported by the surrounding consolidation, 
their resistance is increased, and the diffusion of the vi- 
brations is diminished. In other words, consolidation 
makes good speaking tubes of the bronchi, and the laryn- 
geal sounds are well conducted, with little change in their 
character, to the wall of the chest. 

Consolidation may be due to pneumonia, phthisis, to 
new growths in the lung substance, to infarcts, and to 
compression of the lung by fluid or tumors. 

Bronchial breathing is also heard over cavities which 
communicate freely with a bronchus, and also over di- 
lated bronchi. In these conditions the laryngeal sounds 
are conducted through fairly large bronchi directly to 
the cavity or dilatation of the bronchus, and these bronchi 
are often quite close to the chest wall, and usually, in the 
case of a cavity, are surrounded by an area of consolida- 
tion. Should the bronchus conducting the sound vibra- 
tions to the consolidated area become occluded, no bron- 
chial breathing will be beard. In pneumonia, for example, 
the bronchi may become filled with inflammatory prod- 
ucts, and the conduction of the laryngeal sounds may be 
thus interrupted. If the patient be made to cough, the 
mucus will be expelled and the tubes cleared, then bron- 
chial breathing will again be audible. 

Broncho- Vesicular Breathing.—This, often called harsh 
or rude respiration, is a respiratory sound combining 


817 


Chest, 
Chest. 





characteristics of bronchial and vesicular breathing. The 
bronchial element may predominate or the vesicular may 
be the more marked. In inspiration the quality is bron- 
cho-vesicular; the pitch is high in comparison with that of 
normal pulmonary inspiration, intensity is more marked, 
and duration the full length of the inspiratory act. The 
quality of expiration is also broncho-vesicular, pitch 
higher than that of inspiration, intensity greater, and the 
duration as long as or longer than that of inspiration. 
The rhythm is not broken. 

This breathing is heard in the normal chest in the infra- 
clavicular region near the sternum, and in the upper part 
of the interscapular region, because the bronchi are large 
and near the chest wall in these localities, and the sounds 
produced in the larynx are therefore little diffused or 
modified in transmission to the observer’s ear. 

When heard over portions of the chest where normally 
vesicular breathing should be heard, it is an indication of 
smaller or larger areas of consolidation surrounded by 
normal lung tissue. Therefore we may have this vari- 
ety of breathing in cases of phthisis in which the infiltra- 
tion is slight, or when a deep-seated pneumonia is sur- 
rounded by normal lung tissue. This variety of breathing 
may be heard over the portion of the lung compressed 
by fluid in cases of pleurisy with effusion. 

The greater the infiltration or consolidation, the more 
marked will be the bronchial element in the respiratory 
sounds; the less the amount of consolidated lung, the 
more will the vesicular element predominate in the breath 
sounds. 

Cavernous Breathing.—This variety of the respiratory 
sounds is heard over cavities, and has a hollow, blowing 
character, from which the sound takes its name. The 
quality of inspiration is cavernous, pitch low, intensity 
variable, and duration full length of the inspiratory act. 
Of expiration the quality is the same as that of inspiration, 
pitch is lower, intensity variable, and the duration usu- 
ally longer than that of inspiration. The rhythm is not 
broken. Cavities over which this breathing is heard must 
have free communication with a bronchus; otherwise 
there will be an absence of breath sounds. ° 

If the cavity is surrounded by consolidated lung, there 
may be a decided bronchial character to the cavernous 
breathing, which is called broncho-cavernous breathing ; 
and should the cavity liein fairly normal lung substance, 
the vesicular element will be marked, and a vesiculo- 
cavernous respiratory murmur be heard. 

Amphoric Respiration.—The peculiarity of this sound 
lies in the musical quality, which may be imitated by 
blowing over the mouth of an empty bottle. The inspi- 
ration is of amphoric quality, fairly low pitch, and of 
some duration. Expiration is like inspiration, except 
that the expiratory sound is much prolonged. This 
breathing is heard over cavities usually large» with 
smooth walls, and in pneumothorax or hydropneumo- 
thorax. The cavity must have free communication with 
a bronchus or there will be no sound during respiration. 
The sound indicates a cavity containing air that is not 
expelled on expiration. 

Sibilant and Sonorous Breathing.—In sibilant breathing 
the quality of the sound is whistling or wheezing, and the 
pitch high, with marked prolongation of the expiratory 
murmur. Of sonorous breathing the quality is snorting 
or snoring and the pitch low; expiration is also prolonged. 
The intensity is variable. These sounds are indicative 
of diminution of calibre of the larger and smaller bronchi. 
This narrowing may be due to the presence in the bron- 
chial tubes of viscid mucus, the product of inflammatory 
processes, or to the spasmodic contraction of the muscle 
fibres within the bronchial walls. The former condition 
obtains in bronchitis, the latter in spasmodic asthma. 

These sibilant and sonorous sounds, or rhonchi, are 
heard in inspiration, in expiration, or in both; they are 
not constant, and often disappear if the patient be made 
to cough. Occasionally the sounds are so loud that they 
may be heard without placing the ear on the chest wall: 
and sometimes a fremitus may be appreciated by the 
palpating hand, the so-called bronchial fremitus. 


818 


alveoli of the lungs and the thoracic walls. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Signe de Sou or Bell Sound.—This sound is heard when 
the chest is percussed with two coins, one used as plex- 
imeter and the other as percussor, and the ear is applied 
to the opposite side of the chest. The sound transmitted 
through healthy lung is of a wooden quality; that heard 
when fluid is present is of a metallic character; while the 
sound transmitted through air, in pneumothorax for ex- 
ample, is clear and ringing, like a bell. 

AUSCULTATION OF THE VOICE AND WHISPER.—The 
voice sounds heard over the chest on auscultation are 
the sounds produced by the vibrations of the vocal cords, 
which are transmitted through the bronchial tubes to the 
Those con- 
ditions which in any way modify the breath sounds pro- 
duced in the larynx will also change the character of the 
voice sounds, whether spoken or whispered. The patient. 
should count “one, two, three,” but not too rapidly and 
in a moderately loud voice. 

Pulmonary voice or normal vocal resonance is heard 
over normal lung substance. The quality is pulmonary ; 
pitch low, and the intensity feeble; it is an indistinct. 
sound seemingly distant and diffused. In men the voice 
sound is usually much more marked than in women and 
children; the intensity varies with the quality of the 
voice; being more marked in deep voices than in high 
voices. The thickness of the chest wall also modifies the: 
intensity of the sound. Pleuritic adhesions, much adi- 
pose and muscle, fluid in the pleural sac, as well as air, 
all diminish the intensity of the vocal resonance. 

If the pleural effusion is large, and over consolidated 
lung, if the bronchi are occluded, the vocal resonance is. 
absent. 

In the infraclavicular regions the vocal resonance is. 
usually increased; this is also true of the voice sounds 
heard in the interscapular space. In the early stages of 
pneumonia and in phthisis, in which the amount of con- 
solidation is slight, the voice sounds are increased in in- 
tensity: also over cavities lying near the chest wall. 

If the person examined be asked to whisper “one, two, 
three,” the examiner hears during expiration the normal 
bronchial whisper. The sound resembles the normal ex- 
piratory sound; it is feeble and blowing in quality, and 
may oftentimes be inaudible. 

When there is moderate consolidation the whispered 
voice is much more intense, and is not unlike the respira- 
tory sound heard in broncho-vesicular breathing. 

Laryngeal or Bronchial Voice.—Bronchophony. This. 
may be normally beard over the larynx and trachea. The 
quality is laryngeal, the pitch high, intensity great, and 
the distinctness marked; the sound seems near, there is. 
a marked thrill, and a sensation, like a shock or concus- 
sion, is conveyed to the ear. When the lung is consoli- 
dated or compressed, so that the bronchial tubes have 
been made good conductors of sound, bronchial voice is. 
heard at those points of the chest wall which lie above 
the consolidated area. It may also be heard over cavi- 
ties, and sometimes over fluid. 

Aigophony, which is a modification of bronchophony, has: 
the same intense character, but in addition has a bleating 
or tremulous quality, from which it derives its name, the - 
quality being likened to the bleating of a goat. It is 
best brought,out by having the patient repeat words like: 
“brant” or “rant.” It is significant of a small amount 
of fluid in the pleural sac, and is heard in pleurisy with 
effusion, where the effusion is not great and where a 
thin layer of fluid lies between the lung and the chest. . 
wall. It is notacommon sign. The most usual location 
for this sign is at the angle of the scapula. 

Pectoriloquy, another variety of bronchophony, is that. 
voice sound where, in addition to the voice, the articula- 
tion of the words is distinctly appreciated. It can be 
heard best when the patient whispers, and is indicative 
of the presence of a cavity; it may also be heard over 
consolidated lung, where the consolidated area is in con- 
tact with a large bronchus. 

Amphoric voice has the quality of amphori¢ breath- 
ing, and is heard when there is air in the pleural sac, 
or over large cavities; the same conditions of the lung 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chest, 
Chest, 





in which amphoric percussion note and breathing may 
be heard. 

Metallic tinkle is the sound produced, during breathing 
and talking in cases of hydropneumothorax, by the drop- 
ping of fluid in the pleural sac. Thissound is also heard 
when there is a large cavity in the lung, containing fluid. 

When listening over a cavity, after the patient coughs, 
a suction-like sound may frequently be heard. This is 
caused, in all probability, by the sudden expansion of the 
cavity, after the violent expulsive effort of coughing, and 
the rush of air back into the cavity. It isa sign distinctive 
of the presence of a cavity in the lung substance, which is 
in free communication with a bronchus. Should the bron- 
chus become occluded the sound would not be heard. 

RALEs.—Rales are adventitious sounds, which are never 
heard in the normal chest. They may be produced in the 
larynx, trachea, bronchi, alveoli, in the pleura or in cav- 
ities. The character of the raéle depends entirely on the 
point at which the sound is produced. 

Crepitant Rales.—The finest of all rales is the crepitant 
rile. This is a fine, dry, crackling sound, which is heard 
only at the end of inspiration and does not disappear 
when the patient is made to cough; coughing in fact 
often makes the sound more intense. The sound is 
likened to the crackling of burning salt, or of hair rubbed 
between the fingers. It is heard in puffs and seems close 
under the observer's ear. 

There are two theories as to the production of the crep- 
itant rile; one considers the sound a pure friction sound 
produced in the pleura by the rubbing of the roughened 
surfaces against one another; the other believes that the 
sound is caused by the separation of the adhering sur- 
faces of the alveoli, when the air enters the alveoli dur- 
ing inspiration. 

The first theory explains satisfactorily the production 
of the fine crepitations heard in dry pleurisy; whereas 
the latter seems the more satisfactory explanation of the 
crepitant rales heard in the early stages of pneumonia 
before consolidation is complete, and again in the later 
stages, when resolution is beginning. At both of these 
periods the walls of the air vesicles are held in contact by 
the products of inflammation, and are separated by the 
entrance of air at the end of inspiration. 

Crepitant rales are heard in pneumonia, in phthisis, in 
dry pleurisy, and at times after a full inspiration at the 
bases of lungs of patients who breathe superficially and 
are contined to bed. 

Suberepitant rdles are fine, moist, crackling or bub- 
bling sounds heard with inspiration, expiration, or with 
both, and which disappear when the patient coughs. 
These sounds are probably produced by small bubbles of 
air breaking through the mucous or inflammatory exu- 
date in the bronchioles. They are commonly heard in 
bronchitis, pneumonia, phthisis and cedema of the lungs. 

Coarse, Mucous, or Bronchial Rdles.—The cause of these 
sounds is the same as that of subcrepitant rales, but the 
point of production is in the larger bronchi, where more 
inflammatory exudate is collected, through which during 
respiration a larger volume of air must pass. 
pathological conditions are indicated by the presence of 
these sounds, viz., bronchitis, pneumonia, phthisis, ete. 

In cavities containing fluid, when the bronchus ¢om- 
municating with the cavity opens below the level of the 
fluid, gurgling rales are produced by the entrance and 
exit of air; the quality of these sounds is moist and 
coarse, and is suggestive of large bubbles of air passing 
through fluid. 

Friction Sounds.—When the surfaces of the pleura are 
inflamed and move during respiration upon one another, 
a rubbing or creaking sound is produced. These friction 
sounds may be fine and dry, like crepitant rales; they are 
heard with expiration as well as with inspiration, they 
may be moist and coarser and resemble subcrepitant rales, 
or they may be creaking and rubbing in quality. The 
sound is close under the ear, and may be intensified by 
making firm pressure with the stethoscope; also, in con- 
tradistinction to rales produced in the lung substance, 
they do not disappear when the patient coughs. 


The same ,; 





Dry pleurisy, pleurisy with effusion, when the fluid is 
absorbed, pneumonia and phthisis, all may cause the pres- 
ence of friction sounds. 

Succussion.—This is a splashing sound produced by 
shaking the patient in cases in which there are air and fluid 
in the pleural sac, or in which there is a large cavity con- 
taining air and fluid. It is not uncommonly heard over 
the normal stomach when it is partially filled with fluid. 


. 


PuHysicaAL EXAMINATION OF THE HEART. 


The same methods are employed in examining the heart 
that are used in examining the lungs; and thus the size 
of the heart, the character of its impulse, the rhythm, 
and the sounds (both normal and abnormal) may be de- 
termined. 

Topographical Anatomy.—The heart is placed somewhat 
more to the left of the median line than to the right. The 
anterior surface, that which is in contact with the chest 
wall, is composed chiefly of the right auricle and ventri- 
cle, and of a narrow strip of the left ventricle. The base 
of the heart, formed by the right auricle, the great vessels, 
and the left auricular appendix, lies at the level of the 
upper border of the third costal cartilage, and extends 
nearly an inch to the right and left of the sternum 
(Fig. 1256). 

The apex, the tip of the left ventricle, lies normally in 
the fifth intercostal space about one inch within the mid- 
clavicular line. 

The right edge, which begins at the third costal carti- 
lage on the right of the sternum and extends to the junc- 
tion of the fifth costal cartilage with the sternum, is 
composed of the right auricle. The line of the right 
edge is somewhat curved with the convexity directed to 
the right. 

The inferior edge is formed by the right ventricle and 
the apex of the left; it extends from the fifth costo-ster- 
nal junction to the apex of the heart. 

The left edge of the heart is made up entirely of the 
left ventricular wall, and extends from the apex to the 
upper border of the third rib, about one inch to the left 
of the sternum. The groove which separates the right 
auricle from the right ventricle may be indicated by a 
line drawn on the surface of the chest from the third 
left to the sixth or seventh right costo-sternal junction. 
The ascending part of the aorta is in closest relation to 
the chest wall in the second right intercostal space, slightly 
beyond the edge of the sternum. The pulmonary artery 
is inthe corresponding position to the left of the sternum 
(Fig. 1256). 

The orifices of the heart are situated beneath the left 
half of the sternum, and near together. The aortic and 
pulmonary at the level of the third costal cartilage, the 
mitral and tricuspid at the level of the fourth and fifth 
respectively. 

InsPEcTION.—The location of the apex beat and its char- 
acter—that is, whether the visible impulse is well defined, 
diffused, heaving, or wave-like—may be observed by in- 
spection. Bulging or retraction in the preecordial region, 
pulsation of the vessels in the neck, and pulsation in the 
epigastrium may also be noted. 

Normally the site of the apex beat is in the fifth space 
about one inch within the mid-clavicular line; it is well 
defined and localized (Fig. 1256). Often the apex beat 
is not visible on account of the thickness of the chest 
wall, the depth of the chest and consequently the dis- 
tance the apex may be from the thoracic wall, or because 
the apex. is separated from the chest wall by lung tissue 
as in emphysema. 

Bulging of the precordium may be caused by hyper- 
trophy of the heart, by fluid in the pericardial sac, by 
aneurism (in which case the bulging is situated at the 
base of the heart), or by tumors. Retraction, usually in 
the third, fourth, and fifth left intercostal spaces, and oc- 
curring with the systole, may be due to adherent peri- 
cardium or to atmospheric pressure; this is the more 
common cause, and it occurs in hypertrophy or dilata- 
tion, in which conditions the volume of the heart is much 


819 


Chest, 
Chest, 





decreased during systole and the pressure of the air causes 
a sinking in of the intercostal spaces. Pulsation of the 
vessels of the neck may be either venous or arterial in 
origin; in the former case the result of an incompetent 
tricuspid valve, and in the latter due to an insufficient 
aortic valve. 

Pulsation in the epigastric region is generally due to 
the pulsation of the right ventricle transmitted through 
the liver to the surface. Should the right ventricle be 
hypertrophied, the epigastric pulsation is much more 
marked. This is ncted in emphysema, and in those cases 
of valvular disease of the left heart which cause the right 
side to hypertrophy in the attempt to compensate for the 
lesion. Epigastric pulsation may also be caused by the 
normal pulsation of the abdominal aorta, by aneurism of 
the abdominal aorta, or by a pulsating liver. 

PaLpATION.—Many of the observations made by in- 
spection may be confirmed by palpation, and may often be 
more easily appreciated. The location of the apex beat, 
often invisible, can usually be felt, and if not palpable 
when the patient stands erect, may become so if the pa- 
tient is made to lean forward. In addition to the site of 
the apex beat, its regularity and force can be observed, 
and the presence of thrills determined. Changes in the 
location of the apex are suggestive of certain abnormal 
conditions. Hypertrophy and dilatation of the left ven- 
tricle and fluid or air in the right pleural cavity displace 
the apex downward and to the left. 

Congenital malformations, retraction of the right lung 
from old pleurisy or tuberculosis, and fluid or air in the 
left pleural sac dislocate the apex to the right. 

Retraction of the left lung, or pressure from below, as 
in ascites, tympanites, enlargement of the abdominal or- 
gans or tumors, displace the apex upward. Downward 
displacement is usually the result of aneurism of the aorta 
or of emphysema. 

The regularity or rhythm may be changed by disease. 
The heart may be irregular in the force “and frequency 
of its beats; and it may intermit or drop out a beat from 
time to time. 

The force of the heart beat may be increased or dimin- 
ished. Itis diminished by any of the exhausting diseases: 
by myocarditis, by lesions of the valves causing dilata- 
tion of the cavities and weakening of the cardiac muscle, 
by the presence of fluid in the pericardium, by the pres- 
ence of lung tissue between the chest wall and the apex, 
as in emphysema, or by very thick chest walls. 

Hypertrophy of the ventricles, over-exertion, or thin 
chest walls increase the force of the apex beat. 

Where the weakness or force is due to changes in the 
thickness of the thoracic wall or to the interposition of 
lung tissue between the costal wall and the apex, the 
weakness or strength is only apparent, and the real 
strength or weakness must be determined by the exam- 
ination of the pulse. 

Thrills may be detected by the palpating hand. When 
noted at the base of the heart and systolic in time they 
are suggestive of aneurism of the aorta or of aortic ste- 
nosis. At the apex a systolic thrill may occur in mitral 
insufficiency ; and a presystolic thrill is observed in mitral 
stenosis. 

-Pericarditis occasionally causes a rubbing, which may 
be appreciated on palpation—the so-called pericardial 
friction fremitus. It is usually to be felt at the base of the 
heart in cases of dry pericarditis, and occurs with systole 
and diastole. 

PEercuss1on.—Percussion of the precordium to deter- 
mine the size of the heart may be practised in the ordi- 
nary manner or auscultatory percussion may be used. 
Both of these methods have their advantages, and may 
be used to supplement each other. 

By this means of examination not only the fact that 
the heart is enlarged can be made out, but the part of the 
heart which is the site of hypertrophy may be determined. 

The superficial and deep areas of cardiac dulness 
should be marked out (Plate XXII., Fig. 1). The su- 
perficial area of cardiac dulness is that portion of the 
heart which is not covered by lung substance in full in- 


820 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





spiration. It is somewhat triangular in shape and is 
bounded internally by the left edge of the sternum, ex- 
ternally by an oblique line drawn from the fourth costal 
cartilage at its sternal junction to the fifth space just 
within the apex, and below by a line drawn from this 
point to the end of the sternum. In marking out this 
area the examiner is finding in reality the edges of the 
lungs, and, as the layer of lung tissue overlying the- 
heart is thin, percussion must be light; for this exami- 
nation finger percussion is most satisfactory. If the vol- 
ume of the lungsis increased as in emphysema, the super- 
ficial area of cardiac dulness will be much diminished ; 
unless the heart is also hypertrophied, in which case the 
borders of the lungs may be pushed back, and an appar- 
ently normal area of superficial cardiac dulness will be 
found on percussion. The deep area of cardiac dulness 
is the dulness detected by percussing over the edges of 
the heart; as there is, however, a thick layer of lung be- 
tween the right and left borders of the heart and the 
chest wall, the area, as made out by digital percussion, 
does not accurately correspond with the outline of the 
heart, and, to determine with more exactness the right 
and left edges of the heart, auscultatory percussion may 
be employed. 'This method of examination was intro- 
duced by Dr. Cammann, who also devised the binaural 
stethoscope, and depends upon the fact that every organ 
has a percussion note peculiar to itself. When ordinary 
digital percussion is practised, the note produced is con- 
veyed to the ear through the air, and the sound is thus 
more or less diffused and changed in character; when, 
however, the sound of the percussion note is brought to 
the ear direct by the use of the stethoscope, differences in 
quality and intensity are readily recognized. 

To practise this method of percussion, the bell of the 
stethoscope, held by an assistant or the patient, should 
be placed over the organ, the dimensions of which are to 
be determined, at the point where the organ comes in 
contact with the thoracic or abdominal walls, and mod- 
erate percussion be made beginning at some distance 
from the point where the stethoscope is placed and grad- 
ually approaching it. When the pleximeter or finger 
reaches the point on the surface of the chest or abdomen 
below which the border of the organ lies, the percussion 
note changes abruptly, becomes much more marked in- 
intensity, and usually higher in pitch. In mapping out 
the outline of the heart, it is best to find a number of 
points on the border of the heart at the extremities of its 
diameters, the vertical, transverse, and right and left 
oblique; these diameters intersect at a point near the 
centre of the heart. The eight points found, on being 
joined, give a fair outline of the heart. The vertical 
diameter is drawn parallel to the left border of the 
sternum; the transverse at right angles to the vertical 
diameter through its centre; the right oblique dia- 
meter is drawn, on the line from the right shoulder to 
the apex, from the right auricle to the apex; and the 
left oblique at a right angle to the latter and through its 
centre. 

It is claimed that a skilful examiner can so accurately 
mark out the cardiac outlines on the cadaver that sharp- 
pointed steel needles driven through the chest wall at the 
given points will pass between the cardiac muscle and 
the pericardium. 

On the living subject the outline cannot be so exactly 
determined, as the heart is constantly changing its size 
in systole and diastole. It is found, however, that the 
sum of the diameters in a large number of cases of adult 
males averaged sixteen and five-sixth inches, and this for 
the purpose of comparison is of use, though the length 
of the diameters considered singly is worthless. 

In addition to determining the size of the heart and the 
location of its borders, this method of examination may 
be-used to locate the edges of the liver in the normal 
subject, or when there is fluid in the pleural sac or ab- 
dominal cavity; also when a consolidated right lobe is in 
contact with the liver. The size of the spleen can be 
made out in ascites, or when in contact with an enlarged 
liver, provided that at some point the spleen is in contact 





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EXPLANATION OF PLATE -XXII. 
(In all the figures the blue color indicates the superficial, and the red color the deep, cardiac dulness. 
The liver dulness is also indicated by the blue color.) 
Fig. 1.—Area of Superficial and Deep Cardiac Dulness in Normal Conditions. 


Fie. 2.—Area of Heart Dulness in Dilatation of the Rignt ventricle. The increase in area of dul- 
ness is almost entirely to the right of sternum. ; 


Fie. 3.—Area of Heart Dulness in Dilatation of the Left Ventricle. The increase in dulness is 
limited to the left side of the sternum. 


Fia. 4.—Area of Heart Dulness in Dilatation of Left Auricle and Ventricle, with Uncovering of the 
Pulmonary Artery. (a) Deep cardiac dulness, right and left ventricles; (0) superficial dulness, 
the left auricle; (c) dulness due to pulmonary artery. 





PLATE XXIII 


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From Sahli’s ‘‘ Lehrbuch der klinischen Untersuc 











GRAPHIC REPRESENTATION OF THE PHYSICAL SIGNS FOUND IN THE FOUR 


MOST COMMON VALVULAR LESIONS OF THE HEART 


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LIBRARY 
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UNIVERSITY of ILLINOIS. 


=e 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES, 





with the parietal wall. The kidneys may be mapped out 
with the exception of the inner border. 

Another form of auscultatory percussion has come into 
use with the invention of the phonendoscope. Here in- 
stead of percussing, the surface of the chest in the neigh- 
borhood of the organ under examination is gently 
scratched with the finger. This produces a sound the 
quality of which, as well as the intensity and pitch, in- 
stantly changes when the density of the organs beneath 
the surface changes. It is merely a modification of aus- 
cultatory percussion, but is perhaps capable, in skilful 
hands, of giving even more definite information in regard 
to the size of the solid organs of the body, of tumors, the 
level of fluid exudates or transudates, and the line of 
contact between tumors and solid organs, or between 
solid organs and fluid. 

As in percussing the lungs, so in the examination of 
the heart by percussion, much information may be gained 
by noting the sense of resistance beneath the finger in 
contact with the chest wall. 

If by either of the methods of percussion described 
the area of the heart dulness is found increased, it is 
suggestive of hypertrophy of the heart muscle, and 
the locality of the dulness indicates the portion of the 
heart which is enlarged; of fluid in the pericardium; of 
aneurism, or of a consolidated lung or tumor displacing 
the heart. 

Should the area of cardiac dulness be diminished, the 
usual cause will be found in an emphysematous condition 
of the lungs. 

AUSCULTATION.—By auscultation the character, rhythm, 
and point of maximum intensity of the normal heart 
sounds are observed, any changes in the intensity or 
rhythm are noted, and the presence of any abnormal 
sounds or murmurs is detected. In this examination the 
immediate or mediate method may be employed. The 
mediate is, however, the more common, and the use of 
the stethoscope enables the examiner to localize the area 
of the maximum intensity of the sounds more exactly ; it 
also intensifies the sounds, so that sounds inaudible to the 
ear may by its aid be clearly heard. 

Two sounds are heard on auscultation: the first, or 
systolic sound, occurring with the systole of the heart, 
somewhat dull and booming in character, and resembling 
the syllable “tubb”; the second, or diastolic sound, oc- 
curring with the diastole of the heart, short, quick, and 
snappy in character, like the syllable “dupp.” 

The first and second sounds are separated by a short 
pause, and a longer pause occurs between the second 
sound and the succeeding first sound. This rhythmical 
recurrence of the first and second sounds with the inter- 
posed pauses makes up the cardiac cycle. 

The first sound is produced by the closure and tension 
of the auriculo-ventricular valves and the tension of the 
walls of the ventricles; it is, therefore, a composite 
sound made up of several elements. The second sound 
is caused by the sudden closing of the aortic and pul- 
monary valves. 

Normally these sounds recur in rhythmical sequence, 
and may be heard all over the precordium. There are, 
however, areas where the individual sounds may be 
heard with greater distinctness. For example, the first 
sound may be heard most clearly at the apex, and not 
immediately over the point of production, the location of 
the mitral and tricuspid valves. This area at the apex is 
called the mitral area. 

The aortic element of the second sound is most clearly 
heard in the aortic area, the second right intercostal space 
near the sternum; and the pulmonary element in the sec- 
ond left intercostal space, the pulmonary area. At the 
apex the quality of the systolic sound is soft and boom- 
ing, the pitch is low, the intensity marked, and the dura- 
tion long. The quality of the second sound is clicking 
or sharp, the pitch is higher than that of the first sound, 
the intensity less, and the duration shorter. 

At the base the intensity of the first sound is dimin- 
ished, and that of the second sound increased. Asarule, 
the secoud sound is heard more distinctly in the aortic 








Chest, 
Chest, 


area than in the pulmonary; in other words, the aortic 
element of the second sound is normally the louder. 

Disease may cause changes in the normal heart sounds, 
which modifications are noted in the quality, intensity, 
duration, and rhythm. 

The quality of the first sound may be impure or rough, 
and there may be reduplication of the first sound, which 
is caused by the non-synchronous contraction of the ven- 
tricles and closure of the auriculo-ventricular valves. 

The intensity of the first sound is much increased in 
cases in which there is hypertrophy of the left ventricle, in 
acute febrile diseases, and in patients with very thin chest 
walls. Diminution in the intensity is noted in emphy- 
sema, in patients with very thick chests, in cases of peri- 
carditis with effusion, in all exhausting diseases, and in 
dilated heart. 

In hypertrophy the duration of the first sound may be 
prolonged, even to the point of sounding like a murmur; 
and in dilatation this sound is so shortened that it may 
be mistaken for the second sound. The same shortening 
of the first sound is often observed in cases of mitral 
stenosis. 

The rhythm is often irregular or intermittent; this is 
particularly marked in cases of mitral stenosis and in di- 
lated heart. The aortic element of the second sound, or 
the aortic second sound as it is called, is accentuated in 
any disease which causes an increase in the blood pressure 
in the aorta and systemic circulation; in other words, 
when the arterial tension is high, or when there is an 
increased amount of blood in the aorta, as in aneurism or 
dilatation of the aorta. When the action of the heart is 
weak, as in dilated heart, in fevers, and in myocarditis, the 
amount of blood and the tension in the aorta are dimin- 
ished, and the intensity of the aortic second sound is 
lessened. The pulmonic second sound is accentuated 
when the pulmonary circulation is under increased ten- 
sion; in mitral disease, either stenosis or insufficiency of 
the valve, and in pneumonia or emphysema. When the 
tension in the pulmonary circulation is low, the second 
sound in the pulmonary area is diminished in intensity. 

There is not uncommonly areduplication of the second 
sound, which is due to the fact that the aortic and pul- 
monary valves do not close at the same moment. This 
occurs when the tension of the blood, or blood pressure, 
is unequal in the systemic and pulmonary circulation. 
It is frequently observed in mitral stenosis. 

In addition to the normal heart sounds, other sounds 
may be heard which are the result of diseased conditions 
of the heart or vessels. These abnormal sounds may be 
produced either within or without the heart or in the 
great vessels, and are therefore called endocardial, exo- 
cardial, or vascular murmurs. In listening to a murmur, 
in order to decide upon its nature and the lesion upon 
which its production depends, it is necessary to note the 
time of the cardiac cycle at which the murmur is heard, 
its point of maximum intensity, the quality of the sound, 
and the direction in which it is transmitted. 

Exocardial Murmurs.—These sounds are produced by 
the rubbing together of the surfaces of the pericardium 
made rough by inflammation, or by the movement of 
the pulmonary pleura against the pericardial sac; hence 
these sounds are called pericardial friction sounds or mur- 
murs or pleuro-pericardial sounds. 

Pericardial murmurs occur in pericarditis, and they are 
heard with both the systole and the diastole of the heart. 
From this fact they are often spoken of as “see-saw ” or 
“to-and-fro” murmurs. The murmur is usually loudest. 
at the base of the heart and along the line indicating the 
auriculo-ventricular groove. The quality is rubbing and 
creaking, not of marked intensity and often very faint; 
the intensity may frequently be increased by pressure on 
the chest wall with the stethoscope. The sound is near 
the ear, and is not transmitted. : 

Pleuro-pericardial frictions or murmurs occur in cases 
of dry pleurisy involving the pleura of the pericardial 
sac and the adjacent lung. The sounds are not syn- 
chronous with the heart action, but occur with the respir- 
atory movements, and may disappear when the patient 


821 


Chest, 
Chest. 





holds his breath; they are usually heard loudest over the 
borders of the ventricles, when respiration is deep. The 
quality is rubbing, the intensity not marked, and it may 
be increased by pressure with the stethoscope. 

Endocardial Murmurs.—Endocardial murmurs may be 
due to gross changes in the valves or lining membrane of 
the heart, or to changes in the quality of the blood. In 
the first case they are called organic, and in the second 
functional, heemic, or inorganic murmurs respectively. 

Organic Endocardial Murmurs.—For the production of 
a murmur two factors are necessary: force and rapidity 
of the blood current, and narrowing or change in calibre 
of the passages through which the blood flows. 

The blood normally flows with force and rapidity 
through a passage with smooth walls, and of even or 
gradually diminishing calibre. When, as the result of 
disease, the cusps of the valves do not open properly to 
allow the blood to flow through, or when the curtains of 
the valves do not close perfectly and so allow the blood 
to flow back through the opening, a sudden diminution 
in the calibre of the passage occurs. Thus the two fac- 
tors for the production of a sound or murmur, the blood 
current passing with force and rapidity through a nar- 
row opening into a wider space, are present within the 
diseased heart. 

Should the velocity and force of the blood current be 
diminished, as the result of a weak heart, when a dimi- 
nution in the calibre exists, either there will be no murmur 
or a murmur of slight intensity will be heard. The 
valves on the left side of the heart are those most com- 
monly the seat of organic disease in adults. In early in- 
fant life and in intra-uterine life the valves of the right 
heart are usually those affected.. 

Inorganic, Functional, and Hemie Murmurs.—In addi- 
tion to the organic valvular lesions which render the 
valves unfit for the work they are destined to perform, 
the valves may be rendered incompetent on account of a 
dilated condition of the muscular walls of the heart and 
a consequent widening of the orifices, which the cusps 
of the valves are unable to fill in and close. This inabil- 
ity to close the dilated auriculo-ventricular orifice, for 
example, is due to the fact that the cusps of the mitral 
valve are too small, and also to the fact that the papillary 
muscles are displaced by the dilatation of the heart and 
so prevent the cusps from closing perfectly. 

An increased blood pressure in the aorta or pulmonary 
artery, or a loss of elasticity of the arterial coats, which 
causes a dilated condition of the vessels, may allow a 
regurgitation of blood at the aortic or pulmonary orifices. 
Murmurs due to these causes are spoken of as inorganic, 
or the result of relative insufficiency of the valves. 

Changes in the character of the blood may also produce 
sounds, to which the name “hemic” or “functional” 
murmurs is given. 

Organie Murmurs.—Sounds due to organic lesions are 
heard during either the systole or the diastole of the 
heart, and are therefore spoken of as systolic or diastolic 
murmurs. Those murmurs which occur during the dias- 
tole, but which end at the beginning of the systole, are 
called “ presystolic ” murmurs. 

Systolic murmurs, heard loudest in the aortic and pul- 
monary areas, are due to a stenosis or obstructed condi- 
tion of the aortic or pulmonary orifices. Systolic murmurs 
heard at the mitral or tricuspid areas are due to incom- 
petent mitral or tricuspid valves, which allow a regurgi- 
tation of blood through them. Diastolic murmurs in the 
aortic and pulmonary areas are produced by blood re- 
gurgitating through an incompetent aortic or pulmonary 
valve. Murmurs diastolic in time and heard in the mitral 
and tricuspid areas are caused by an obstructed or sten- 
otic mitral or tricuspid valve. 

The relative frequency of these murmurs is in the fol- 
lowing order (Broadbent): mitral regurgitation, mitral 
stenosis, aortic regurgitation, aortic stenosis, tricuspid 
regurgitation, tricuspid stenosis, pulmonary stenosis, 
pulmonary regurgitation. To take up the consideration 
of the murmurs in the order of their frequency: 

Mitral Systolic Murmur.—Mitral valve incompetent, 


822 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





blood regurgitates into left auricle during systole of left 
ventricle. The most common cause of incompetence of 
the mitral valve is rheumatic endocarditis. Myocarditis, 
dilated left ventricle from any cause, or the infectious 
diseases may also produce this lesion. 

The murmur occurs with the systole of the heart; the 
quality is soft and blowing like a whispered “who,” 
pitch is low and intensity not loud; the duration is long. 
Area of maximum intensity at the apex; the murmur 
may be localized or may be transmitted toward the left 
into the axilla; it may also be heard in the left inter- 
scapular region along the internal border of the scapular. 

Mitral Presystolic Murmur.—The mitral valve is sten- 
osed or obstructed, and the blood is therefore hindered in 
its passage from the left auricle to the left ventricle dur- 
ing the auricular systole. The cause in nearly all cases 
is rheumatic endocarditis. 

The murmur occurs during the auricular systole ; toward 
the end of the long pause it becomes gradually louder 
and louder, and ends with the first sound of the heart. 
The quality is harsh, rough, and rolling, intensity marked, 
the area of maximum intensity usually small and just 
within the apex. This murmur is not, as a rule, trans- 
mitted. 

Aortic Diastolic Murmur.—Aortic valve incompetent, 
the blood therefore regurgitates into the left ventricle 
during the period of diastole. Rheumatic endocarditis 
is a common cause of this lesion; also atheromatous 
changes in the aorta and the cusps of the valve, as well 
as dilatation of the orifice. 

The murmur occurs with and replaces the second sound 
of the heart; it is soft and blowing in quality, often al- 
most musical; generally of rather bigh pitch, of variable 
intensity and short duration. The area of maximum 
intensity varies, it may be most marked in the aortic 
area; sometimes to the left of the sternum in the second, 
third, or fourth intercostal space; and at times at the tip 
of the sternum. It is transmitted across and down the 
sternum to the ensiform cartilage, and to the apex. 

Aortic Systolic Murmur.—Aortic valve stenosed or ob- 
structed, the blood hindered in its passage during the 
systole of the left ventricle from the ventricle into the 
aorta. This murmur may be due to true stenosis of 
the orifice resulting from rheumatic endocarditis or athe- 
romatous changes. It may be caused by atheroma of 
the first part of the aorta, by thickening and roughening 
of the aortic cusps, and sometimes as the result of aneu- 
rism and rupture of the valves. 

The murmur occurs with or replaces the first sound. 
Its quality is harsh and rough; it may, however, at times 
be soft, the intensity is usually marked and the dura- 
tion long. Heard with maximum intensity in the aortic 
area, and transmitted up the vessels of the neck. It may 
sometimes be heard all over the preecordium, and in the 
second, third, and fourth intercostal spaces on the left side 
near the vertebral column. 

HYPERTROPHY AND DILATATION OF THE HEART.— 
Hypertrophy of the heart is a thickening of the walls of 
the heart which may involve the walls of all the cavi- 
ties or be limited to those of one. Dilatation is’an in- 
crease in the capacity of the cavities of the heart; as in 
hypertrophy one or more of the cavities may be involved 
at the same time. 2 

Hypertrophy and dilatation may occur together or sep- 
arately. With hypertrophy there is usually a certain 
amount of ‘dilatation. Hypertrophy results from the 
effort of the heart to do more work than normal. This 
demand for extra work may be due to excessive exercise, 
to functional causes, for example exophthalmic goitre, 
to mechanical defectsin the circulatory system, to valvu- 
lar disease, or to increased resistance in the peripheral or 
in the pulmonary circulation, depending on Bright’s 
disease, chronic bronchitis, or emphysema. The en- 
deavor of the heart to overcome any of the valvular 
lesions by hypertrophy is an effort of the organism 
to supply extra force where extra work is needed. If 
the hypertrophy is sufficient to overcome the symptoms 
arising from the valvular lesion, the lesion is said to be 


pies 
i 


Pts 


Pha 


# 
i. 


et ee 


Ct an 


nf 97° 


%, ® y i 


2) 
Woe) 6 


vi a, 








- 
aw 





EXPLANATION OF PLATE XXIII. 


(In all the figures the blue color indicates the superficial, and the red color the deep, cardiac dulness. 
The shaded wedges show the area over which the murmurs-are heard, and indicate by their 
thickness the intensity of the sound.) 


Fic. 1.—Mitral Insufficiency. Showing slight hypertrophy of left ventricle, and marked hyper- 
trophy of the right side of the heart. Accentuation of pulmonic second sound, indicated by 
the sign u-Z at the base. Murmur heard at apex with maximum intensity, transmitted to the 
left (>) and diminishing. 


Fic. 2.—Mitral Stenosis. Left ventricle of normal size. Hypertrophy of left auricle and of right. 
side of heart. Pulmonic secona sound accentuated. Maximum intensity within apex: mur- 
mur increasing to first sound (<). Not transmitted. 


Fic. 3.—Aortic Insufficiency. Left ventricle greatly hypertrophied. Right side of heart normal 
in size. Murmur heard over a considerable area, at times with maximum intensity at base in 
aortic area, at times at lower end of sternum. No accentuation of second sounds. 


Fic. 4.—Aortic Stenosis. Left ventricle somewhat hypertrophied. No changes on right side of 
heart. Murmur heard with maximum intensity in aortic area, transmitted up into cervical 
vessels. 


PEATE ALL 


REFERENCE HANDBOOK 


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MEDICAL SCIENCES 












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GRAPHIC REPRESENTATION OF THE PHYSICAL SIGNS FOUND IN THE FOUR 


MOST COMMON VALVULAR LESIONS OF THE HEART 


Lehrbuch der klinisc 


From Sahli’s ‘ 





REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


compensated. This compensation results from the hyper- 
trophy of the walls of the cavity immediately behind 
the obstructed orifice. 

After the hypertrophy has existed for some time, the 
heart muscle fails to respond to the extra demand made 
upon it and becomes weakened; this is followed by 
a dilatation of the cavity and a failure of compensa- 
tion. 

Tuer PrystcAL Siens or HyPERTROPHY OF THE LEFT 
VENTRICLE (Plate XXII., Fig. 3).—Inspection.—Bulg- 
ing of preecordium, especially in children and adults with 
thin chest walls; apex displaced downward and to the 
left of the mid-clavicular line; @ heaving impulse over 
the precordium. 

Palpation.—A slow, heaving, and forcible apex beat. 
Pulse strong, and tension increased. 

Percussion.—Deep cardiac dulness extends more to the 

left and downward than normal; where the increase in 
deep cardiac dulness is very great there is probably dila- 
tation with the hypertrophy. 
* Auscultation.—First sound prolonged; occasionally 
there is amurmur to be heard, this occurs where the dila- 
tation of the ventricle and auriclo-ventricular orifice 
causes an incompetent mitral valve. The aortic second 
sound is usually markedly accentuated; it is clear and 
ringing, where the cusps of the valves are normal; muf- 
- fled and duller where atheroma has caused a thickening 
of the valves. There may also be a reduplicated second 
sound. In cases of emphysema the physical signs of 
hypertrophy are not marked; this is due to the volumi- 
nous lungs, which lie between the heart and the chest 
wall, and which interfere with the physical signs elicited 
by inspection, palpation, and percussion, especially in 
the latter method of examination, where apparently the 
area of superficial cardiac dulness is normal. In cases of 
emphysema where there is no hypertrophy of the heart 
the cardiac dulness is always diminished. 

Tue PuysicaL Signs oF HYPERTROPHY OF THE RIGHT 
VENTRICLE (Plate XXII., Fig. 2).—Jnspection.—Bulging 
of the lower part of the precordium, with pulsation in 
intercostal spaces to the right of the sternum and in the 
epigastrium. The apex beat is somewhat displaced to 
the left by hypertrophy of the right ventricle. 

Palpation.—Heaving pulsation and the dislocated apex 
beat are also detected by this means of examination. 

Percussion.—Dulness may extend for an inch or more 
to the right of the sternum from the enlargement of the 
right auricle. 

Auscultation.—Sounds are not much changed unless 
there is dilatation. There may be reduplication of the 
pulmonary second sound. 

DILATATION OF THE HEART gives these physical signs: 
Inspection discloses an apex beat, usually to the left of the 
normal site, and much less visible than in health; it is at 
times invisible. Thereisa diffused, undulatory, or wave- 
like character to the pulsation observed over the preecor- 
dium (Plate XXII.). 

Palpation shows a feeble impulse of irregular and flop- 
ping character. The pulse is irregular, small, of little 
tension, and rapid. 

Percussion dulness extends both to the right and left, 
depending of course on the portion of the heart most 
involved by the dilatation. 

Auscultation.—The heart sounds are feeble, and the 
rhythm is irregular. From the relative insufficiency of 
the valves murmurs may arise. When the dilatation is 
extreme and the force of the heart’s muscular contraction 
feeble, even though valvular lesions exist, no murmur 
may be heard. In such cases, after rest and the use of 
cardiac tonics, the contractions of the heart become more 
forcible and the murmurs again become audible. 

PurysicaL SigNs oF PERICARDITIS.— When pericarditis 
is unaccompanied by effusion of serum, the only physical 
sign is the friction murmur, the “see-saw ” sound, which 
is heard usually at the base of the heart. 

If the inflammation goes on, and an effusion of serum 
into the pericardial sac takes place, the following signs 
are noted: 


. 


Chest, 
Chest, 





Inspection.—Bulging of the preecordium; apex beat 
not visible or above the normal location. 

Palpation.—No apical impulse, or an impulse felt in 
the third and fourth left intercostal spaces. Fluctuation 
may be present, though this is a rare sign. 

Percussion.—W hen fluid is present in moderate amount 


_ the area of deep cardiac dulness is not increased, but the 


change from pulmonary resonance to flatness is sudden 
and marked. When the pericardial sac is distended with 
exudate, the dulness or flatness begins at the first or 
second costal cartilage, and extends downward to the 
sixth rib, and laterally beyond the normal limits of deep 
cardiac dulness. The outline of the flat area may be 
pyramidal and extend beyond the normal site of the apex 
beat. The sense of resistance on percussion is marked. 

Often the dulness of pericardial effusion is at first noted 
in the second left and fifth right intercostal spaces, 

Auscultation.—Friction sounds due to rubbing of the 
pericardial surfaces on one another may be heard, when 
the fluid is present in only small amount; when large 
amounts of fluid fill the pericardial sac, friction sounds 
are usually absent. The heart sounds are heard faintly 
and apparently at a distance; but when no endocardial 
murmurs exist they are normal in character. 

The difficulty of differentiating betweema dilated heart 
and a pericardial sac filled with fluid is often difficult. 
The fact that the apex impulse is absent or displaced up- 
ward, and not of the undulating character so typical of 
a dilated heart, in which also the apex beat is usually 
displaced downward and outward; the shape of the dull 
area, pyramida] in pericarditis, and square in a dilated 
heart; the muffled character of the sound in pericarditis, 
and the accentuated valvwtar sounds in dilatation; Bam- 
berger’s sign, dulness at the angle of scapula, and in- 
creased fremitus and bronchial breathing at this point 
when the patient sits upright, which signs disappear 
when the patient leans forward, in pericarditis and not in 
dilated heart, will aid in the differential diagnosis of 
these conditions. 

Mirra INsuFFICIENCY.—The mitral valve, incompe- 
tent, permits regurgitation of, blood into the left auricle 
during systole. This causes an increased amount of 
blood in the auricle and an increase in the blood pressure 
of the pulmonary circulation. The auricle becomes pri- 
marily dilated and hypertrophied. During each diastole, 
as a result.of the increased amount of blood in the left 
auricle and of the increased pressure under which this 
blood is, more blood enters the left ventricle than normal 
and with greater force; this causes an increase in the 
capacity of the left ventricle from the yielding of the 
walls, and then hypertrophy from the endeavor of the left 
ventricle to empty itself completely during systole. 

The increased pressure of the blood in the pulmonary 
circulation causes hypertrophy and dilatation of the right 
ventricle—the effort of nature to supply force for the 
lack of power in the left auricle. When dilatation of 
the right ventricle ensues, the tricuspid valve becomes 
incompetent and the blood during systole regurgitates 
into the right auricle, thence into the ascending and de- 
scending ven cave; pulsation of the veins of the neck 
and pulsating liver follow. 

As long as the hypertrophy of the ventricles is sufficient 
to overcome the valvular deficiency, just so long will no 
changes be noted in the character of the pulse, and no 
subjective symptoms will be observed (Plate XXIIL., 
Fig. 1). 

Inspection.—Bulging of precordium at times; apex 
beat displaced down and to the left; pulsation of the cer- 
vical veins and of the liver in extreme cases. 

Palpation.—Impulse displaced, but nothing character- 
istic; very rarely a thrill at apex. Pulse small and of 
low tension. If the compensation is failitig the pulsations 
of the liver may be felt. 

Percussion.—Area of cardiac dulness inereased to left, 
and also to the right of sternum, often an inch or more. 

Auscultation.—At the apex, in the mitral area, a soft 
systolic murmur is heard, transmitted to the left, to the 
axilla, and at times heard in back along the internal border 


823 


Chest, 
Chestnut, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





of left scapula. Though the area of maximum intensity 
is at the apex, the murmur may be heard along the left 
edge of the sternum, and also at the base of the heart. 
The pulmonary second sound is accentuated. 

When dilatation of the right heart with the accom- 
panying insufliciency of the tricuspid valve has occurred, 
a tricuspid systolic murmur may be heard in the tricus- 
pid area; at this stage the pulmonic second sound is 
weakened. 

Mirrat SreNosts.—Mitral valve narrowed and the 
blood flow from left auricle to ventricle obstructed. The 
first result of the interference with the passage of blood 
through the mitral orifice is dilatation and hypertrophy 
of the left auricle, and an increase in the blood pressure 
in the pulmonary circulation; then hypertrophy and dila- 
tation of the right side of the heart follow, and engorge- 
ment of the systemic venous circulation. _ So little blood 
enters the left ventricle during the period of diastole 
that the cavity is not filled, therefore it neither dilates 
nor hypertrophies, and is not affected by the changes 
occurring in the other cavities of the heart. There being 
little blood in the ventricle, little is forced into the aorta 
with each systole, hence the pulse is small in size (Plate 
XXIII., Fig. 2). 

Inspection.—Bulging of preecordium, especially of ster- 
num and ribs to the right of sternum; apex beat not dis- 
placed, usually visible. Epigastric pulsation marked. 

Palpation.—The apical impulse is short and snapping, 
often accompanied by a presystolic thrill. Pulse is small ; 
may be regular if compensation is good, irregular when 
compensation is failing. 

Percussion.—Area of cardiac dulness is increased to 
right of sternum and upward. 

Auscultation.—Presystolic murmur heard at or just 
within the location of apex beat, over a limited area, 
rough and harsh in character, not transmitted, and end- 


ing suddenly with the first sound of the heart. The pul- 
monic second sound is usually accentuated. There is 


often a reduplication of the second sound at the base. 
At the apex the second sound may be inaudible. 

When compensation has failed this lesion may exist, 
and yet no murmur be heard. 

Aortic INSUFFICIENCY.—The aortic valve is incompe- 
tent, and allows blood to regurgitate into left ventricle 
during the period of diastole. The first result. of this 
lesion is, that during diastole the cavity of the left ven- 
tricle is overdistended with blood, flowing from the auricle 
through the mitral orifice and from the aorta through the 
incompetent aortic orifice. The ventricular walls yield 
to the pressure, and a primary dilatation results; this is 
followed by hypertrophy of the ventricle in the effort to 
force the increased amount of blood contained in the cav- 
ity into the aorta. It not infrequently happens that 
from the dilatation of the ventricle there isan incomplete 
closure of the mitral valve, the so-called relative mitral 
insufficiency, which acts in a beneficial way by allowing 
regurgitation and so relieving the pressure in the ventricle 
during systole. Aortic regurgitation produces a marked 
effect on the pulse. The more than normal quantity of 
blood forced into the aorta during each systole causes a 
sudden and marked filling of the arteries, a quick and 
full pulse; this as quickly disappears during diastole, 
when the arteries are emptying themselves in the normal 
manner, and also backward through the incompetent 
aortic valve. The pulse seems to collapse; it is the 
“water-hammer” or Corrigan’s pulse, and is character- 
istic of this lesion (Plate XXIII., Fig. 3). 

Inspection.—There may be bulging of the preecordium ; 
the apex beat is dislocated downward and to the left, and 
the impulse is usually marked and of the heaving char- 
acter of hypertrophy. 

There is marked visible pulsation in the cervical ves- 
sels and also in the temporal, brachial, radial, and other 
arteries. Capillary pulsation in the finger nails is visible 
at times. 

Palpation.—The abnormal location of apex beat and 
the forcible and heaving character of the impulse are 
easily made out. There may be a thrill in the aortic area 


824 








diastolic in time. The pulse, the characteristic Corrigan 
or “water-hammer,” is not marked when compensation 
fails, or when a marked stenosis of the aortic valve exists 
with the insufficiency. 

Percussion.—Cardiac dulness increased to the left from 
hypertrophy of the left ventricle. 

Auscultation.—Diastolic murmur heard over the aortic 
area, and transmitted across the sternum and downward 
along left edge to the tip of the ensiform cartilage. This 
is usually a soft and blowing murmur coming with or 
replacing the second sound of the heart. 

A systolic aortic murmur is not an uncommon accom- 
paniment of the diastolic murmur; and a mitral systolic 
murmur is also often heard, the result of the relative mitral 
insufficiency. 

Aortic STENOsIS.—The aortic orifice is narrowed, and 
an obstruction is thus offered to the passage of the blood 
from the left ventricle into the aorta. This causes an in- 
erease of blood pressure in the ventricle during systole; 
the ventricular walls at first give way to this increase of 
pressure and a primary dilatation results. This is rapidly 
compensated by hypertrophy of the left ventricular 
walls, which takes place as the result of the heart’s 
effort to empty the ventricle of the excess of blood 
through the narrowed orifice. The pulse is usually 
small, because of the small amount of blood forced into 
the aorta with each contraction of the heart, and regular. 
The tension is usually high (Plate XXIII., Fig. 4). 

Inspection.—Apex beat displaced downward and some- 
what to the left, visible and somewhat heaving. When 
compensation fails impulse is wave-like. There is no 
visible pulsation in any of the peripheral vessels. 

Palpation.—Apex beat palpable in sixth space and to 
left of the mammary line: impulse is slow, regular, and 
forcible. There is often a systolic thrill in the aortic 
area. The pulse is regular, small, and of high tension. 

Percussion.—Area of cardiac dulness increased to left 
from hypertrophy and dilatation of the left ventricle. 

Auscultation.—In the aortic area a loud systolic mur- 
mur is heard, often audible over the whole precordium 
and in the vessels of the neck. It may even be heard in 
the second, third, and fourth left intercostal spaces near 
the vertebral column. The murmur is systolic in time 
and usually very harsh in quality; it is transmitted up the 
vessels of the neck. The second sound is usually faint, 
it may be absent; or there may be a diastolic murmur 
replacing the second sound, due to an incompetent con- 
dition of the aortic valve. 

Murmurs occurring at the same time of the cardiac 
cycle arising from the same pathological conditions of 
the valves of the right heart may be heard, and the phys- 
ical signs resulting from these valvular lesions are much 
the same as those already enumerated. Lesions of the 
tricuspid and pulmonary valves are, however, compara- 
tively rare; and the murmurs heard indicating trouble at 
these orifices arise more commonly from the relative in- 
sufficiency of these valves, which is the result of organic 
lesions of the valves of the left side of the heart, than 
from structural lesions of these valves themselves. 

TricusPIp REGURGITATION.—Of the lesions at the tri- 
cuspid orifice regurgitation is the more common, and is 
usually the result of dilatation secondary to mitral dis- 
ease and consequent stasis of the pulmonary circulation. 

Inspection.—Pulsation in epigastrium, in intercostal 
spaces to right of sternum, and in the vessels of the neck. 

Palpation.—Pulsation in epigastrium and to the right 
of the sternum, and at times the pulsating of the liver 
may be felt. 

Percussion.—Heart dulness increased to the right edge 
of the sternum or beyond it, and upward, from the hy- 
pertrophy and dilatation of the right ventricle and auricle. 

Auscultation.—In the tricuspid area, at the end of the 
sternum and in the fourth and fifth left intercostal spaces 
near the sternum, a soft blowing systolic murmur is 
heard; it may be transmitted slightly to the right, but is 
not heard at the apex. The second sound in the pul- 
monary area is weak. 

Tricuspid STENOsIs.—This lesion is usually con- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





- 


Chest, 
Chestnut, 





genital and is accompanied by dilatation of the right 
auricle. 

Inspection.—Cyanosis is marked, and visible pulsation 
may be noted to the right of sternum. 

Palpation.—The pulsation and at times a presystolic 
thrill to the right of the sternum may be felt. 

Percussion.—Cardiac dulness, from the dilated right 
auricle, increased: to right of sternum. 

Auscultation.—Presystolic murmur, harsh in quality, of 
maximum intensity in tricuspid area, and not transmitted. 

PULMONARY REGURGITATION.—The physical signs are 
those due to the regurgitation of blood into the right 
ventricle causing it to dilate and hypertrophy. The 
murmur is like that of aortic insufficiency, diastolic in 
time and soft in quality; it is heard with maximum in- 
tensity in the second left intercostal space, and is trans- 
mitted down the sternum. The pulse alone makes it 
possible to differentiate the murmur from that due to 
aortic insufficiency. 

PutmMonarRyY STENOsIs.—This lesion, usually con- 
genital, causes hypertrophy of the right ventricle, with 
the usual train of physical signs. 

The murmur is systolic in time, harsh in quality, heard 
loudest in the second left intercostal space and at times 
all over the preecordium; a thrill may also be detected in 
the pulmonary area. The sound is not transmitted up the 
vessels of the neck, like the systolic murmur of aortic 
stenosis. 

FunctionaL Murmurs.—Functional murmurs are 
those which occur not as the result of any organic val- 
vular lesion, but from functional changes in the heart, 
vessels, or blood. These murmurs are often spoken of 
as inorganic, hemic, or anemic, from the fancied cause of 
their production. It is usual to find these murmurs in 
cases of anzemia, or in the debility following any exhaust- 
ing disease. 

The following characteristics of functional murmurs 
will aid in differentiating them from organic murmurs. 
They are always systolic in time, and are as a rule heard 
loudest in the pulmonary area, though they may be heard 
at the apex, and in the aortic and tricuspid areas. The 
murmur is soft and blowing, and usually louder when 
the patient is in the recumbent position. There is no 
transmission, and usually no hypertrophy or dilatation. 
The second sound in anemic murmurs is usually some- 
what accentuated. 

There may be vascular murmurs associated with the 
functional cardiac murmurs; the most common is that 
heard in cases of aneemia in the neck over the jugular 
veins: the so-called “ venous hum,” or “ bruit du diable.” 
This sound may be produced by pressure on the veins 
with the bell of the stethoscope in persons who are in 
perfect health. 

ANEURISM OF THE THORACIC AoRTA.—Aneurism of 
the arch of the aorta may be fusiform or sacculated, and 
is usually secondary to syphilis, alcohol, gout, or great 
muscular strain. The physical signs depend on the loca- 
tion of the aneurismal tumor, the presence of the tumor, 
and the pressure the tumor exerts on the surrounding 
structures. ’ 

The physical signs due to the tumor itself are pulsa- 
tion, usually expansile, thrill, dulness, and murmur. It 
is quite possible, however, for an aneurism to exist with- 
out giving any physical signs. 

Inspection.—If the aneurism is of the ascending arch, 
there is often bulging in the first and second right inter- 
costal spaces, and here also a pulsation may be visible. 
When the aneurism is located in the transverse arch of 
the aorta, the manubrium is pushed forward and the 
tumor shows itself in this location ; the pulsation is noticed 
here, and also in the suprasternal notch. Aneurism of 
the descending arch is usually accompanied by a tumor 
in the second left intercostal space in front, or in the 
third, fourth and fifth intercostal spaces of the left inter- 
scapular region. 

The use of the z-ray in examining patients in whom 
aneurism is suspected is of great assistance. By means 
of the fluoroscope the presence of a dark and pulsating 


shadow, larger than that seen in examining the normal 
heart, is made out, often when no other physical signs 
of aneurism can be detected. It is most important to 
make use of this means of examination in all cases of 
suspected aneurism. 

On inspection also the apex beat of the heart may be 
found dislocated downward and to the left. 

Palpation.—At the point of bulging, pulsation, usually 
expansile in character, may be noted, and a systolic thrill 
may sometimes be felt. When the aneurism is of the 
transverse or upper part of the descending aorta, tracheal 
tugging may be present. To obtain this sign, the head 
of the patient, who sits, should be supported against the 
body of the observer, who stands behind the patient; the 
observer then places the first or second finger of each 
hand on either side of the cricoid cartilage. The head 
should be slightly bent forward and the patient told to 
stop breathing. With each systole of the heart the 
fingers appreciate a distinct tug transmitted to them 
through the trachea and cricoid cartilage, which are 
dragged down by the expansion of the aneurism upon 
the left bronchus. 5; 

A difference in the character, time, and force of the 
pulse in the two wrists may be noted; the vessels re- 
ceiving their blood supply from the aneurismal sac hav- 
ing a weak and retarded pulse wave. 

Percussion.—There is dulness over the location of the 
tumor. When there is no visible tumor, dulness in the 
second right intercostal space or in the left interscapular 
region near the vertebral column is suggestive of aneu- 
rism. 

Auscultatory percussion is of much value in diagnosis 
of the presence of a tumor in the mediastinum. 

The heart dulness is usually not increased unless there 
is valvular disease, usually incompetence of the aortic 
orifice, associated with the aneurism. 

Auscultation.—There may be a systolic or a systolic 
and diastolic murmur heard over the tumor. Ina large 
number of cases, however, no murmur can be made out. 
The second aortic sound is accentuated; at times the 
closure of the valves is so forcible that the palpating 
hand can feel the shock. 

Pressure Symptoms.—An aneurism may exist and give 
no physical signs, yet characteristic pressure symptoms 
may be present. The symptoms caused by pressure 
often coexist with the physical signs due to the tumor, 
and depend largely on the location of the tumor and the 
structures upon which the pressure is exerted. 

Pain is usually a constant symptom, sharp and stabbing 
in character, and may occur in paroxysms. The pain 
may be due to the erosion of bone, sternum, or vertebre ; 
may be anginal in nature, or result from pressure on the 
nerves, and shoot down the arm to the fingers or along 
the intercostal spaces. 

Pressure on trachea and bronchi gives rise to cough, 
bronchorrheea, and hemorrhage, at times slight and ap- 
parently from the lungs, at times profuse and fatal from 
ulceration of the aneurismal sac and rupture into the 
trachea or bronchus, 

Pressure on vena cava, if on superior, causes cyanosis, 
enlargement of the veins, and cedema of the head, neck, 
and arms, usually the right; if on the inferior, there may 
be cedema of the thorax and feet. 

Pressure on the esophagus causes dysphagia, and the 
aneurism at times ruptures into the @sophagus. Pressure 
on the recurrent laryngeal nerves produces a dry me- 
tallic cough and aphonia. The paralysis of the ab- 
ductor muscles of the larynx is easily made out by laryn- 
goscopic examination. The left vocal cord is the one 
most frequently paralyzed. Pressure on the sympathetic 
nerves may produce contraction of one pupil, and flush- 
ing and sweating of one side of the face. Pressure on 
the brachial plexus, sternum, and vertebra produces 
pain. William EK. Draper. 


CHESTNUT.—Castanea. “The leaves of Castanea 
dentata (Marshall) Borckh. (fam. Fagacee), collected in 
September or October, while still green” (U. 8. P.). This 





825 


Chewstick, 
Chick’s Springs. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





is one of the largest and most valuable of our timber trees, 
growing rather rapidly, and producing an abundance of 
straight-grained, rather coarse, but very durable wood. 
The ripe fruit or nuts well known. The official descrip- 
tion is as follows: “From six to ten inches (15 to 25. cm.) 
long, about two inches (5 cm.) wide, petiolate, oblong- 
lanceolate, acuminate, mucronate, feather-veined, sinu- 
ate-serrate, smooth, odor slight, taste somewhat astrin- 
gent.” Doubtless other species of chestnut leaves have 
the same composition and might with equal propriety 
be used. Nothing peculiar has been found among the 
constituents of chestnut leaves; nine per cent. of tannin, 
resin, and a number of mineral compounds in the ash, 
are the principal things observed. 


Their use is entirely empirical. The leaves for a good 


many years have had a popular reputation for the relief , 
of whooping-cough, and within the last ten or fifteen - 


years have been considerably used in its treatment by 
physicians; their value for this purpose is, to say the 
least, uncertain. Sometimes there appears to be a 
marked decrease in the number and severity of the 
coughing spells; at others no effect is produced. They 
are not put to any other use. The fluid extract is offi- 
cial, the dose being 2 to 8 c.c. (fl. 3 ss.-ij.). 
W. P. Bolles. 


CHEWSTICK.—The stems of Gouwania Domingensis 
(fam. Rhamnacee). This is a beautiful woody climber, 
growing both wild and cultivated in the West Indies, 
and other parts of tropical America, whose stems are 
used there as tooth-brush and powder combined. These 
stems are very tough and fibrous, and when cut in short- 
ish pieces the ends are chewed until a rude, stiff brush 
is formed, with which the teeth are rubbed; a pleasant 
saponaceous froth of an aromatic bitter taste is formed 
in the operation, and the teeth are said to be whitened 
and the gums hardened by it. <A tincture and powder 
are proposed as dental remedies. Internally, it acts as 
a mild aromatic bitter, and is used in its home as a con- 
stituent of small beers. Manufacturing houses offer a 
fluid extract, the dose of which is 4 to 8 c.c. (fl. 3 i.-ij.). 

Henry H. Rusby. 


CHEYNE-STOKES RESPIRATORY PHENOMENON. 
See Dyspnea and Respiration. 


CHICAGO, ILL.—A city of a million and a half or 
more inhabitants, situated upon the west shore of Lake 
Michigan. Its climate, although a very variable one 
and subject to sudden changes, with excessive heat or 
cold and increased humidity, is not an unwholesome one; 
and the death rate from consumption along the west 
shore of the lake is less than farther inland. According 
to Dr. John A. Robinson * the physiological effect of the 
lake climate is to promote physical activity and mental 
vigor, and to increase bodily nutrition. “Persons,” he 
says, “who have been predisposed to pulmonary tuber- 
culosis have enjoyed robust health in this climate so long 
as they have avoided its bad features and observed other 
precautions.” The favorable features of the climate, as 
Dr. Robinson gives them, are: first, air in motion, the 
winds sweeping down into the dark corners of the streets 
and alleys, and whirling the filth into the highways 
where the rain and sunshine disinfect it; these winds 
act as great atmospheric purifiers. Second, the lake 
purifies the air as it blows from its surface toward the 
land. ‘Third, the large amount of sunshine. “ Observa- 
tions for several years,” continues Dr. Robinson, “ prove 
that the monthly mean of cloudy days is about ten 
a month; which means that the sunshine is present 
about two-thirds of the time.” From the accompany- 
ing climatic table it will be seen also that the number 
of clear and fair days is two hundred and fifty-seven 
a year. 


*North American Practitioner, Chicago, 1897, ix., pp. 296-298, 
“Chicago as a Health Resort.” 


826 


CLIMATE OF CHICAGO, ILL.—LATITUDE, 41° 52’; LONGITUDE, 87° 38’. 
PERIOD OF OBSERVATION, THIRTEEN YEARS. 


x 
Ss — . 
Data. | E i 3 
S loa) Soa 
Temperature (Fahr.)— 
> 8¥A VETAGELOL NOLMAl census taieme ates 25.8° | 45.4° | 72.8° | 48.8° 
AVerage Cally TANGLE. « vs \sisisiciny vie eciiolns s2 14.9 | 14.8 | 14.3. 
Mean Of WATMOSt Ty scccatinet oer cs teileteare 82.6 | 54 80.1 
Mean Of Coldest.) csile Seeder aaalaie te tals 17.7 | 39.7 | 65.8 
Tighest Or MAXIMUM Fj. cleais ciclsiniele careers 65 83 99 
Lowest or miniMuM <....... 63 cccey.-s 0. —20 | 17 50 
Humidity— 
Average OP relative jen ens co sscemern den 76% | 66.5% | 70.6% | 70.8% 
Precipitation— 
ae iia rainfall in inches ..........+..+. 2.04 | 3.65] 3.96 | 37.58 
ind— : 
Prevailing direction... cnict cies eescleealcies ct S.W.| N. |S.W. | S.W: 
Average hourly velocity in miles ........ 9 D5 ihe vek 8.4 
Weather— 
Average number of clear days.....2..... 7.8 8.1 | 12.9. | 108.5 
Average number of fair days ...........+. 12.9 | 12.2 | 12.5 | 148.6 
Average number of clear and fair days ..| 20.7 | 20.3 | 25.4 | 257.1 





The authority above quoted does not think the Chicago 
climate contraindicates the establishment.of a sanatorium, 
in the vicinity, for the treatment of curable cases of con- 
sumption. “At any rate,” he says, “the climate in the 
lake region affords as good an opportunity as the climates 
of England and New England.” For a statistical ac- 
count of the Chicago climate one is referred to “The 
Climate of Chicago,” by Professor Hazen, 1893, of the 
Weather Bureau, published by the United States Gov- 
ernment. Edward O, Otis. 


CHICHANCANAB.—Yucatan, Mexico. The water of 
this lake is perfectly clear and very bitter in taste. It 
deposits crystals similar in appearance to those of mag- 
nesium sulphate. NV. J. Ponce de Léon. 


_ CHICHIMEQUILLAS.—Querétaro, Mexico. Nothing 
much is known of these waters. The laity recommends 
them in cases of rheumatism, leprosy, and disorders of 
menstruation. NV. J. Ponce de Léon. 


CHICHIPICO.—Puebla, Mexico. This is a lukewarm- 
sulphureted calcic water. Although there are no bath- 
ing facilities at this spring, many people take the baths, 
as they are highly recommended by local physicians, for 
the treatment of rheumatism and nervous disorders. 

NV. J.. Ponce de Léon. 


CHICKENPOX. — (Synonyms: Varicella, Crystalli, 
Swinepox; Fr., La Varicelle; Ger., Wasserpocken.) 
Chickenpox is an acute, specific, infectious fever, char- 
acterized by successive crops of vesicles distributed over 
the entire surface of the body, which disappear, in from 
four to seven days, by desiccation. It is the mildest and 
least important of the eruptive fevers. 

The belief, formerly generally entertained by the pro- 
fession, that varicella is not an independent affection 
but a modified variola, is now abandoned, save by a few 
clinicians who follow the teaching of Kaposi and the 
Vienna school. The proof of the non-identity of the two 
diseases is overwhelming. 

Varicella, like the other members of the exanthematic 
group, is due to a specific virus, or poison, the nature of 
which isunknown. It is pre-eminently a disease of early 
life. It affects babes at the breast, attains its maximum 
frequency about the fifth year, and is rarely met with 
after the tenth year of age. It rarely occurs a second 
time in the same individual. Adults enjoy special im- 
munity from the disease, even when unprotected by an 
attack in childhood. 

Sporadic cases of chickenpox are sometimes observed, 
but it usually prevails as an epidemic. It is highly con- 
tagious, and few children who are susceptible to its in- 
fluence escape when exposed. Many authors affirm that 
inoculation with the contents of the vesicles yields nega- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chewstick, 
Chick’s Springs, 





— 


tive results, but Steiner and others have repeatedly re- 


produced the disease in this way. The period of incuba- 
tion in these experimental cases is about eight days, but 
when the disease is transmitted in the ordinary manner 
it is longer and more variable, running from ten to seven- 
teen days. : 

Prodromal. symptoms are not infrequently wholly 
absent, the appearance of the eruption giving the first 
indication that the child is ailing. When present, they 
rarely last longer than twenty-four hours, and are such 
as usher in mild febrile attacks, namely, anorexia, lassi- 
tude, general bodily discomfort, chilliness, and slight 
elevation of temperature. 

The initial fever is mild, seldom measuring more than 
101° F., and the constitutional disturbances are corre- 
spondingly slight, but in exceptional cases they may be 
as severe as those which commonly attend mild attacks 
of the other eruptive diseases. The eruption follows 
promptly on the first increase in temperature, and in a 
few hours attains its full development. Small hypersemic 
patches resembling roseola spots first appear and are 
speedily followed by vesicles. When fully formed, the 
' eruption consists of perfectly transparent vesicles, more 
or less abundantly scattered over the body, globular or 
ovoid in form, and varying in size from a pinhead to a 
split pea, or even larger. They are unicellular in struc- 
ture, collapse when pricked, and leave behind no swell- 
ing or elevation of the skin. A distinct areola may or 
may not be present. 

The wall of the vesicle, formed by the outer layer of 
the epidermis, is very thin and easily broken. 

When the eruption is abundant the body, as well de- 
scribed by Dr. Gregory, presents the appearance of hav- 
ing been exposed to a momentary shower of boiling 
water, each drop of which has produced a small blister. 

The eruption appears first upon the trunk, and spreads 
irregularly over the entire body. It is most abundant 
upon the back and breast, and least so upon the face, 
where it is usually limited to the forehead. The scalp 
nearly always exhibits a full crop of eruptions, which, 
protected by the hair, maintains its physical integrity 
longer than in any other location, and thus renders valu- 
able aid in diagnosis. The eruption is never confluent. 

The occurrence of two, three, or more successive crops 
of eruption, each running an independent course, consti- 
tutes a striking and unique feature of varicella. Be- 
tween the vesicles first formed new roseola spots appear, 
and soon ripen into fully developed vesicles. Thus, 
newly formed vesicles may be seen side by side with 
others in all stages of development, even to advanced 
desiccation. The irregularity in the course and develop- 
ment of the eruption is an important point in the diag- 
nosis of the disease. 

The mucous membranes are often implicated. The 
tongue, buccal.membrane, and the mucous surfaces of 
the genital organs, especially in girls, are favorite sites 
for the formation of vesicles. In these locations the 
vesicles soon lose their epithelial covering, and leave 
small, round, superficial ulcers resembling the ulcers of 
herpetic stomatitis. 

If unbroken by accident or by the scratching of the 
child to relieve the itching so generally present, the 
vesicles remain until the third day without change, when 
their contents become cloudy and desiccation begins. 

At this stage a few scattered pustules may be ob- 
served, but these are purely accidental and not essential 
features of the disease. The vesicles begin to dry up in 
the centre and form thin, brownish-yellow crusts, which 
soon become detached. Faint red spots remain, which 
pass away in a few days, and carry with them every 
trace of the eruption; but very exceptionally depressed, 
slightly pitted cicatrices permanently mark the seat of a 
few of the vesicles. 

Mr. Hutchinson has called attention to the gangrenous 
ulcers which sometimes, though rarely, complicate 
chickenpox in feeble, ill-nourished infants. In these 
cases a greater or less number of vesicles, instead of pur- 
suing the ordinary benign course, become gangrenous, 





increase in size, and form black scabs of. one-half to one 
inch in diameter, surrounded by dusky red areole. The 
ulcers heal slowly. In fact this.condition may result 
fatally in infants whose constitutions are depraved by 
inherited taints or bad surroundings. It is not peculiar 
to varicella and is described on other pages of the Hanp- 
BOOK under the name of Varicella Gangreenosa. 

The varieties of chickenpox described by authors 
under the names of Varicella lenticularis, Varicella 
conotdes, and Varicella globata, based on the various 
shapes assumed by the eruption, may be wholly ignored, 
since in every well-marked case vesicles answering all of 
these descriptions are abundantly found. In fact this 
variability in size and form of the typical varicellar erup- 
tion is a characteristic feature of the disease. The prog- 
nosis is always favorable. 

Erysipelas is the most serious, though a rare complica- 
tion. Holt has met with three fatal cases. 

Henoch and others have reported cases of nephritis 
occurring both as complications and as sequels. Vari- 
cella is not infrequently complicated by other infectious 
fevers. The combination of scarlatina and varicella has 
been often observed. 

Varicella derives its chief importance from the liability 
of inexperienced or careless diagnosticians to mistake it 
for smallpox, or vice versd. 

In variola, or well-marked varioloid, the physiognomy 
is so distinctive as almost to preclude the possibility of 
error. But in exceptional cases of varioloid the consti- 
tutional symptoms are so mild and the eruption so rudi- 
mentary and irregular that a careless examination will 
not suffice to distinguish them from the graver forms of 
varicella. 

For two years or more an unusually mild form of 
variola has prevailed extensively throughout the country, 
especially in the South and middle West. The mortality 
has been almost nil. In 2,819 cases recorded in Ohio up 
to January, 1900, the death rate was 1.4 percent. Dur- 
ing most Of the time varicella has been epidemic ina 
part of the same territory, which with the exceedingly 
mild type. of variola has given rise to much confusion 
and many mistakes in diagnosis. 

Time will always clear up the diagnosis, but in the 
meanwhile the reputation of the physician and the safety 
of the community may be seriously compromised. 

The absence of prodromal manifestations, the short 
initial fever, the rapidity and irregularity with which 
the eruption spreads over the body, the globular, non- 
umbilicated, transparent, unicellular vesicles, the absence 
of a distinct pustular stage, and the successive crops of 
eruption, which show roseola spots, vesicles, and crusts 
in close proximity, will rarely give room to hesitate in 
the presence of chickenpox. 

While any case of varicella may present an occasional 
vesicle slightly umbilicated or with purulent contents, 
due to accidental causes, the fact that this appearance is 
only.exhibited by a few scattered vesicles, and is not the 
predominating character of the eruption, will suffice to 
establish the diagnosis. 

It is well to bear in mind that a vesicular eruption which 
occurs ina child over ten or twelve years of age, and 
especially in an adult, is open to grave suspicion. The 
writer cannot, however, agree with those authors, by no 
means few in number, who maintain that varicella never 
occurs in the adult. He can recall three cases in adults, 
all females, which have come under his observation. 

Varicella is a self-limited disease and needs but little 
treatment. 

Light diet, cooling drinks, a gentle aperient, and con- 
finement within doors while the fever lasts, is all that 
will ordinarily be required. To prevent the infection of 
other children isolation should be maintained until the 
crusts have fallen. W. J. Conklin. 


CHICK’S SPRINGS.—Greenville County, South Caro- 
lina. 

Post-OFrFicE.—Greenville. Hotel and cottages. 

Access.—Via Atlanta and Charlotte Air-Line (Southern 


827 


Chicory. 
Childhood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





Railway system), to Taylor’s Station, 10 miles from 
Greenville. thence 1 mile to springs. 

Chick’s Springs are located in a broken, rugged coun- 
try, about 1,200 feet above the sea level. Paris Moun- 
tain, a spur of the Blue Ridge, is only three or four 
miles distant. The climate of this region is very salu- 
brious and well adapted for pulmonary cases during the 
winter months. The air is dry, and clear weather with 
invigorating breezes the rule. The resort has had a wide 
reputation in the South for many years, but owing to 
the destruction of the hotel by fire it has not been open 
to the public until two or three years since, when the 
present owner built a small hotel and several cottages. 
A large, new hotel is projected, which, with other im- 
provements, will bring the place up to its old standard 
of excellence. The springs are two in number, known 
as the “Iron” and the “Sulphur” Springs, and are about 
one hundred and fifty feet apart. The following analysis 
by Dr. Charles U. Shepherd, of Charleston, was sent to 
us by Mr. Julius C. Smith, of Greenville: 


ONE UNITED STATES GALLON CONTAINS: 


Solids. 


Calcitim sulphate try aerstetaverrcielaeeccteleeneetretelet- tats 
Magnesium sulphate 
Sodium sulphate............ Co uS 

Sodium. Silicate Secs iro) werews, «el siner einetee Mente nema rte rete 
Potassitim SUICate i. Ae vcieieess ros itelsioserthorelaiers sieved cuter ewieetele 
Silla cc cuase acinasoot eee ie ontaeicie pelea clea te er peatapeers 3 
Tron OX9dO ohana we tice cteie stro neynismeionc ee omen aera’ Al 


Grains. 





Carbonic acid gas present in appreciable quantities. 


These waters have been found of great advantage in 
cases of atonic dyspepsia accompanied by hepatic con- 
gestion. They arealso useful auxiliaries in Bright’s dis- 
ease of the kidneys. James K. Crook. 


CHICORY.—Cichorium. The root of Cichorium In- 
tybus L. (fam. Cichoriacee). A perennial, milky-juiced, 
European herb, with dandelion-like leaves and _ tall, 
sparsely branching stems, bearing large, delicate, bright 
blue flowerheads. It is very abundantly naturalized in 
this country, along roadsides, and is also extensively 
cultivated both here and abroad. The root is fleshy and 
branched, very much like that of dandelion when dry, 
but rather larger, and deficient in regard to the bright 
yellow woody ring so distinctly seen in the cross section 
of dandelion. It is grayish brown externally, whitish 
within, generally odorless, and but slightly bitter. The 
cultivated root is larger and darker than the wild. It 
occurs in commerce mostly cut into halves and quarters 
of transverse sections, and is heavily wrinkled in drying. 
The leaves, which are somewhat employed as a salad, are 
irregularly pinnatified, with a large terminal and small 
lateral segments. They resemble lettuce in taste, but 
are more bitter. 

The roasted root is very extensively used as an adul- 
terant of, or addition to, or substitute for coffee, and this 
use is steadily increasing. In some European countries, 
especially England, it is generally assumed that the cus- 
tomer desires the addition of chicory unless he directs 
otherwise. To the natural taste, it imparts a bitter and 
nauseous flavor to the beverage, but this, by custom, be- 
comes tolerable or even agreeable. 

Chicory is scarcely entitled to rank as a medicine, al- 
though it is laxative and about similar to dandelion in its 
effects. The root contains énulin, like many others in the 
order, bitter extractive, and sugar. The flowers contain 
a peculiar glucoside. Henry H. Rusby. 


CHIGOE. — Synonyms. — Besides the classical terms 
Pulex penetrans, Dermatophilus, Rhynchoprion penetrans, 
and Sarcopsylla penetrans, this troublesome tropical para- 
site is known by the following names: aagrini, atten, 
bicho, bichos dos pes, chego, chegoe, chegre, chica, 
chico, chicque, chigga, chigger, chiggre, chigo, chigoe, 
chigua, chique, ckicke, earth-flea, jatecuba, jigger, mi- 
gor, nigua, pico, picque, pigne, pigue, pique, punque, 


828 


sand-flea, sandfloh, seccec, sico, sike, sikka, siko, tchike, 
tom, ton, tschicke, tschik, tschike, ti, tunga, tungay, 
xique. 

ErymMo.Locy.—Chigoe is supposed to be derived from 
the Spanish chiquito, small. 

For natural history, classification, anatomy, etc., see 
article /nsects. 

GEOGRAPHICAL DisTRIBUTION.—The chigoe is confined 
exclusively to the tropics, and is probably indigenous to. 
South America. It is most prevalent in the West Indies, 
and Central and tropical America, its bounds being about 
30° of latitude North and South. Within these limits it 
is certainly very common indeed, and for its size is the 
most troublesome of all the tropical pests. Till about 
twenty-five years ago it had never been known out of 
the Western hemisphere, save for a stray case imported 
into Europe from South America or the West Indies (one 
such case is elaborately reported by Laboulbéne); but in 
1872 or 1878 it was found in tropical Africa, and within 
the last decade it is said to have reached South China. 

Probably it will be found all over the tropics. It is 
most abundant in the dry sandy soil, and in the parts 
near the sea; also in pens, stables, and in the dust, ashes, 
etc., of neglected, unswept houses. Negroes are chiefly 
affected, and those who work or go about with bare feet, 
and are not accustomed to hygienic surroundings and 
conditions. Europeans and newcomers suffer the most, 
but probably because the older residents know what 
trouble these little pests can give, and have learnt from 
experience to appreciate the first signs of the presence of 
the parasite. Women and children with their thinner 
and more delicate skin suffer very much. Soldiers have 
been attacked by these tiny parasites and have been dis- 
comfited if not routed by them. “It is stated that as early 
as 1538 a division of Spanish troops was disabled from 
marching by swarms of the parasite settling in their feet. 
In recent times the French troops under Bazaine, in the 
Mexican expedition, had the same unfortunate experi- 
ence” (Hirsch). 

Short Description.—The chigoe is a parasite of the 
“flea” tribe; it is smaller than the flea, but has a larger 
head. It attacks birds, warm-blooded animals both wild 
and domestic, as well as the human subject. The male 
and immature female are both free parasites, obtaining 
their board and lodging wherever they can, but on im- 
pregnation the female seeksa host. It isthe impregnated 
female that causes all the trouble, and it is to her alone 
that we refer in the present article. With its head the 
chigoe bores into the skin, going obliquely through the 
epidermis; it then enters betweén the epidermis and 
dermis, and burrows down into the latter, but probably 
never goes deeper; from the capillaries of this region it 
obtains its food supply. 

Parts Affected.—All portions of the body are liable to 
attack, but the chigoe exhibits a decided preference for 
the feet. These are nearly always involved, especially 
under and around the nails, and in the digito-plantar fold. 
The insertion of the tendo Achillis is another favorite 
place. The dorsum of the foot is very seldom involved. 
Next to the feet, the scrotum, prepuce, corona glandis, 
axilla, arm, forearm, palm of hand, lower eyelid, cheek, 
neck, elbow, and knee are places of predilection; and as 
the feet and genitals are oftenest attacked, the question 
has been raised as to how far the chigoe is attracted by 
the odor of those parts, especially in the uncleanly. As 
a rule only one or a few chigoes are found, but Bonnett 
reports a case in which he found no fewer than three 
hundred in one person. It has also been stated that the 
chigoe likes to effect an entrance either near to another 
chigoe, or into the very spot which another chigoe has 
previously occupied; the neighborhood of an ulcer pro- 
duced by her comrades is also attractive to the chigoe. 

CLINICAL CoURSE AND SympToms.—Three stages have 
been described, but ordinarily only the first two are ob- 
served; and if proper care be bestowed the trouble is 
limited to the first stage. 

1. Period of Invasion.—This lasts for from twenty-four 
to thirty-six hours, and is marked by itching and tick- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





ling, due to the perforation of the skin. The sensation, 
which at first is not very definitely localized and some- 
times is a little way from the actual seat of the trouble, 
is rather pleasant than otherwise; and many people have 
been known to keep the insect for a day or two before 
extracting it. The pain.or discomfort is intermittent; 
but as the sac with the eggs increases in size it presses 
on the neighboring tissues and gives rise to a slight pain, 
which later becomes dull and throbbing and increases in 
intensity. At first there is nothing to be seen, but as the 
sac grows there can be observed a small spot, black or 
dark blue in color, and somewhat deeply set in the skin 
which at this stage is hardly raised. If the trouble be 
near a nail (as it is very apt to be) inflammation will soon 
follow unless the sac be carefully extracted. In delicate 
people even one chigoe will cause lameness and hinder 
walking. 

2. Period of Inflammation.—If the insect be allowed to 
remain in the tissues, or the sac be ruptured and some of 
the eggs remain, inflammation ensues, the intensity of 
which depends on the thickness of the skin and the rich- 
ness of its vascular and nerve supply. If the skin is 
thick, there are pain, very little heat or redness, and little 
or no swelling; in other cases there are considerable pain, 
heat, and redness, and a serous fluid is present. If there 
are several parasites with well-developed sacs, the degree 
of inflammation is very great, and there is the possibility 
of further trouble. This second stage lasts for four or 
five days, sometimes longer; the inflammation only 
ceasing on the extraction of the chigoe. 

3. Period of Ulceration.—lIf the part be still neglected 
and the inflammation remain unchecked, a large ulcera- 
tion occurs; the vessels may become obliterated, and 
gangrene is a possible result. Ulceration is very com- 
mon when several chigoesare present in close proximity : 
and the union of several small ulcers gives a very ugly 
sore. The ulcer is characterized by red, scalloped 
edges, grayish base, and thin fetid pus which may separ- 
ate the epidermis from the dermis. These ulcers are apt 
to spread along the surface, and in very severe cases the 
skin is destroyed, subjacent structures are denuded, 
tendons laid bare, phalanges may be necrosed, and toes 
drop off. This is exceedingly rare, and we believe that 
the severe symptoms attributed to this stage have been 
exaggerated. 

PROPHYLAXIS consists in personal cleanliness, particu- 
larly in constant bathing of the feet. Avoid sleeping on 
the ground, and do not go barefooted. Keep socks and 
bedroom slippers off the floor when not in use. See that 
rooms are swept and floors sprinkled. Some people use 
a -pungent essential oil to keep away the insect, the 
natives employing an infusion of tobacco leaves for this 
purpose. 

TREATMENT.—There is but one method that can be 
recommended, and that is careful extraction of the sac at 
the earliest possible moment. On the first itching sensa- 
tion a search should be instituted for the insect, which 
when found should be at once dislodged. This is best 
accomplished with a sharp needle, which should be steril- 
ized by passing through a flame, and then carefully in- 
serted in the opening made by the chigoe, and passed 
round the sac, separating it from the tissues, and when 
thus loosened it can be extruded. Great care must be 
taken to avoid breaking the sac and scattering the eggs. 
If unfortunately this should occur, wash out the débris 
with water (sterile if possible) or a mild solution of 
bichloride of mercury. If the skin is very thick an incision 
may be necessary. The negresses are skilful in “echi- 
quage” (as extraction of a chigoe is termed), but it is 
very necessary to see that they employ a surgically clean 
needle. Ifa dressing is considered necessary, a three or 
four per cent. solution of carbolic is as good as any. If 
the wound is large and intractable to ordinary treatment, 
you may have to curette and treat as any other fresh 
wound. Care must be taken to prevent the entrance of 
any pathogenic bacteria. Inflammation is treated in the 
usual way. If ulceration has occurred, chloroform lini- 
ment or mercurial ointment can be employed; and in the 


‘may be necessary. 


Chicory. 
Childhood, 


very worst cases, and those badly neglected, amputation 
RR. J. E. Scott. 


REFERENCES. 


Bonnet: Arch. de méd. nay., 1867. 
Brassac: Arch. de méd. nay., 1865. 
Hirsch : Handbook of Geog. and Hist. Path. New Syd. Soc., vol. ii., 1885. 
Laboulbene : Dict. Encyclop. des Sciences Médicales, Paris, 1875, tom. 


Xvi. 
In the last two of these there is a very complete bibliography. 
CHILBLAIN. See Dermatitis calorica. 


CHILDHOOD.—In the arbitrary division of life em- 
ployed for purposes of description or discussion, child- 
hood includes the period from the end of the second year 
to puberty. The material for our consideration, there- 
fore, includes all the phenomena that belong to the 
human organism in its progress from the conditions pre- 
vailing at the end of the second year of life to those of 
maturity. 

Naturally at the outset of this period the organism, 
both in conformation and in function, corresponds closely 
to the infantile type, yet it has progressed sufficiently 
far to exhibit in some degree nearly all the powers that 
belong to the fully developed organism. No essentially 
new powers are developed until the concluding years of 
the period introduce the changes incident to puberty. 

At the end of the second year the body still maintains 
many of the infantile characteristics. The head is large 
in proportion to the size of the body, its circumference 
being about nineteen inches; the trunk is large in pro- 
portion to the extremities, the general outlines are full 
and round. The child at this age, however, has attained 
such a degree of muscular co-ordination that he is able to 
stand, walk, or run, and to use the hands freely.. The 
special senses are all awakened to a degree, and he has ac- 
quired a certain small store of experience, is constantly 
adding to that store, and in a feeble way reasoning upon 
the results of it. The same development from the condi- 
tion at birth, which is so especially notable in the case of 
the brain and nervous system, is also to be observed in 
the other organs of the body. The lachrymal glands are 
very active, the mouth has filled with teeth, the salivary 
glands have assumed their functions, the stomach and 
intestines are possessed of increased digestive power, and 
the eliminative functions of the kidneys are more in evi- 
dence. A more detailed consideration of some of the an- 
atomical and physiological peculiarities of childhood will 
be in order. 

The Skin.—The superficial area of the body in child- 
hood relatively to the size and weight of the body is 
much greater than in adult life. Changes in the condi- 
tion of the skin have, therefore, a relatively greater influ- 
ence in the earlier years. Children react to cold or hot 
applications to the surface of the body very quickly and 
markedly. Hydropathic treatment must therefore be 
carried out very carefully, and the length of exposure to 
either heat or cold regulated by the effect upon the gen- 
eral condition. Under proper regulation we can expect 
more marked and lasting effects from such measures in 
children in an inverse relation to their age. Thus simple 
sponging of the surface of the body with cold water or 
the application of a cold pack may be quite sufficient in 
a child to produce an effect which in an adult would re- 
quire a prolonged cold bath. 

The sensitiveness of the child to sudden changes of the 
temperature of the body should not be lost sight of in 
considering the questions of hygiene. The surface of 
the body should, as a rule, be protected, even in summer, 
The exposure of the neck and chest, arms and legs of a 
delicate child—often resorted to by mothers in the belief 
that it will “harden” the child—is much more likely to 
result in weakening it or even producing definite and 
severe illness. ; 

Except in the hottest part of summer flannel or wool 
should be worn next the skin, and whenever it is dis- 
pensed with, particular care should be exercised to pre- 
vent sudden chilling of the surface of the body. Proper 


829 


Childhood, 
Childhood. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 











care of the surface of the body will protect a child from 
many of the attacks of inflammation of the respiratory or 
alimentary tract to which childhood is so susceptible. 

On the other hand, daily bathing should be as sys- 
tematically carried out in childhood as in infant or adult 
life. No specific rule can be given for the temperature 
or duration of the daily bath. These must be regulated 
according to age and constitutional vigor. A bath that 
leaves a child blue, cold, and shivering for some time 
after it must be harmful, but such results are unneces- 
sary. Either-by lessening the duration of the bath or by 
raising the temperature of the water, they may not only 
be avoided, but in their stead we can secure a healthy 
reaction which will leave the skin warm and glowing and 
the child stimulated and strengthened. No other one 
measure is so potent in increasing the vitality of weakly 
children and enabling them to avoid the constant recur- 
rence of colds as systematic bathing with water at the 
lowest temperature compatible with a proper reaction. 
Asa rule, the gradual reduction of the temperature of 
the bath is not only feasible, but advisable. The rate of 
reduction must be regulated by the effects produced. 

Not only is the skin area relatively greater in child- 
hood, but the skin itself is more delicate and more readily 
affected by any application. The use of external reme- 
dies, either in the form of lotions, ointments, dressings, 
or local applications, must be carefully watched and lim- 
ited to small areas. Local irritants or caustics are to be 
employed with care. Blisters, burns, and severe ulcera- 
tions are readily produced by incautious applications to 
the skin; even grave constitutional effects may be pro- 
duced by the external use of such readily absorbable sub- 
stances as carbolic acid and its allies. 

The skin in childhood readily reflects disturbances of 
other parts of the body, especially the gastro-intestinal 
tract. Eruption’ dependent upon disturbances of the 
stomach or bowels are frequently seen, and the dietetic 
treatment of skin diseases is seemingly much more potent 
in childhood than in adult years. 

The Bones.—At the beginning of childhood the bones 
are still very cartilaginous and soft. Ossification pro- 
gresses very slowly till puberty is reached. The fonta- 
nels are closed, but the bones of the skull are still rela- 
tively thin and soft, and the sutures remain open for 
many years. The spine of a child is remarkably soft and 
flexible, because of the limited ossification of the verte- 
bre. At the end of the second year it still presents the 
nearly perpendicular column characteristic of infancy. 
During childhood the S-like antero-posterior curvature 
characteristic of adult life is developed. Owing to the 
softness of the vertebree and the laxity of the ligaments, 
the conformation of the spine during childhood is readily 
influenced by the attitudes of the body, and much more 
attention than is usually given should be paid to the pos- 
tures and carriage of the child. 

The thorax of the child gradually changes its form 
from the change in the curvature of the spine and 
attendant changes in the direction of the ribs. The ribs, 
as age increases, are directed more obliquely downward. 
The thorax becomes relatively broader above than be- 
low, a reversal of the conditions found in infancy. 

The pelvis in childhood gradually enlarges so as to be 
more capacious,-and receives more of the abdominal vis- 
cera, thus diminishing the prominence of the abdomen so 
notable in early life. There is practically no difference 
in the pelves of the two sexes until the changes of puberty 
introduce the special characters of the sexes. 

The bones of the extremities in childhood show the di- 
vision into diaphyses and epiphyses. There is active 
growth at the junction of the shaft and epiphysis; the 
bones are still soft and easily affected by pressure. In 
consequence of these conditions deformities are easily 
produced, and are also, as a rule, readily amenable to 
proper mechanical treatment. 

The Teeth.—At the close of the second year, or within 
the following sixth months, the eruption of temporary 
teeth, twenty in number, is completed. At this time the 
child has not only the temporary teeth, but also the cal- 


830 . 


cified crowns of all the permanent teeth except the second 
and third molars. The crowns of the second molars begin 
to be calcified during the fourth or the fifth year, but the 
third molars, or wisdom teeth, are not calcified till pu- 
berty. At the end of the fifth, or the beginning of the 
sixth year, therefore, the jaws contain not only the tem- 
porary teeth, but all the permanent excepting the wis- 
dom teeth. At this period there occurs a marked devel- 
opment of the jaws in the horizontal plane, in order to 
accommodate the permanent molars, which make their 


appearance posteriorly to the temporary molars. The 
permanent teeth are cut in the following erder: 
Year. 

MOISE OU Shia dahtacscstlalarielve sone Sixth. 

Incisor, COmUraly ncurses creistentersters Seventh 

Incisor, lateralis vss esis. eres Eighth 

Bicuspid, anterior............+. Ninth. 

Bicuspid, posterior ............. Tenth. : 

CANINES Fic cescie tsclelsinh srewisiacivet aie Eleventh to twelfth. 

Molars, SCCON .<eialve's sbieputeeas Twelfth to thirteenth. 

Seventeenth to twenty-fifth. 


Molars; third aes meen tie ieee 


Owing to this eruption of the permanent teeth, the 
care of the teeth in childhood is of especial importance. 
Undoubtedly much of the common early decay of the 
permanent teeth is to be attributed to lack of care of the 
mouth during the critical period of their eruption. 
ally as soon as the proper care is given, the decay ceases, 
and the condition of the teeth remains good for many 
years. Good teeth are so necessary to the preparation 
of food for digestion that every effort made for their 
preservation is a step toward improved digestion and 
assimilation. 

The Alimentary Tract.—Anatomically the child pos- 
sesses practically the digestive apparatus of an adult. 
That is, he has teeth, salivary glands, cesophagus, stom- 
ach, small intestine (relatively longer than in an adult), 
large intestine, rectum, liver, gall bladder, and pancreas. 
There are certain slight anatomical differences from the 
adult type. The stomach occupies still a somewhat. 
more vertical position, and the cardiac sphincter is poorly 
developed. The liver is relatively large. The small in- 
testine is relatively long. Little of the intestines is found 
in the pelvis owing to its small size. The sigmoid flexure 
is remarkably long and may be found in almost any part. 
of the abdomen. These differences, however, are not. 
sufficient to account for any marked difference in the di- 
gestion of this period from that of adult life. Function- 
ally also the several parts of the digestive apparatus are 
active. Still there isa notable deficiency in the digestive 
powers in the earlier years of childhood. The several 
digestive fluids have not the power that they acquire in. 
later life, and undoubtedly much harm is done children 
by allowing them from their earliest years the general 
diet of their parents. The transition from the milk diet. 
of the first two years to a general diet should be slowly 
and cautiously made. 

The rapidity of bodily growth and the unceasing actiy- 
ity of children render the metabolism of the organism 
much more rapid than in adult life. A child therefore: 
requires an amount of food greatly out of proportion to: 
its size and weight. According to the estimates, partly 
based on experiment, partly arbitrarily assumed, of At- 
water and Bryant,' a child from 3 to 5 years old requires. 
0.4 the food of a man; a child from 6 to 9 years old re- 
quires 0.5 the food of a man, and a child from 10 to 13. 
years old, 0.6 the food of a man. 

According to Edward Smith, the growing child, in 
proportion to its weight, requires about three times as. 
much carbonaceous food as the adult and six times as. 
much animal food. Evidently if these demands are to. 
be met, care will be required in both the selection and the 
preparation of the food during this period of life. In the 
absence of such care disorders of stomach and intestines. 
naturally result. Probably the great majority of chil- 
dren, especially those of school age, suffer in greater or 
less degree from indigestion and constipation, or diar- 
rhea. In the earlier years the parents require instruction 
as to the proper care of their children’s diet; later the: 


Usu- - 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Childhood, 
Childhood, 








children themselves require instruction and training in 
these fundamental matters of health. It is impossible in 
this article to go minutely into the diet of children of 
various ages. Thompson’s “Practical Dietetics” con- 
tains a store of information on the subject. 

The Kidneys.—In keeping with the generally more 
active metabolism of the child, it is commonly agreéd 
that children void relatively more urine than adults 
and that the proportion of urea is higher. The most ex- 
tensive observations the writer has been able to find are 
those of F. 8. Churchill,? made upon the children of the 
Half-Orphan “Asylum of Chicago. These observations 
are so complete as to make them especially valuable, and 
they are therefore reproduced in full: 


disturbance of the general health or impairment of ner’ 
vous tone is marked in early childhood by loss of this con- 
trol of the bladder. Incontinence of urine is a very com- 
mon complaint at this period of life and is usually 
accompanied by a marked increase in the frequency of 
micturition, a child of three to five years often urinating 
every hour or even more frequently. In health the abil- 
ity to control the bladder should at this period of life in- 
crease steadily with increasing years. | 

The Lymphatie System.—The lymphatics and lymph 
nodes in children are relatively large and much more 
active than in the adult. Absorption from the surface, 
either of skin or mucous membranes, occurs with marked 
rapidity. Asa consequence the lymph nodes are found 












































URINE IN CuILDHOOD—F, 8. CHURCHILL. 

PES ee ets on Oe =I g s ; |e8s a2 

a3 342 /§843/ of $2 laqe2| 32 |] nee 12 |SS8 sl2e.5 

_ Age. Sah| sex | 222 |S8s5| 25 | £8 | 282| Se | Bee| 23 |S" e5/3823 

Es @e (ghee! ab Z| PPh) sh | Mah) “SA lesoeesaas 

Bereary tigate toes vaic tos. 16.8 | 2 males. 5 | 358 | 10m.0/ 22 | 787 | 12.50 | 12.00 | 108 | 213 | 0468 
BU ert a sac Sot 16.94) | male |b Bl | 208, | tora | 20 | ser | aay | oz | 1a | 176 | os 
Bin = te atios sesiae saccidens ws « 16.84) pmaee bt ly 392 | 1024.5 | 26 | 10.19 | 10.37 | 889 | 113 | 233 606 
CR ens fe aty eons os «3 16.7 | 2females.| 2 | 405 | 1023 | 27 | 10.94 | 1100 | 6.50 | 113 | 242 | 655 
Beng ede cfecegceget ce 20.9}|Amale. jt 4 | set | ios | 11 | 620 | 7.00 | 563 | 85 | 269 | 296 
CE ie AES ee Renna 22.6}| 7males |t 20 | e28 | 1oz1| 22 | 1282 | 916 | 7.82] 111 |* 278 | on 
RE rns Se catow ers ese: 26.24| 5 male: | 2 | v1 | 10207) 28 | 1681 | 846 | 761 | 110 | 279 | eu 
(As 0 aanecneicea seco 27.5 a tansien t 15 768 | 1023.5] 21 | 11.28 | 9.29 | 685 | 110 | 219 592 
MM Ri hans hs Stae ceahce isc 27.2} basal t 7 716 | 10188 | 23 | 16.83 | 10.03 | 7.50 92 | 26.3 618 
PNG SRF adsot tates 5. 36.44) males. |¢ 8 | 920 | 1025) 28 | 2x21 | o27 | 677 | 1.00 | 227 | car 





The quantities given in this table, although their accu- 
racy is emphasized by the observer, are notably below 
those reported by others. Holt’s* table, compiled by 
combining the results of eight observers, gives the aver- 
age quantity at the ages of 2 to 5 yearsas 500 to 800 c.c. ; 
at 5 to 8 years as 600 to 1,200 c.c.; at 8 to 14 years as 
1,000 to 1,500 c.c. The amounts are also below those 
given by Vierordt in Gerhardt’s “ Handbook.” 

The specific gravity noted by Churchill is, as would be 
expected with the smaller quantity, notably higher than 
that given by other observers. The percentage of urea 
is also notably high and remarkably constant. The ratio 
of urea to 1 kgm. of body weight,’ while lower than that 
given by other observers, is still higher than that obtained 
in adult life. 

The elimination of chlorides is not remarkable. The 
phosphates are lower than in adult life, the deficiency 
being explained on the ground that they are retained in 
the system to facilitate the development of bone which 
belongs to the period of childhood. 

Carriére and Marfet thus sum up the results of their 
observations upon the urine in childhood: : 

1. The child voids relatively more urine than the adult. 

2. The specific gravity is higher. 

3. The acidity is greater. 

4. The nitrogenous metabolism is more active than in 
the adult, that is, 1 kgm. of a child uses up a weight of 
nitrogen more completely, the adult percentage of util- 
ized nitrogen being eighty-five, while in a child it is 
ninety. 

5. The mineral nutrition shows marked differences, the 
younger organism being more highly mineralized. 

6. All the phenomena of nutrition are much more active 
in the child than in the adult, the maximum being from 
the fifth to the tenth year. ~ 

7. The standard figures of the composition of normal 
urine for the adult are not applicable to children. 

The process of urination in early childhood is marked 
by frequency and lack of control. In the third year the 
urine may be retained during sleep for eight or nine hours, 
during the day for twoor three hours. Any unfavorable 





enlarged with unusual frequency. Indeed, enlargement 
of the lymph nodes, to such a degree as to render them 
palpable, is so common in children whose nutrition is 
under par or whose general care of the body is poor, that 
it assumes much less importance as a symptom of disease 
than we attach to it in later life. The lymph nodes are 


_ especially affected in tuberculosis and in all acute inflam- 


matory processes, especially those of the throat. 

The Nervous System.—In the comparison of a child 
with an adult the greatest disparity is found in the rela- 
tion of brain weight to body weight. Thus at birth the 
brain weighs one-sixth the weight of the body, in the 
third year it is one-eighteenth, in adult life one-forty- 
third. The cord is also relatively large, although not to 
the degree noted with reference to the brain. Side by 
side with this large size of the nervous system we must 
note its unusual activity and sensitiveness during the 
early years of life. The normal healthy child during its 
waking hours is never still. Ceaseless action is an actual 
requirement behind which must lie a ceaseless activity of 
the brain and cord. Every sense is constantly on the 
alert for the new impressions that are pouring in upon 
the awakening mind, every muscle is in almost constant 
action in carrying out the impulses that result from these 
stimuli. Rapid development in the functions of the brain 
and nervous system marks the years of childhood. Re- 
cent investigations have shown that this mental develop- 
ment is accompanied by definite changes in the individ- 
ual cells of the spinal cord and brain. The immature 
cells of the cortex or of the cord show steadily progressive 
changes in the development of new, more numerous, and 
more intricate communication with one another. Hand- 
in-hand with these rapid changes,, both in functions and 
in physical structure, there goes a remarkable sensitive- 
ness of the nervous system of the child. Children are, 
therefore, peculiarly subject to functional nervous dis- 
orders. Much of the irritability and peevishness of child- 
hood is simply the expression of abnormal conditions of 
the nervous system. 

In acute diseases of all kinds the nervous symptoms in 
childhood are likely to be very marked. The onset of 


831 


Childhood, 
Childhood, 





the acute infectious diseases with convulsions is well 
known, likewise convulsions resulting from an over- 
burdened stomach or from the decomposition of food in 
the bowels. It is less generally known that, especially 
in pneumonia, children may present many of the symp- 
toms of meningitis, profound stupor, or coma, strabismus, 
rigidity of the neck, etc., without any involvement of the 
meninges, the severe nervous symptoms arising from the 
toxemia of the pneumonia. Examples might be multi- 
plied to show how sensitive the nervous system of the 
child is and how profoundly it may be affected by the 
condition of organs or parts apparently remotely con- 
nected with it. Perfect health of the whole body is es- 
sential to the equilibrium of the nervous system, and if 
we desire the best results in the development of intellect 
we must attend to the health of each and every part of 
the body. a: 

Development of the Body.—\t is evidently impossible to 
follow the development of the various organs and parts 
of the body in detail. Within recent years a vast amount 
of work has been done in measuring the height and 
weight of school-children of various ages and calculating 
the averages of largenumbers. The accompanying table 
gives the results obtained by combining a large number 
of such tables. Naturally the larger the number of cases 
comprised in a table, the nearer the results approximate 
a true average. In comparing any two of the tables em- 
braced in this computation, remarkable differences are at 
times notable; at other times the agreement between 
measurements of children in widely separated communi- 
ties and under different social conditions is equally re- 
markable. The figures herewith given may be considered 
to represent a safe average for the field covered. In later 
observations along this line, notably those of Dr. W. T. 
Porter on the school-children of St. Louis, the girth of 
the chest is calculated for each year, also the probable 
deviation in any one of three factors—height, weight, 
and chest circumference. By comparison with such 
standards we may calculate how closely a child in its 
physical development corresponds to the average, and 
regulate its life accordingly. 


AVERAGE HEIGHT IN CENTIMETRES AND WEIGHT IN KILOGRAMS 
OF CHILDREN. COMPILED FROM TABLES OF QUETELET, BRUSSELS; 
BOWDITCH, BOSTON; KOTELMAN, HAMBURG: PAGLIANI, TURIN, 
AND THE SWEDISH AND DANISH COMMISSIONS. 














Age. Height.| Weight. Age. Height.| Weight. 
2-3 years....... 79.1 at 9-10 years...... 126.1 25.6 
Ba ee ee ek 86.2 12,5 TO=L Tae acess 129.8 27.6 
eS eC COUT 92.4 13.8 1-12 ae Mee 133.9 29.6 
Lie ee eet So. 102.8 16.9 APHIS hed Wenaeos 138.2 82.1 
Bh ee Secrets 109.4 19.3 B14 oO es 142.8 35.2 
yo etn VR A 115 21.4 1415 ee tee ya 148.5 39.3 
8-9 teen A eee 120.4 23.4 U5 =1658es deere 154.6 45.4 

















In studying boys and girls separately certain differences 
are notable. Up to the eleventh or twelfth year boys are 
somewhat taller and heavier than girls of the same age. 
At the twelfth year the girls begin to grow rapidly, and 
from that time till the fourteenth or fifteenth year, the 
measurements of the girls are the larger. Then from 
fourteen to sixteen years the boys begin to grow rapidly, 
regain the lead and continue to hold it. This rapid 
growth, in girls from the twelfth to the fourteenth year, in 
boys from the fourteenth to the sixteenth, is spoken of as 
the prepubertal increase, as it is, of course, associated with 
the well-known earlier maturity of the female organism. 
Investigation has also shown that the growth, either in 
height or weight, is not continuous throughout the year. 
Spring and early summer are the time of most rapid 
increase in height, and in the course of a few months at 
this time most of the annual increase in height is accom- 
plished. Ina similar way most of the gain in weight is 
made in the latter part of summer and the fall. The 
winter, therefore, is a period of no gain; there may even 
be a loss of weight. 

It is inadvisable in this place to attempt to discuss the 
physical and mental changes which belong to the transi- 


832 








REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


tion from childhood to puberty. It may, however, be 
urged that the child’s welfare, both of body and mind, 
demands such preparation for the changes that belong to 
this period, such education that the knowledge that must 
come shall come cleanand undefiled. Parents and teach- 
ers have been too long negligent of these matters. They 
should be roused to their duties. The evil consequences 
of the policy of “laissez faire” are matters of common 
knowledge. It should no longer be permitted that any 
child should pass through one of the crises of life without 
a word of instruction or admonition as to the meaning of 
the changes that he or she must experience. 

Mental Development.—To fully describe the mental de- 
velopment of childhood would require a complete psy- 
chology. What mainly interests us here is the initial 
stages. Bain® has given a simple account of these, and 
from him the following exposition is taken: In describing 
the mental status and progress of children, “there are,” 
he says, “a few set phrases that are regularly brought 
into service. The child, it is said, has a great love of 
activity, a desire to be occupied somehow; dislikes con- 
tinuous application or attention to any one thing; is joy- 
ous, mirthsome, fond of fun and frolic; delights in the 
exercise of the senses, and sensation generally ; is curious 
and inquisitive even to destructiveness; is strongly given 
to imitation; is remarkably credulous; is imaginative and 
fond of dramatizing; is sociable and sympathetic. On 
the more exclusively intellectual side the child is prone 
to observation and averse to abstraction; strong in mem- 
ory and weak in judgment.” 

He then proceeds to recast these observations in formal 
psychological terms under the several classes of activi- 
ties, senses, emotions, and intellectual powers. 

Activity is spontaneous and abundant, but fluctuating, 
uncertain, and indirect, being the outpouring and over- 


flow of natural energy. Among the first efforts at edu- - 


cation is the attempt to give it useful directions, but the 
readiest way is not to force it, but to take it at the mo- 
ment when it is fallen on a good course. 

The Senses.—These being fresh, and everything being 
new, sensation as such is delightful and coveted; hence 
the employment of the senses and the fruition of the 
effects are intense in infancy. But at first the emotional 
side preponderates, and the intellectual side, which is 
nourished by nice distinctions, does not attain an early 
development. The emotional force partly paves the way 
for, but partly obstructs, the intellectual. 

The emotions, strictly so called, are distinguished from 
the sense enjoyments. These are mainly the strong social 
feelings, love and affection; the strong anti-social feel- 
ings, anger, egotism, domination, together with the 
workings of fear. All are powerful from the dawn of 
life; education, while connecting them with special ob- 
jects, may do something to intensify or enfeeble their 
total force. 

The Intellect.—The fundamental tendencies or fune- 
tions—discrimination, discovery of agreements, retentive- 
ness or memory, are at work from the first; but the active 
emotional development keeps them all down at the out- 
set, although doing something that will provide materials 
that will be used in a future day. The operation of in- 
tellect is requisite to such complex growths as curiosity, 
imagination, dramatization, imitation, and fancy. The 
higher workings of intellect become necessary even to 
the observation of facts in any form that deserves the 
name. 

Turning to the question of progress in mental develop- 
ment, Bain shows that the first start in knowledge is 
made through spontaneous and overflowing activity and 
in the interest of the impressions upon the senses; all 
which in the pristine freshness afford an abounding en- 
joyment. He then goes on to show how the child’s field 
of knowledge is enlarged by attention to things or im- 
pressions which, not directly pleasurable in themselves, 
gain attention by association with the pleasurable. Thus 
the child is gradually led up to the acquisition of the 
indifferent, that is, knowledge devoid of the element of 
pleasure. However far along this path the child may be 


ee 


Se 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





led by mingling the indifferent with the pleasurable, the 
time comes when nothing short of the wish or will of a 
superior will keep the child to the acquisition of such 
knowledge. Fixed or concentrated attention to what is 
devoid of pleasure is unnatural and only to be secured by 
means of education. 


It is evident from the foregoing that the early mental _ 


life of a child is made up of accumulating sensations or 
sense impressions. Most of these are very simple and 
erude. Only gradually does a child learn to observe 
closely or accurately. Still more slowly does he learn to 
associate his impressions one with the other, to compare 
them or toreach general propositions. According to one 
authority, it is years before the child learns to distinguish 
between the subjective and the objective. The power of 
abstract reasoning is developed, as a rule, only as the 
child nears maturity. 

Study of the mental development of a child attains its 
all-important practical application in the arrangement of 
studies in the course of education. 

Development of motor power and control should not 
be lost sight of in considering the growth of the mind. 
Gradually the child attains more and more control over 
the movements of the eyes, the imperfect speech of early 
years gives place to clear and distinct enunciation, the 
hands and feet are used with constantly increasing skill 
and accuracy, and finally, the movements of the several 
parts of the body may be co-ordinated in actions of ex- 
treme delicacy and complexity. Increasing strength 
should also naturally be developed in the years of child- 
hood. 

School Life.—All but the earliest years of childhood are 
now regularly occupied in attendance upon schools. The 
conditions of school life must, therefore, have most im- 
portant influences upon the welfare of the child. It is 
coming to be recognized that however important educa- 
tion may be, it need not and must not be sought at the 
expense of the child’s health. As Spencer ® says: “ Peo- 
ple are beginning to see that the first requisite to success 
in life is to be a good animal.” Care is being taken that 
schoolrooms are so constructed as to give proper light, 
heat, and ventilation, that the seats should no longer be 
so made as to directly contribute to deformities of the 
body, that the children are so seated as to avoid unfavor- 
able straining of the eyes, that in every possible way the 
appointments of the schools shall contribute to health 
and not to disease. The tendencies of the timesare plain, 
but there are unhappily many places where they are lit- 
tle felt. 

In the larger cities daily inspection. of the school- 
children by competent physicians has been instituted in 
the effort to prevent the spread of contagious diseases, 
of which the schools have been notorious hotbeds. In 
New York City many of the schools are thrown open as 
places of recreation for the pupils during the summer 
months. 

Health of mind is no less to be sought than health of 
body. Recent years have brought great changes in the 
methods of school instruction, especially in the earlier 
years. The names of Pestolozzi and Froebel are con- 
stantly heard as the ideal teachers of the young, and the 
popular opinion is that their leading should be followed. 
As amatter of fact it is the spirit rather than the method 
of these men that still lives. The efforts made to follow 
their methods have resulted, as Oppenheim’ very clearly 
shows, in much that is not only valueless but even harm- 
ful, yet on the whole the present education of the young 
is on a vastly higher and better level than ever before. 
Not a little of the change has been due to the teachings 
of such men as Spencer and Bain that the best method 
of education is that which observes the natural unfolding 
of the child’s mind; that in the arrangement of studies 
or in the introduction or pursuit of any subject we should 
follow or consult the natural leadings of the mind of the 
child and not attempt to force it according to our pre- 
conceived ideas. Education is recognized asa process to 
be wrought out from within, and not to be put upon the 
child from without. 


Vor. IT.—53 





Childhood, 
Childhood, 





Moreover, much attention is now being given to the 
study of. the immediate effects of confinement in school, 
hours of study, etc., upon the nervous system of the 
child, as these are shown by various nerve reactions, 
Nearly all such investigations go to show that our school 
sessions are altogether too long, that the periods of 
application to individual subjects are likewise too 
long, that there is not sufficient variety in the tasks as- 
signed, and that the periods of relaxation are far too 
infrequent. 

Pauli,® discussing this subject, advises one school ses- 
sion a day with limitation of the period of study of any 
one subject to three-quarters of an hour, with an interval 
of rest before the next study period. 

A much-needed reform in these several directions may 
be looked for, but it is not probable that we shall ever be 
able to reach the ideal position, pictured by zealous ad- 
vocates of reform, where the pursuit and acquirement of 
knowledge shall be an unintegrupted pleasure. Nay, 
were this hope realized, we would only have succeeded 
in destroying one of the most essential features in either 
physical or mental training, the ability to face and ac- 
complish unpleasant or difficult tasks. That such things 
must be met in mature life is undoubted; that we should 
be trained to meet them seems, therefore, to be unques- 
tionable. Theories of education should not lead us to 
ignore the teachings of common experience. 

Disease in Childhood.—Partly by reason of susceptibil- 
ity, partly from the conditions of life, childhood is pre- 
eminently the period of the acute infectious diseases, 
especially measles, scarlet fever, diphtheria, and whoop- 
ing-cough. Greater attention to prophylaxis, especially 
the isolation of the sick and the disinfection of the infected 
room or apartment, is slowly but steadily lessening the 
ravages of these diseases. In the case of diphtheria the 
discovery of the specific micro-organism, resulting in 
earlier diagnosis and the early use of antitoxin, has pro- 
duced a most remarkable reduction of the mortality, and 
to a larger extent robbed the disease of its terror. The 
other members of this group have thus far refused to 
yield the secret of their power, the pathogenic micro- 
organisms remain unknown, and progress waits on their 
discovery. 

Affections of the respiratory system are not socommon 
in childhood as in infancy, but still constitute a large 
part of the sick lists, and are responsible for many deaths. 
Bronchitis and broncho- pneumonia are the most common. 
Empyema is much less frequent, but not so rare as gen- 
erally supposed. The latter is rarely primary; in the 
great majority of cases it followsa pneumonia, especially 
the complicating pneumonias of the acute infectious dis- 
eases. Tuberculosis limited to the lungs is rare in the 
early years of childhood; it becomes relatively more com- 
mon later on, especially after the seventh year. 

Disorders of the alimentary tract are very common in 
childhood, but are much less severe than in infancy. 
They are in great part acute inflammations produced by 
improper food and, as a rule, are readily amenable to 
treatment. As already stated, indigestion, constipation, 
and chronic diarrhceas from improper feeding are very 
frequent. 

As a class, children are very susceptible to tuberculosis, 
which manifests itself in many forms. In the earlier 
years the common form is a general miliary tuberculosis. 
The terminal stage of such a general process is very fre- 
quently a tuberculous meningitis. The meningitis may 
occur independently of involvement of other organs, but 
rarely so. Recently in studying the reports of a large 
orthopeedic dispensary and hospital the writer found that 
of all the deaths reported in cases of hip-joint or knee 
disease (nearly all of which are tuberculous), twenty-five 
per cent. were due to meningitis. Children with tuber- 
culous disease of the bones (especially the spine and larger 
joints) constitute the major part of the clientéle of ortho- 
peedic institutions. 

Tuberculous enlargements of the lymph nodes are very 
common in childhood. 

Intestinal tuberculosis is common in children suffering 


833 


nt ie 


Chillies. 
Chloasma, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





from tuberculous processes in the lungs; as a primary af- 
fection it is very rare. The main avenue of infection in 
children is the respiratory tract. In the tables of North- 
rup and the writer,* out of two hundred autopsies on 
cases of tuberculosis in children, in three only were the 
intestines the port of entry, the remainder being all cases 
of primary infection of the bronchial lymph nodes. 
Therefore, while recognizing the possibility of intestinal 
infection from tuberculous milk or meat and taking every 
precaution to prevent entrance by that route, we shall 
not check the ravages of tuberculosis among children till 
we have solved the problem of preventing infection 
through the air they breathe. 

Mortality.—The mortality of the early years of child- 
hood (7.¢., from the second to the fifth year) is still high, 
but not at all comparable to that of infancy. ‘Thus in 
round numbers the death records of New York City for 
1899 in a population somewhat over 3,500,000 show 20,- 
000 deaths in the first two years of life, 4,000 in the suc- 
ceeding three years. In three years we have but one- 
fifth the number of deaths credited to the first two years 
of life. The contrast is even more remarkable with the 
later years of childhood. After the fifth year the num- 
ber of deaths is calculated only for periods of five years 
each. 

In 1899 in New York City there were but 1,815 deaths 
in children from five to ten years of age, while of those 
from ten to fifteen years but 788 died. As there is no 
means of calculating the numbers of children living of 
these several ages, we cannot calculate the ratio of deaths 
to the number of living. It is evident, however, from 
the data obtainable that the period from the tenth to the 
fifteenth year shows the lowest death rate of any equal 
period of life. Coincident with the fall in the mortality 
lists after the second year, there is a change in the causes 
of death. In infancy diarrhceal diseases are the great 
cause of death, while the acute infectious diseases take 
the first rank in childhood. Of these it is generally 
agreed that diphtheria and scarlet fever are the most 
malignant. Measles is not generally regarded as a dan- 
gerous disease, but in the same year, 1899, in New York 
City, there were 533 deaths from scarlet fever and 587 from 
measles. Upon the basis of cases of these diseases re- 
ported during the year, 7,387 for scarlet fever and 12,530 
for measles, the death rate for scarlet fever is about 7.2 
per cent., for measles, 4.6 per cent., yet the total loss to 
the community from measles is greater than that from 
scarlet fever. Doubtless the lack of appreciation of the 
malignity of measles is due to the fact that its ravages 
are greatest in hospitals or asylums, while in private 
families the disease is usually of a milder type; there is 
no such difference in the action of scarlet fever. Inas- 
much as the deaths from diseases are not tabulated ac- 
cording to the ages of the victims, we have been obliged 
to assume that the total figures as given for all ages 
would have the same relations as those of childhood alone; 
considering the known predilection of these diseases for 
the years of childhood, this is probably true. 

Next to the acute infectious diseases, the worst enemies 
of childhood are pneumonia and tuberculosis. There is 
nothing peculiar in the relation of pneumonia to child- 
hood; it is the scourge of all ages. Tuberculosis in the 
early years, in a fatal form, is generally, as previously 
noted, either a diffuse process, affecting many parts, or 
tuberculous meningitis. As age increases a change is no- 
ticeable, and in the latter part of childhood pulmonary 
tuberculosis becomes the more common and deadly form 
of the disease. 

It would be improper to leave this subject with the 
thought that the only importance of disease in childhood 
is the number of deaths caused thereby. The affections 
of childhood assume a new and greater importance when 
we consider the number of those affected who are des- 
tined, by reason of the permanent damages produced 
by disease, to enter the battle of life with impaired vital- 
ity and possibly a crippled body. The waste, the suffer- 
ing, the torture produced in this way is beyond compu- 
tation. David Bovaird, Jr. 


834 


REFERENCES. 


1 Atwater and Bryant: Dietary Studies, U. S. Dept. Agriculture. 
2 Churchill: Arch. of Pediatrics, September, 1898. 

3 Holt: Diseases of Infancy and Childhood, 1897. 

4 Carriere and Morfet: Bull. de l’Acad. de Méd., 1897, p. 534. 

5 Bain: Education as Science. 

6 Spencer: Education. 

7 Oppenheim: Development of the Child. 

8 Bovaird: N. Y. Med. Journ., July 1st, 1899. 

® Pauli: Berl. klin. Wochenschr., September 6th, 1897, 


CHILLIES. See Capsicum, sp. 


CHINAPHT OL.—(C,,.H-OHSO3H)2, Coo Hos N2Oro. Be- 
tanaphtol alpha-monosulphonate of quinine. This isa 
yellow crystalline powder of bitter taste, insoluble in 
cold water, somewhat soluble in hot water and alcohol, 
and containing about forty-two per cent. of quinine. 
Riegler states that in the intestines it is decomposed into 
quinine and naphtol-sulphonic acid, and therefore is both 
an intestinal antiseptic and an antipyretic. He has used 
it with satisfaction in typhoid fever, dysentery, intestinal 
tuberculosis, and acute rheumatism, in daily dosage of 
.5 to 5 gm. (gr. viij. to 1xxv.). W. A. Bastedo. 


CHINASEPTOL. — (C.H;,OH,SO;H,N.) Diaphtol, 
ortho-oxychinolin-meta-sulphonic acid. This occurs in 
yellowish crystals melting at 295° C. (563° F.), and is 
slightly soluble in water, the solution turning green with 
ferric chloride. Chemically it bears the same relation to 
chinolin as phenol-sulphonic acid bears to benzol. It is 
used as a non-poisonous antiseptic or as a substitute 
for salol. W. A. Bastedo. 


CHINO, EL. — Within the municipality of Ucareo, 
Michoacan, Mexico, there are several springs—Laguna 
Verde, Nopalito Maritaro, Laguna Seca, etc. The only 
one that enjoys any reputation is “ El Chino,” to which 
people resort when suffering from rheumatism, sciatica, 
and other disorders. Bathers are compelled to erect their 
own tents if they wish protection from the weather and 
the curious. NV. J. Ponce de Léon. 


CHINOIDINE. See Cinchona. 


CHINOLINE.—Chinoline, or quinoline, as it is also 
called, is a non-oxygenated basic body represented by 
the formula C,H;N, and obtained by the distillation of 
certain natural alkaloids—notably quinine and cinchonine 
—with potassium hydroxide, and also, synthetically, by 
a patented process (Skraup’s), from a mixture of aniline, 
nitrobenzol, glycerin, and sulphuric acid. An isomeric 
body—leucoline—obtained from coal tar responds to chem- 
ical tests differently from chinoline, and is to be regarded 
as a distinct compound. . 

Chinoline is a colorless limpid fluid, of alkaline reac- 
tion, forming, with acids, crystallizable salts. Of such 
salts, those of the so-called mineral acids are mostly too 
deliquescent for convenient medicinal use, but chinoline 
tartrate is free from this objection and is available as a 
medicine. Chinoline tartrate is in minute, white, silky 
crystals, which, in a specimen made by Merck, of Darm- 
stadt, the writer found to be of a faint combined bitter- 
almond and coal-gas odor, of a peculiar, sharp, yet cool- 
ing taste, having a flavor as of kerosene with a sowpcon 
of peppermint, and to be slowly soluble in about twenty- 
five parts of cold water. 

The effects of chinoline tartrate are analogous to those 
of salts of quinine. In solutions ranging from 0.2 to 0.4 
per cent. it has been said to inhibit fermentative and 
putrefactive processes (Donath), and in doses such as 
would be given of quinine, to prove antipyretic and anti- 
periodic after the manner of that alkaloid (Donath, Loewy, 
and others). As against quinine, chinoline tartrate has 
the advantage of comparatively low price; but the dis- 
advantage of a decided tendency to sicken, vomiting 
being quite a common consequence of a medicinal dose. 
Furthermore, later experience has failed to confirm the 
claim of antiperiodic powers at first asserted. The drug 
is best given in a sweetened aromatic water, and a tea- 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


spoonful of lemon juice or a lump of ice after the dose 
is said to lessen the tendency to nauseate. 

Neither chinoline nor any of its salts is official in the 
United States Pharmacopeeia. Edward Curtis. 


CHINOSOL.—(C,.H«-NO,SO;K + Aq.) Oxy-chinoline 
sulphonate of potassium. This is a yellow crystalline 
powder of feebly aromatic odor, freely soluble in water 
and insoluble in alcohol and ether. Its dilute aqueous 
solution turns green with ferric chloride, and forms a 
green coating on steel instruments. It is stated to be a 
more powerful antiseptic than bichloride of mercury, 
with great penetrating power, and is highly spoken of 
by European clinicians; a 1-to-500 solution killed the 
plague bacillus in ten minutes. It has been used with 
advantage by Gilles in vaginitis in strength of 1 to 8,000 
to 1 to 1,000, also in leprosy and bone tuberculosis. 
Mixed with five to ten per cent. of boric acid it may be 
used asan antiseptic powder in place of iodoform. Hob- 
day found it a powerful disinfectant for the hands, the 
site of operation, and sutures, a solution of 1 to 60 
producing no irritation. For cellulitis or other severe 
infection it should be used in strength of 1 to 500, but 
for ordinary use 1 to 1,000 is better. Cipriani recom- 
mends it by mouth and hypodermically for tubercu- 
losis. It hasalso been used as an antipyretic. Hobday’s 
experiments on cats indicate the limit of safe dosage to 
be .0087 gm. (gr. =z) per 500 gm. (1 lb.) of body weight. 
Cadavers are said to be effectively preserved by intra- 
arterial injection of five-per-cent. solution. 

Pulvis chinosol comp. consists of chinosol, chinaseptol, 
talc, and silica. W. A. Bastedo. 


CHIRATA.—Chiretta. “The entire plant, Swertia Chi- 
rvayita (Roxb.) Hamilton (fam. Gentianacee)” (U.S. P.) 
(It is spelled “ Chirata” by Hamilton.) The following is 
the official description of this herb: 

“Root nearly simple, about 7 cm. long; stem branched, 
nearly 1 metre long, slightly quadrangular above; ¢con- 
taining a narrow wood circle and a large yellowish pith. 
Leaves opposite, sessile, ovate, entire, five-nerved. Flow- 
ers numerous, small, with a four-lobed calyx and corolla. 
The whole plant smooth, pale brown, inodorous, and in- 
tensely bitter.” 

Special attention should be given to this large pith, as 
there is a spurious article which is destitute of it, being 
quite hollow. 

Chirata is a native of Northern India, especially in 
mountainous districts in Nepal, where it is found at an 
elevation of from five to nine thousand feet (Bentley and 
Trimen). Its use was introduced from India, where it 
has been long employed, into European medicine about 
fifty years ago. 

The plant is gathered when fully grown; the flowering 
stems being pulled up entire, dried, and tied into long 
bundles. ; 

In composition, Chirata is almost the exact equivalent 
of gentian, as it is also in properties and uses. Bitter 
ophelic acid (Cy3H20010), soluble in both alcohol and 
water, replaces the gentisic acid of the latter, chiratin 


(Co¢HisOi5), a yellow, bitter, crystalline glucoside, soluble | 


in warm water and alcohol, replaces gentiopicrin, and as 
with gentian, there is no tannin, though ferric salts pro- 
duce a dark color, without inky precipitate. 

Chirata is a simple bitter and tonic. We have official 
a fluid extract, dose 1 to 4c.c. (fl. 34 to i.) and a ten-per- 
cent. tincture, made with sixty-five-per-cent alcohol, dose 
1 to 8c.c. (fl. 34 toij.). The latter is much the better 
preparation, especially in small doses. 

Henry H, Rusby. 


CHIROL is a solution of various oils and resins in ether 
and alcohol, forming an antiseptic varnish for the sur- 
geon’s hands. It is applied by immersing the hands, 
opening and shutting them a few times and spreading 
the fingers, then exposing them to the air for two or three 
minutes to dry. The pellicle formed is said to wash off 
easily, not to peel or crack, and not to be sticky. It 





Chillies, 
Chloasma, 


covers the hands with a flexible, impermeable coating 
like arubber glove. It has also been used for prelim- 
inary sterilization of the surface to be operated upon. 

W. A. Bastedo. 


CHITTENANGO SULPHUR’ SPRINGS. — Madison 
County, N. Y. 

Post-OF¥FIcE.—Chittenango. 

AccrEss.—This pleasant summer resort is located about 
3 miles south of the Chittenango station, on the New 
York Central and on the New York, West Shore, and 
Buffalo railroads, between the beautiful villages of Chit- 
tenango and Cazenovia. The Springs are reached from 
Chittenango by an electric railroad, by carriage, and by 
a Stage line. 

The country surrounding the Springs is hilly and cov- 
ered by a growth of hemlock, pine, beech, and maple. 
Through the valley between the hills flows the outlet of 
Cazenovia Lake to Oneida Lake, affording a stream twenty 
to seventy feet in width and well stocked with California, 
German, and brook trout. The hotel is large and com- 
modious, with extensive verandas, spacious parlors, and 
high and well-ventilated rooms, capable of accommodat- 
ing three hundred guests. The hillside grounds, in the 
rear of the hotel, including several acres, are covered 
with wild woods, intersected with walks, affording a cool 
and delightful strolling place in hot summer days. The 
Springs are three in number, known as the “ White Sul- 
phur,” the “Magnesium Sulphur,” and the “Lithium 
Sulphur” Springs. The following analyses were made 
by Professor Chandler, of New York: 


ONE UNITED STATES GALLON CONTAINS: 






























White Lithium Magnesia 
Solids. Sulphur Sulphur or Sulphur 
Spring. Cave Spring. Spring. 
Grains. Grains. Grains. 
Magnesium carbonate........ 22.02 23.97 
IVON CarbOnat@yaseadees avis alie ves ever | lh, » caeesine 20.78 
Tron DICHLDONALE:<. sce siea vl sieiele 08 16 32 
Sodium hyposulphite.........]  ...... 26 02 
Sodium sulphate .....:..0.60. PAL 
Calcium sulphate............. 81.42 106.12 115.09 
Strontium sulphate.... Trace. Trace. Trace 
Magnesium sulphate 1.95 7.59 12.72 
Sodium chloride. ... 1.04 1.57 1.83 
Potassium chloride. . 16 20 03 
Lithium chloride ...:........- Trace Trace. Trace 
Sodium sulphide.............. 12 39 05 
Caleruin SUlpMIGe vrjetsyerateieletsl cial Materia dele 1.12 .93 
HAINATIVETI Aes losers sieiwia'e: cretaretotes tie ee .08 22 Trace. 
iliGdaem stories cate dee ae 28 52 58 
LOCAL alle ctecercins Gavel S stovarttens 107.36 142.15 153.35 
Gases. Cubic ins. Cubic ins. Cubic ins. 
Sulphureted hydrogen ........ 0.88 2.75 5.62 
Carnboniciael din ncmeteaceies ae «ts 20.48 15.98 19.43 














Temperature of water, 45° F. 


The water of the White Sulphur Spring also contains 
a trace of free sulphur, which accounts for its pearly- 
white hue. This water is reeommended for rheumatism, 
neuralgia, gout, and skin diseases. The magnesia water 
is transparent, but deposits a sediment said to consist of 
magnesia, yellow sulphur, and a chloride of potassium. 
This water possesses marked tonic properties, and is 
much used in general debility, nervous affections, and 
insomnia. The water of the Lithium Spring is also per- 
fectly clear and very pleasant to the, taste. It has en- 
joyed much reputation in the treatment of kidney affec- 
tions. There is a large bath-house in connection with 
the Springs, in which hot mineral Water, vapor, and 
electric baths are furnished. James K. Crook. 


CHLOASMA.— (Synonyms: Liver Spot, Moth Patch, 


Mask; Fr., Chioasme ; Ger., Pigmentflecken.) 
DEFINITION.—An abnormal pigmentation of the skin 


835 


Ss 6. ae 


Chloasma, 
Chieral, 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 





occurring usually in patches of yellow, brown, or black 
color, of various shapes and sizes. 

It is used as a generic term and includes all discolora- 
tions of the skin, either circumscribed or diffuse, which 
are not accompanied by any other apparent objective 
changes. The color is of a yellow, brown, or black, 
changing in some conditions to a bronze or black (mela- 
noderma). The discolorations may be unilateral, irregu- 
lar, or symmetrical in their distribution, consisting of 
patches or of more or less diffuse pigmentations, stop- 
ping abruptly at the border, or they may shade off into 
the normal color of the part. 

From the generic use of the term, chloasma is usually 
divided into the idiopathic or the symptomatic varieties. 

Idiopathic chloasma is due to external causes or irritants: 
(1) Mechanical; (2) chemical; (8) thermal; (4) parasitic. 

1. Mechanical.—As a result of abrasions and of trauma, 
and also in consequence of scratching, in pruritus senilis, 
prurigo, and other pruriginous diseases, deep pigmenta- 
tion occurs in certain individuals, especially the run-down 
and elderly. 

2. Chemical.—In this class may be placed those cases in 
which pigmentation follows sinapisms, vesicants, and 
counter-irritants.- It is a question whether this is due 
directly to chemical effect or merely to the irritation. 
Tattooing may be placed here. 

3. Thermal.—Bronzing following the erythematous 
stage of sunburn is nota true chloasma; it is simply a 
pigmentation of the exposed parts—deep brown in the 
case of blondes—produced by the sun’s rays, and occur- 
ing generally in rather large and well-defined areas. 
Older people of a certain type have a tendency toward 
patchy pigmentation of the neck, arms, hands, and face, 
which is undoubtedly excited and increased by the sun’s 
rays. Stokers and those exposed to hot fires often have 
peculiar darkened areas upon the exposed parts. Cold 
has been known to produce like conditions. 

4. Parasitic.—De Amicis has lately descriked a pecul- 
jar café-au-lait pigmentation upon the chin and lip, due 
to the demodex folliculorum. 
seen twocases. Pityriasis nigricans (Willan) is the deep 
pigmentation seen in vagrants and tramps, produeed by 
scratching and generally due to pediculi corporis. 

The various fungi which flourish upon the skin and 
cause yellowish or brownish spots, such as tinea versi- 
color, erythrasma, mal del pinto, are described under 
their respective titles. 

Symptomatic chloasma may be a sequel of, or accom- 
pany, certain physiological or pathological conditions of 
the system. 

After certain inflammatory skin diseases—e.g., der- 
matitis herpetiformis, psoriasis, lichen planus, eczema, 
syphilitic eruptions, etc.—the sites occupied by the for- 
mer eruption often display a yellow or brown pigmen- 
tation, a part of which is of hematogenous origin, while 
another part comes from the cells of the locality. 

In cases of varicose veins the legs often have a deep 
patchy brown color, beginning about the follicles. 

Chloasma uterinum is either a physiological or a patho- 
logical condition. Pregnant women usually have a deep- 
ening of the color, in pigmented portions of the body, of 
a greater or less degree. They also sometimes are affected 
with an abnormal deposit of pigment, which occurs in 
patches of a dirty yellow to brown color over the face, 
especially on the forehead, cheeks, and chin. Often it 
becomes diffuse in the shape of a.sharply defined mask, 
the so-called masque des femmes enceintes. 


In uterine and ovarian diseasesa similar condition may | 


be seen, the pigmentation occurring either in spots or in 
the form of a diffuse mask. In the latter case the neck 
is especially involved, though in this location the rough 
and tightly fitting rutHe or neck ornament may be a con- 
tributing factor, 

In all cases of pigmentation of the face and neck the 
uterus and ovaries should be examined. 

Various blood diseases of unknown origin (hzemato- 
chromatoses of von Recklinghausen) are sometimes ac- 
companied by abnormal pigmentation of the skin. 


856 


Majocchi has likewise’ 


In exophthalmic goitre, abnormal pigmentation, in the 
form of patchy or diffuse freckles, is quite common, espe- 
cially along the course of the musculo-cutaneous nerves 
on the hands and arms, and over those parts of the face 
which are supplied by the fifth nerve (Blake). 

In abdominal tumors, tuberculosis, cancer, and lym- 
phoma, pigment is common on the face and hands. 

Diseases of the liver give rise more often to jaundice, 
but they are also accompanied by a patchy or diffuse 
pigmentation of the skin, often simulating, in this re- 
spect, Addison’s disease, as is seen in diabetic cirrhosis. 

It was formerly the fashion to ascribe, in a general 
way, all “moth spots” or patchy pigmentations to liver 
disorders (so-called “liver spots”). This idea was erro- 
neous, for the pigment due to liver diseases is deposited 
more or less generally, and not in sharply circumscribed — 
spots or patches, as is the case in the so-called “liver 
spots.” These remarks may be also applied to malarial 
pigmentations, which are produced by chronic malarial 
poisoning. 

Diseases of certain glands—e.g., the suprarenal (Addi- 
son’s disease) and the thyroid (Graves’ disease) glands— 
are accompanied by dyschromias. 

Pigmentations of varying degree and extent have been 
observed in cases of melanotic cancer and also in those 
of other forms of malignant growths. 

Cachectic conditions often produce a universal deepen- 
ing of pigment, from a sallow yellow to a yellowish- 
brown color. This is particularly true of tuberculosis, 
chronic rheumatism, syphilis, and leprosy; in the last- 
named disease the pigmentation is quite marked about 
the face and extremities in the late stages. 

It is a fact which is often overlooked, that gastro-in- 
testinal disorders play a réle in certain cases of chloasma. 
Chronic constipation and intestinal and gastric fermenta- 
tion of a chronic character, in which certain poisonous 
bodies are absorbed, produce besides other symptoms a 
patchy pigmentation of the face and hands, which is 
almost always symnietrically distributed. 

Syphilitic pigmentation of the neck, usually seen in 
women, is accompanied by other local symptoms and 
does not belong here. 

In respect to drugs, the most important discoloration 
is produced by nitrate of silver, for which see Argyria. 

Arsenic also produces a brown or bronze pigmentation 
of the face, neck, and abdomen after prolonged adminis- 
tration of the drug, but, as I have endeavored to show, 
this is not an essential primary pigmentation, for it is 
always preceded by a sensible degree of inflammation of 
the skin 

Little is known of the histopathology of chloasma, 
The pigment, in the more superficial forms, is deposited 
in the epidermis, either as something which was not there 
before, or else as an addition to a previously existing de- 
posit; but in many varieties the cutis also contains a 
great amount of yellow granules, either in connective- 
tissue cells, which may form pigment themselves, or in 
the lymph spaces. : 

Van der Vegt found that in sections the epidermic pig- 
ment was soluble in a weak solution of caustic potash in 
peroxide of hydrogen, while that of the cutis was not sol- 
uble in this solution, though perfectly so in strong hydro- 
chlorie acid. 

The treatment of chloasma consists simply in properly 
treating the cause or the disease upon which it is depend- 
ent. Consequently the reader is referred to the differ- 
ent articles which treat of the various conditions above 
mentioned. But no matter what the cause may be, the 
pigment is always slow to disappear; however, local 
treatment may in some cases assist in its removal. The 
results from local treatment depend, of course, upon the 
depth or location of the pigment. The remedies com- 
monly used for this purpose cause desquamation of the 
epidermis, thus attempting by the desquamation to re- 
move the pigmented cells. Some of these remedies are 
also supposed to have a bleaching effect, which at least 
is doubtful. 

If after a thorough trial of the usual remedies no 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


Chloasma, 
Chloral, 





marked improvement is perceptible, treatment should be 
discontinued, as this probably shows that there is a de- 
posit in the cutis, and such a deposit is often increased 
by continued irritation. Even in cases in which the spots 
are removed, there is often a reappearance with increased 
pigmentation. — 

The smaller areas can be very effectually removed by 
electrolysis, by inserting the needle just to the cutis 
margin, or by quick successive superficial stabs of the 
instrument. 

Peroxide of -hydrogen is recommended. It should be 
applied on cotton and allowed to remain on the spot sev- 
eral minutes. This procedure may be repeated several 
times a day. 

The various scaling agents used are: salicylic acid in 
a saturated alcohol solution or in a paste; resorcin in 
from ten to twenty per cent. solution in alcohol or ina 
paste; corrosive sublimate, one per cent. in almond emul- 
ion; and nightly frictions of green soap. The following 
prescription is to be recommended: 


erivarargyri ammoniati.....:.-...:.... 


dij 
Bismuthi subnitratis:....-............ dij 
(OSL So BV aeee ger ate alls ipl an daa Zi. 
MOU OGea rere. oa chee rye actke se astovc toy ecsts shee" A: 


This ointment in the course of time will materially 
lighten the patches, and is greatly to be preferred to the 
strong lotions of corrosive sublimate, which often pro- 
duce disastrous results, W. A. Hardaway. 


CHLORAL.—By the title Chloral, Chloral, the United 
States Pharmacopeeia recognizes not what is, chemically 
speaking, chloral proper, but an entirely distinct body, 
chloral hydrate. Chloral proper, C.HCl1;0, is, chemically, 
acetic aldehyde (common aldehyde) with three atoms of 
hydrogen in the molecule replaced by chlorine. It is a 
thin, vily, colorless, heavy fluid. On mixing chloral with 
water the two bodies unite, forming acrystalline hydrate 
of chloral, C.HCl,;0,H.O, which is the substance used in 
medicine under the misnomer chloral. Chloral hydrate, 
or “chloral,” appears in “separate, rhomboidal, colorless, 
and transparent crystals, having an aromatic, penetrat- 
ing, and slightly acrid odor, and a bitterish, caustic taste ; 
slowly volatilized when exposed to the air. Freely solu- 
ble in water, alcohol, or ether; also in chloroform, benzo}, 
benzin, carbon disulphide, fixed and volatile oils. It 
liquefies when triturated with about an equal quantity 
of camphor, menthol, thymol, or carbolic acid. When 
heated to about 58° C. (136.4° F.) it melts, forming a 
liquid having a specific gravity of about 1.575, which 
at a higher temperature should not evolve inflammable 
vapors. Liquefied chloral solidifies to a crystalline mass 
between 35° and 50° C. (95° and 122° F.). Chloral is de- 
composd by caustic alkalies, alkaline earths, and am- 
monia, chloroform being formed, and a formate of the 
base produced. A freshly prepared aqueous solution 
of chloral is neutral, but gradually acquires an acid re- 
action” (U. 8. P.). Chloral hydrate should be kept in 
glass-stoppered bottles in a cool and dark place. 

Chloral hydrate was proposed as a medicine by Lie- 
breich, in 1869, on the theoretical assumption that when 
absorbed into the circulation it would, by virtue of the 
warmth and alkalinity of the blood, undergo decomposi- 
tion and conversion into chloroform. But, though 
chloral hydrate has proved itself a valuable medicine, 
it is now certainly known not to undergo the assumed 
decomposition in the circulation, so that its effects are 
those of itself as such, and not of chloroform. 

The effects of chloral hydrate upon the animal economy, 
while much resembling those of chloroform, yet differ 
therefrom in many marked respects. Chloral hydrate, 
like chloroform, is locally a sharp irritant, and constitu- 
tionally a powerful neurotic, capable of producing arrest 
of the more important of the nervous functions, and so 
death, The most important difference between the action 





of chloral and that of chloroform is that the former drug 
has, relatively, a greater tendency to determine sleep, 
depression ‘of respiration, and fall of temperature, and 
a distinctly less pronounced power to dull sensation, 
than has chloroform. In ordinary medicinal dosage (a 
single dose of from 2 to 3 gm., equivalent to from gr. 
‘xxx. to xlv.) the only marked effect of chloral hydrate 
is a gentle, calm, agreeable, dreamless sleep, which, if 
induced at bedtime, will, unless there be special reasons 
to the contrary, probably last till morning, and from 
which the waking will be natural, unattended by the 
disagreeable by-effects of an opiate. During the chloral 
sleep, forced awakening is as easy as during a natural 
heavy sleep, and the subject, when roused, is perfectly 
rational. Pulse and respiration are a little slowed, but 
otherwise the functions are not obviously affected. In 
increased dosage natural sleep deepens into coma; respi- 
ration, blood pressure, and pulse rate are markedly de- 
pressed, or the heart’s action may be rapid while weak; 
temperature distinctly falls; sensation, after an initial 
temporary hyperesthesia, becomes moderately blunted ; 
motor paralysis, voluntary and reflex, comes on, and, if 
the dose has been sufficiently large, death ensues by fail- 
ure of respiration; or, if the action has been sudden and 
overwhelming, death is by syncope, as in shock. The 
principal post-mortem revelation in fatal chloral poison- 
ing is congestion of the lungs and of the cerebro-spinal 
axis. These various phenomena are undoubtedly pro- 
duced by a direct action of the poison upon the nerve 
centres presiding over the functions deranged. Of the 
effects, those of greatest clinical importance are the hyp- 
notism and the paresis of the respiratory centre and of 
the motor tract of the spinal cord generally. 

When chloral hydrate is taken habitually, certain pecul- 
iar effects may follow. Perhaps the most common is 
some form of skin eruption, which is generally erythema- 
tous, though sometimes papular. In certain subjects, 
urticaria or purpura may result; in other cases, conjunc- 
tival or faucial irritation; in still others, dyspnea; and 
in unique cases, pains in all the limbs and partial para- 
plegia have clearly been traced to chloral poisoning 
(Anstig). Quite a common effect, seen even in cases of 
single dosage, is one where chloral and alcohol have been 
taken together, namely, deep flushing of the face and 
throbbing of the vessels, exactly as produced by amyl 
nitrite. Prolonged habitual use of the drug probably 
tends to debase the mind and morals of the subject in 
the same manner as indulgence in alcohol, ether, or chloro- 
form; and sudden discontinuance, after a fixed habit of 
excess, may naturally lead to the same consequences as 
the sudden breaking of a pronounced alcohol habit. 

In the matter of toxicology, cases of fatal or of even 
dangerous poisoning have generally resulted from inad- 
vertent medicinal overdosage. The smallest authenti- 
cated fatal dose is twenty grains (1.30 gm.), and the fact 
that such dose—one less than the usual medicinal dose— 
has killed only emphasizes the fact, now pretty gener- 
ally recognized by the profession, that individuals show 
very different degrees of susceptibility to the action of 
chloral hydrate. The condition of dangerous poisoning 
is one of narcosis, distinguishable from the narcosis of 
opium, with which it is most likely to be confounded, 
by the conditions of the pupils. The pupils, in chloral 
poisoning, are either dilated, or if contracted are but 
moderately so, and dilate upon the subject’s awakening. 
Very often, also, in chloral narcosis, the face is deeply 
‘flushed and somewhat bloated, the lips and eyelids 
swollen, and the eyes blood-shot. The treatment of 
poisoning by chloral hydrate is to evacuate the stomach, 
best by the stomach pump, and to sustain the flagging 
lungs and heart by artificial respiration. Medicinal 
respiratory and cardiac stimulants, though theoretically 
indicated, are practically of little use, because of the al- 
ready hopelessly paralyzed condition of the tissue upon 
which they are to act. 

Therapeutically, chloral hydrate is available to pro- 
cure sleep, to oppose spasm, and to blunt pain. As a 
hypnotic it takes front rank among medicines, because 


837 


Chioral Aceto-Phe- 
Chlorates, [non-Oxime, 





of the combined certainty and yet pleasantness of its 
action. Yet the indiscriminate use of the drug in all 
conditions of wakefulness may easily work great harm. 
Thus, remembering the strong specific action of chloral 
hydrate to depress respiratory activity, it is plain that in 
the restlessness and wakefulness that result. from dysp- 
nea, in such conditions as congestion of the lungs, 
emphysema, or bronchitis with obstructed circulation, 
the drug is the most improper thing that could be pre- 
scribed. Similarly, from its associated cardiac depression, 
all conditions caused or attended by feeble or embarrassed 
circulation contraindicate chloral. As an antispasmodic, 
chloral hydrate is peculiarly appropriate where the cause 
of the spasms is morbidly excited reflex irritability of the 
nerve centres. In tetanus it has thus worked many cures. 
As an anodyne this remedy is inferior to many others, 
as might be inferred from the fact, already mentioned, 
that anesthesia is not a very pronounced element of its 
physiological operation. 

A special use of chloral hydrate, not medicinal, yet 
utilized by the physician, is as a preservative. Like the 
related substances, the volatile alcohols and ethers, chloral 
hydrate is markedly antiseptic, and possesses the peculiar 
feature that, while preserving putrefiable tissues from 
decay, it yet does not obviously change the physical 
appearance of even the most delicate structures. The 
agent is, therefore, peculiarly useful as a preservative 
for urines set aside for microscopical examination. As 
much of the drug in crystals as will lie on the thumb-nail 
added to about 100 c.c. (about fl. Ziij.) of urine will 
preserve the same perfectly for days or even weeks, and 
that, too, without affecting the ready recognizability of 
casts, blood or pus corpuscles, epithelial scales, or sper- 
matozoa. Theaddition does not affect the heat and nitric 
acid test for albumin, but it vitiates the test for sugar by 
Fehling’s solution, since a solution of chloral hydrate of 
sufficient concentration will itself reduce the copper of 
that test fluid. The antiseptic action of chloral hydrate 
is available for use in surgery, and lotions of from one to 
three per cent. strength have been proposed for wounds. 
Such weak percentages are necessary, else the application 
will smart and perchance develop constitutional poison- 
ing by absorption. 

Lastly, chloral hydrate has been suggested as an anes- 
thetic for surgical use, by the procedure of injecting an 
aqueous solution directly into.a vein. The quantity of 
one hundred grains has been so injected, with the effect 
of producing in eight minutes a complete anesthesia that 
lasted an hour, and was followed by a deep sleep, with 
blunted sensibility, for fourteen hours. In other cases 
death has been reported as a consequence, as might natu- 
rally have been anticipated, and the procedure is little 
likely to find favor with conscientious surgeons. 

For medicinal giving for its legitimate purposes, the 
dose of chloral hydrate for an adult should not at first 
exceed 1.30 gm. (gr. xx.). Often twice and three times 
that quantity is perfectly well borne, but, until the indi- 
vidual susceptibility of a given subject is tested, it is 
best to prescribe the smaller doses. The remedy is given 
in solution, with the sharp twang of the taste disguised 
by some syrupy and aromatic addition. 

Edward Curtis. 


CHLORAL ACETO-PHENON-OXIME.—C,H;CH;,C,- 
NO,CH,OHCCl);. This is obtained by the interaction of 
chloral and acetophenonoxime at low temperatures. It 
occurs in colorless, prismatic crystals, insoluble in water, 
soluble in alcohol and ether, and decomposed by acids. 
It is hypnotic, and has been used in epilepsy and tetanus, 
but its effective dose has not yet been determined. 

W. A. Bastedo. 


CHLORAL ALCOHOLATE.—This body, C.,HC1,0, 


C:H.O, forms during the process of manufacture of | phenon-oxime). 


for chloral hydrate. 


REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. 


chloral from alcohol. It isin white crystals, distinguished 
from those of chloral hydrate by their insolubility in cold 
water, although they melt on admixture with hot water. 
This body is not used as a medicine, and needs mention 
only because it may possibly be mistaken in the market 
Edward Curtis. 


CHLORAL-AMMONIUM is’ obtained by passing dry 
ammonia gas through a solution of chloral in chloroform, 
It forms colorless needles melting at 84° C. (183.2° F.) 
and is almost insoluble in water. Boiled with water it 
forms chloroform and ammonium formate. It is given 
as an analgesic and hypnotic in dose of 1-2 gm. (gr. 
XV.-XXX.). W. A. Bastedo. 


CHLORAL CAMPHOR.—This name has been applied 
to the clear fluid that results from trituration of equal 
parts of chloral hydrateand camphor. The fluid is solu- 
ble in alcohol, ether, glycerin, and fixed oils, but on 
mixture with water suffers precipitation of the camphor. 
It possesses the medicinal properties of its ingredients, 
and in a teaspoonful dose in one case produced severe, 
irritant, and narcotic poisoning. The compound is not 
official, but has been used medicinally as a nervous seda- 
tive in doses of from gtt. x. to xx. Edward Curtis. 


CHLORAL CYANHYDRATE.—CCI1;COH, HCN, chloral 
hydrocyanin, chloral cyanhydrin. It occurs in small 
crystals or a crystalline powder having a mixed odor of 
hydrocyanic acid and chloral and readily soluble in water, 
alcohol, and ether. Its aqueous solution is only fairly 
stable, and it is decomposed by alkalies or boiling water. 
Hermes states that it has the action of hydrocyanic acid 
with about one-seventh its strength. A solution of 14.4 
parts in sufficient water to make 100 parts corresponds 
with the Acidum Hydrocyanicum Dilutum of the United 
States Pharmacopeia. Six parts in 1,000 make a solution 
equivalent to the German Pharmacopeceia bitter almond 
water. W. A. Bastedo. 


CHLORALOSE.—C;H,:C01;0.6, anhydro-gluco-chloral. 
By heating chloral and glucose together for an hour at 
about 96° C., chloralose and parachloralose are formed. 
The latter is not used in medicine. Chloralose occurs in 
fine, colorless needles or small crystals of bitter, unpleas- 
ant taste, soluble in 170 parts of cold water and readily 
soluble in hot water or alcohol. The crystals melt at 
184°-186° C, (363.2°-866.8° F.). Following experiments 
on dogs, it was introduced in 1893 by Hanriot and Richet 
as a certain hypnotic devoid of depressing effects on 
respiration and circulation. In 1897 following experi- 
ments on man, Richet again recommended it highly, yet 
subsequent investigations have shown it to be extremely 
variable in its effects, and even unsafe in so small a dose 
as eight or ten grains. It is said to cause nausea, vomit- 
ing, slow weak heart, involuntary urination during sleep, 
and various nervous symptoms, such as delirium, tremors, 
and paralysis. The dose is 0.2-0.5 gm. (gr. iij.—viij.). 

By treating arabinose and xylose in the same manner 
as glucose, the above investigators have obtained analo- 
gous compounds named respectively arabinochloralose 
and xylochloralose. The former is stated to produce 
quiet sleep without nervous symptoms and to be much 
less toxic than chloralose. Xylochloralose, however, was 
found to be more toxic and less hypnotic. 

W. A. Bastedo. 


CHLORALOXIMES are compounds of chloral with 
various oximes and are nearly insoluble in water, de- 
composed by hot water, and soluble in alcohol. The 
principal ones are chloralacetoxime, chloralcamphor- 
oxime, chloral acetaldoxime, chloral nitroso-betanaphtol- 
oxime, chloral benzaldoxime, and chloral acetophenon- 
oxime. They all act as hypnotics (see Chloral aceto- 
W. A. Bastedo. 


END OF VOLUME II. 


838 











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